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+The Project Gutenberg EBook of Manual of Surgery Volume Second:
+Extremities--Head--Neck. Sixth Edition., by Alexander Miles and Alexis Thomson
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever. You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: Manual of Surgery Volume Second: Extremities--Head--Neck. Sixth Edition.
+
+Author: Alexander Miles
+ Alexis Thomson
+
+Release Date: March 29, 2009 [EBook #28428]
+
+Language: English
+
+Character set encoding: ISO-8859-1
+
+*** START OF THIS PROJECT GUTENBERG EBOOK MANUAL OF SURGERY ***
+
+
+
+
+Produced by Jonathan Ingram, Chris Logan and the Online
+Distributed Proofreading Team at http://www.pgdp.net
+
+
+
+
+
+
+
+
+
++--------------------------------------------------------------------+
+| |
+| Transcriber's note: The inverted 'Y' symbol used in this book has |
+| been transcribed as [inverted Y]. |
+| |
++--------------------------------------------------------------------+
+
+
+
+
+ OXFORD MEDICAL PUBLICATIONS
+
+
+
+ MANUAL OF SURGERY
+
+
+
+ BY
+
+ ALEXIS THOMSON, F.R.C.S.Ed. AND Eng.
+ _PROFESSOR OF SURGERY, UNIVERSITY OF EDINBURGH_
+ SURGEON EDINBURGH ROYAL INFIRMARY
+
+ AND
+
+ ALEXANDER MILES, F.R.C.S.Ed.
+ SURGEON EDINBURGH ROYAL INFIRMARY
+
+
+ VOLUME SECOND
+ EXTREMITIES--HEAD--NECK
+
+
+ _SIXTH EDITION REVISED AND ENLARGED_
+ _WITH 288 ILLUSTRATIONS_
+
+
+
+ LONDON
+ HENRY FROWDE and HODDER & STOUGHTON
+ THE _LANCET_ BUILDING
+ 1 & 2 BEDFORD STREET, STRAND, W.C.2
+
+
+
+
+
+
+ First Edition 1904
+ Second Edition 1907
+ Third Edition 1909
+ Fourth Edition 1912
+ " " Second Impression 1913
+ Fifth Edition 1915
+ " " Second Impression 1919
+ Sixth Edition 1921
+
+
+
+ PRINTED IN GREAT BRITAIN BY
+ MORRISON AND GIBB LTD., EDINBURGH
+
+
+
+
+CONTENTS
+
+
+ PAGE
+ CHAPTER I
+ INJURIES OF BONES 1
+
+ CHAPTER II
+ INJURIES OF JOINTS 32
+
+ CHAPTER III
+ INJURIES IN THE REGION OF THE SHOULDER AND UPPER ARM 44
+
+ CHAPTER IV
+ INJURIES IN THE REGION OF THE ELBOW AND FOREARM 79
+
+ CHAPTER V
+ INJURIES IN THE REGION OF THE WRIST AND HAND 102
+
+ CHAPTER VI
+ INJURIES IN THE REGION OF THE PELVIS, HIP-JOINT, AND THIGH 122
+
+ CHAPTER VII
+ INJURIES IN THE REGION OF THE KNEE AND LEG 155
+
+ CHAPTER VIII
+ INJURIES IN REGION OF ANKLE AND FOOT 185
+
+ CHAPTER IX
+ DISEASES OF INDIVIDUAL JOINTS 201
+
+ CHAPTER X
+ DEFORMITIES OF THE EXTREMITIES 241
+
+ CHAPTER XI
+ THE SCALP 319
+
+ CHAPTER XII
+ THE CRANIUM AND ITS CONTENTS 328
+
+ CHAPTER XIII
+ INJURIES OF THE SKULL 361
+
+ CHAPTER XIV
+ DISEASES OF THE BRAIN AND MEMBRANES 373
+
+ CHAPTER XV
+ DISEASES OF THE CRANIAL BONES 406
+
+ CHAPTER XVI
+ THE VERTEBRAL COLUMN AND SPINAL CORD 411
+
+ CHAPTER XVII
+ DISEASES OF THE VERTEBRAL COLUMN AND SPINAL CORD 431
+
+ CHAPTER XVIII
+ DEVIATIONS OF THE VERTEBRAL COLUMN 461
+
+ CHAPTER XIX
+ THE FACE, ORBIT, AND LIPS 474
+
+ CHAPTER XX
+ THE MOUTH, FAUCES, AND PHARYNX 496
+
+ CHAPTER XXI
+ THE JAWS, INCLUDING THE TEETH AND GUMS 507
+
+ CHAPTER XXII
+ THE TONGUE 528
+
+ CHAPTER XXIII
+ THE SALIVARY GLANDS 543
+
+ CHAPTER XXIV
+ THE EAR 553
+
+ CHAPTER XXV
+ THE NOSE AND NASO-PHARYNX 567
+
+ CHAPTER XXVI
+ THE NECK 582
+
+ CHAPTER XXVII
+ THE THYREOID GLAND 604
+
+ CHAPTER XXVIII
+ THE OESOPHAGUS 616
+
+ CHAPTER XXIX
+ THE LARYNX, TRACHEA, AND BRONCHI 634
+
+ INDEX 645
+
+
+
+
+LIST OF ILLUSTRATIONS
+
+
+ FIG. PAGE
+
+ 1. Multiple Fracture of both Bones of Leg 4
+
+ 2. Radiogram showing Comminuted Fracture of both Bones of 5
+ Forearm
+
+ 3. Oblique Fracture of Tibia; with partial Separation of 6
+ Epiphysis of Upper End of Fibula; and Incomplete Fracture
+ of Fibula in Upper Third
+
+ 4. Excess of Callus after Compound Fracture of Bones of 9
+ Forearm
+
+ 5. Multiple Fractures of both Bones of Forearm showing 11
+ Mal-union
+
+ 6. Radiogram of Un-united Fracture of Shaft of Ulna 13
+
+ 7. Excessive Callus Formation after Infected Compound 27
+ Fracture of both Bones of Forearm
+
+ 8. Partial Separation of Epiphysis, with Fracture running 29
+ into Diaphysis
+
+ 9. Complete Separation of Epiphysis 29
+
+ 10. Partial Separation with Fracture of Epiphysis 29
+
+ 11. Complete Separation with Fracture of Epiphysis 29
+
+ 12. Os Innominatum showing new Socket formed after 41
+ Old-standing Dislocation
+
+ 13. Oblique Fracture of Right Clavicle in Middle Third, 45
+ united
+
+ 14. Fracture of Acromial End of Clavicle 46
+
+ 15. Adhesive Plaster applied for Fracture of Clavicle 49
+
+ 16. Forward Dislocation of Sternal End of Right Clavicle 51
+
+ 17. Diagram of most common varieties of Dislocation of the 53
+ Shoulder
+
+ 18. Sub-coracoid Dislocation of Right Shoulder 55
+
+ 19. Sub-coracoid Dislocation of Humerus 56
+
+ 20. Kocher's Method of reducing Sub-coracoid 57
+ Dislocation--First Movement
+
+ 21. Kocher's Method--Second Movement 58
+
+ 22. Kocher's Method--Third Movement 59
+
+ 23. Miller's Method of reducing Sub-coracoid 60
+ Dislocation--First Movement
+
+ 24. Miller's Method--Second Movement 61
+
+ 25. Dislocation of Shoulder with Fracture of Neck of Humerus 64
+
+ 26. Transverse Fracture of Scapula 68
+
+ 27. Fracture of Surgical Neck of Humerus, united with 70
+ Angular Displacement
+
+ 28. Impacted Fracture of Neck of Humerus 71
+
+ 29. Ambulatory Abduction Splint for Fracture of Humerus 72
+
+ 30. Radiogram of Separation of Upper Epiphysis of Humerus 73
+
+ 31. "Cock-up" Splint 77
+
+ 32. Gooch Splints for Fracture of Shaft of Humerus; and
+ Rectangular Splint to secure Elbow 77
+
+ 33. Radiogram of Supra-condylar Fracture of Humerus in a 81
+ Child
+
+ 34. Radiogram of T-shaped Fracture of Lower End of Humerus 83
+
+ 35. Radiogram of Fracture of Olecranon Process 86
+
+ 36. Backward Dislocation of Elbow in a Boy 89
+
+ 37. Bony Outgrowth in relation to insertion of Brachialis 90
+ Muscle
+
+ 38. Radiogram of Incomplete Backward Dislocation of Elbow 91
+
+ 39. Forward Dislocation of Elbow, with Fracture of Olecranon 93
+
+ 40. Radiogram of Forward Dislocation of Head of Radius, with 95
+ Fracture of Shaft of Ulna
+
+ 41. Greenstick Fracture of both Bones of the Forearm 98
+
+ 42. Gooch Splints for Fracture of both Bones of Forearm 99
+
+ 43. Colles' Fracture showing Radial Deviation of Hand 103
+
+ 44. Colles' Fracture showing undue prominence of Ulnar 103
+ Styloid
+
+ 45. Radiogram showing the Line of Fracture and Upward 104
+ Displacement of the Radial Styloid in Colles' Fracture
+
+ 46. Radiogram of Chauffeur's Fracture 107
+
+ 47. Radiogram of Smith's Fracture 108
+
+ 48. Manus Valga following Separation of Lower Radial 109
+ Epiphysis in Childhood
+
+ 49. Radiogram showing Fracture of Navicular (Scaphoid) Bone 111
+
+ 50. Dorsal Dislocation of Wrist at Radio-carpal Articulation 113
+
+ 51. Radiogram showing Forward Dislocation of Navicular Bone 114
+
+ 52. Extension Apparatus for Oblique Fracture of Metacarpals 117
+
+ 53. Radiogram of Bennett's Fracture of Base of Metacarpal 118
+ of Right Thumb
+
+ 54. Splints for Bennett's Fracture 119
+
+ 55. Multiple Fracture of Pelvis through Horizontal and 123
+ Descending Rami of both Pubes, and Longitudinal Fracture
+ of left side of Sacrum
+
+ 56. Fracture of Left Iliac Bone; and of both Pubic Arches 124
+
+ 57. Many-tailed Bandage and Binder for Fracture of Pelvic 125
+ Girdle
+
+ 58. Nélaton's Line 128
+
+ 59. Bryant's Line 129
+
+ 60. Section through Hip-Joint to show Epiphyses at Upper 130
+ End of Femur, and their relation to the Joint
+
+ 61. Fracture through Narrow Part of Neck of Femur on Section 131
+
+ 62. Impacted Fracture through Narrow Part of Neck of Femur 132
+
+ 63. Fracture of Neck of Right Femur, showing Shortening, 133
+ Abduction, and Eversion of Limb
+
+ 64. Fracture of Narrow Part of Neck of Femur 134
+
+ 65. Coxa Vara following Fracture of Neck of Femur in a Child 136
+
+ 66. Non-impacted Fracture through Base of Neck 137
+
+ 67. Fracture through Base of Neck of Femur with Impaction 137
+ into the Trochanters
+
+ 68. Non-impacted Fracture through Base of Neck 138
+
+ 69. Fracture of the Femur just below the small Trochanter, 140
+ united, showing Flexion and Lateral Rotation of Upper
+ Fragment
+
+ 70. Adjustable Double-inclined Plane 141
+
+ 71. Diagram of the most Common Dislocations of the Hip 142
+
+ 72. Dislocation of Right Femur on to Dorsum Ilii 143
+
+ 73. Dislocation on to Dorsum Ilii 144
+
+ 74. Dislocation into the Vicinity of the Ischiatic Notch 145
+
+ 75. Longitudinal Section of Femur showing Fracture of Shaft 148
+ with Overriding of Fragments
+
+ 76. Radiogram of Steinmann's Apparatus applied for Direct 150
+ Extension to the Femur
+
+ 77. Hodgen's Splint 151
+
+ 78. Long Splint with Perineal Band 152
+
+ 79. Fracture of Thigh treated by Vertical Extension 153
+
+ 80. Section of Knee-joint showing Extent of Synovial Cavity 156
+
+ 81. Extension applied by means of Ice-tong Callipers for
+ Fracture of Femur 158
+
+ 82. Radiogram of Separation of Lower Epiphysis of Femur, 160
+ with Backward Displacement of the Diaphysis
+
+ 83. Separation of Lower Epiphysis of Femur, with Fracture 161
+ of Lower End of Diaphysis
+
+ 84. Radiogram of Fracture of Head of Tibia and upper Third 163
+ of Fibula
+
+ 85. Radiogram illustrating Schlatter's Disease 164
+
+ 86. Diagram of Longitudinal Tear of Posterior End of Right 171
+ Medial Semilunar Meniscus
+
+ 87. Radiogram of Fracture of Patella 173
+
+ 88. Fracture of Patella, showing wide Separation of Fragments 175
+
+ 89. Radiogram of Transverse Fracture of both Bones of Leg 178
+ by Direct Violence
+
+ 90. Radiogram of Oblique Fracture of both Bones of Leg by 178
+ Indirect Violence
+
+ 91. Box Splint for Fractures of Leg 180
+
+ 92. Box Splint applied 181
+
+ 93. Section through Ankle-joint showing relation of 186
+ Epiphyses to Synovial Cavity
+
+ 94. Radiogram of Pott's Fracture, with Lateral Displacement 187
+ of Foot
+
+ 95. Ambulant Splint of Plaster of Paris 189
+
+ 96. Dupuytren's Splint applied to Correct Eversion of Foot 190
+
+ 97. Syme's Horse-shoe Splint applied to Correct Backward 191
+ Displacement of Foot
+
+ 98. Radiogram of Fracture of Lower End of Fibula, with 192
+ Separation of Lower Epiphysis of Tibia
+
+ 99. Radiogram of Backward Dislocation of Ankle 195
+
+ 100. Compound Dislocation of Talus 197
+
+ 101. Radiogram of Fracture-Dislocation of Talus 198
+
+ 102. Radiogram of Dislocation of Toes 199
+
+ 103. Arthropathy of Shoulder in Syringomyelia 203
+
+ 104. Radiogram of Specimen of Arthropathy of Shoulder in 204
+ Syringomyelia
+
+ 105. Radiogram showing Multiple partially Ossified 205
+ Cartilaginous Loose Bodies in Shoulder-joint
+
+ 106. Diffuse Tuberculous Thickening of Synovial Membrane of 206
+ Elbow
+
+ 107. Contracture of Elbow and Wrist following a Burn in 207
+ Childhood
+
+ 108. Advanced Tuberculous Disease of Acetabulum with Caries 210
+ and Perforation into Pelvis
+
+ 109. Early Tuberculous Disease of Right Hip-joint in a Boy 212
+
+ 110. Disease of Left Hip; showing Moderate Flexion and 213
+ Lordosis
+
+ 111. Disease of Left Hip; Disappearance of Lordosis on 213
+ further Flexion of the Hip
+
+ 112. Disease of Left Hip; Exaggeration of Lordosis 214
+
+ 113. Thomas' Flexion Test, showing Angle of Flexion at 214
+ Diseased Hip
+
+ 114. Tuberculous Disease of Left Hip: Third Stage 215
+
+ 115. Advanced Tuberculous Disease of Left Hip-joint in a Girl 216
+
+ 116. Extension by Adhesive Plaster and Weight and Pulley 220
+
+ 117. Stiles' Double Long Splint to admit of Abduction of 221
+ Diseased Limb
+
+ 118. Thomas' Hip-splint applied for Disease of Right Hip 222
+
+ 119. Arthritis Deformans, showing erosion of Cartilage and 225
+ lipping of Articular Edge of Head of Femur
+
+ 120. Upper End of Femur in advanced Arthritis Deformans 226
+ of Hip
+
+ 121. Femur in advanced Arthritis Deformans of Hip and Knee 227
+ Joints
+
+ 122. Tuberculous Synovial Membrane of Knee 230
+
+ 123. Lower End of Femur from an Advanced Case of Tuberculous 231
+ Arthritis of the Knee
+
+ 124. Advanced Tuberculous Disease of Knee, with Backward 233
+ Displacement of Tibia
+
+ 125. Thomas' Knee-splint applied 236
+
+ 126. Tuberculous Disease of Right Ankle 239
+
+ 127. Female Child showing the results of Poliomyelitis 243
+ affecting the Left Lower Extremity
+
+ 128. Radiogram of Double Congenital Dislocation of Hip in 249
+ a Girl
+
+ 129. Innominate Bone and Upper End of Femur from a case of 250
+ Congenital Dislocation of Hip
+
+ 130. Congenital Dislocation of Left Hip in a Girl 251
+
+ 131. Contracture Deformities of Upper and Lower Limbs 255
+ resulting from Spastic Cerebral Palsy in Infancy
+
+ 132. Rachitic Coxa Vara 258
+
+ 133. Coxa Vara, showing Adduction Curvature of Neck of Femur 260
+ associated with Arthritis of the Hip and Knee
+
+ 134. Bilateral Coxa Vara, showing Scissors-leg Deformity 260
+
+ 135. Genu Valgum and Genu Varum 265
+
+ 136. Female Child with Right-sided Genu Valgum, the result of 266
+ Rickets
+
+ 137. Double Genu Valgum; and Rickety Deformities of Arms 267
+
+ 138. Radiogram of Case of Double Genu Valgum in a Child 268
+
+ 139. Genu Valgum in a Child. Patient standing 269
+
+ 140. Genu Valgum. Same Patient as Fig. 139, sitting 270
+
+ 141. Bow-knee in Rickety Child 271
+
+ 142. Bilateral Congenital Club-foot in an Infant 274
+
+ 143. Radiogram of Bilateral Congenital Club-foot in an Infant 275
+
+ 144. Congenital Talipes Equino-varus in a Man 277
+
+ 145. Bilateral Pes Equinus in a Boy 280
+
+ 146. Extreme form of Pes Equinus in a Girl 281
+
+ 147. Skeleton of Foot from case of Pes Equinus due to 282
+ Poliomyelitis
+
+ 148. Pes Calcaneo-valgus with excessive arching of Foot 284
+
+ 149. Pes Calcaneo-valgus, the result of Poliomyelitis 285
+
+ 150. Pes Cavus in Association with Pes Equinus, the Result 286
+ of Poliomyelitis
+
+ 151. Radiogram of Foot of Adult, showing Changes in the 286
+ Bones in Pes Cavus
+
+ 152. Adolescent Flat-Foot 287
+
+ 153. Flat-Foot, showing Loss of Arch 288
+
+ 154. Imprint of Normal and of Flat Foot 290
+
+ 155. Bilateral Pes Valgus and Hallux Valgus in a Girl 293
+
+ 156. Radiogram of Spur on Under Aspect of Calcaneus 295
+
+ 157. Radiogram of Hallux Valgus 296
+
+ 158. Radiogram of Hallux Varus or Pigeon-Toe 298
+
+ 159. Hallux Rigidus and Flexus in a Boy 299
+
+ 160. Hammer-Toe 300
+
+ 161. Section of Hammer-Toe 301
+
+ 162. Congenital Hypertrophy of Left Lower Extremity in a Boy 302
+
+ 163. Supernumerary Great Toe 303
+
+ 164. Congenital Elevation of Left Scapula in a Girl: also 304
+ shows Hairy Mole over Sacrum
+
+ 165. Winged Scapula 305
+
+ 166. Arrested Growth and Wasting of Tissues of Right Upper 307
+ Extremity
+
+ 167. Lower End of Humerus from case of Cubitus Varus 309
+
+ 168. Intra-Uterine Amputation of Forearm 310
+
+ 169. Radiogram of Arm of Patient shown in Fig. 168 310
+
+ 170. Congenital Absence of Left Radius and Tibia in a Child 311
+
+ 171. Club-Hand, the Result of Imperfect Development of Radius 312
+
+ 172. Congenital Contraction of Ring and Little Fingers 314
+
+ 173. Dupuytren's Contraction 315
+
+ 174. Splint used after Operation for Dupuytren's Contraction 316
+
+ 175. Supernumerary Thumb 317
+
+ 176. Trigger Finger 318
+
+ 177. Multiple Wens 324
+
+ 178. Adenoma of Scalp 325
+
+ 179. Relations of the Motor and Sensory Areas to the 330
+ Convolutions and to Chiene's Lines
+
+ 180. Diagram of the Course of Motor and Sensory Nerve Fibres 333
+
+ 181. Chiene's Method of Cerebral Localisation 336
+
+ 182. To illustrate the Site of Various Operations on the Skull 337
+
+ 183. Localisation of Site for Introduction of Needle in Lumbar 338
+ Puncture
+
+ 184. Contusion and Laceration of Brain 343
+
+ 185. Charts of Pyrexia in Head Injuries 348
+
+ 186. Relations of the Middle Meningeal Artery and Lateral 353
+ Sinus to the Surface as indicated by Chiene's Lines
+
+ 187. Extra-Dural Clot resulting from Hæmorrhage from the 354
+ Middle Meningeal Artery
+
+ 188. Depressed Fracture of Frontal Bones with Fissured 365
+ Fracture
+
+ 189. Depressed and Comminuted Fracture of Right Parietal 365
+ Bone: Pond Fracture
+
+ 190. Pond Fracture of Left Frontal Bone, produced during 366
+ Delivery
+
+ 191. Transverse Fracture through Middle Fossa of Base of Skull 368
+
+ 192. Diagram of Extra-Dural Abscess 374
+
+ 193. Pott's Puffy Tumour in case of Extra-Dural Abscess 375
+ following Compound Fracture of Orbital Margin
+
+ 194. Diagram of Sub-Dural Abscess 376
+
+ 195. Diagram illustrating sequence of Paralysis, caused by 380
+ Abscess in Temporal Lobe
+
+ 196. Chart of case of Sinus Phlebitis following Middle Ear 384
+ Disease
+
+ 197. Occipital Meningocele 388
+
+ 198. Frontal Hydrencephalocele 389
+
+ 199. Nævus at Root of Nose, simulating Cephalocele 390
+
+ 200. Hydrocephalus in a Child 391
+
+ 201. Patient suffering from Left Facial Paralysis 402
+
+ 202. Skull of Woman illustrating the appearances of Tertiary 408
+ Syphilis of Frontal Bone--Corona Veneris--in the Healed
+ Condition
+
+ 203. Sarcoma of Orbital Plate of Frontal Bone in a Child at 409
+ Age of 11 months and 18 months
+
+ 204. Destruction of Bones of Left Orbit, caused by Rodent 410
+ Cancer
+
+ 205. Distribution of the Segments of the Spinal Cord 417
+
+ 206. Attitude of Upper Extremities in Traumatic Lesions of 418
+ the Sixth Cervical Segment
+
+ 207. Compression Fracture of Bodies of Third and Fourth 426
+ Lumbar Vertebræ
+
+ 208. Fracture-Dislocation of Ninth Thoracic Vertebra 428
+
+ 209. Fracture of Odontoid Process of Axis Vertebra 429
+
+ 210. Tuberculous Osteomyelitis affecting several Vertebræ at 432
+ Thoracico-Lumbar Junction
+
+ 211. Osseous Ankylosis of Bodies (_a_) of Dorsal Vertebræ, 434
+ (_b_) of Lumbar Vertebræ following Pott's Disease
+
+ 212. Radiogram of Museum Specimen of Pott's Disease in a Child 435
+
+ 213. Radiogram of Child's Thorax showing Spindle-shaped 437
+ Shadow at Site of Pott's Disease of Fourth, Fifth, and
+ Sixth Thoracic Vertebræ
+
+ 214. Attitude of Patient suffering from Tuberculous Disease 441
+ of the Cervical Spine
+
+ 215. Thomas' Double Splint for Tuberculous Disease of the 442
+ Spine
+
+ 216. Hunch-back Deformity following Pott's Disease of Thoracic 443
+ Vertebræ
+
+ 217. Attitude in Pott's Disease of Thoracico-Lumbar Region of 444
+ Spine
+
+ 218. Arthritis Deformans of Spine 449
+
+ 219. Meningo-Myelocele of Thoracico-Lumbar Region 454
+
+ 220. Meningo-Myelocele of Cervical Spine 454
+
+ 221. Meningo-Myelocele in Thoracic Region 456
+
+ 222. Tail-like Appendage over Spina Bifida Occulta in a Boy 457
+
+ 223. Congenital Sacro-Coccygeal Tumour 458
+
+ 224. Scoliosis following upon Poliomyelitis affecting Right 463
+ Arm and Leg
+
+ 225. Rickety Scoliosis in a Child 464
+
+ 226. Vertebræ from case of Scoliosis showing Alteration in 466
+ Shape of Bones
+
+ 227. Adolescent Scoliosis in a Girl 467
+
+ 228. Scoliosis with Primary Curve in Thoracic Region 468
+
+ 229. Scoliosis showing Rotation of Bodies of Vertebræ, and 469
+ widening of Intercostal Spaces on side of Convexity
+
+ 230. Diagram of Attitudes in Klapp's Four-Footed Exercises for 473
+ Scoliosis
+
+ 231. Head of Human Embryo about 29 days old 475
+
+ 232. Simple Hare-Lip 476
+
+ 233. Unilateral Hare-Lip with Cleft Alveolus 477
+
+ 234. Double Hare-Lip in a Girl 478
+
+ 235. Double Hare-Lip with Projection of the Os Incisivum 479
+
+ 236. Asymmetrical Cleft Palate extending through Alveolar 480
+ Process on Left Side
+
+ 237. Illustrating the Deformities caused by Lupus Vulgaris 483
+
+ 238. Sarcoma of Orbit causing Exophthalmos and Downward 488
+ Displacement of the Eye, and Projecting in Temporal
+ Region
+
+ 239. Sarcoma of Eyelid in Child 489
+
+ 240. Dermoid Cyst at Outer Angle of Orbital Margin 490
+
+ 241. Macrocheilia 492
+
+ 242. Squamous Epithelioma of Lower Lip in a Man 493
+
+ 243. Advanced Epithelioma of Lower Lip 494
+
+ 244. Recurrent Epithelioma in Glands of Neck adherent to 495
+ Mandible
+
+ 245. Cancrum Oris 497
+
+ 246. Perforation of Palate, the Result of Syphilis, and Gumma 498
+ of Right Frontal Bone
+
+ 247. Cario-necrosis of Mandible 510
+
+ 248. Diffuse Syphilitic Disease of Mandible 512
+
+ 249. Epulis of Mandible 513
+
+ 250. Sarcoma of the Maxilla 515
+
+ 251. Malignant Disease of Left Maxilla 516
+
+ 252. Dentigerous Cyst of Mandible containing Rudimentary Tooth 517
+
+ 253. Osseous Shell of Myeloma of Mandible 518
+
+ 254. Multiple Fracture of Mandible 520
+
+ 255. Four-Tailed Bandage applied for Fracture of Mandible 522
+
+ 256. Defective Development of Mandible from Fixation of Jaw 526
+ due to Tuberculous Osteomyelitis in Infancy
+
+ 257. Leucoplakia of the Tongue 531
+
+ 258. Papillomatous Angioma of Left Side of Tongue in a Woman 538
+
+ 259. Dermoid Cyst in Middle Line of Neck 539
+
+ 260. Temporary Unilateral Paralysis of Tongue 541
+
+ 261. Series of Salivary Calculi 545
+
+ 262. Acute Suppurative Parotitis 546
+
+ 263. Mixed Tumour of Parotid 550
+
+ 264. Mixed Tumour of the Parotid of over twenty years' 551
+ duration
+
+ 265. Acute Mastoid Disease showing Oedema and Projection of 565
+ Auricle
+
+ 266. Rhinophyma or Lipoma Nasi 569
+
+ 267. The Outer Wall of Left Nasal Chamber after removal of 571
+ the Middle Turbinated Body
+
+ 268. Congenital Branchial Cyst in a Woman 584
+
+ 269. Bilateral Cervical Ribs 586
+
+ 270. Transient Wry-Neck 587
+
+ 271. Congenital Wry-Neck in a Boy 589
+
+ 272. Congenital Wry-Neck seen from behind to show Scoliosis 590
+
+ 273. Recovery from Suicidal Cut-Throat after Low Tracheotomy 596
+ and Gastrostomy
+
+ 274. Hygroma of Neck 599
+
+ 275. Lympho-Sarcoma of Neck 600
+
+ 276. Branchial Carcinoma 601
+
+ 277. Parenchymatous Goitre in a Girl 606
+
+ 278. Larynx and Trachea surrounded by Goitre 607
+
+ 279. Section of Goitre shown in Fig. 278 to illustrate 607
+ Compression of Trachea
+
+ 280. Multiple Adenomata of Thyreoid in a Woman 611
+
+ 281. Cyst of Left Lobe of Thyreoid 612
+
+ 282. Exophthalmic Goitre 614
+
+ 283. Radiogram of Safety-Pin impacted in the Gullet and 620
+ Perforating the Larynx
+
+ 284. Denture Impacted in Oesophagus 621
+
+ 285. Radiogram, after swallowing an Opaque Meal, in a Man 626
+ suffering from Malignant Stricture of Lower End of Gullet
+
+ 286. Diverticulum of the Oesophagus at its Junction with the 627
+ Pharynx
+
+ 287. Larynx from case of Sudden Death due to Oedema of 637
+ Ary-Epiglottic Folds
+
+ 288. Papilloma of Larynx 641
+
+
+
+
+MANUAL OF SURGERY
+
+
+
+
+CHAPTER I
+
+INJURIES OF BONES
+
+
+Contusions--Wounds--FRACTURES: _Pathological_; _Traumatic_;
+ _Varieties_--Simple fractures--Compound fractures--Repair of
+ fractures--Interference with repair--Gun-shot
+ fractures--SEPARATION OF EPIPHYSES.
+
+The injuries to which a bone is liable are Contusions, Open Wounds,
+and Fractures.
+
+#Contusions of Bone# are almost of necessity associated with a similar
+injury of the overlying soft parts. The mildest degree consists in a
+bruising of the periosteum, which is raised from the bone by an
+effusion of blood, constituting a _hæmatoma of the periosteum_. This
+may be absorbed, or it may give place to a persistent thickening of
+the bone--_traumatic node_.
+
+#Open Wounds of Bone# of the incised and contused varieties are
+usually produced by sabres, axes, butcher's knives, scythes, or
+circular saws. Punctured wounds are caused by bayonets, arrows, or
+other pointed instruments. They are all equivalent to compound,
+incomplete fractures.
+
+
+FRACTURES
+
+A fracture may be defined as a sudden solution in the continuity of a
+bone.
+
+
+PATHOLOGICAL FRACTURES
+
+A pathological fracture has as its primary cause some diseased state
+of the bone, which permits of its giving way on the application of a
+force which would be insufficient to break a healthy bone. It cannot
+be too strongly emphasised that when a bone is found to have been
+broken by a slight degree of violence, the presence of some
+pathological condition should be suspected, and a careful examination
+made with the X-rays and by other means, before arriving at a
+conclusion as to the cause of the fracture. Many cases are on record
+in which such an accident has first drawn attention to the presence of
+a new-growth, or other serious lesion in the bone. The following
+conditions, which are more fully described with diseases of bone, may
+be mentioned as the causes of pathological fractures.
+
+_Atrophy_ of bone may proceed to such an extent in old people, or in
+those who for long periods have been bed-ridden, that slight violence
+suffices to determine a fracture. This most frequently occurs in the
+neck of the femur in old women, the mere catching of the foot in the
+bedclothes while the patient is turning in bed being sometimes
+sufficient to cause the bone to give way. Atrophy from the pressure of
+an aneurysm or of a simple tumour may erode the whole thickness of a
+bone, or may thin it out to such an extent that slight force is
+sufficient to break it. In general paralysis, and in the advanced
+stages of locomotor ataxia and other chronic diseases of the nervous
+system, an atrophy of all the bones sometimes takes place, and may
+proceed so far that multiple fractures are induced by comparatively
+slight causes. They occur most frequently in the ribs or long bones of
+the limbs, are not attended with pain, and usually unite
+satisfactorily, although with an excessive amount of callus.
+Attendants and nurses, especially in asylums, must be warned against
+using force in handling such patients, as otherwise they may be
+unfairly blamed for causing these fractures.
+
+Among diseases which affect the skeleton as a whole and render the
+bones abnormally fragile, the most important are rickets,
+osteomalacia, and fibrous osteomyelitis. In these conditions multiple
+pathological fractures may occur, and they are prone to heal with
+considerable deformity. In osteomalacia, the bones are profoundly
+altered, but they are more liable to bend than to break; in rickets
+the liability is towards greenstick fractures.
+
+Of the diseases affecting individual bones and predisposing them to
+fracture may be mentioned suppurative osteomyelitis, hydatid cysts,
+tuberculosis, syphilitic gummata, and various forms of new-growth,
+particularly sarcoma and secondary cancer. It is not unusual for the
+sudden breaking of the bone to be the first intimation of the presence
+of a new-growth. In adolescents, fibrous osteomyelitis affecting a
+single bone, and in adults, secondary cancer, are the commonest local
+causes of pathological fracture.
+
+_Intra-uterine fractures_ and fractures occurring _during birth_ are
+usually associated with some form of violence, but in the majority of
+cases the foetus is the subject of constitutional disease which
+renders the bones unduly fragile.
+
+
+TRAUMATIC FRACTURES
+
+Traumatic fractures are usually the result of a severe force acting
+from without, although sometimes they are produced by muscular
+contraction.
+
+When the bone gives way at the point of impact of the force, the
+violence is said to be _direct_, and a "fracture by compression"
+results, the line of fracture being as a rule transverse. The soft
+parts overlying the fracture are more or less damaged according to the
+weight and shape of the impinging body. Fracture of both bones of the
+leg from the passage of a wheel over the limb, fracture of the shaft
+of the ulna in warding off a stroke aimed at the head, and fracture of
+a rib from a kick, are illustrative examples of fractures by direct
+violence.
+
+When the force is transmitted to the seat of fracture from a distance,
+the violence is said to be _indirect_, and the bone is broken by
+"torsion" or by "bending." In such cases the bone gives way at its
+weakest point, and the line of fracture tends to be oblique. Thus both
+bones of the leg are frequently broken by a person jumping from a
+height and landing on the feet, the tibia breaking in its lower third,
+and the fibula at a higher level. Fracture of the clavicle in its
+middle third, or of the radius at its lower end, from a fall on the
+outstretched hand, are common accidents produced by indirect violence.
+The ribs also may be broken by indirect violence, as when the chest is
+crushed antero-posteriorly and the bones give way near their angles.
+In fractures by indirect violence the soft parts do not suffer by the
+violence causing the fracture, but they may be injured by displacement
+of the fragments.
+
+In fractures by _muscular action_ the bone is broken by "traction" or
+"tearing." The sudden and violent contraction of a muscle may tear off
+an epiphysis, such as the head of the fibula, the anterior superior
+iliac spine, or the coronoid process of the ulna; or a bony process
+may be separated, as, for example, the tuberosity of the calcaneus,
+the coracoid process of the scapula, or the larger tubercle (great
+tuberosity) of the humerus. Long bones also may be broken by muscular
+action. The clavicle has snapped across during the act of swinging a
+stick, the humerus in throwing a stone, and the femur when a kick has
+missed its object. Fractures of ribs have occurred during fits of
+coughing and in the violent efforts of parturition.
+
+Before concluding that a given fracture is the result of muscular
+action, it is necessary to exclude the presence of any of the diseased
+conditions that lead to pathological fracture.
+
+Although the force acting upon the bone is the primary factor in the
+production of fractures, there are certain subsidiary factors to be
+considered. Thus the age of the patient is of importance. During
+infancy and early childhood, fractures are less common than at any
+other period of life, and are usually transverse, incomplete, and of
+the nature of bends. During adult life, especially between the ages of
+thirty and forty, the frequency of fractures reaches its maximum. In
+aged persons, although the bones become more brittle by the marrow
+spaces in their interior becoming larger and filled with fat,
+fractures are less frequent, doubtless because the old are less
+exposed to such violence as is likely to produce fracture.
+
+Males, from the nature of their occupations and recreations, sustain
+fractures more frequently than do females; in old age, however,
+fractures are more common in women than in men, partly because their
+bones are more liable to be the seat of fatty atrophy from senility
+and disease, and partly because of their clothing--a long skirt--they
+are more exposed to unexpected or sudden falls.
+
+[Illustration: FIG. 1.--Multiple Fracture of both Bones of Leg.]
+
+#Clinical Varieties of Fractures.#--The most important subdivision of
+fractures is that into simple and compound.
+
+In a _simple_ or subcutaneous fracture there is no communication,
+directly or indirectly, between the broken ends of the bone and the
+surface of the skin. In a _compound_ or open fracture, on the other
+hand, such a communication exists, and, by furnishing a means of
+entrance for bacteria, may add materially to the gravity of the
+injury.
+
+A simple fracture may be complicated by the existence of a wound of
+the soft parts, which, however, does not communicate with the broken
+bone.
+
+Fractures, whether simple or compound, fall into other clinical
+groups, according to (1) the degree of damage done to the bone, (2)
+the direction of the break, and (3) the relative position of the
+fragments.
+
+(1) _According to the Degree of Damage done to the Bone._--A fracture
+may be incomplete, for example in _greenstick fractures_, which occur
+only in young persons--usually below the age of twelve--while the
+bones are still soft and flexible. They result from forcible bending
+of the bone, the osseous tissue on the convexity of the curve giving
+way, while that on the concavity is compressed. The clavicle and the
+bones of the forearm are those most frequently the seat of greenstick
+fracture (Fig. 41). _Fissures_ occur on the flat bones of the skull,
+the pelvic bones, and the scapula; or in association with other
+fractures in long bones, when they often run into joint surfaces.
+_Depressions_ or indentations are most common in the bones of the
+skull.
+
+The bone at the seat of fracture may be broken into several pieces,
+constituting a _comminuted_ fracture. This usually results from severe
+degrees of direct violence, such as are sustained in railway or
+machinery accidents, and in gun-shot injuries (Fig. 2).
+
+[Illustration: FIG. 2.--Radiogram of Comminuted Fracture of both Bones
+of Forearm.]
+
+_Sub-periosteal_ fractures are those in which, although the bone is
+completely broken across, the periosteum remains intact. These are
+common in children, and as the thick periosteum prevents displacement,
+the existence of a fracture may be overlooked, even in such a large
+bone as the femur.
+
+A bone may be broken at several places, constituting a _multiple_
+fracture (Fig. 1).
+
+_Separation of bony processes_, such as the coracoid process, the
+epicondyle of the humerus, or the tuberosity of the calcaneus, may
+result from muscular action or from direct violence. _Separation of
+epiphyses_ will be considered later.
+
+(2) _According to the Direction of the Break._--_Transverse_ fractures
+are those in which the bone gives way more or less exactly at right
+angles to its long axis. These usually result from direct violence or
+from end-to-end pressure. _Longitudinal_ fractures extending the
+greater part of the length of a long bone are exceedingly rare.
+_Oblique_ fractures are common, and result usually from indirect
+violence, bending, or torsion (Fig. 3). _Spiral_ fractures result from
+forcible torsion of a long bone, and are met with most frequently in
+the tibia, femur, and humerus.
+
+[Illustration: FIG. 3.--Showing (1) Oblique fracture of Tibia; (2)
+Oblique fracture with partial separation of Epiphysis of upper end of
+Fibula; (3) Incomplete fracture of Fibula in upper third. Result of
+railway accident. Boy æt. 16.]
+
+(3) _According to the Relative Position of the Fragments._--The bone
+may be completely broken across, yet its ends remain in apposition,
+in which case there is said to be _no displacement_. There may be an
+_angular_ displacement--for example, in greenstick fracture. In
+transverse fractures of the patella or of the olecranon there is often
+_distraction_ or pulling apart of the fragments (Fig. 35). The broken
+ends, especially in oblique fractures, may _override_ one another, and
+so give rise to shortening of the limb (Fig. 2). Where one fragment is
+acted upon by powerful muscles, a _rotatory_ displacement may take
+place, as in fracture of the radius above the insertion of the
+pronator teres, or of the femur just below the small trochanter. The
+fragments may be _depressed_, as in the flat bones of the skull or the
+nasal bones. At the cancellated ends of the long bones, particularly
+the upper end of the femur and humerus, and the lower end of the
+radius, it is not uncommon for one fragment to be _impacted_ or wedged
+into the substance of the other (Fig. 28).
+
+_Causes of Displacement._--The factors which influence displacement
+are chiefly mechanical in their action. Thus the direction and nature
+of the fracture play an important part. Transverse fractures with
+roughly serrated ends are less liable to displacement than those which
+are oblique with smooth surfaces. The direction of the causative force
+also is a dominant factor in determining the direction in which one or
+both of the fragments will be displaced. Gravity, acting chiefly upon
+the distal fragment, also plays a part in determining the
+displacement--for example, in fractures of the thigh or of the leg,
+where the lower segment of the limb rolls outwards, and in fractures
+of the shaft of the clavicle, where the weight of the arm carries the
+shoulder downwards, forwards, and medially. After the break has taken
+place and the force has ceased to act, displacement may be produced by
+rough handling on the part of those who render first aid, the careless
+or improper application of splints or bandages, or by the weight of
+the bedclothes.
+
+In certain situations the contraction of unopposed, or of unequally
+opposed, groups of muscles plays a part in determining displacement.
+For example, in fracture immediately below the lesser trochanter of
+the femur, the ilio-psoas tends to tilt the upper fragment forward and
+laterally; in supra-condylar fracture of the femur, the muscles of the
+calf pull the lower fragment back towards the popliteal space; and in
+fracture of the humerus above the deltoid insertion, the muscles
+inserted into the inter-tubercular (bicipital) groove adduct the upper
+fragment.
+
+
+REPAIR OF INJURIES OF BONE
+
+In a _simple fracture_ the vessels of the periosteum and the marrow
+being torn at the same time as the bone is broken, blood is poured
+out, and clots around and between the fragments. This clot is soon
+permeated by newly formed blood vessels, and by leucocytes and
+fibroblasts, the latter being derived from proliferation of the cells
+of the marrow and periosteum. The granulation tissue thus formed
+resembles in every particular that described in the repair of other
+tissues, except that the fibroblasts, being the offspring of cells
+which normally form bone, assume the functions of _osteoblasts_, and
+proceed to the formation of bone. The new bone may be formed either by
+a direct conversion of the fibrous tissue into osseous tissue, the
+osteoblasts arranging themselves concentrically in the recesses of the
+capillary loops, and secreting a homogeneous matrix in which lime
+salts are speedily deposited; or there may be an intermediate stage of
+cartilage formation, especially in young subjects, and in cases where
+the fragments are incompletely immobilised. The newly formed bone is
+at first arranged in little masses or in the form of rods which unite
+with each other to form a network of spongy bone, the meshes of which
+contain marrow.
+
+The reparative material, consisting of granulation tissue in the
+process of conversion into bone, is called _callus_, on account of its
+hard and unyielding character. In a fracture of a long bone, that
+which surrounds the fragments is called the _external_ or _ensheathing
+callus_, and may be likened to the mass of solder which surrounds the
+junction of pipes in plumber-work; that which occupies the position of
+the medullary canal is called the _internal_ or _medullary callus_;
+and that which intervenes between the fragments and maintains the
+continuity of the cortical compact tissue of the shaft is called the
+_intermediate callus_. This intermediate callus is the only permanent
+portion of the reparative material, the external and internal callus
+being only temporary, and being largely re-absorbed through the agency
+of giant cells.
+
+Detached fragments or splinters of bone are usually included in the
+callus and ultimately become incorporated in the new bone that bridges
+the gap.
+
+In time all surplus bone is removed, the medullary canal is re-formed,
+the young spongy bone of the intermediate callus becomes more and more
+compact, and thus the original architectural arrangement of the bone
+may be faithfully reproduced. If, however, apposition is not perfect,
+some of the new bone is permanently required and some of the old bone
+is absorbed in order to meet the altered physiological strain upon the
+bone resulting from the alteration in its architectural form. In
+overriding displacement, even the dense cortical bone intervening
+between the medullary canal of the two fragments is ultimately
+absorbed and the continuity of the medullary canal is reproduced.
+
+The amount of callus produced in the repair of a given fracture is
+greater when movement is permitted between the broken ends. It is also
+influenced by the character of the bone involved, being less in bones
+entirely ossified in membrane, such as the flat bones of the skull,
+than in those primarily ossified in cartilage.
+
+If the fragments are widely separated from one another, or if some
+tissue, such as muscle, intervenes between them, callus may not be
+able to bring about a bony union between the fragments, and
+_non-union_ results.
+
+Bones divided in the course of an operation, for example in osteotomy
+for knock-knee, or wedge-shaped resection for bow-leg, are repaired by
+the same process as fractures.
+
+#Excess of Callus.#--In comminuted fractures, and in fractures in
+which there is much displacement, the amount of callus is in excess,
+but this is necessary to ensure stability. In fractures in the
+vicinity of large joints, such as the hip or elbow, the formation of
+callus is sometimes excessive, and the projecting masses of new bone
+restrict the movements of the joint. When exuberant callus forms
+between the bones in fractures of the forearm, pronation and
+supination may be interfered with (Fig. 4). Certain nerve-trunks, such
+as the radial (musculo-spiral) in the middle of the arm, or the ulnar
+at the elbow-joint, may become included in or pressed upon by callus.
+
+[Illustration: FIG. 4.--Excess of Callus after compound fracture of
+Bones of Forearm.]
+
+#Absorption of Callus.#--It sometimes happens that when an acute
+infective disease, especially one of the exanthemata, supervenes while
+a fracture is undergoing repair, the callus which has formed becomes
+softened and is absorbed. This may occur weeks or even months after
+the bone has united, with the result that the fragments again become
+movable, and it may be a considerable time before union finally takes
+place.
+
+#Tumours of Callus.#--Tumours, such as chondroma and sarcoma, and
+cysts which are probably of the same nature as those met with in
+osteomyelitis fibrosa, are liable to occur in callus, or at the seat
+of old fractures, but the evidence so far is inconclusive as to the
+causative relationship of the injury to the new-growth. They are
+treated on the same lines as tumours occurring independently of
+fracture.
+
+#Badly United Fracture--Mal-Union.#--Union with marked displacement of
+the fragments is most common in fractures that have not been properly
+treated--as, for example, those occurring in sailors at sea; and in
+cases in which the comminution was so great that accurate apposition
+was rendered impossible. It may also result from imperfect reduction,
+or because the apparatus employed permitted of secondary displacement.
+Restlessness on the part of the patient from intractability, delirium
+tremens, or mania, is the cause of mal-union in some cases; sometimes
+it has resulted because the patient was expected to die from some
+other lesion and the fracture was left untreated.
+
+Whether or not any attempt should be made to improve matters depends
+largely on the degree of deformity and the amount of interference with
+function.
+
+When interference is called for, if the callus is not yet firmly
+consolidated, it may be possible, under an anæsthetic, to bend the
+bone into position or to re-break it, either with the hands or by
+means of a strong mechanical contrivance known as an osteoclast. In
+the majority of cases, however, an open operation yields results which
+are more certain and satisfactory. When the deformity is comparatively
+slight, the bone is divided with an osteotome and straightened; when
+there is marked bending or angling, a wedge is taken from the
+convexity, as in the operation for bow-leg. To maintain the fragments
+in apposition it may be necessary to employ pegs, plates, bone-grafts,
+or other mechanical means. Splints and extension are then applied, and
+the condition is treated on the same lines as a compound fracture.
+
+[Illustration: FIG. 5.--Multiple Fractures of both Bones of Forearm
+showing mal-union.]
+
+#Delayed Union.#--At the time when union should be firm and solid, it
+may be found that the fragments are only united by a soft
+cartilaginous callus, which for a prolonged period may undergo no
+further change, so that the limb remains incapable of bearing weight
+or otherwise performing its functions. The normal period required for
+union may be extended from various causes. The most important of these
+is general debility, but the presence of rickets or tuberculosis, or
+an intercurrent acute infectious disease, may delay the reparative
+process. The influence of syphilis, except in its gummatous form, in
+interfering with union is doubtful. The influence of old age as a
+factor in delaying union has been overestimated; in the great majority
+of cases, fractures in old people unite as rapidly and as firmly as
+those occurring at other periods of life.
+
+_Treatment._--The general condition of the patient should be improved,
+by dieting and tonics. One of the most reliable methods of hastening
+union in these cases is by inducing passive hyperæmia of the limb
+after the method advocated by Bier, and this plan should always be
+tried in the first instance. An elastic bandage is applied above the
+seat of fracture, sufficiently tightly to congest the limb beyond,
+and, to concentrate the congestion in the vicinity of the fracture, an
+ordinary bandage should be applied from the distal extremity to within
+a few inches of the break. The hyperæmia should be maintained for
+several hours (six to twelve) daily. An apparatus should be adjusted
+to enable the patient to get into the open air, and in fractures of
+the lower extremity the patient should move about with crutches in the
+intervals, putting weight on the fractured bone. This method of
+treatment should be persevered with for three or four weeks, and the
+limb should be massaged daily while the constricting bandage is off.
+
+Among the other methods which have been recommended are the injection
+between the fragments of oil of turpentine (Mikulicz), a quantity of
+the patient's own blood (Schmieden), or alcohol and iodine; the
+forcible rubbing of the ends together, under an anæsthetic if
+necessary; and the administration of thyreoid extract. If these
+methods fail, the case should be treated as one of un-united fracture.
+As a rule, satisfactory union is ultimately obtained, although much
+patience is required.
+
+#Non-Union.#--Sometimes the fragments become united by a dense band of
+fibrous tissue, and the reparative process goes no further--_fibrous
+union_. This is frequently the case in fractures of the patella, the
+olecranon, and the narrow part of the neck of the femur.
+
+_False Joint--Pseudarthrosis._--In rare cases the ends of the
+fragments become rounded and are covered with a layer of cartilage.
+Around their ends a capsule of fibrous tissues forms, on the inner
+aspect of which a layer of endothelium develops and secretes a
+synovia-like fluid. This is met with chiefly in the humerus and in the
+clavicle.
+
+_Failure of Union--"Un-united Fracture."_--As the time taken for union
+varies widely in different bones, and ossification may ultimately
+ensue after being delayed for several months, a fracture cannot be
+said to have failed to unite until the average period has been long
+overpassed and still there is no evidence of fusion of the fragments.
+Under these conditions failure of union is a rare complication of
+fractures. In adults it is most frequently met with in the humerus,
+the radius and ulna (Fig. 6), and the femur; in children in the bones
+of the leg and in the forearm.
+
+[Illustration: FIG. 6.--Radiogram of Un-united Fracture of Shaft of
+Ulna of fifteen years' duration.]
+
+In a radiogram the bones in the vicinity of the fracture, particularly
+the distal fragment, cast a comparatively faint shadow, and there may
+even be a clear space between the fragments. When the parts are
+exposed by operation, the bone is found to be soft and spongy and the
+ends of the fragments are rarefied and atrophied; sometimes they are
+pointed, and occasionally absorption has taken place to such an extent
+that a gap exists between the fragments. The bone is easily penetrated
+by a bradawl, and if an attempt is made to apply plates, the screws
+fail to bite. These changes are most marked in the distal fragment.
+
+The want of union is evidently due to defective activity of the
+bone-forming cells in the vicinity of the fracture. This may result
+from constitutional dyscrasia, or may be associated with a defective
+blood supply, as when the nutrient artery is injured. Interference
+with the trophic nerve supply may play a part, as cases are recorded
+by Bognaud in which union of fractures of the leg failed to take place
+after injuries of the spinal medulla causing paraplegia. The condition
+has been attributed to local causes, such as the interposition of
+muscle or other soft tissue between the fragments, or to the presence
+of a separated fragment of bone or of a sequestrum following
+suppuration. In our experience such factors are seldom present.
+
+If the treatment recommended for delayed union fails, recourse must be
+had to operation, the most satisfactory procedure being to insert a
+bone graft in the form of an intra-medullary splint. In certain cases
+met with in the bones of the leg in children, the degree of atrophy of
+the bones is such that it has been found necessary to amputate after
+repeated attempts to obtain union by operative measures have failed.
+
+In the tibia we have found that with the double electric saw a rod of
+bone can be rapidly and accurately cut, extending well above as well
+as below the site of fracture but unequally in the two directions; the
+rod is then reinserted into the trough from which it was taken _with
+the ends reversed_, so that a strong bridge of bone is provided at the
+seat of non-union.
+
+
+CLINICAL FEATURES OF SIMPLE FRACTURES
+
+In the first place, the _history of the accident_ should be
+investigated, attention being paid to the nature of the
+violence--whether a blow, a twist, a wrench, or a crush, and whether
+the violence was directly or indirectly applied. The degree of the
+violence may often be judged approximately from the instrument
+inflicting it--whether, for example, a fist, a stick, a cart wheel, or
+a piece of heavy machinery. The position of the limb at the time of
+the injury; whether the muscles were braced to meet the blow or were
+lax and taken unawares; and the patient's sensations at the moment,
+such as his feeling something snap or tear, may all furnish
+information useful for purposes of diagnosis.
+
+_Signs of Fracture._--The most characteristic signs of fracture are
+unnatural mobility, deformity, and crepitus.
+
+_Unnatural mobility_--that is, movement between two segments of a limb
+at a place where movement does not normally occur--may be evident when
+the patient makes attempts to use his limb, or may only be elicited
+when the fragments are seized and moved in opposite directions.
+_Deformity_, or the part being "out of drawing" in comparison with the
+normal side, varies with the site and direction of the break, and
+depends upon the degree of displacement of the fragments. _Crepitus_
+is the name applied to the peculiar grating or clicking which may be
+heard or felt when the fractured surfaces are brought into contact
+with one another.
+
+The presence of these three signs in association is sufficient to
+prove the existence of a fracture, but the absence of one or more of
+them does not negative this diagnosis. There are certain fallacies to
+be guarded against. For example, a fracture may exist and yet
+unnatural mobility may not be present, because the bones are impacted
+into one another, or because the fracture is an incomplete one. Again,
+the extreme tension of the swollen tissues overlying the fracture may
+prevent the recognition of movement between the fragments. Deformity
+also may be absent--as, for instance, when there is no displacement of
+the fragments, or when only one of two parallel bones is broken, as in
+the leg or forearm. Similarly, crepitus may be absent when impaction
+exists, when the fragments completely override one another, or are
+separated by an interval, or when soft tissues, such as torn
+periosteum or muscle, are interposed between them. A sensation
+simulating crepitus may be felt on palpating a part into which blood
+has been extravasated, or which is the seat of subcutaneous emphysema.
+The creaking which accompanies movements in certain forms of
+teno-synovitis and chronic joint disease, and the rubbing of the
+dislocated end of a bone against the tissues amongst which it lies,
+may also be mistaken for the crepitus of fracture.
+
+It is not advisable to be too diligent in eliciting these signs,
+because of the pain caused by the manipulations, and also because
+vigorous handling may do harm by undoing impaction, causing damage to
+soft parts or producing displacement which does not already exist, or
+by converting a simple into a compound fracture.
+
+It is often necessary for purposes of diagnosis to administer a
+general anæsthetic, particularly in injuries of deeply placed bones
+and in the vicinity of joints. Before doing so, the appliances
+necessary for the treatment of the injury should be made ready, in
+order that the fracture may be reduced and set before the patient
+regains consciousness.
+
+_Radiography in the Diagnosis of Fractures._--While radiography is of
+inestimable value in the diagnosis of many fractures and other
+injuries, particularly in the vicinity of joints, the student is
+warned against relying too implicitly on the evidence it seems to
+afford.
+
+A radiogram is not a photograph of the object exposed to the X-rays
+but merely a picture of its shadow, or rather of a series of shadows
+of the different structures, which vary in opacity. As the rays
+emanate from a single point in the vacuum tube, and as they are not,
+like the sun's rays, approximately parallel, the shadows they cast are
+necessarily distorted. Hence, in interpreting a radiogram, it is
+necessary to know the relative positions of the point from which the
+rays proceed, the object exposed, and the plate on which the shadow is
+registered. The least distortion takes place when the object is in
+contact with the plate, and the shadow of that part of the object
+which lies perpendicularly under the light is less distorted than that
+of the parts lying outside the perpendicular. The light and the plate
+remaining constant, the amount of distortion varies directly with the
+distance between the object and the plate.
+
+To ensure accuracy in the diagnosis of fracture by the X-rays, it is
+necessary to take two views of the limb--one in the sagittal and the
+other in the coronal plane. By the use of the fluorescent screen, the
+best positions from which to obtain a clear impression of the fracture
+may be determined before the radiograms are taken. Stereoscopic
+radiograms may be of special value in demonstrating the details of a
+fracture that is otherwise doubtful.
+
+Imperfect technique and faulty interpretation of the pictures obtained
+lead to certain fallacies. In young subjects, for example, epiphysial
+lines may be mistaken for fractures, or the ossifying centres of
+epiphyses for separated fragments of bone. The os trigonum tarsi has
+been mistaken for a fracture of the talus. In the vicinity of joints
+the bones may be crossed by pale bands, due to the rays traversing the
+cavity of the joint. In this way fracture of the olecranon or of the
+clavicle may be simulated. The neck of the femur may appear to be
+fractured if a foreshortened view is taken.
+
+It is possible, on the other hand, to overlook a fracture--for
+example, if there is no displacement, or if the line of fracture is
+crossed by the shadow of an adjacent bone. In deeply placed bones such
+as those about the hip, or in bones related to dense, solid
+viscera--for example, ribs, sternum, or dorsal vertebræ--it is
+sometimes difficult to obtain conclusive evidence of fracture in a
+radiogram.
+
+It is to be borne in mind also, and especially from the medico-legal
+point of view, that, as early callus does not cast a deep shadow in a
+radiogram, the appearance of fracture may persist after union has
+taken place. The earliest shadow of callus appears in from fourteen to
+twenty-one days, and can hardly be relied upon till the fourth or
+sixth week. The disturbed perspective produced by divergence of the
+rays may cause the fragments of a fracture to appear displaced,
+although in reality they are in good position. If the limb and the
+plate are not parallel, the bones may appear to be distorted, and
+errors in diagnosis may in this way arise. In this relation it should
+be mentioned that perfect apposition of the fragments and anatomically
+accurate restoration of the outline of the bones are not always
+essential to a good functional result.
+
+ * * * * *
+
+As most of the remaining signs are common to all the lesions from
+which fractures have to be distinguished, their diagnostic value must
+be carefully weighed.
+
+_Interference with Function._--As a rule, a broken bone is incapable
+of performing its normal function as a lever or weight-bearer; but
+when a fracture is incomplete, when the fragments are impacted, or
+when only one of two parallel bones is broken, this does not
+necessarily follow. It is no uncommon experience to find a patient
+walk into hospital with an impacted fracture of the neck of the femur
+or a fracture of the fibula; or to be able to pronate and supinate the
+forearm with a greenstick fracture of the radius or a fracture of the
+ulna.
+
+_Pain._--Three forms of pain may be present in fractures: pain
+independent of movement or pressure; pain induced by movement of the
+limb; and pain elicited on pressure or "tenderness." In injuries by
+direct violence, pain independent of movement and pressure is never
+diagnostic of fracture, as it may be due to bruising of soft tissues.
+In injuries resulting from indirect violence, however, pain localised
+to a spot at some distance from the point of impact is strongly
+suggestive of fracture--as, for example, when a patient complains of
+pain over the clavicle after a fall on the hand, or over the upper end
+of the fibula after a twist of the ankle. Pain elicited by attempts to
+move the damaged part, or by applying pressure over the seat of
+injury, is more significant of fracture. Pain elicited at a particular
+point on pressing the bone at a distance, "pain on distal
+pressure,"--for example, pain at the lower end of the fibula on
+pressing near its neck, or at the angle of a rib on pressing near the
+sternum,--is a valuable diagnostic sign of fracture. When nerve-trunks
+are implicated in the vicinity of a fracture, pain is often referred
+along the course of their distribution.
+
+_Localised swelling_ comes on rapidly, and is due to displacement of
+the fragments and to hæmorrhage from the torn vessels of the marrow
+and periosteum.
+
+_Discoloration_ accompanies the swelling, and is often widespread,
+especially in fracture of bones near the surface and when the tension
+is great. It is not uncommon to find over the ecchymosed area,
+especially over the shin-bone, large blebs containing blood-stained
+serum. In fractures of deep-seated bones, discoloration may only show
+on the surface after some days, and at a distance from the break.
+
+Alterations in the relative position of _bony landmarks_ are valuable
+diagnostic guides. Alteration in the _length_ of the limb, usually in
+the direction of shortening, is also an important sign. Before drawing
+deductions, care must be taken to place both limbs in the same
+position and to determine accurately the fixed points for measurement,
+and also to ascertain if the limbs were previously normal.
+
+_Shock_ is seldom a prominent symptom in uncomplicated fractures,
+although in old and enfeebled patients it may be serious and even
+fatal. During the first two or three days after a fracture there is
+almost invariably some degree of traumatic _fever_, indicated by a
+rise of temperature to 99° or 100° F.
+
+#Complications.#--_Injuries to large arteries_ are not common in
+simple fractures. The popliteal artery, however, is liable to be
+compressed or torn across in fractures of the lower end of the femur;
+extravasation of blood from the ruptured artery and gangrene of the
+limb may result. If large _veins_ are injured, thrombosis may occur,
+and be followed by pulmonary embolism.
+
+_Injuries to nerve-trunks_ are comparatively common, especially in
+fractures of the arm, where the radial (musculo-spiral) nerve is
+liable to suffer.
+
+The nerve may be implicated at the time of the injury, being
+compressed, bruised, lacerated, or completely torn across by broken
+fragments, or it may be involved later by the pressure of callus. The
+symptoms depend upon the degree of damage sustained by the nerve, and
+vary from partial and temporary interference with sensation and motion
+to complete and permanent abrogation of function.
+
+In rare instances _fat embolism_ is said to occur, and fat globules
+are alleged to have been found in the urine. In persons addicted to
+excess of alcohol, _delirium tremens_ is a not infrequent
+accompaniment of a fracture which confines the patient to bed.
+
+#Prognosis in Simple Fractures.#--_Danger to life_ in simple fractures
+depends chiefly on the occurrence of complications. In old people, a
+fracture of the neck of the femur usually necessitates long and
+continuous lying on the back, and bronchitis, hypostatic pneumonia,
+and bed-sores are prone to occur and endanger life. Fractures
+complicated with injury to internal organs, and fractures in which
+gangrene of the limb threatens, are, of course, of grave import.
+
+The prognosis as regards the _function of the limb_ should always be
+guarded, even in simple fractures. Incidental complications are liable
+to arise, delaying recovery and preventing a satisfactory result, and
+these not only lead to disappointment, but may even form a ground for
+actions for malpraxis.
+
+The chief and most frequent cause of permanent disability after
+fracture is angular displacement. A comparatively small degree of
+angularity may lead to serious loss of function, especially in the
+lower limb; the joints above and below the fracture are placed at a
+disadvantage, arthritic changes result from the abnormal strain to
+which they are subjected, and rarefaction of the bone may also ensue.
+
+Fibrous union is a common result in fractures of the neck of the femur
+in old people and in certain other fractures, such as fracture of the
+patella, of the olecranon, coronoid and coracoid processes, and
+although this does not necessarily involve interference with function,
+the patient should always be warned of the possibility.
+
+Impairment of growth and eventual shortening of the limb may result
+from involvement of an epiphysial junction.
+
+Stiffness of joints is liable to follow fractures implicating
+articular surfaces, or it may result from arthritic changes following
+upon the injury.
+
+Osseous ankylosis is not a common sequel of simple fractures, but
+locking of joints from the mechanical impediment produced by the
+union of imperfectly reduced fragments, or from masses of callus, is
+not uncommon, especially in the region of the elbow.
+
+Wasting of the muscles and oedema of the limb often delay the complete
+restoration of function. Delayed union, want of union, and the
+formation of a false joint have already been referred to.
+
+#Treatment.#--The treatment of a fracture should be commenced as soon
+after the accident as possible, before the muscles become contracted
+and hold the fragments in abnormal positions, and before the blood and
+serum effused into the tissues undergo organisation.
+
+Care must be taken during the transport of the patient that no further
+damage is done to the injured limb. To this end the part must be
+secured in some form of extemporised splint, the apparatus being so
+designed as to control not only the broken fragments, but also the
+joints above and below the fracture.
+
+When the ordinary method of removing the clothes involves any risk of
+unduly moving the injured part, they should be slit open along the
+seams.
+
+The patient should be placed on a firm straw, horse-hair, or spring
+mattress, stiffened in the case of fractures of the pelvis or lower
+limbs by fracture-boards inserted beneath the mattress. Special
+mattresses constructed in four pieces, to facilitate the nursing of
+the patient, are sometimes used.
+
+In many cases, particularly in muscular subjects, in restless
+alcoholic patients, and in those who do not bear pain well, a general
+anæsthetic is a valuable aid to the accurate setting of a fracture, as
+well as a means of rendering the diagnosis more certain.
+
+The procedure popularly known as "setting a fracture" consists in
+restoring the displaced parts to their normal position as nearly as
+possible, and is spoken of technically as the _reduction_ of the
+fracture.
+
+_The Reduction of Fractures._--In some cases the displacement may be
+overcome by relaxing the muscles acting upon the fragments, and this
+may be accomplished by the stroking movements of massage. In most
+cases, however, it is necessary, after relaxing the muscles, to employ
+_extension_, by making forcible but steady traction on the distal
+fragment, while _counter-extension_ is exerted on the proximal one,
+either by an assistant pulling upon that portion of the limb, or by
+the weight of the patient's body. The fragments having been freed, and
+any shortening of the limb corrected in this way, the broken ends are
+moulded into position--a process termed _coaptation_.
+
+The reduction of a recent greenstick fracture consists in forcibly
+straightening the bend in the bone, and in some cases it is necessary
+to render the fracture complete before this can be accomplished.
+
+In selecting a means of retaining the fragments in position after
+reduction, the various factors which tend to bring about
+re-displacement must be taken into consideration, and appropriate
+measures adopted to counteract each of these.
+
+In addition to retaining the broken ends of the bone in apposition,
+the after-treatment of a fracture involves the taking of steps to
+promote the absorption of effused blood and serum, to maintain the
+circulation through the injured parts, and to favour the repair of
+damaged muscles and other soft tissues. Means must also be taken to
+maintain the functional activity of the muscles of the damaged area,
+to prevent the formation of adhesions in joints and tendon sheaths,
+and generally to restore the function of the injured part.
+
+_Practical Means of Effecting Retention--By Position._--It is often
+found that only in one particular position can the fragments be made
+to meet and remain in apposition--for example, the completely supine
+position of the forearm in fracture of the radius just above the
+insertion of the pronator teres. Again, in certain cases it is only by
+relaxing particular groups of muscles that the displacement can be
+undone--as, for instance, in fracture of the bones of the leg, or of
+the femur immediately above the condyles, where flexion of the knee,
+by relaxing the calf muscles, permits of reduction.
+
+_Massage and Movement in the Treatment of
+Fractures._--Lucas-Championnière, in 1886, first pointed out that a
+certain amount of movement between the ends of a fractured bone
+favours their union by promoting the formation of callus, and
+advocated the treatment of fractures by massage and movement,
+discarding almost entirely the use of splints and other
+retentive appliances. We were early convinced by the teaching of
+Lucas-Championnière, and have adopted his principles in fractures.
+
+In the majority of cases the massage and movement are commenced at
+once, but circumstances may necessitate their being deferred for a few
+days. The measures adopted vary according to the seat and nature of
+the fracture, but in general terms it may be stated that after the
+fracture has been reduced, the ends of the broken bone are retained in
+position, and gentle massage is applied by the surgeon or by a trained
+masseur. The lubricant may either be a powder composed of equal parts
+of talc and boracic acid, or an oily substance such as olive oil or
+lanolin. The rubbing should never cause pain, but, on the contrary,
+should relieve any pain that exists, as well as the muscular spasm
+which is one of the most important causes of pain and of displacement
+in recent fractures. The parts on the proximal side of the injured
+area are first gently stroked upwards to empty the veins and
+lymphatics, and to disperse the effused blood and serum. The process
+is then applied to the swollen area, and gradually extended down over
+the seat of the fracture and into the parts beyond. In this way the
+circulation through the damaged segment of the limb is improved, the
+veins are emptied of blood, the removal of effused fluid is
+stimulated, and the muscular irritability allayed. The joints of the
+limb are gently moved, care being taken that the broken ends of the
+bone are not displaced. After the rubbing has been continued for from
+fifteen to twenty minutes, the limb is placed in a comfortable
+position, and retained there by pillows, sand-bags, or, if found more
+convenient, by a light form of splint.
+
+The massage is repeated once each day; the sittings last from ten to
+fifteen minutes. The sequence should be, first, massage; second,
+passive movement; and third, active movement. At first massage
+predominates, and more passive than active movement; gradually massage
+is lessened and movements are increased, active movements ultimately
+preponderating.
+
+_Splints and other Appliances._--The appropriate splints for
+individual fractures and the method of applying them will be described
+later; but it may here be said that the general principle is that when
+dealing with a part where there is a single bone, as the thigh or
+upper arm, the splint should be applied in the form of a _ferrule_ to
+surround the break; while in situations where there are two parallel
+bones, as in the forearm and leg, the splint should take the form of a
+_box_.
+
+_Simple wooden splints_ of plain deal board or yellow pine, sawn to
+the appropriate length and width; or _Gooch's splinting_, which
+consists of long strips of soft wood, glued to a backing of
+wash-leather, are the most useful materials. Gooch's splinting has the
+advantage that when applied with the leather side next the limb it
+encircles the part as a ferrule; while it remains rigid when the
+wooden side is turned towards the skin. Perforated sheet lead or tin,
+stiff wire netting, and hoop iron also form useful splints.
+
+When it is desirable that the splint should take the shape of the part
+accurately, a plastic material may be employed. Perhaps the most
+convenient is _poroplastic felt_, which consists of strong felt
+saturated with resin. When heated before a fire or placed in boiling
+water, it becomes quite plastic and may be accurately moulded to any
+part, and on cooling it again becomes rigid. The splint should be cut
+from a carefully fitted paper pattern. Millboard, leather, or
+gutta-percha softened in hot water, and moulded to the part, may also
+be employed.
+
+In conditions where treatment by massage and movement is
+impracticable, and where movable splints are inconvenient, splints of
+_plaster of Paris_, _starch_, or _water-glass_ are sometimes used,
+especially in the treatment of fractures of the leg. When employed in
+the form of an immovable case, they are open to certain
+objections--for example, if applied immediately after the accident
+they are apt to become too tight if swelling occurs; and if applied
+while swelling is still present, they become slack when this subsides,
+so that displacement is liable to occur.
+
+When it is desired to enclose the limb in a plaster case, coarse
+muslin bandages, 3 yards long, and charged with the finest quality of
+thoroughly dried plaster of Paris, are employed. The "acetic plaster
+bandages" sold in the shops set most quickly and firmly. Boracic lint
+or a loose stocking is applied next the skin, and the bony prominences
+are specially padded. The plaster bandage is then placed in cold water
+till air-bubbles cease to escape, by which time it is thoroughly
+saturated, and, after the excess of water is squeezed out, is applied
+in the usual way from below upward. From two to four plies of the
+bandage are required. In the course of half an hour the plaster should
+be thoroughly set. To facilitate the removal of a plaster case the
+limb should be immersed for a short time in tepid water.
+
+A convenient and efficient splint is made by moulding two pieces of
+poroplastic felt to the sides of the limb, and fixing them in position
+with an elastic webbing bandage; this apparatus can be easily removed
+for the daily massage.
+
+_Padding_ is an essential adjunct to all forms of splints. The whole
+part enclosed in the splint must be covered with a thick layer of soft
+and elastic material, such as wool from which the fat has not been
+removed. All hollows should be filled up, and all bony projections
+specially protected by rings of wadding so arranged as to take the
+pressure off the prominent point and distribute it on the surrounding
+parts. Opposing skin surfaces must always be separated by a layer of
+wool or boracic lint. A bandage should never be applied to the limb
+underneath the splints and pads, as congestion or even gangrene may be
+induced thereby.
+
+#Operative Treatment of Simple Fractures.#--Operation in simple
+fracture is specially called for (1) in fracture into or near a joint
+where a permanently displaced fragment will cause locking of the
+joint; (2) when fragments are drawn apart, as in fractures of the
+patella or olecranon; (3) when displacement, especially shortening,
+cannot be remedied by other means; (4) when complications are present,
+such as a torn nerve-trunk or a main artery; (5) when non-union is to
+be feared, as in certain cases of fracture of the neck of the femur in
+old people. Under such circumstances it is necessary to expose the
+fracture by operation, and to place the fragments in accurate
+apposition, if necessary, fixing them in position by wires, pegs,
+plates, or screws (_Op. Surg._, p. 52). Operative interference is
+usually delayed till about five to seven days after the injury, by
+which time the effect of other measures will have been estimated,
+accurate information obtained by means of the X-rays regarding the
+nature of the lesion and the position of the fragments, and the
+tissues recovered their normal powers of resistance. Such operations,
+however, are not to be undertaken lightly, as they are often
+difficult, and if infection takes place the results may be disastrous.
+Arbuthnot Lane and Lambotte advocate a more general resort to
+operative measures, even in simple and uncomplicated fractures, and it
+must be conceded that in many fractures an open operation affords the
+only means of securing accurate apposition and alignment of the
+fragments.
+
+Both before and after operation, massage and movement are to be
+carried out, as in fractures treated by other methods.
+
+
+COMPOUND FRACTURES
+
+The essential feature of a compound fracture is the existence of an
+open wound leading down to the break in the bone. The wound may vary
+in size from a mere puncture to an extensive tearing and bruising of
+all the soft parts.
+
+A fracture may be rendered compound _from without_, the soft parts
+being damaged by the object which breaks the bone--as, for example, a
+cart wheel, a piece of machinery, or a bullet. Sloughing of soft parts
+resulting from the pressure of improperly applied splints, also, may
+convert a simple into a compound fracture. On the other hand, a simple
+fracture may be rendered compound _from within_--for example, a sharp
+fragment of bone may penetrate the skin; this is the least serious
+variety of compound fracture.
+
+As a rule, it is easy to recognise that the fracture is compound, as
+the bone can either be seen or felt.
+
+The _prognosis_ depends on the success which attends the efforts to
+make and to keep the wound aseptic, as well as on the extent of damage
+to the tissues. When asepsis is secured, repair takes place as in
+simple fracture, only it usually takes a little longer; sometimes the
+reason for the delay is obvious, as when the compound fracture is the
+result of a more severe form of violence and where there is
+comminution and loss of one or more portions of bone that would have
+contributed to the repair. Sometimes the delay cannot be so explained;
+Bier suggested that it is due to the escape of blood at the wound,
+whereas in simple fractures the blood is retained and assists in
+repair.
+
+If sepsis gains the upper hand in a compound fracture there is,
+firstly, the risk of infection of the marrow--osteomyelitis--which in
+former times was liable to result in pyæmia; in the second place, not
+only do loose fragments tend to die and be thrown off as sequestra,
+but the ends of the fragments themselves may undergo necrosis;
+involving as this does the dense cortical bone of the shaft, the dead
+bone is slow in being separated, and until it is separated and thrown
+off, no actual repair can take place. The sepsis stimulates the
+bone-forming tissues and new bone is formed in considerable amount,
+especially on the surface of the shaft in the vicinity of the
+fracture; in macerated specimens it presents a porous, crumbling
+texture. Sometimes the new bone--which corresponds to the involucrum
+of an osteomyelitis--imprisons a sequestrum and prevents its
+extrusion, in which case one or more sinuses may persist indefinitely.
+Cases are met with where such sinuses have existed for the best part
+of a long life and have ultimately become the seat of epithelioma.
+
+It should be noted that all the above changes can be followed in
+skiagrams.
+
+_Treatment._--The leading indication is to ensure asepsis. Even in the
+case of a small punctured wound caused by a pointed fragment coming
+through the skin it is never wise to assume that the wound is not
+infected. It is much safer to enlarge such a wound, pare away the
+bruised edges, and disinfect the raw surfaces.
+
+In cases of extensive laceration of the soft parts, all soiled,
+bruised, or torn portions of tissue should be clipped away with
+scissors, blood-clots removed, and the bleeding arrested by
+forci-pressure or ligature. If there is any reason to believe that
+the wound is infected, any fragments of bone completely separated from
+the periosteum should be removed. In comminuted fractures, extension
+applied by strips of plaster or by means of ice-tong callipers or
+Steinmann's apparatus (p. 150) often facilitates replacement of the
+fragments and their retention in position. Plates and screws are not
+recommended for comminuted fractures, owing to the mechanical
+difficulty of fixing a number of small fragments and the risks of
+infection. The wound should be purified with eusol, and the
+surrounding parts painted with iodine. On the whole, it is safer not
+to attempt to obtain primary union by completely closing such wounds,
+but rather to drain or pack them. To increase the local leucocytosis
+and so check the spread of infection, a Bier's constricting bandage
+may be applied.
+
+In other respects the treatment is carried out on the same lines as in
+simple fractures, provision being made for dressing the wound without
+disturbance of the fracture. Massage and movement should be commenced
+after the wound is healed and the condition has become analogous to a
+simple fracture.
+
+#Question of Amputation in Compound Fractures.#--Before deciding to
+perform primary amputation of a limb for compound fracture, the
+surgeon must satisfy himself (1) that the attainment of asepsis is
+impossible; (2) that the soft parts are so widely and so grossly
+damaged that their recovery is improbable; (3) that the vascular and
+nervous supply of the parts beyond has been rendered insufficient by
+destruction of the main blood vessels and nerve-trunks; (4) that the
+bones have been so shattered as to be beyond repair; and (5) that the
+limb, even if healing takes place, will be less useful than an
+artificial one.
+
+In attempting to save the limb of a young subject, it is justifiable
+to run risks which would not be permissible in the case of an older
+person. To save an upper limb, also, risks may be run which would not
+be justifiable in the case of a lower limb, because, while a
+serviceable artificial leg can readily be procured, any portion of the
+natural hand or arm is infinitely more useful than the best substitute
+which the instrument-maker can contrive. The risk involved in
+attempting to save a limb should always be explained to the patient or
+his guardian, in order that he may share the responsibility in case of
+failure.
+
+Whether or not the amputation should be performed at once, depends
+upon the general condition of the patient. If the injury is a severe
+one, and attended with a profound degree of shock, it is better to
+wait for twenty-four or forty-eight hours. Meanwhile the wound is
+purified, and the limb wrapped in a sterile dressing. Means are taken
+to counteract shock and to maintain the patient's strength, and
+evidence of infection or of hæmorrhage is carefully watched for. When
+the shock has passed off, the operation is then performed under more
+favourable auspices. Clinical experience has proved that by this means
+the mortality of primary amputations may be materially diminished,
+especially in injuries necessitating removal of an entire limb.
+
+Having decided to amputate, it is important to avoid having bruised,
+torn, or separated tissues in the flaps, as these are liable to slough
+or to become the seat of infection. In this connection it should be
+borne in mind that the damage to soft tissues is always wider in
+extent than appears from external examination.
+
+The attempt to save a limb may fail and amputation may be called for
+later because of spreading infective processes, osteomyelitis, or
+gangrene; to prevent exhaustion from prolonged suppuration and toxin
+absorption; or on account of secondary hæmorrhage.
+
+#Gun-shot Injuries of Bone.#--Fractures resulting from the impact of
+bullet or fragments of shell are of necessity compound, and are
+usually infected from the outset by organisms carried in by the
+missile or by portions of clothing or other foreign material. Not
+infrequently the missile lodges in the bone.
+
+[Illustration: FIG. 7.--Excessive Callus Formation after infected
+Compound Fracture of both Bones of Forearm--result of gun-shot wound.
+Fusion of Bones across Interosseous Space.]
+
+The extent of the injury to the bone varies infinitely, from a mere
+chip or gutter-shaped wound to complete pulverisation of the portion
+struck. The fracture is of the comminuted and fissured variety, the
+cracks radiating from the point of impact and extending for a
+considerable distance, sometimes even implicating the articular
+surface of the bone some inches away. In comminuted fractures of the
+shafts of long bones there is often a large wedge-shaped fragment
+completely isolated from the rest, and in the presence of infection
+this may form a sequestrum. Healing is often delayed by the separation
+of sequestra, which takes place slowly, and union is attended with
+excessive formation of callus. When a considerable section of the
+shaft has been lost, want of union, fibrous union, or the formation of
+a false joint may result.
+
+The treatment is carried out on the same lines as in other forms of
+compound fracture, except that mention should be made of the
+irrigation method of Carrel, found to be the most potent means of
+overcoming the associated infection.
+
+
+SEPARATION OF EPIPHYSES[1]
+
+[1] We do not employ the term "diastasis," which has been used in
+different senses by different writers.
+
+In young subjects before the bones are fully developed the epiphyses
+may be separated from the diaphyses. The use of the X-rays has added
+greatly to our knowledge of these lesions.
+
+It is useful to remember that in the upper extremity the epiphyses in
+the regions of the shoulder and wrist, and, in the lower extremity,
+those in the region of the knee, are the latest to unite; and that it
+is in these situations that growth in length of the bone goes on
+longest and most actively (twenty to twenty-one years). Injuries of
+these epiphyses, therefore, are most liable to interfere with the
+growth of the limb.
+
+An epiphysis is nourished from the articular arteries and through the
+vessels of the periosteum.
+
+_Pathological Separation of Epiphyses._--There are certain
+pathological conditions, such as rickets, scurvy, congenital syphilis,
+tubercle, suppurative conditions, and tumour growths, which render
+separation of the epiphyses liable to occur from injuries altogether
+insufficient to produce such lesions under normal conditions.
+
+#Traumatic Separations.#[2]--Speaking generally, it may be said that
+injuries which in an adult would be liable to produce dislocation, are
+in a young person more apt to cause separation of an epiphysis.
+Indirect violence, especially when exerted in such a way as to combine
+traction with torsion,--for example, when the foot is caught in the
+spokes of a carriage wheel,--is the commonest cause of epiphysial
+separation. Direct violence is a much less frequent cause. Muscular
+action occasionally produces separation of the epiphyses--for example,
+the anterior superior iliac spine, the small trochanter of the femur,
+or the upper end of the fibula.
+
+[2] We desire here to acknowledge our indebtedness to Mr. John
+Poland's work on _Traumatic Separation of the Epiphyses_.
+
+[Illustration: FIG. 8.--Partial Separation of Epiphysis, with Fracture
+running into Diaphysis.]
+
+[Illustration: FIG. 9.--Complete Separation of Epiphysis.]
+
+[Illustration: FIG. 10.--Partial Separation with Fracture of
+Epiphysis.]
+
+[Illustration: FIG. 11.--Complete Separation with Fracture of
+Epiphysis.]
+
+The majority of separations take place between the eleventh and the
+eighteenth years, chiefly because during this period the injuries
+liable to produce such lesions are most common. They do not occur
+after twenty-five, because by that time all the epiphyses have united.
+In females this form of injury is rare, and almost invariably occurs
+before puberty.
+
+The following are the most common seats of separation in the order of
+their frequency: (1) the lower end of the femur; (2) the lower end of
+the radius; (3) the upper end of the humerus; (4) the lower end of the
+humerus; (5) the lower end of the tibia; and (6) the upper end of the
+tibia.
+
+_Morbid Anatomy._--In a true separation the epiphysial cartilage
+remains attached to the epiphysis. As a rule the epiphysis is not
+completely separated from the diaphysis, the common lesion being a
+separation along part of the epiphysial line, with a fracture running
+into the diaphysis (Fig. 8). It is not uncommon for more than one
+epiphysis to be separated by the same accident--for example, the lower
+end of the femur and the upper ends of the tibia and fibula.
+Epiphysial separations, like fractures, may be _simple_ or _compound_.
+Incomplete separations are liable to be overlooked at the time of the
+accident, but there is reason to believe that they may form the
+starting-point of disease. Strain of the epiphysial junction--the
+_juxta-epiphysial strain_ of Ollier--is a common injury in young
+children.
+
+_Clinical Features._--The symptoms simulate those of dislocation
+rather than of fracture. Thus, _unnatural mobility_ at an epiphysial
+junction may closely resemble movement at the adjacent joint,
+especially when the epiphysis is an intra-capsular one. The
+relationship of the bony points, however, serves to indicate the
+nature of the lesion. The degree of _deformity_ is often slight,
+because the transverse direction of the lesion, the breadth of the
+separated surfaces, and the firmness of the periosteal attachment
+along the epiphysial line often prevent displacement. In many cases a
+distinct, rounded, smooth, and regular ridge, caused by the projection
+of the diaphysis, can be felt. The peculiar "muffled" nature of the
+_crepitus_ is one of the most characteristic signs. The older the
+patient, and the further ossification has progressed, the more does
+the crepitus resemble that of fracture.
+
+Of the subsidiary signs, _loss of power_ in the limb is one of the
+most constant; indeed, in young children it is sometimes the first,
+and may be the only, sign that attracts attention. _Pain_ and
+_tenderness_ along the epiphysial line are valuable signs,
+particularly when the lesion is due to indirect or muscular violence
+and there is no bruising of soft parts. Localised _swelling_,
+accompanied by _ecchymosis_, is often marked; and the adjacent joint
+may be distended with fluid.
+
+As distinguishing this injury from a dislocation, it may be noted that
+in epiphysial separation there is no snap felt when the deformity is
+reduced, the tendency to re-displacement is greater, and the amount of
+relief given by reduction less than in dislocation. The use of the
+Röntgen rays at once establishes the diagnosis.
+
+_Prognosis and Results._--In the majority of cases union takes place
+satisfactorily by the formation of callus in the spongy tissue of the
+diaphysis and on the deep surface of the periosteum. In spite of the
+favourable nature of the prognosis in general, however, the friends of
+the patient should be warned that a completely satisfactory result
+cannot always be relied upon.
+
+Deformity, with stiffness and locking at the adjacent joint,
+especially at the elbow, may result from imperfect reduction, or from
+exuberant callus. Arrest of growth of the bone in length is a rare
+sequel, and when it occurs, it is due, not to premature union of the
+epiphysis with the shaft, but to diminished action at the ossifying
+junction.
+
+When the growth of one of the bones of the leg or forearm is arrested
+after separation of its epiphysis while the other bone continues to
+grow, the foot or hand is deviated towards the side of the shorter
+one.
+
+Partial separations may be overlooked at the time of the accident and
+cause trouble later from bending of the bone, as in one variety of
+coxa vara. The epiphysis at the lower end of the femur may be
+displaced into the ham and press on the popliteal vessels.
+
+_Treatment._--The general principles which govern the treatment of
+fractures apply equally to epiphysial separations, the essential being
+the accurate replacement of the epiphysis.
+
+In _compound separations of epiphysis_, the end of the diaphysis may
+be pushed through the skin. The entrance of sepsis may prove an
+obstacle to any operative measure that would otherwise be indicated.
+
+
+
+
+CHAPTER II
+
+INJURIES OF JOINTS
+
+
+SURGICAL ANATOMY--INJURIES: _Contusions_; _Wounds_; _Sprains_;
+ _Dislocations_--TRAUMATIC DISLOCATIONS: _Causes_: _Varieties_;
+ _Clinical features_; _Treatment_--Compound
+ dislocations--Old-standing dislocations.
+
+#Surgical Anatomy.#--The function of a joint is to permit of the
+movement of one bone upon another. The articular surfaces are covered
+with a thin layer of hyaline cartilage, and are retained in apposition
+by the tension of ligaments and of the muscles surrounding the joint.
+The articular capsule (capsular ligament) is directly continuous with
+the periosteum, and is lined by a synovial layer, which at the line of
+attachment of the capsule is reflected on to the bone as far as the
+articular cartilage. The synovial layer invests intra-articular
+ligaments, and is projected into the interior of the joint in the form
+of loose folds wherever the articulating surfaces are not in immediate
+contact. The surface of the synovial layer is covered with minute
+processes or villi, which in diseased conditions may become
+hypertrophied. The synovia owes its lubricating property to mucin,
+derived from the solution of the endothelial cells on the free surface
+of the synovial layer. The opposing surfaces of a joint being always
+in accurate contact, the so-called cavity is only a potential one. If
+fluid is poured out into the joint, the synovial layer and the capsule
+are put upon the stretch, causing discomfort or actual pain, which is
+partly relieved by slightly flexing the joint. If the distension
+persists, the ligaments become elongated and the joint unstable.
+
+The common origin of bone, cartilage, periosteum, and synovial layer
+from one parent tissue of the embryo, accords with the readiness with
+which any one of these tissues may be converted into another under
+traumatic or pathological influences; and how in ligaments and in
+synovial membrane foci of hyaline cartilage may form and, after
+increasing in size, undergo ossification.
+
+Joints derive an abundant blood supply through the articular arteries.
+The lymphatics, which take origin in the synovial layer, pass to
+efferent vessels which run in the intermuscular and other
+connective-tissue planes of the limb. The nerve supply is derived
+chiefly from the nerves distributed to the muscles acting on the joint
+and to the skin over it.
+
+#Sources of Joint Strength.#--The capacity of a joint to resist
+dislocation depends upon (1) the shape of its osseous elements; (2)
+the strength and arrangement of its ligaments; (3) the support it
+receives from muscles or tendons placed in relation to it; and (4) the
+relative stability of adjacent structures. While all these factors
+contribute to the strength of a given joint, one or other of them
+usually predominates, so that certain joints are osseously strong,
+others are ligamentously strong, while a few depend chiefly upon
+adjacent muscles for their stability.
+
+The hip and elbows are the best examples of joints deriving their
+strength mainly from the architectural arrangement of the constituent
+bones. These joints are dislocated only by extreme degrees of
+violence, and not infrequently--especially in the elbow--portions of
+the bones are fractured before the articular surfaces are separated.
+
+The knee, the wrist, the carpal, the tarsal, and the clavicular joints
+depend for their stability almost entirely on the strength of their
+ligaments. These joints are rarely dislocated, but as the main
+incidence of the violence falls on the ligaments they are frequently
+sprained.
+
+The shoulder is the typical example of a joint depending for its
+security chiefly upon the muscles and tendons passing over it, and
+hence the frequency with which it is dislocated when the muscles are
+taken unawares. At the same time the great mobility of the scapula and
+clavicle materially increases the stability of the shoulder-joint. The
+tendons passing in relation to the knee, ankle, and wrist add to the
+stability of these joints.
+
+The proximity of an easily fractured bone also contributes to prevent
+dislocation of certain joints--for example, fracture of the clavicle
+prevents an impinging force expending itself on the shoulder-joint;
+and the frequency of Colles' fracture of the radius, and of Pott's
+fracture of the fibula, doubtless accounts to some extent for the
+rarity of dislocation of the wrist and ankle-joints respectively. The
+immunity from dislocation which the joints of young subjects enjoy is
+partly due to the ease with which an adjacent epiphysis is separated.
+
+The mechanical axiom that "what is gained in movement is lost in
+stability" applies to joints, those which have the widest range of
+movement being the most frequently dislocated.
+
+ * * * * *
+
+The injuries to which a joint is liable are Contusions, Wounds,
+Sprains, and Dislocations.
+
+#Contusions of Joints.#--Contusion is the mildest form of injury to a
+joint. Whether the violence is transmitted from a distance, as in
+contusion of the hip from a fall on the feet, or acts more directly,
+as in a fall on the great trochanter, the bones are violently driven
+against one another, and the force expends itself on their articular
+surfaces. The articular cartilages and the underlying spongy bone, as
+well as the synovial lining, are bruised, and there is an effusion of
+blood and serous fluid into the joint and surrounding tissues.
+
+The most prominent _clinical features_ are swelling and discoloration.
+The swelling, especially in superficially placed joints, is an early
+and marked symptom, and is mainly due to the effusion of blood into
+the joint (_hæmarthrosis_). In deeply placed joints, discoloration may
+not appear on the surface for some days, especially if the violence
+has been indirect. The joint is kept in the flexed position, and is
+painful only when moved. In hæmophilic subjects, considerable effusion
+of blood into a joint may follow the most trivial injury.
+
+A slight degree of serous effusion into the joint (_hydrarthrosis_)
+often persists for some time, and tuberculous affections of joints not
+infrequently date from a contusion.
+
+The _treatment_ is the same as for sprains (p. 36).
+
+#Wounds of Joints.#--The importance of accidental wounds of
+joints--such, for example, as result from a stab with a penknife or
+the spike of a railing--lies in the fact that they are liable to be
+followed by infection of the synovial cavity. The infection may
+involve only the synovial layer (_septic synovitis_), or may spread to
+all the elements of the joint (_septic arthritis_). These conditions
+are described with diseases of joints.
+
+Penetration of the joint may sometimes be recognised by the escape of
+synovia from the wound, or the synovial layer or articular cartilage
+may be exposed. When doubt exists, the wound should be enlarged. The
+use of the probe is to be avoided, on account of the risk of carrying
+infective material from the track of the wound into the joint.
+
+Penetrating wounds of joints are treated on the same lines as compound
+fractures. If the penetrating instrument is to be regarded as
+infected,--as, for example, when the spoke of a motor bicycle is
+driven through the upper pouch of the knee,--the injury is to be
+looked upon as serious and capable of endangering the function of the
+joint, loss of the limb, or even life itself. Reliance is chiefly laid
+on primary excision of the edges and track of the wound, and other
+measures employed in the treatment of gun-shot wounds. While the wound
+in the synovialis and capsule is sutured, that in the soft parts is
+left open. If drainage is employed, the tube extends down to the
+opening in the synovialis, but not into the joint itself. If sepsis
+supervenes, the joint is opened and irrigated by Carrel's method. Some
+form of splint and a Bier's bandage are valuable adjuncts. The final
+recourse is to amputation.
+
+#Gun-shot injuries# of joints vary in severity from a mere puncture of
+the synovial layer by a chip of shell to complete shattering of the
+articular surfaces. Between these extremes are cases in which the
+capsular and synovial layer are extensively lacerated without
+involvement of the bones, and others in which the bones are implicated
+without serious damage being done to ligaments or synovial layer--for
+example, by a bullet passing through and through the cancellated part
+of one of the constituent bones, or by a fissure extending into the
+articular surface.
+
+In all degrees the great risk is from septic infection, which may be
+assumed to be present in all but the last-named variety.
+
+The _treatment_ consists in immediately cleansing the wound by
+excising grossly damaged tissue and removing any foreign body that may
+have lodged; disinfecting the exposed part of the joint cavity with
+eusol, "bipp," or other antiseptic, and closing the wound or
+establishing drainage, according to circumstances. The joint is then
+immobilised till the wound has healed, after which massage and
+movement are commenced. When the bones are shattered or when sepsis
+gets the upper hand and disorganises the joint, amputation is called
+for.
+
+#Sprains.#--A sprain results from a stretching or twisting form of
+violence which causes the joint to move beyond its physiological
+limits, or in some direction for which it is not structurally adapted.
+The main incidence of the force therefore falls upon the ligaments,
+which are suddenly stretched or torn. The synovial layer also is torn,
+and the joint becomes filled with blood and synovial fluid.
+
+Muscles and tendons passing over the joint are stretched or torn, and
+their sheaths filled with serous effusion. It is not uncommon for
+portions of bone to be torn off at the site of attachment of strong
+ligamentous bands or tendons, constituting a "sprain fracture"; or for
+intra-articular cartilages to be torn and displaced, as in the knee.
+
+_Clinical Features._--The injury is accompanied by intense sickening
+pain, and this may persist for a considerable time. At first it is
+aggravated by moving the joint, but if the movement is continued it
+tends to pass off. The particular ligaments involved may be recognised
+by the tenderness which is elicited on making pressure over them, or
+by putting them on the stretch. In this way a sprain may often be
+diagnosed from a fracture in which the maximum tenderness is over the
+injury to the bone.
+
+The effusion of blood and synovia into the joint and into the tissues
+around gives rise to swelling and discoloration, and the fluid effused
+into tendon sheaths often produces a peculiar creaking sensation,
+which may be mistaken for the crepitus of fracture. In sprains, the
+bony points about the joint retain their normal relations to one
+another, and this usually enables these injuries to be diagnosed from
+dislocations. When the swelling is great, it is often necessary to
+have recourse to the Röntgen rays to make certain that there is no
+fracture or dislocation. The special features and complications of
+sprains of the knee are discussed with other injuries of that joint.
+
+_Repair of Sprains._--Blood and synovia are absorbed and torn
+structures become reunited, but in this process adhesions may form
+inside the joint and in the surrounding tendon sheaths and interfere
+with the movement of the joint.
+
+_Prognosis._--Stiffness, lasting for a longer or shorter time, follows
+most sprains, but may be largely prevented by proper treatment. In old
+and rheumatic persons, changes of the nature of arthritis deformans
+are liable to supervene, interfering greatly with movement. While
+suppuration is rare, tuberculous disease is alleged to have resulted
+from a sprain.
+
+_Treatment._--If seen immediately after the accident, firm pressure
+should be applied by means of an elastic bandage over a thick layer of
+cotton wool, to prevent bleeding and effusion of synovia. Later the
+best treatment is by massage and movement. In the ankle, for example,
+massage should be commenced at once, the part being gently stroked
+upwards. If the massage is light enough there is no pain, it is
+actually soothing. The rubbing is continued for from fifteen to twenty
+minutes, and the patient is encouraged to move the toes and ankle; a
+moderately firm elastic bandage is then applied. The massage is
+repeated once or twice a day, the sittings lasting for about fifteen
+minutes. The patient should be encouraged to move the joint from the
+first, beginning with the movements that put least strain upon the
+damaged ligaments, and gradually increasing the range. In the course
+of a few days he is encouraged to walk or cycle, or otherwise to use
+the joint without subjecting it to strain, or to a repetition of the
+movement that caused the accident. Alternate hot and cold douching, or
+hot-air baths, followed by massage, are also useful. Complete rest and
+prolonged immobilisation are to be condemned.
+
+
+TRAUMATIC DISLOCATIONS
+
+A dislocation or luxation is a persistent displacement of the opposing
+ends of the bones forming a joint. We are here concerned only with
+such dislocations as immediately follow upon injury. Those that are
+congenital or that result from disease will be studied later.
+
+_Causes._--The majority of dislocations are the result of _indirect_
+violence, the more movable bone acting as a lever, on a fulcrum
+furnished by the natural check to movement in the form of ligament,
+bone, or muscle. It is in this way that most dislocations of the
+shoulder, hip, and elbow are produced.
+
+At the moment the violence is applied, the muscles are relaxed or
+otherwise taken at a disadvantage, so that the joint is for the time
+being deprived of their support. The joint is moved beyond its
+physiological range, and the end of one of the bones being brought to
+bear upon the capsule, tears it, and passes through the rent thus
+made. The muscles then contract reflexly, and pull the head of the
+bone into an unnatural position outside the capsule. The position
+assumed will depend upon such factors as the direction of the force,
+the structure of the joint, the position of the limb at the time of
+the accident, and the relative strength of the different groups of
+muscles acting upon the bone which is displaced.
+
+Violence applied _directly_ to the joint is a much less frequent cause
+of dislocation. In this way, however, the knee-joint may be
+dislocated, one bone being driven past the other--for example, by a
+kick from a horse; or the acromio-clavicular joint by a blow on the
+shoulder.
+
+_Muscular contraction_ is not often the sole cause of dislocation,
+although, as has been mentioned, it plays an important rôle in the
+production of the majority of these injuries. The shoulder, mandible,
+and patella are, however, not infrequently displaced by muscular
+action alone. Acrobats sometimes acquire the power of dislocating
+certain joints by voluntary contraction of their muscles.
+
+_Age and Sex._--Dislocations occur most frequently in adult males,
+doubtless on account of the nature of their occupations and
+recreations. In children the epiphyses are separated, and in old
+people the bones are broken by such forms of violence as cause
+dislocation in the middle-aged.
+
+Muscular debility and undue laxness of ligaments resulting from
+disease or previous dislocation are also predisposing factors.
+
+_Clinical Varieties._--The separation between the bones may be
+_complete_ or _partial_. When partial, portions of the articular
+surfaces remain in apposition, and the injury is known as a
+_sub-luxation_. Like fractures, dislocations may be _simple_ or
+_compound_, the latter being specially dangerous on account of the
+risk of infection. When seen within a few days of its occurrence, a
+dislocation is looked upon as _recent_; but when several weeks or
+months have elapsed, it is spoken of as an _old-standing_ dislocation.
+The latter will be described later.
+
+Dislocations, like fractures, may be _complicated_ by injuries to
+large blood vessels or nerve-trunks, by injuries to internal organs,
+or by a wound of the soft tissues which does not communicate with the
+joint. Further, a fracture may coexist with a dislocation--a most
+important complication.
+
+_Clinical Features._--The most characteristic signs of dislocation are
+_preternatural rigidity_, or want of movement where movement should
+naturally take place; _mobility in abnormal directions_; and
+_deformity_, the part being "out of drawing" as compared with the
+uninjured side (Fig. 18). The bony landmarks lose their normal
+relationship to one another; and the deformity is characteristic, and
+is common to all examples of the same dislocation.
+
+Although any of the subsidiary signs may occur in lesions other than
+dislocations, due weight must be given to them in making a diagnosis.
+_Loss of function_ is complete as a rule. _Pain_ is much more intense
+than in fracture, usually because the displaced bone presses upon
+nerve-trunks, and from the same cause there is often numbness and
+partial paralysis of the limb beyond. _Swelling_ of the soft parts due
+to effused blood is usually less marked in dislocation than in
+fracture, but is often sufficiently great to interfere with diagnostic
+manipulations. The displaced bone, and sometimes the empty socket, may
+be palpable. _Discoloration_ is usually later of appearing than in
+fractures. _Alteration in the length_ of the injured limb--usually in
+the direction of shortening--is a common feature; while girth
+measurements usually show an increase. A peculiar soft _grating_ or
+_creaking sensation_ is often felt on attempting to move the joint;
+this is due to cartilaginous or ligamentous structures rubbing on one
+another, and must not be mistaken for the crepitus of fracture. In the
+majority of cases, although not in all, after reduction has been
+effected, the bones retain their proper relations without external
+support, a point in which a dislocation differs from a fracture. A
+careful investigation of the kind of force which produced the injury,
+particularly as regards its intensity and direction of action, may aid
+in the diagnosis. The diagnosis can always be verified by the use of
+the Röntgen rays, and this should be had recourse to whenever
+possible, as a fracture may be shown that otherwise would escape
+recognition.
+
+_Prognosis._--After having once been dislocated, a joint is seldom as
+strong as it was formerly, although for all practical purposes the
+limb may be as useful as ever. Some degree of stiffness, of limited
+movement, or of muscular weakness, and occasional arthritic changes
+and a liability to re-dislocation, are the commonest sequelæ.
+Prolonged immobilisation is liable to lead to stiffness by permitting
+of the formation of adhesions; while too early movement tends to
+produce a laxity of the ligaments which favours re-displacement from
+slight causes.
+
+_Treatment._--Reduction should be attempted at the earliest possible
+moment. Every hour of delay increases the difficulty. The guiding
+principle is to cause the displaced bone to re-enter its socket by
+the same route as that by which it left it--that is, through the
+existing rent in the capsule. This is done by carrying out certain
+manipulations which depend upon the anatomical arrangement of the
+parts, and which vary, not only with different joints, but also with
+different varieties of dislocation of the same joint. In general terms
+it may be said that the main impediments to reduction are: the
+contraction of the muscles acting upon the displaced bone; the
+entanglement of the bone among tendons or ligamentous bands which fix
+it in its abnormal position; and the rent in the capsule being small
+or valvular, so that it forms an obstacle to the bone reentering the
+socket.
+
+Muscular contraction is best overcome by the administration of a
+general anæsthetic, and in all but the simplest cases this should be
+given to ensure accurate and painless reduction. Failing this,
+however, the muscles may be wearied out by the surgeon making steady
+and prolonged traction on the limb, while an assistant makes
+counter-extension on the proximal segment of the joint. Advantage may
+also be taken of such muscular relaxation as occurs when the patient
+is already faint, or when his attention is diverted from the injured
+part, to carry out the manipulations necessary to restore the bone to
+its normal position.
+
+The appropriate manoeuvres for disengaging the head of the bone from
+tendons, ligaments, or bony processes with which it may be entangled,
+will be suggested by a consideration of the anatomy of the particular
+joint involved, and will be described with individual dislocations.
+
+In reducing a dislocation, no amount of physical force will compensate
+for a want of anatomical knowledge. All tugging, twisting, or
+wrenching movements are to be avoided, as they are liable to cause
+damage to blood vessels, nerves, or other soft parts, or even--and
+especially in old people--to fracture one of the bones concerned.
+
+After reduction, great benefit is gained by the systematic use of
+_massage_ and movement. Before any restraining apparatus is applied
+the whole region should be gently stroked in a centrifugal direction
+for fifteen or twenty minutes; and this is to be repeated daily, each
+sitting lasting for about twenty minutes. From the first day onward,
+movement of the joint is carried out in every direction, except that
+which tends to bring the head of the bone against the injured part of
+the capsule; and the patient is encouraged to move the joint as early
+as possible. The appropriate apparatus and the period during which it
+should be worn will be considered with the individual dislocations.
+
+_Operation in Simple Dislocations._--In a limited number of cases,
+even with the aid of an anæsthetic, reduction by manipulation is found
+to be impossible. Resort must then be had to operation, which is a
+comparatively safe and satisfactory proceeding, although often
+difficult. It may happen in rare instances that the undoing of the
+displacement is only possible after the removal of a portion of one or
+other of the bones.
+
+#Compound Dislocations.#--Compound dislocations are usually the result
+of extreme violence produced by machinery or railway accidents, or by
+a fall from a height. In the majority of cases they are complicated by
+fracture of one or more of the constituent bones of the joint, as well
+as by laceration of muscles, tendons, and blood vessels. In the region
+of the ankle, wrist, and joints of the thumb, however, compound
+dislocation is sometimes met with uncomplicated by other lesions. The
+great risk is infection, which may result in serious impairment of the
+usefulness of the joint or even in its complete destruction, results
+towards which the concomitant injuries materially contribute. In many
+instances where infection has occurred, ankylosis is the best result
+that can be hoped for.
+
+_Treatment._--As a rule, the first question that arises is whether
+amputation is necessary or not, and the considerations that determine
+this point are the same as in compound fractures (p. 26). If an
+attempt is to be made to save the limb, the treatment is the same as
+in compound fracture (p. 25).
+
+#Dislocation complicated by Fracture.#--In certain dislocations the
+separation of small portions of bones or of epiphyses is of common
+occurrence--for example, fracture of the tip of the coronoid process
+in dislocation of the elbow backwards, and chipping off of a portion
+of the edge of the acetabulum in dislocation of the hip.
+
+The most important example of a fracture complicating a dislocation is
+fracture of the surgical neck of the humerus coexisting with
+dislocation of the shoulder. Here the difficulty of diagnosis is
+greatly increased, and the treatment of both injuries requires to be
+modified. The dislocation must be reduced--by operation if
+necessary--before the fracture is treated, and in many cases it is
+advisable to secure the fragments of the broken bone by pegs, or
+plates, to admit of movement being commenced early, and so to prevent
+stiffness of the joint.
+
+#Old-standing Dislocations.#--When, from want of recognition--and,
+curiously enough, a dislocation is much more liable to be overlooked
+than would have been thought possible--or from unsuccessful treatment,
+a dislocation is left unreduced, changes take place in and around the
+joint which render reduction increasingly difficult or impossible. The
+rent in the capsule closes upon the neck of the bone, and fibrous
+adhesions form between muscles, tendons, and other structures that
+have been torn. The articular cartilage of the head, being no longer
+in contact with an opposing cartilage, tends in time to be converted
+into fibrous tissue, and may become adherent to other fibrous
+structures in its vicinity. By pressing on adjacent structures it may
+form for itself a new socket of dense fibrous tissue which in time
+becomes lined with a secreting membrane. When the displaced head lies
+against a bone, the continuous pressure produces a new osseous socket,
+from the margins of which osteophytic outgrowths may spring, and as
+the surrounding fibrous tissue becomes condensed and forms a strong
+capsule, a new joint results. The occurrence of these changes in the
+direction of a new ball-and-socket joint is largely dependent on the
+behaviour of the patient: a vigorous man, anxious to recover the use
+of the limb, will employ it with a degree of determination and
+indifference to pain that could not be expected in a sensitive elderly
+female. The most perfect example of a new ball-and-socket joint,
+following upon an unreduced dislocation at the hip, that has come
+under our observation, was in a hunting dog, given one of us by an
+Australian pupil, who testified that the animal was as fleet with the
+new joint as it had been with the original one. Meanwhile the
+cartilage of the original socket is converted into fibrous tissue,
+which may come to fill up the cavity. Changes resembling those of
+arthritis deformans may occur. The large blood vessels and nerves in
+the vicinity may be pressed upon or stretched by the displaced bone,
+or may be implicated in fibrous adhesions. In course of time they
+become lengthened or shortened in accordance with the altered attitude
+of the limb.
+
+[Illustration: FIG. 12.--Os Innominatum showing new socket formed
+after old-standing dislocation. The acetabulum is almost obliterated.]
+
+In many cases the new joint is remarkably mobile and useful; but in
+others, pain, limited movement, and atrophy of muscles render it
+comparatively useless, and surgical intervention is called for.
+
+_Treatment._--It is always a difficult problem to determine the date
+after which it is inadvisable to attempt reduction by manipulation in
+an old dislocation and no rules can be laid down which will cover all
+cases. Rather must each case be decided on its own merits, due
+consideration being had to the risks that attend this line of
+treatment. The chief of these are: rupture of a large blood vessel or
+nerve that has formed adhesions with the displaced bone, or has become
+shortened in adaptation to the altered shape or length of the limb;
+tearing of muscles or tendons, or even of skin; fracture of the bone,
+especially in old people; and separation of epiphyses in the young.
+
+Before carrying out the manipulations appropriate to the particular
+dislocation, all adhesions must first be broken down; and during the
+proceedings no undue force is to be employed. The first attempt at
+reduction may fail, and yet subsequent efforts, at intervals of a few
+days, may ultimately prove successful; the vigorous traction and
+twisting of the soft parts, matted together as they are by
+scar-tissue, causes reactive changes in the vessels and tissues which
+render them more liable to yield on subsequent attempts at reduction.
+In old people, and where there is an absence of suffering from
+pressure on nerves or vessels, it may be wiser to leave the
+dislocation unreduced, and strive rather by massage and movement to
+obtain a useful variety of false joint. If the conditions are
+otherwise, it may be better to improve the function of the limb by an
+_open operation_. Tight ligaments and other structures are divided,
+and the socket is cleared out. If reduction is still impossible, a
+partial excision may be performed and a flap of fascia lata introduced
+to prevent ankylosis (arthroplasty). In the case of the hip, the
+dislocation may be left alone and the femur divided below the
+trochanter, especially if there is pronounced flexion.
+
+#Habitual or recurrent dislocation# is almost exclusively met with in
+the shoulder, and will be described with the injuries of that joint.
+
+#Pathological Dislocations.#--Joints may become dislocated in the
+course of certain diseases. These pathological dislocations fall into
+different groups: (1) those due to gradual stretching of the capsular
+and other ligaments weakened by inflammatory and suppurative
+processes, such as sometimes follow on typhoid, scarlet fever, or
+diphtheria, and in pyæmia; (2) those due to destructive changes in the
+ligaments and bones--typically seen in tuberculous arthritis, in
+arthritis deformans, in Charcot's disease, and in nerve lesions,
+_e.g._ dislocation of the hip in spastic conditions, such as Little's
+disease; (3) those associated with deformed attitudes of the limb; (4)
+those due to changes in the articular surfaces, _e.g._ the phalanges
+in arthritis deformans. These will be considered with the conditions
+which give rise to them.
+
+#Congenital Dislocations.#--Congenital dislocations are believed to be
+the result of abnormal or arrested development _in utero_, and are to
+be distinguished from dislocations occurring during birth, which are
+essentially traumatic in origin. They will be described along with the
+Deformities of the Extremities.
+
+
+
+
+CHAPTER III
+
+INJURIES IN THE REGION OF THE SHOULDER AND UPPER ARM
+
+
+Surgical Anatomy--FRACTURES OF CLAVICLE: _Varieties_--DISLOCATION OF
+ CLAVICLE: _Varieties_--DISLOCATION OF SHOULDER:
+ _Varieties_--Sprains and contusions of shoulder--FRACTURE OF
+ SCAPULA: Sites--FRACTURE OF UPPER END OF HUMERUS: _Surgical neck_;
+ _Separation of epiphysis_; _Fracture of head, anatomical neck, or
+ tuberosities_--FRACTURES OF SHAFT OF HUMERUS.
+
+The injuries met with in the region of the shoulder include fractures
+and dislocations of the clavicle, fractures of the scapula,
+dislocations and sprains of the shoulder-joint, and fractures of the
+upper end of the humerus.
+
+#Surgical Anatomy.#--For the examination of an injury in the region of
+the shoulder the patient should be seated on a low stool or chair.
+After inspecting the parts from the front, the surgeon stands behind
+the patient and systematically examines by palpation the shoulder
+girdle and upper end of the humerus. The uninjured side should be
+examined along with the other for purposes of comparison.
+
+Immediately lateral to the supra-sternal notch, the sterno-clavicular
+articulation may be felt, the large end of the clavicle projecting to
+a varying degree beyond the margins of the small and shallow articular
+surface on the sternum. Any dislocation of this joint is at once
+recognised. The clavicle being subcutaneous throughout its whole
+length, any irregularity in its outline can be easily detected. A
+small tubercle (deltoid tubercle) which frequently exists near the
+acromial end is liable to suggest the presence of a fracture. The
+lateral end forms with the acromion the acromio-clavicular joint,
+which, however, is not always readily identified. The fingers are now
+carried over the acromion, which often exhibits in the situation of
+its epiphysial cartilage a prominent ridge, which must not be mistaken
+for a fracture. The tip of the acromion is usually employed as a fixed
+point in measuring the length of the upper arm.
+
+The outline of the spine of the scapula can be traced back to the
+vertebral border; and the body of the bone may be manipulated, and its
+movements tested by moving the arm.
+
+The coracoid process can be recognised in the upper and lateral angle
+of the triangular depression bounded by the pectoralis major, the
+deltoid, and the clavicle.
+
+The head and surgical neck of the humerus may now be felt from the
+axilla, if the axillary fascia is relaxed by bringing the arm to the
+side. The great tuberosity can be indistinctly felt on the lateral
+aspect of the shoulder through the fibres of the deltoid. It lies
+vertically above the lateral epicondyle, and may be felt to rotate
+with the shaft. The inter-tubercular (bicipital) groove looks forward,
+and lies in a line drawn vertically through the biceps muscle.
+
+The subclavian artery, with its vein to the median side and the cords
+of the brachial plexus to the lateral side, passes under the middle of
+the clavicle, and may be compressed against the first rib immediately
+above this bone.
+
+
+FRACTURE OF THE CLAVICLE
+
+Fracture of the clavicle is one of the commonest injuries met with in
+practice. As about one-third of the cases occur in children, the
+fracture is often of the greenstick variety. The fractures are seldom
+compound or complicated, unless as a result of gun-shot injuries; but
+occasionally one of the fragments pierces the skin, or comes to press
+upon the subclavian vessels or the cords of the brachial plexus,
+arresting the pulsation in the vessels of the limb, and causing severe
+pain in the arm.
+
+[Illustration: FIG. 13.--Oblique Fracture of Right Clavicle in Middle
+Third, united.]
+
+The most common site of fracture is in the _middle third_ (Fig. 13),
+and this usually results from indirect violence, such as a fall on the
+outstretched hand, the elbow, or the outer aspect of the shoulder, the
+force being transmitted through the glenoid cavity to the scapula, and
+thence by the coraco-clavicular ligaments to the clavicle. The
+violence is therefore of a twisting character, and the bone gives way
+near the junction of the lateral and middle thirds, just where the two
+natural curves of the bone meet, and where the supporting muscular and
+ligamentous attachments are weakest.
+
+The fracture so produced is usually oblique from above, downwards and
+inwards. The sternal fragment may be slightly drawn upwards by the
+clavicular fibres of the sterno-mastoid, while the acromial fragment
+falls by the weight of the arm, and the fragments usually overlap to
+the extent of about half an inch. The shoulder, having lost the
+buttressing support of the clavicle, falls in towards the chest wall,
+narrowing the axillary space, while the weight of the arm pulls it
+downward, and the muscles inserted in the region of the bicipital
+groove pull it forward.
+
+Fracture of the middle third may result also from a direct stroke,
+such as the recoil of a gun, or from violent muscular contraction, the
+fracture as a rule being transverse, and the displacement less marked
+than in fracture by indirect violence.
+
+_Clinical Features._--The attitude of the patient is characteristic:
+the elbow is flexed and is supported by the opposite hand, while the
+head is inclined towards the affected shoulder to relax the muscles of
+the neck. Crepitus is elicited on bracing back the shoulders, or on
+attempting to raise the arm beyond the horizontal, and these movements
+cause pain. Tenderness is elicited on making pressure over the seat of
+fracture, and also on distal pressure. The sternal fragment almost
+invariably overrides the acromial, and can usually be palpated through
+the skin; on measurement, the clavicle is found to be shortened. When
+the fracture is incomplete (greenstick) or transverse, the symptoms
+are less marked.
+
+[Illustration: FIG. 14.--Fracture of Acromial End of Clavicle. Shows
+forward rotation of lateral fragment, and line of fracture united by
+bone.]
+
+Fracture of the _lateral_ or _acromial third_ of the clavicle is a
+common form of accident at football matches, and usually results from
+direct violence, the bone being driven down against the coracoid
+process, and broken as one breaks a stick over the knee. The fracture
+may take place through the attachment of the conoid and trapezoid
+ligaments, in which case the only symptoms are pain and tenderness at
+the seat of fracture, with impaired movement of the limb. Displacement
+and crepitus are prevented by the splinting action of the ligaments.
+
+When the break is lateral to the attachment of the trapezoid ligament,
+the fracture is usually transverse, and is almost always due to a fall
+on the back of the shoulder--the angle between the spine and the
+acromion process striking the ground. The acromial fragment rotates
+forward (Fig. 14), sometimes even to a right angle, causing the tip of
+the shoulder to pass forwards, and so to lie slightly nearer the
+middle line. The integrity of the coraco-clavicular ligaments prevents
+any marked drooping of the shoulder. It is noteworthy that the
+displacement is not always evident at first.
+
+Fractures of the _medial_ or _sternal third_ are rare, are usually
+oblique, and result either from an indirect force acting in the line
+of the clavicle, or, less frequently, from direct violence or muscular
+action. As a rule, the deformity is insignificant, except when the
+costo-clavicular ligament is torn, in which case the medial end of the
+distal fragment is tilted up by the weight of the arm. The shoulder
+passes downwards, forwards, and medially. When close to the sternal
+end, this fracture may simulate a dislocation of the sterno-clavicular
+joint or a _separation of the clavicular epiphysis_. This last is a
+rare accident, which may occur between the seventeenth and the
+twenty-fifth years, and is usually the result of violent muscular
+action. It differs from the other injuries in this region in being
+more easily reduced and retained in position, the epiphysis lying
+entirely within the limits of the articular capsule of the
+sterno-clavicular joint.
+
+_Simultaneous fracture of both clavicles_ usually results from a
+severe transverse crush of the upper part of the thorax or from a fall
+on the outstretched hands--for example, in hunting. The middle third
+of the bone is implicated, and there is marked displacement and
+overriding. The patient is rendered helpless, and from the extrinsic
+muscles of respiration being thrown out of action and the weight of
+the powerless limbs pressing on the chest, there is considerable
+difficulty in breathing, and this is often increased by the fracture
+being complicated by injuries of the lung or pleura.
+
+The _prognosis_ as to union in all these injuries is good. Firm bony
+union usually occurs within twenty-one days. Non-union, false-joint,
+or fibrous union is but rarely met with. At the same time it is to be
+borne in mind that, in spite of all precautions, some deformity and
+shortening may result, without, however, interfering with the
+usefulness of the limb.
+
+_Treatment._--The displacement in complete fractures of the clavicle
+is readily reduced by supporting the elbow, bracing back the
+shoulders, and levering out the tip of the affected shoulder. In a few
+cases the interposition of some fibres of the subclavius muscle
+between the fragments has prevented perfect reduction.
+
+In the greenstick variety the bone may be bent back into its normal
+position, but no great force should be employed, as, in spite of
+imperfect reduction, the clavicle usually straightens as it grows, and
+although some deformity may persist, the function of the limb is not
+interfered with.
+
+_Recumbent Position._--There is little doubt that the most perfect
+æsthetic results are obtained by treating the patient in the recumbent
+position. In girls, therefore, in whom it is desired that the
+shoulders should be perfectly symmetrical, the best results are
+obtained from placing the patient on a firm mattress, with a narrow,
+firm cushion between the shoulder-blades, so that the weight of the
+shoulder may carry the acromial fragment laterally and backwards. A
+pad is inserted in the axilla, the elbow raised, and the arm placed by
+the side on a pillow and steadied with sand-bags. Massage is applied
+daily. As this position must be maintained uninterruptedly for two or
+three weeks, it proves too irksome for most patients. When both
+clavicles are fractured, however, it is, short of operation, the only
+available method of treatment.
+
+In ordinary cases the arm should be placed in that position which
+gives the best alignment of the fragments and least deformity. A thin
+layer of wool is placed in the axilla to separate the skin surfaces. A
+sling, supporting the _elbow_, is now applied, maintaining the arm in
+position, and a body bandage fixes the arm to the side. Massage and
+movement should be commenced at once.
+
+A simple method, which yields satisfactory results, is that suggested
+by Wharton Hood. The fracture having been reduced, three strips of
+adhesive plaster, each an inch and a half wide, are applied from a
+point immediately above the nipple to a point 2 inches below the angle
+of the scapula (Fig. 15). The middle strap covers the seat of
+fracture, and is applied first: the others, slightly overlapping it,
+extend about half an inch on either side. The elbow is supported in a
+sling. This plan has the advantage that it permits of movement of the
+shoulder being carried out from the first, but the plaster rather
+interferes with massage.
+
+_The Handkerchief Method._--In cases of emergency, one of the best
+methods applicable to all fractures of the clavicle is to brace back
+the shoulders by means of two padded handkerchiefs, folded _en
+cravate_, placed well over the tips of the shoulders and tied, or
+interlaced, between the scapulæ. The forearm is then supported by a
+third handkerchief applied as a sling, the base of which is placed
+under the elbow, the ends passing over the sound shoulder.
+
+_Operative treatment_ may be called for in compound or comminuted
+fractures when the fragments have injured, or are likely to injure,
+the subclavian vessels or the cords of the brachial plexus, or when it
+is otherwise impossible to reduce the fracture or to retain the
+fragments in apposition. It is also indicated in some cases of
+fracture of both clavicles.
+
+These various methods of treatment are not equally applicable to all
+cases. In our experience, in the circumstances indicated, the
+following methods have proved the most satisfactory: (1) As a
+temporary means of retention in emergency cases,--for example,
+accidents occurring on the football field,--the handkerchief method.
+(2) In uncomplicated fractures of average severity in any part of the
+bone, the method of sling and body bandage. (3) In cases where, for
+æsthetic reasons, the chief consideration is the avoidance of
+deformity and the maintenance of the symmetry of the shoulders, as in
+girls, the treatment by recumbency. (4) When retentive apparatus
+fails, or when the fragments are exerting injurious pressure,
+operative treatment.
+
+[Illustration: FIG. 15.--Adhesive Plaster applied for Fracture of
+Clavicle.]
+
+In quite a number of cases, there is an excessive amount of pain,
+preventing sleep; where this is due to cramp-like contractions of the
+muscles and movements of the fragments, it is relieved by more
+accurate fixation, as by strips of plaster; otherwise a hypodermic
+injection of heroin or morphin is indicated.
+
+
+DISLOCATION OF THE CLAVICLE
+
+Dislocation of the #acromial end#--sometimes, and perhaps more
+correctly, spoken of as dislocation of the scapula--is more frequent
+than that at the sternal end, and it usually results from a blow from
+behind, or from a fall on the tip of the shoulder, driving down the
+scapula, so that the clavicle projects _upwards_ and overrides the
+acromion process.
+
+_Downward_ displacement of the acromial end of the clavicle is much
+rarer, and may follow a fall on the elbow or a blow over the clavicle.
+The end of the bone lies under the acromion process, in contact with
+the capsule of the shoulder-joint, and the acromion stands out
+prominently.
+
+The _clinical features_ are so well marked that the diagnosis is
+unmistakable. The head inclines towards the affected side, and the tip
+of the shoulder tends to pass slightly downward, forward, and
+medially. The displaced end of the bone can be seen and felt as a
+prominence under the skin, or the empty socket can be palpated, while
+the muscles attached to the displaced clavicle stand out in relief.
+The movements at the shoulder are restricted, particularly in the
+direction of abduction above the level of the shoulder. These injuries
+are sometimes associated with fracture of the ribs, a complication
+which adds materially to the difficulties of treatment.
+
+_Treatment._--Reduction is easily effected by bracing back the
+shoulders and replacing the bone in its socket by manipulation; but
+retention is invariably difficult, and in many cases impossible; even
+when the displacement is permanent, however, the usefulness of the arm
+is not necessarily impaired.
+
+Treatment is similar to that for fracture of the clavicle by sling and
+body bandage. Another plan is to place a pad over the acromial end of
+the clavicle, and fix it in this position by a few turns of elastic
+bandage carried over the shoulder and under the elbow. The forearm is
+placed in a sling with the elbow well supported, and the arm is bound
+to the side by a circular bandage. When the bone cannot be kept in
+position and the usefulness of the limb is impaired, the joint
+surfaces may be rawed and the bones wired, with a view to obtaining
+ankylosis.
+
+#The sternal end# may be dislocated forwards, backwards, or upwards.
+
+_Forward_ dislocation is the most common; the end of the clavicle lies
+on the front of the sternum, somewhat below the level of the
+sterno-clavicular joint, and its articular surface can be distinctly
+palpated (Fig. 16). The inter-articular cartilage sometimes remains
+attached to one bone, sometimes to the other; the rhomboid ligament is
+usually intact.
+
+In the _backward_ dislocation the end of the clavicle lies behind the
+manubrium sterni and the muscles attached to it; there is a marked
+hollow in the position of the joint, and the facet on the sternum can
+be felt. In a comparatively small number of cases the bone exerts
+pressure upon the trachea and oesophagus, producing difficulty in
+breathing and swallowing. It has also been known to press upon the
+subclavian artery and on other important structures at the root of the
+neck.
+
+[Illustration: FIG. 16.--Forward Dislocation of Sternal End of Right
+Clavicle. From a fall on a polished floor, in a man æt. 40.]
+
+In rare cases the rhomboid ligament is torn, and the end of the
+clavicle passes _upwards_, and rests in the episternal notch behind
+the sterno-mastoid muscle.
+
+The bone may be retained in position by keeping the shoulders braced
+back by a figure-of-eight bandage, or by padded handkerchiefs, and
+making pressure over the displaced end of the bone with a pad. The
+forearm is supported by a sling, and the arm fixed to the side.
+Massage is employed from the first, and the patient is allowed to move
+the arm by the end of a week. Imperfect reduction interferes so little
+with the functions of the limb that operative measures are seldom
+required except for æsthetic reasons.
+
+Dislocation of #both ends# of the clavicle has occasionally occurred
+from a severe crush. The ultimate result has been satisfactory, as one
+or other end has always healed in normal position, and the function of
+the arm has thus been maintained.
+
+
+DISLOCATION OF THE SHOULDER
+
+The shoulder is more frequently dislocated than all the other joints
+in the body taken together. This is explained by its exposed position,
+the wide range of movement of which it is capable, the length of the
+lever afforded by the humerus, and the anatomical construction of the
+joint--the large, round humeral head imperfectly fitting the small and
+shallow glenoid cavity, and the ligaments being comparatively lax and
+thin. The capsule of the joint is materially strengthened in its upper
+and back parts by the tendons of the supra- and infra-spinatus and
+teres minor muscles; while it is weakest below and in front, between
+the subscapularis and teres major tendons. It is here that it most
+frequently gives way and allows of the escape of the head of the bone.
+The determining factor is probably that when the arm is abducted the
+neck of the humerus comes in contact with the tip of the acromion, and
+further abduction forces the head against the lower, weak portion of
+the capsule, which gives way.
+
+The violence is usually transmitted from the hand or elbow, less
+frequently from the lateral aspect of the shoulder, the limb being
+usually abducted and the muscles relaxed and taken unawares. The head
+of the humerus, thus brought to bear on the weakest part of the
+capsule, ruptures it and passes out through the rent. Dislocation is
+readily produced in an unconscious person--as, for example, in
+conducting artificial respiration in a patient suffering from opium
+poisoning, the arms being hyper-abducted to exert traction on the
+chest.
+
+_Varieties._--Several varieties of dislocation are recognised,
+according to the position in which the head of the humerus finally
+rests (Fig. 17). The simplest of these is the _sub-glenoid_ variety,
+in which the head rests on the long tendon of the triceps, where it
+arises from the axillary border of the scapula just below the glenoid
+cavity. In almost all dislocations of the shoulder the head of the
+bone is at least momentarily in this position, but the sharp edge of
+the scapula and the rounded head are ill adapted to one another, and
+the position is not long maintained. The subsequent course taken by
+the humerus depends upon the nature and direction of the force, the
+position of the limb at the moment of injury, and the relative
+strength and capacity for effective action of the different groups of
+muscles acting upon the bone.
+
+[Illustration: FIG. 17.--Diagram of most common varieties of
+Dislocation of the Shoulder.]
+
+In the great majority of cases it passes forward and medially, and
+comes to lie against the anterior surface of the neck of the
+scapula, under cover of the tendons of origin of the biceps and
+coraco-brachialis muscles, constituting the _sub-coracoid
+dislocation_. Much less frequently it passes under cover of the
+pectoralis minor and against the edge of the clavicle--the
+_sub-clavicular_ variety. In rare cases the head passes backward and
+lies against the spine on the dorsum of the scapula, beneath the
+infra-spinatus muscle--the _sub-spinous_ variety. Other varieties are
+so rare that they do not call for mention.
+
+_Clinical Features common to all Varieties._--Dislocation of the
+shoulder is commonest in adult males; in advanced life the proportion
+of female sufferers increases. It is usually attended with great pain,
+and there is often numbness of the limb due to pressure of the head of
+the bone upon the large nerve-trunks. There is sometimes considerable
+shock. The patient inclines his head towards the injured side, and,
+while standing, the forearm is supported by the hand of the opposite
+side. The acromion process stands out prominently, the roundness of
+the shoulder giving place to a flattening or depression immediately
+below it, so that a straight-edge applied to the lateral aspect of the
+limb touches both the acromion and the lateral epicondyle. The
+vertical circumference of the shoulder is markedly increased; this
+test is easily made with a piece of tape or bandage and is compared
+with a similar measurement on the normal side--we lay great stress on
+this simple measure, as it is a most reliable aid in diagnosis. The
+head of the bone can usually be felt in its new position, and the axis
+of the humerus is correspondingly altered, the elbow being carried
+from the side--forward or backward according to the position of the
+head. The empty glenoid may sometimes be palpated from the axilla. In
+most cases, although not in all, the patient is unable at one and the
+same time to bring his elbow to the side and to place his hand upon
+the opposite shoulder (Dugas' symptom). Measurements of the length of
+the limb from acromion to lateral epicondyle are rarely of any
+diagnostic value.
+
+The #sub-coracoid dislocation# (Fig. 18) is that most frequently met
+with. It usually results from hyper-abduction of the arm while the
+scapula is fixed, as in a fall on the medial side of the elbow when
+the arm is abducted from the side. The surgical neck of the humerus is
+then brought to bear upon the under aspect of the acromion, which
+forms a fulcrum, and the head of the bone is pressed against the
+medial and lower part of the capsule. In some cases muscular action
+produces this dislocation; it may also result from force applied
+directly to the upper end of the humerus.
+
+[Illustration: FIG. 18.--Sub-coracoid Dislocation of Right Shoulder.]
+
+The head leaves the capsule through the rent made in its lower part,
+and, either from a continuation of the force or from contraction of
+the muscles inserted into the inter-tubercular (bicipital) groove,
+particularly the great pectoral, passes medially under cover of the
+biceps and coraco-brachialis till it comes to rest against the
+anterior surface of the neck of the scapula, just below the coracoid
+process. The anatomical neck of the humerus presses against the
+anterior edge of the glenoid, and there is frequently an _indentation
+fracture of the head of the humerus_ where the two bones come into
+contact (F. M. Caird). The subscapularis is bruised or torn, the
+muscles inserted into the great tuberosity are greatly stretched, or
+the tuberosity itself may be avulsed, allowing the long tendon of the
+biceps to slip laterally, where it may form an impediment to
+reduction. The axillary (circumflex) nerve is often bruised or torn,
+and the head of the humerus is liable to press injuriously on the
+nerves and vessels in the axilla.
+
+The _clinical features_ common to all dislocations are prominent,
+although Dugas' symptom is not constant.
+
+[Illustration: FIG. 19.--Sub-coracoid Dislocation of Humerus.
+
+(Sir H. J. Stiles' case. Radiogram by Dr. Edmund Price.)]
+
+_Treatment._--The guiding principle in the reduction of these
+dislocations is to make the head of the bone retrace the course it
+took in leaving the socket. The main obstacles to reduction being
+muscular contraction and the entanglement of the head with tendons,
+ligaments, or bony points, appropriate means must be taken to
+counteract each of these factors.
+
+A general anæsthetic is an invaluable aid to reduction, and should be
+given unless there is some reason for withholding it. It is specially
+indicated in strong muscular subjects, and in nervous patients who do
+not bear pain well, and particularly when the dislocation has existed
+for a day or two. In quite recent cases, however, the surgeon may
+succeed in replacing the bone by taking advantage of a temporary
+faintness, or by engaging the patient's attention with other matters
+while he carries out the appropriate manipulations.
+
+When an anæsthetic is employed, the patient should be laid on a
+mattress on the floor, or on a narrow, firm table; otherwise he should
+be seated on a chair.
+
+_Kocher's method_ is suitable for the great majority of cases of
+sub-coracoid dislocation. (1) The elbow is firmly pressed against the
+side, and the forearm flexed to a right angle. The surgeon grasps the
+wrist and elbow and firmly _rotates the humerus away from the middle
+line_ (Fig. 20) till distinct resistance is felt and the deltoid
+becomes more prominent. In this way the rent in the lower part of the
+capsule is made to gape, and the head of the humerus rolls away from
+the middle line till it lies opposite the opening, rotation taking
+place about the fixed point formed by the contact of the anatomical
+neck of the humerus with the anterior lip of the glenoid cavity (D.
+Waterston). (2) _The elbow is next carried forward, upward, and
+towards the middle line_ (Fig. 21); the humerus acting as the long arm
+of a lever on the fulcrum furnished by the muscles inserted in the
+region of the surgical neck, the head, which forms the short arm of
+the lever, is carried backward, downward, and laterally, and is thus
+directed towards the socket. (3) The humerus is now _rotated towards
+the middle line_ by carrying the hand across the chest towards the
+opposite shoulder (Fig. 22). The anatomical neck of the humerus is
+thus disengaged from the edge of the glenoid, and the head is pulled
+into the socket by the tension of the surrounding muscles.
+
+[Illustration: FIG. 20.--Kocher's Method of reducing Sub-coracoid
+Dislocation--First Movement; Rotation of Arm away from Middle Line.]
+
+[Illustration: FIG. 21.--Kocher's Method--Second Movement; Elbow
+carried forward, upward, and towards the Middle Line.]
+
+[Illustration: FIG. 22.--Kocher's Method--Third Movement; Rotation of
+Arm towards Middle Line.]
+
+A method of reduction has been formulated by A. G. Miller, which we
+have found to be quite as successful as Kocher's method. The limb is
+grasped above the wrist and elbow, the forearm flexed to a right
+angle, and the upper arm abducted to the horizontal (Fig. 23). While
+an assistant makes counter-extension and fixes the scapula, the
+surgeon gradually draws the arm away from the body till the head of
+the humerus is felt to pass laterally. The humerus is then rotated
+medially by dropping the hand (Fig. 24), and the bone gradually glides
+into the socket.
+
+[Illustration: FIG. 23.--Miller's Method of reducing Sub-coracoid
+Dislocation--First Movement.]
+
+[Illustration: FIG. 24.--Miller's Method of reducing Sub-coracoid
+Dislocation--Second Movement.]
+
+In a certain number of cases reduction can be effected by
+_hyper-abduction_ of the shoulder with traction. The patient is laid
+upon a firm mattress, and the surgeon, seated behind him while an
+assistant fixes the acromion, slowly and steadily extends the arm
+until it is raised well above the head. In some cases the head of the
+humerus spontaneously slips into its socket; in others it may be
+manipulated into position by pressure from the axilla. This method is
+restricted to recent cases, as in those of long standing the axillary
+vessels are liable to be stretched or torn.
+
+The method of reduction by traction on the arm with the heel in the
+axilla is only to be used when other measures have failed, as it
+depends for its success on sheer force.
+
+_After-Treatment._--After reduction, the part is gently massaged for
+ten or fifteen minutes, a layer of wool is placed in the axilla, the
+forearm is supported by a sling, and the arm fixed to the side by a
+circular bandage. Massage is carried out from the first, and movement
+of the shoulder in every direction except that of abduction may be
+commenced on the first or second day. The circular bandage may be
+dispensed with at the end of a week, and abduction movements
+commenced, and by the end of a month the patient should be advised to
+use the arm freely.
+
+The #sub-clavicular dislocation# (Fig. 17) is to be looked upon as an
+exaggerated degree of the sub-coracoid rather than as a separate
+variety. It is produced by the same mechanism, but the violence is
+greater, and the damage to the soft parts more severe. The head passes
+farther upwards and towards the middle line under cover of the
+pectoralis minor, resting under the clavicle against the serratus
+anterior and chest wall. The symptoms are usually so marked that they
+leave no doubt as to the diagnosis. The outline of the head of the
+humerus in its abnormal position is visible through the skin, and the
+shortening of the limb is more marked than in the sub-coracoid
+variety. The treatment is the same as for sub-coracoid dislocation.
+
+#Sub-glenoid dislocation# (Fig. 17) is less frequently met with than
+the sub-coracoid variety, and almost always results from forcible
+abduction of the arm. The head of the humerus passes out through a
+small rent in the lower and medial portion of the capsule, and rests
+against the anterior edge of the triangular surface immediately below
+the glenoid cavity, supported behind by the long head of the triceps,
+and in front by the subscapularis muscle. It is readily felt in the
+axilla. All the tendons in relation to the upper end of the humerus
+are stretched or torn, and the great tuberosity is not infrequently
+avulsed. There is sometimes bruising of the axillary nerve.
+
+The projection of the acromion, the flattening of the deltoid, the
+increased depth of the axillary fold, and the abduction of the elbow
+are well marked; the arm is slightly lengthened, rotated out, and
+carried forward. It is reduced by the hyper-abduction method (p. 60).
+
+#Sub-spinous Dislocation.#--Backward dislocation is usually termed
+sub-spinous, although in a considerable proportion of cases the head
+of the humerus does not pass beyond the root of the acromion process
+(_sub-acromial_) (Fig. 17). This dislocation is usually produced by a
+fall on the elbow, the arm being at the moment adducted and rotated
+medially, so that the head of the humerus is pressed backwards and
+laterally against the capsule, which ruptures posteriorly. All the
+muscles attached to the upper end of the humerus are liable to be
+torn, and the tuberosities are frequently avulsed. The long tendon of
+the biceps may slip from its position between the tuberosities, and
+prevent reduction or favour re-dislocation, necessitating an open
+operation.
+
+In the milder cases the _clinical features_ are not always well
+marked, and on account of the swelling this dislocation is apt to be
+overlooked. In addition to the ordinary symptoms, the shoulder is
+broadened, there is a marked hollow in front in which the coracoid
+projects, and the arm is held close to the side with the elbow
+directed forward. The head of the bone may be seen and felt in its
+abnormal position below the spine of the scapula.
+
+Reduction can usually be effected by making traction on the arm with
+medial rotation, and pressing the head forward into position, while
+counter-pressure is made upon the acromion.
+
+_Prognosis._--The ultimate prognosis in dislocations of the shoulder
+should always be guarded. The axillary nerve may be stretched or torn,
+and this may lead to atrophy of the deltoid; or other branches of the
+brachial plexus may be injured and the muscles they supply permanently
+weakened. In a certain number of cases traumatic neuritis has resulted
+in serious disability of the limb. The movements of the shoulder-joint
+may be restricted by cicatricial contraction of the torn portion of
+the capsule and of the damaged muscles. A marked tendency to recurrent
+dislocation may follow if abduction movements are permitted before
+repair of the capsule has had time to occur.
+
+#Dislocation of the Shoulder complicated with Fracture of the Upper
+End of the Humerus.#--In these injuries the dislocation is almost
+always of the sub-coracoid variety, and the most common fractures by
+which it is complicated are those of the surgical neck, the anatomical
+neck, or the greater tuberosity. The most common cause is a fall
+directly on the shoulder, and it seems probable that the head of the
+bone is first dislocated, and, the force continuing to act, the upper
+end of the humerus is then broken; or the two lesions may be produced
+synchronously.
+
+When seen soon after the accident, the existence of the fracture of
+the humerus is liable to be overlooked, the condition being mistaken
+for dislocation alone, or for a fracture through the neck of the
+scapula. On careful examination under an anæsthetic, however, it is
+observed that not only is the head of the humerus absent from the
+glenoid cavity, but that it does not move with the rest of the bone,
+abnormal mobility and crepitus are recognised at the seat of fracture,
+and the upper arm is shortened. The extravasation in the axilla is
+usually greater than that accompanying a simple dislocation, and the
+pain and shock are more severe. A fracture through the neck of the
+scapula alone is readily recognised by the ease with which the
+deformity is reduced, and the way in which it at once recurs when the
+support is withdrawn. In many cases it is only by the aid of a
+radiogram that an accurate diagnosis can be made (Fig. 25).
+
+[Illustration: FIG. 25.--Dislocation of Shoulder with Fracture of Neck
+of Humerus.
+
+(Sir Robert Jones' case. Radiogram by Dr. D. Morgan.)]
+
+_Treatment._--Unless the dislocation is reduced at once, the movements
+of the arm are certain to be seriously restricted, and painful
+pressure effects from excess of callus are liable to ensue. An attempt
+should first be made, under anæsthesia, to replace the head in its
+socket, by making extension on the arm in the hyper-abducted
+(vertical) position, and manipulating the upper fragment from the
+axilla.
+
+On no account should the lower fragment be employed as a lever in
+attempting reduction. When reduction by manipulation fails, recourse
+should be had to an open operation. The upper fragment should be
+exposed by an incision over its lateral aspect, and made to return to
+the socket by using Arbuthnot Lane's levers or M'Burney's hook, or a
+long steel pin may be inserted into the fragment to give the necessary
+leverage.
+
+Reduction having been accomplished, the fracture is adjusted in the
+usual way, advantage being taken of the open wound, if necessary, to
+fix the fragments together by plates. The best position in which to
+fix the limb is that of abduction at a right angle. Massage and
+movement should be commenced early to prevent stiffness of the joint.
+
+When it is found impossible to reduce the dislocation, it is usually
+advisable to remove the upper fragment.
+
+The method of allowing the fracture to unite without reducing the
+dislocation, and then attempting reduction, usually results in
+re-breaking the bone, or else in failure to replace the head in the
+socket, and has nothing to recommend it.
+
+#Old-standing Dislocation of the Shoulder.#--It is impossible to lay
+down definite rules as to the date after which it is inadvisable to
+attempt reduction by manipulation of an old-standing dislocation of
+the shoulder. Experience of a hundred cases in Bruns' clinic led
+Finckh to conclude that, provided there are no complications,
+reduction can generally be effected within four weeks of the accident;
+that within nine weeks the prospect of success is fairly good; but
+that beyond that time reduction is exceptional.
+
+The patient is anæsthetised, and all adhesions broken down by free yet
+gentle movement of the limb. The appropriate manipulations for the
+particular dislocation are then carried out, care being taken that no
+undue force is employed, as the humerus is liable to be broken. If
+these are not successful, they should be repeated at intervals of two
+or three days, as it is frequently found that reduction is
+successfully effected on a second or third attempt.
+
+Should manipulative measures fail, it may be advisable to have
+recourse to operation if the age of the patient and his general health
+warrant it, and if the condition of the limb is interfering with his
+occupation or involves serious disability. If operation is deemed
+advisable, a few days should be allowed to elapse to permit of the
+parts recovering from the effects of the manipulations. The joint is
+freely exposed, the capsule divided, the head of the bone freed and
+returned to the glenoid cavity. It is sometimes so difficult to
+replace the head of the bone that it is necessary to resect it and aim
+at the formation of a new joint, an operation which usually yields
+satisfactory results.
+
+#Habitual or Recurrent Dislocation.#--Cases are occasionally met with
+in which the shoulder-joint shows a marked tendency to be dislocated
+from causes altogether insufficient to produce displacement under
+ordinary circumstances. This condition is usually met with in young
+women, and, in some cases at least, appears to be due to too early and
+too free movement of the joint after an ordinary dislocation, so that
+the capsule is stretched and remains lax. In some cases it would
+appear that the liability to dislocation is due to some structural
+defect in the joint, and under these conditions both sides are
+sometimes affected, and the accident is not attended with the usual
+pain and disability either at the time or after reduction. The
+facility and frequency with which dislocation recurs render the limb
+comparatively useless, and may seriously incapacitate the patient. We
+have had cases under observation in which dislocation resulted from
+the hyper-abduction of the arm in swimming, from throwing the arms
+above the head in dancing and in gymnastic exercises, and even in
+"doing" the hair.
+
+The _treatment_ consists in preventing the patient making the
+particular movements which tend to produce the dislocation. These are
+chiefly movements of hyper-abduction and overhead movements; we have
+found an apparatus consisting of a belt applied around the thorax, and
+fixed to another around the upper arm by a band which passes above the
+axillary fold of the dress, useful in restraining these movements. If
+these measures fail, it may be advisable to have recourse to
+operation; this may consist in tightening up the capsule, the results
+of which are said to be uncertain, or in detaching a portion of the
+deltoid or subscapularis muscle and stitching it beneath the joint to
+cover and strengthen the weakened portion of the capsule. It is
+suggestive that in performing this operation no rent in the capsule is
+discovered.
+
+The condition is also met with in epileptics; and it is generally
+found that the head of the bone is deficient, as a result either of
+fracture or disease; that the muscles which naturally support the
+joint are atrophied or torn; and that the capsule is unduly lax.
+
+#Sprain# of the shoulder-joint is comparatively rare, because of the
+wide range of movement of which it is capable. The region of the
+shoulder becomes swollen and tender to pressure, the point of maximum
+tenderness being over the front of the joint, just below the acromion
+process; pain is elicited also when the ligaments or tendons are put
+upon the stretch.
+
+#Contusion# of the region of the shoulder, on the other hand, is
+exceedingly common. In most cases it is merely the deltoid muscle and
+the subcutaneous tissue over it that are bruised, but sometimes a
+hæmatoma forms either in the muscle or in the sub-deltoid bursa. There
+is pain on moving the limb, and the patient may be unable to abduct
+the arm at the shoulder-joint. Under treatment by massage and
+movement, the symptoms usually pass off completely in two or three
+weeks. The affections of the _bursa_ are described elsewhere.
+
+In other cases, the cords of the brachial plexus above the clavicle
+are stretched, or the axillary nerve is bruised, and these injuries
+are liable to be followed by prolonged pain, loss of abduction, and
+stiffness in the arm. The deltoid frequently undergoes considerable
+atrophy, and there is severe neuralgic pain in the axillary nerve,
+especially marked in the region of the insertion of the deltoid.
+
+In addition to maintaining the limb in the abducted position, it is
+necessary to keep up the nutrition of the muscles by massage and
+electricity.
+
+
+FRACTURE OF THE SCAPULA
+
+Fractures of the scapula may implicate the body, the surgical neck,
+the acromion, or the coracoid process. They are rarely compound.
+
+#Fracture of the Body.#--Considering its exposed position, the body of
+the scapula is comparatively seldom fractured, doubtless because of
+its mobility, and the support it receives from the elastic ribs and
+soft muscular cushions on which it lies. Apart from gun-shot injuries,
+it is most frequently broken by a severe blow or crush. The scapula
+presents two natural arches--one longitudinal, the other
+transverse--and when the bone is crushed or struck, the force produces
+fracture by undoing its curves (E. H. Bennett). A main fissure usually
+runs transversely across the infra-spinous fossa, and secondary cracks
+radiate from it (Fig. 26). In other cases the line of the primary
+fracture is longitudinal, passing through the spine and involving both
+fossæ.
+
+[Illustration: FIG. 26.--Transverse Fracture of Scapula, with fissures
+radiating into spinous process and dorsum.]
+
+The _clinical features_ are obscured by swelling of the overlying soft
+parts. Crepitus may sometimes be elicited by placing one hand firmly
+over the bone, and with the other moving the arm and shoulder. When
+the spine is implicated, the fragments may be grasped and made to move
+one upon another. The displacement, which usually consists in
+overlapping of the fragments--although sometimes they are drawn
+apart--is partly due to the action of the serratus anterior and teres
+major muscles, and partly depends on the direction of the force.
+Movement is restricted and painful. Osseous union usually takes place
+rapidly, and although displacement often persists, the function of the
+limb is unimpaired.
+
+_Treatment._--As these fractures are usually complicated by other
+injuries, especially of the thorax, and are accompanied by severe
+shock, it is necessary to confine the patient to bed. It is usually
+sufficient to fix the arm and shoulder to the chest wall by a firm
+binder, in the position which admits of the most complete apposition
+of fragments. This retentive apparatus is employed for about three
+weeks, after which the patient is allowed to use his arm. The bandages
+are removed daily to admit of massage.
+
+#Fracture of the surgical neck of the scapula#, although a rare
+accident, is of importance, as it is liable to be mistaken for
+dislocation of the shoulder. The line of fracture runs through the
+scapular notch, downwards and laterally to the lower margin of the
+glenoid, so that the glenoid and the coracoid process are separated
+from the rest of the bone.
+
+The coraco-acromial and coraco-clavicular ligaments are usually torn,
+and the detached fragment, along with the head of the humerus, sinks
+into the axilla, causing a flattening of the shoulder, and leaving a
+depression below the projecting acromion. These signs may be obscured
+by the general swelling of the shoulder. The arm may be lengthened
+about an inch. By supporting the arm the deformity is at once reduced,
+but recurs as soon as the support is withdrawn. Crepitus is usually
+detected on carrying out this manipulation; and the coracoid process
+is found to move with the arm and not with the scapula. By these
+tests, and by the X-rays, this injury is distinguished from a
+dislocation.
+
+A partial fracture carrying away the lower part of the _glenoid
+cavity_ simulates a sub-glenoid dislocation. This is, however, a rare
+injury.
+
+The _treatment_ consists in bracing back the shoulders and supporting
+the elbow, and this is most satisfactorily done by a body bandage and
+sling for the elbow, as for fracture of the middle third of the
+clavicle. Passive movements and massage are employed from the first.
+
+#Fracture of the acromion process# may result from a blow or fall on
+the shoulder. It is often overlooked on account of the swelling
+resulting from bruising of the soft parts, and the absence of marked
+displacement. On palpation, crepitus and an irregularity at the seat
+of fracture may sometimes be detected. The shoulder is slightly
+flattened, and abduction of the arm is difficult. In rare cases the
+fracture passes into the acromio-clavicular joint, and is associated
+with dislocation of the clavicle.
+
+In connection with this fracture, reference must be made to a
+condition frequently met with, in which the epiphysial portion
+of the acromion is found to be separate from the body of the
+process--_separate acromion_. This is by some (Symington, Hamilton)
+looked upon as a want of union of the epiphysis, but the weight of
+evidence seems to prove that it is rather of the nature of an
+un-united fracture at this level, even when, as sometimes happens, it
+is bilateral (Struthers, Arbuthnot Lane).
+
+Between the fourteenth and twenty-second years a true _separation of
+the epiphysis_ may be met with, but it is seldom possible to make a
+positive diagnosis of this injury. As is the case in all fractures of
+the acromion, bony union seldom takes place.
+
+The _treatment_ is the same as for fracture of the lateral end of the
+clavicle.
+
+#Fracture of the coracoid process# is rare. It may result from direct
+violence, such as the recoil of a gun, but it is more often an
+accompaniment of dislocation of the shoulder or of the lateral end of
+the clavicle upward. As the coraco-clavicular ligaments usually remain
+intact, there is no displacement; but when these are torn the coracoid
+is dragged downwards and laterally by the combined action of the
+pectoralis minor, biceps, and coraco-brachialis muscles. Crepitus may
+be elicited on moving the fragment. _Separation of the epiphysial
+portion_ of the coracoid may occur up to the seventeenth year.
+
+The _treatment_ consists in placing the arm across the front of the
+chest, to relax the muscles causing the displacement, and retaining it
+in that position by a sling and roller bandage.
+
+
+FRACTURE OF THE UPPER END OF THE HUMERUS
+
+It is most convenient to study fractures of the upper end of the
+humerus in the following order: (1) fracture of the surgical neck; (2)
+separation of the epiphysis; (3) fracture of head, anatomical neck, or
+tuberosities.
+
+[Illustration: FIG. 27.--Fracture of Surgical Neck of Humerus, united
+with Angular Displacement.]
+
+#Fracture of the Surgical Neck.#--The surgical neck of the humerus
+extends from the level of the epiphysial junction to the insertion of
+the pectoralis major and teres major muscles, and it is within these
+limits that most fractures of the upper end of bone occur. This
+fracture is most common in adults, and usually follows direct violence
+applied to the shoulder, but may result from a fall on the hand or
+elbow, or from violent muscular action, as, for example, in throwing a
+stone. It is usually transverse, and there is often little or no
+displacement, the fragments being retained in position by the long
+tendon of the biceps and the long head of the triceps. When the
+fracture is oblique, the fragments are often comminuted, and sometimes
+impacted. The displacement of the upper fragment seems to depend upon
+the attitude of the limb at the moment of fracture. When the upper arm
+is approximated to the side, the upper fragment retains its vertical
+position, but is slightly rotated laterally by the muscles inserted
+into the greater tuberosity, while the lower fragment is drawn upwards
+and medially towards the coracoid process by the muscles inserted into
+the inter-tubercular groove and the longitudinal muscles of the upper
+arm, and can be felt in the axilla. The elbow points laterally and
+backwards, and the upper arm is shortened. The shoulder retains its
+rotundity, but there is a slight hollow some distance below the
+acromion. On grasping the elbow and moving the shaft, it is found that
+the head and tuberosities do not move with it, and unnatural mobility
+and crepitus at the seat of fracture may be detected. When the upper
+arm is abducted at the moment of fracture, the upper fragment is
+retained in that position by the lateral rotator and abductor muscles
+inserted into it, while the lower fragment passes upwards and
+medially.
+
+[Illustration: FIG. 28.--Impacted Fracture of Neck of Humerus, in man
+æt. 75.
+
+(Sir H. J. Stiles' case. Radiogram by Dr. Edmund Price.)]
+
+Although there is sometimes overlapping and broadening after union,
+beyond some limitation of the range of abduction the usefulness of the
+limb is seldom impaired.
+
+_Treatment._--Massage, by allaying spasm of the muscles, soon
+overcomes the moderate amount of displacement which is usually met
+with. Further, the skin surfaces of the axilla having been separated
+by a thin layer of cotton wool, a sling is applied to support the
+wrist, and the arm is bound to the side by a body bandage.
+
+In comminuted fractures and those with marked displacement, a general
+anæsthetic may be required to ensure accurate reduction; and to
+maintain the fragments in apposition, and to avoid any limitation of
+abduction after union, the limb may be fixed in the position of
+abduction at a right angle by means of a Thomas' arm splint with
+swivel ring, and extension applied, if necessary, to maintain this
+attitude. After a week or ten days the patient is allowed up, wearing
+an abduction frame (Fig. 29), or a splint, such as Middeldorpf's,
+which consists of a double inclined plane, the base of which is fixed
+to the patient's side, while the injured arm rests on the other two
+sides of the triangle. Massage and movement are employed daily.
+
+[Illustration: FIG. 29.--Ambulatory Abduction Splint for Fracture of
+Humerus.]
+
+Should these measures fail, the fracture may be exposed by an incision
+carried along the anterior border of the deltoid, and the ends
+mechanically fixed, after which the limb is put up in the abducted
+position for three or four weeks. Massage is commenced on the second
+or third day. Union is usually complete in about four weeks.
+
+#Separation of Epiphysis.#--The upper epiphysis of the humerus
+includes the head, both tuberosities, and the upper fourth of the
+inter-tubercular groove. On its under aspect is a cup-like depression
+into which the central pyramidal-shaped portion of the diaphysis fits.
+This epiphysis unites about the twenty-first year.
+
+[Illustration: FIG. 30.--Radiogram of Separation of Upper Epiphysis of
+Humerus.]
+
+Traumatic separation is met with chiefly between the fifth and
+fifteenth years, and is most common in boys. It usually results from
+forcible traction of the arm upwards and away from the side, as in
+lifting a child by the upper arm, or from direct violence, but may be
+caused by a fall on the lateral side of the elbow.
+
+The epiphysis, especially in young children, may be separated without
+being displaced, or the displacement may be incomplete.
+
+When the epiphysis is completely separated from the shaft, the
+clinical features closely resemble those of fracture of the surgical
+neck, and the diagnosis is made by a consideration of the age of the
+patient, and the muffled character of the crepitus, when it can be
+elicited. The upper end of the diaphysis forms a projecting ridge
+which may be felt below and in front of the acromion. The diagnosis
+can usually be established by the use of the X-rays (Fig. 30).
+Dislocation is rare at the age when separation of the epiphysis
+occurs.
+
+Reduction is often difficult on account of the periosteum and other
+soft tissues getting between the fragments, and on account of the
+small size of the upper fragment. Union almost invariably results, but
+the growth of the limb may be interfered with and its shape altered,
+especially when the injury occurs at an early age and its nature is
+overlooked.
+
+_Treatment._--This injury is treated on the same general lines as
+fracture of the surgical neck. General anæsthesia is almost always
+necessary to secure satisfactory reduction, and retention is most
+easily secured if the patient is confined to bed with the upper arm
+fixed in the fully abducted position. Operative treatment is called
+for in exceptional cases.
+
+#Fractures of the Head, Anatomical Neck, and Tuberosities of
+Humerus.#--These fractures are met with as accompaniments of
+dislocation of the shoulder, and as results of gun-shot injuries,
+blows, or falls.
+
+In sub-coracoid dislocation the _head_ of the humerus may be indented
+by coming in contact with the anterior edge of the glenoid cavity (F.
+M. Caird).
+
+The _anatomical neck_ may be fractured in an old person by a direct
+blow on the shoulder. In a few cases the fracture is entirely
+intra-capsular, the head of the bone remaining loose in the cavity of
+the joint. As a rule, however, the fracture passes laterally and
+implicates the tuberosities. In some cases there is impaction, and in
+others comminution of the fragments. The use of the X-rays has shown
+that in many cases in which prolonged stiffness has followed a severe
+blow of the shoulder, there has been a fracture of the anatomical
+neck.
+
+The _tuberosities_ may be implicated in other fractures in this region
+and in dislocation of the shoulder; and either of them may be
+separated by muscular contraction or by direct violence.
+
+_Clinically_ all these injuries are difficult to diagnose with
+accuracy, and, without the use of the X-rays, it is impossible in many
+cases to go further than to say that a fracture exists above the level
+of the surgical neck. Fracture of the anatomical neck is attended with
+little deformity beyond slight flattening of the shoulder and
+sometimes slight shortening of the upper arm.
+
+When the _great tuberosity_ is torn off, considerable antero-posterior
+broadening of the shoulder may be recognised by grasping the region of
+the tuberosities between the fingers and thumb. Crepitus can be
+elicited on rotating the humerus. At the same time it will be
+recognised that the tuberosity does not move with the shaft. Firm
+union, with considerable formation of callus and some broadening of
+the shoulder, usually results, but the usefulness of the joint is not
+necessarily impaired. There may, however, be prolonged stiffness and
+impaired movement from adhesion; or pain and crackling in the joint
+may result from arthritic changes like those of arthritis deformans.
+
+_Treatment._--These fractures are treated on the same lines as
+fracture of the surgical neck of the humerus.
+
+The combination of fracture of the upper end of the humerus with
+dislocation of the shoulder has already been referred to.
+
+
+FRACTURE OF THE SHAFT OF THE HUMERUS
+
+Fractures occurring in the shaft of the humerus between the surgical
+neck and the base of the condyles may, for convenience of description,
+be divided into those above, and those below, the level of the deltoid
+insertion--the majority being in the latter situation.
+
+Direct violence is the most common cause of these fractures, but they
+may occur from a fall on the elbow or hand; and a considerable number
+of cases are on record where the bone has been broken by muscular
+action--as in throwing a cricket-ball. Twisting forms of violence may
+produce spiral fractures.
+
+The fracture is usually transverse in children and in cases in which
+it is due to muscular action. In adults, when due to external
+violence, it is usually oblique, the fragments overriding one another
+and causing shortening of the limb. The displacement depends largely
+on the direction of the force and the line of fracture, but to a
+certain extent also on the action of muscles attached to the
+fragments. Thus, in fractures above the insertion of the deltoid the
+upper fragment is usually dragged towards the middle line by the
+muscles inserted into the inter-tubercular groove, while the lower is
+tilted laterally by the deltoid. When the break is below the deltoid
+insertion the displacement of the fragments is reversed. The signs of
+fracture--undue mobility, deformity, shortening, and crepitus--are at
+once evident, and the patient himself usually recognises that the bone
+is broken.
+
+The nerve-trunks in the arm--the median, ulnar, and radial
+(musculo-spiral)--are apt to be damaged in these injuries; in
+fractures of the lower part of the shaft the radial nerve is specially
+liable to be implicated. This may occur at the time of the injury, the
+nerve being contused by the force causing the fracture, or pressed
+upon by one or other of the fragments, or its fibres may be partly or
+completely torn across. When there is evidence of nerve injury, the
+practitioner should draw the attention of the patient to it then and
+there, and so guard himself against actions for malpraxis should
+paralysis of the muscles ensue. Later, the nerve may become involved
+in callus, or be damaged by the pressure of ill-fitting splints.
+Weakness or paralysis of the extensors of the wrist and hand results,
+giving rise to the characteristic "wrist-drop." The actions of the
+muscles should always be tested before applying splints, and each time
+the apparatus is removed or readjusted, to assure that no undue
+pressure is being exerted on the nerves.
+
+Union takes place in from four to six weeks in adults, and in from
+three to four weeks in children. Delayed union, or want of union and
+the formation of a false joint, is more common in fractures of the
+middle of the shaft of the humerus than in any other long bone--a
+point to be borne in mind in treatment. Arrest of growth in the bone
+from injury to the nutrient artery is also said to have occurred.
+
+_Treatment._--To restore the alignment of the bone, extension is made
+on the lower fragment and the ends are manipulated into position. This
+may necessitate the use of a general anæsthetic, and care must be
+taken that no soft tissue intervenes between the fragments, as is
+evidenced radiographically by the persistence of a clear space between
+the ends even when they appear to be in apposition.
+
+In _transverse_ fractures the position may be maintained by a simple
+ferrule of poroplastic or Gooch-splinting. The elbow is flexed at a
+right angle, and the forearm supported in a sling midway between
+pronation and supination. For a few days the limb may be bound to the
+chest by a broad roller bandage.
+
+[Illustration: FIG. 31.--"Cock-up" Splint, for maintaining
+Dorsiflexion at Wrist.]
+
+The splints are removed daily to admit of massage and movement being
+carried out, and while the splints are off, the patient is allowed to
+exercise the fingers and wrist. If at the end of four or five weeks,
+osseous union has not occurred, the reparative process may be hastened
+by inducing venous congestion by Bier's method.
+
+In _oblique and spiral_ fractures it is often necessary to control the
+shoulder and elbow-joints to prevent re-displacement. This can be done
+by means of a plaster of Paris case enclosing the upper part of the
+thorax, together with the upper arm, abducted, and the elbow, at right
+angles.
+
+[Illustration: FIG. 32.--Gooch Splints for Fracture of Shaft of
+Humerus; and Rectangular Splint to secure Elbow.]
+
+It is sometimes necessary to apply continuous extension to the lower
+fragment to prevent overriding. For this purpose a Thomas' arm splint
+is employed, the extension tapes being attached to its lower end, but
+care must be taken that the traction is not sufficient to separate
+the fragments and leave a gap between them. The elbow should not be
+retained in the extended position for more than three weeks.
+
+In rare cases it is necessary to have recourse to operative treatment.
+
+When there is evidence that the radial nerve has been injured, and no
+sign of improvement appears within three or four days of the accident,
+operative interference is indicated. An incision is made on the
+lateral side of the arm, and the nerve exposed and freed from
+pressure, or stitched, as may be necessary; the opportunity should
+also be taken of dealing with the fracture. The limb is put up in a
+"cock-up" splint, with the hand in the attitude of marked dorsiflexion
+(Fig. 31).
+
+Satisfactory results have been obtained without the use of splints, by
+relying upon massage to overcome the spasm of muscles, and allowing
+the weight of the arm to act as an extending force (J. W. Dowden and
+A. Pirie Watson).
+
+In cases of _un-united fracture_, a vertical or semilunar incision is
+made over the lateral aspect of the bone, and the muscles separated
+from one another till the fracture is exposed, care being taken to
+avoid injuring the radial nerve. The fibrous tissue is removed from
+the ends of the bone, and the rawed surfaces fixed in apposition; the
+wound is then closed, and appropriate retentive apparatus applied. As
+soon as the wound has healed, massage and movement are employed.
+
+
+
+
+CHAPTER IV
+
+INJURIES IN THE REGION OF THE ELBOW AND FOREARM
+
+
+Surgical Anatomy--Examination of injured elbow--FRACTURE OF LOWER END
+ OF HUMERUS: _Supra-condylar_; _Inter-condylar_; _Separation of
+ epiphysis_; _Fracture of either condyle alone_; _Fracture of
+ either epicondyle alone_--FRACTURE OF UPPER END OF ULNA:
+ _Olecranon_; _Coronoid_--FRACTURE OF UPPER END OF RADIUS: _Head_;
+ _Neck_; _Separation of epiphysis_--DISLOCATION OF ELBOW: _Both
+ bones_; _Ulna alone_; _Radius alone_--FRACTURE OF FOREARM: _Both
+ bones_; _Radius alone_; _Ulna alone_.
+
+The injuries met with in the region of the elbow-joint include the
+various fractures of the lower end of the humerus, and upper ends of
+the bones of the forearm, including the olecranon; and dislocations
+and sprains of the elbow-joint. The differential diagnosis is often
+exceedingly difficult on account of the swelling and tension which
+rapidly supervene on most of these injuries, the pain caused by
+manipulating the parts, and the difficulty of determining whether
+movement is taking place _at_ the joint or _near_ it.
+
+#Surgical Anatomy.#--The medial epicondyle of the humerus is more
+readily felt through the skin than the lateral. The two epicondyles
+are practically on the same level, and a line joining them behind
+passes just above the tip of the olecranon when the arm is fully
+extended. On flexing the joint, the tip of the olecranon gradually
+passes to the distal side of this line, and when the joint is fully
+flexed the tip of the olecranon is found to have passed through half a
+circle. The head of the radius can be felt to rotate in the dimple on
+the back of the elbow just below the lateral epicondyle. The coronoid
+process may be detected on making deep pressure in the hollow in front
+of the joint. As the line of the radio-humeral joint is horizontal,
+while that of the ulno-humeral joint slopes obliquely downwards, the
+arm forms with the fully extended and supinated forearm an obtuse
+angle, opening laterally--the "carrying angle." This angle is usually
+more marked in women, in harmony with the greater width of the female
+pelvis. The ulnar nerve lies in the hollow between the olecranon and
+the medial condyle, and the median nerve passes over the front of the
+joint, with the brachial artery and biceps tendon to its lateral side.
+The radial nerve divides into its superficial and deep (posterior
+interosseous) branches at the level of the lateral condyle.
+
+In _examining an injured elbow_, the thumb and middle finger are
+placed respectively on the two epicondyles, while the index locates
+the olecranon and traces its movements on flexion and extension of the
+joint. The movements of the head of the radius are best detected by
+pressing the thumb of one hand into the depression below the lateral
+epicondyle, while movements of pronation and supination are carried
+out by the other hand. The uninjured limb should always be examined
+for purposes of comparison.
+
+In injuries about the elbow much aid in diagnosis is usually obtained
+by the use of the X-rays; but in young children it is sometimes
+impossible, even with excellent pictures, to make an accurate
+diagnosis by means of radiograms alone. In cases of suspected
+fracture, a radiogram should be taken with the back of the limb
+resting on the plate, the forearm being extended and supinated. If a
+dislocation is suspected and a lateral view is desired, the arm should
+be placed on its medial side. In obscure cases it is useful to take
+radiograms of the healthy limb in the same position.
+
+
+FRACTURES OF THE LOWER END OF THE HUMERUS
+
+The following fractures occur at the lower end of the humerus: (1)
+supra-condylar fracture; (2) inter-condylar fracture; (3) separation
+of epiphyses; (4) fracture of either condyle alone; and (5) fracture
+of either epicondyle alone.
+
+All these injuries are common in children, and result from a direct
+fall or blow upon the elbow, or from a fall on the outstretched hand,
+especially when at the same time the joints are forcibly moved beyond
+their physiological limits, more particularly in the direction of
+pronation or abduction. While it is generally easy to diagnose the
+existence of a fracture, it is often exceedingly difficult to
+determine its exact nature. Although the ulnar and median nerves are
+liable to be injured in almost any of these fractures, they suffer
+much less frequently than might be expected.
+
+Ankylosis, or, more frequently, locking of the joint, is a common
+sequel to many of these injuries. This is explained by the difficulty
+of effecting complete reduction, and by the wide separation of
+periosteum which often occurs, favouring the production of an
+excessive amount of new bone, particularly in young subjects.
+
+The #supra-condylar# fracture usually results from a fall on the
+outstretched hand with the forearm partly flexed, from a direct blow,
+or from a twisting form of violence. The line of fracture is generally
+transverse, or but slightly oblique from behind downwards and
+forwards, so that the lower fragment is forced backward together with
+the bones of the forearm, simulating backward dislocation of the
+elbow; the lower end of the upper fragment lies in front (Fig. 33).
+
+[Illustration: FIG. 33.--Radiogram of Supra-condylar Fracture of
+Humerus, in a child æt. 7.]
+
+_Clinical Features._--The elbow is flexed at an angle of 120° or 130°,
+and the forearm, held semi-pronated, is supported by the other hand.
+Around the seat of fracture great swelling rapidly ensues. The
+olecranon projects behind, but the mutual relations of the bony points
+of the elbow are unaltered. The lower end of the upper fragment may be
+felt in front above the level of the joint, as a rough and sharp
+projection, and this sometimes pierces the soft parts and renders the
+fracture compound. Movement at the joint is possible, but unnatural
+mobility may be detected above the level of the joint. Crepitus and
+localised tenderness may be elicited. The displacement is readily
+reduced by manipulation, but usually returns when the support is
+withdrawn. The arm is shortened to the extent of about half an inch.
+
+In rare cases the obliquity of the fracture is downward and backward,
+and the lower fragment is displaced forward.
+
+The #inter-condylar# fracture is a combination of the supra-condylar
+with a vertical split running through the articular surface, and so
+implicating the joint. The condyles are thus separated from one
+another, as well as from the shaft, by a T- or Y-shaped cleft. As such
+fractures usually result from severe forms of direct violence, they
+are often comminuted and compound. In addition to the signs of
+supra-condylar fracture, the joint is filled with blood. The condyles
+may be felt to move upon one another, and coarse crepitus, which has
+been likened to the feeling of a bag of beans, may be elicited if the
+fragments are comminuted.
+
+[Illustration: FIG. 34.--Radiogram of T-shaped Fracture of Lower End
+of Humerus.]
+
+#Separation of the lower epiphysis# of the humerus is met with in
+children of three or four years of age, but it may occur up to the
+thirteenth or fourteenth year. The more common lesion, however, is a
+combination of separated epiphysis with fracture, and this lesion is
+produced by the same forms of violence as cause supra-condylar
+fracture. If the periosteum is not torn, there is little or no
+displacement, but as a rule the clinical features closely resemble
+those of transverse fracture above the condyles, or of dislocation of
+the elbow. In separation of the epiphysis there is a peculiar
+deformity of the posterior aspect of the joint, consisting of two
+projections--one the olecranon, and the other the prominent capitellum
+with a scale of cartilage which it carries with it from the lateral
+condyle (R. W. Smith and E. H. Bennett). The end of the diaphysis may
+be palpated through the skin in front. Muffled crepitus can usually be
+elicited, and there is pain on pressing the segments against one
+another. Sometimes the separation is _compound_, the diaphysis
+protruding through the skin.
+
+Union takes place more rapidly than in fracture, but, owing to the
+excessive formation of callus from the torn periosteum in front of the
+joint, full flexion is often interfered with. If the displaced
+epiphysis is imperfectly reduced, serious interference with the
+movements of the elbow is liable to ensue, and may call for operative
+treatment.
+
+#Fracture of either Condyle alone.#--The lateral condyle or trochlea
+is more frequently separated from the rest of the bone than is the
+medial or capitellum. In either, the size of the fragment varies, but
+the line of fracture is partly extra-capsular and partly
+intra-capsular, so that the joint is always involved. Pain, crepitus,
+and the other signs of fracture are present. As the ligaments of the
+joint are not as a rule torn, there is little or no immediate
+displacement of the fragment. Secondary displacement is liable to
+occur, however, during the process of union, producing alterations in
+the "carrying angle" of the limb--_cubitus varus_ or _cubitus valgus_.
+
+#Fracture of Epicondyles.#--Fracture of the _lateral epicondyle_ alone
+is so rare that it need only be mentioned.
+
+The _medial epicondyle_ may be chipped off by a fall on the edge of a
+table or kerbstone, or it may be forcibly avulsed by traction through
+the ulnar collateral (internal lateral) ligament, as an accompaniment
+of dislocation. It is usually displaced downwards and forwards by the
+flexor muscles attached to it, and may thus come to exert pressure on
+the ulnar nerve. The fragment may be grasped and made to move on the
+shaft, producing crepitus. Fibrous union is the usual result.
+
+Up to the age of seventeen or eighteen the epiphysis of the epicondyle
+may be separated.
+
+#Treatment of Fractures in Region of Elbow.#--The administration of a
+general anæsthetic is a valuable aid to accurate reduction and
+fixation of fractures in this region. Much discussion has taken place
+as to the best position in which to treat these fractures. In our
+experience the best approximation of the fragments, as shown by the
+X-rays, is obtained when the limb is fixed in the position of full
+flexion with supination. American surgeons favour the position of
+flexion at a right angle. In the region of the elbow there is a risk
+of promoting too much callus formation by early and vigorous massage,
+with the result that the movements of the joint are restricted by
+locking of the bony projections. This is probably due to bone cells
+being forced into the surrounding tissues, where they multiply and
+form new bone on an exaggerated scale.
+
+The _supra-condylar fracture_ is reduced by first extending the elbow
+to free the lower fragment from the triceps, and then, while making
+traction through the forearm, manipulating the fragments into
+position, and finally flexing the elbow to an acute angle and
+supinating the forearm. In this way the triceps is put upon the
+stretch and forms a natural posterior splint. A layer of wadding is
+placed in the bend of the elbow to separate the apposed skin surfaces,
+the arm placed in a sling so arranged as to support the elbow, and
+fixed to the side by a body bandage. This position is maintained for
+three weeks, with daily massage and movement. The last movement to be
+attempted is that of complete extension. Operative treatment is rarely
+called for.
+
+_Separation of the epiphysis_ and _fracture of the medial epicondyle_
+are treated on the same lines as supra-condylar fracture.
+
+_T- or Y-shaped fractures_ and _fractures of the condyles_, inasmuch
+as they implicate the articular surfaces, present greater difficulties
+in treatment, but they are treated on the same lines as the
+supra-condylar. In young subjects whose occupation entails free
+movement of the elbow-joint, it is sometimes advisable to expose the
+fracture by operation and secure the fragments in position. The
+details of the operation vary in different cases, and depend upon the
+line of obliquity of the fracture, and the disposition of the
+individual fragments, points which may usually be determined by the
+use of the X-rays. In performing the operation, care must be taken to
+disturb the periosteum as little as possible, otherwise there may
+follow excessive formation of new bone.
+
+Operative interference is sometimes necessary for ankylosis or locking
+of the joint after the fracture is united, or to relieve the ulnar
+nerve when it is involved in callus. _Volkmann's ischæmic contracture_
+is liable to occur after fractures in the region of the elbow from
+impairment of the blood supply as a result of tight bandaging.
+
+
+FRACTURE OF THE UPPER END OF THE ULNA
+
+#Fracture of the olecranon# is a comparatively common injury in
+adults. It usually follows a fall on the flexed elbow, and results
+from the direct impact, supplemented by the traction of the triceps
+muscle. In a few cases it has been produced by muscular action alone.
+The line of fracture may pass through the tip of the process, or
+through its middle, less frequently through the base. It may be
+transverse, oblique, T- or V-shaped, but is rarely comminuted or
+compound.
+
+_Clinical Features._--As the fracture almost invariably implicates the
+articular surface, there is considerable swelling from effusion of
+blood into the joint. The power of extending the forearm is impaired,
+and other symptoms of fracture are present. The amount of displacement
+depends upon the level of the fracture, and the extent to which the
+aponeurotic expansion of the triceps is torn. As the fracture is
+usually near the tip, the displacement is comparatively slight, the
+prolongation of the fibres of insertion of the triceps on to the sides
+and posterior part of the process holding the small fragment in
+position; and the fracture may easily escape recognition. When the
+line of fracture is nearer the base, however, the contraction of the
+triceps tends to separate the fragments widely (Fig. 35), and a
+distinct gap, which is increased on flexing the elbow, may often be
+felt between them, and if the elbow is passively extended, the
+fragments may be brought into apposition, and crepitus elicited.
+
+[Illustration: FIG. 35.--Radiogram of Fracture of Olecranon Process,
+showing marked degree of displacement.
+
+(Sir Robert Jones' case. Radiogram by Dr. D. Morgan.)]
+
+When there is little displacement, bony union may result, but in many
+cases the fragments are united only by fibrous tissue. The upper
+fragment sometimes forms attachments to the shaft of the humerus, and
+this leads to stretching of the fibrous band between the fragments and
+to marked wasting of the triceps.
+
+Separation of the olecranon _epiphysis_ is one of the rarest forms of
+epiphysial detachment (Poland). When the epiphysis is displaced
+upwards and unites in this position, it may interfere with complete
+extension of the elbow.
+
+_Treatment._--It would appear that too much stress has hitherto been
+laid on the necessity of bringing the fragments into perfect
+apposition, and too little attention paid to the importance of
+maintaining the functions of the triceps and the movements of the
+elbow-joint.
+
+Massage and movements are carried out from the first, and the forearm
+is supported in a sling. Full flexion is the last movement to be
+attempted. In carrying out the movements, the tip of the olecranon is
+pressed down with the thumb, so that it is obliged to follow the
+movements of the ulna, and is prevented from adhering to the humerus.
+
+It was formerly the practice to have the arm almost, but not quite,
+fully extended, and a Gooch splint, extending from the lower border of
+the axilla to the finger-tips, and cut to the shape of the extended
+limb, applied anteriorly and fixed in position by a bandage, the
+region of the elbow being covered by a convergent spica.
+
+_Operative Treatment._--Operative treatment may be had recourse to,
+particularly in cases in which there is wide separation of the
+fragments. The fracture is exposed, the joint cavity opened up and
+cleared of clots, and silver-wire sutures passed through the fragments
+without encroaching upon the articular cartilage. The limb is fixed
+with the elbow-joint in the position of almost complete extension.
+Movement may be commenced at the end of a week, the angle at which the
+joint is fixed being changed morning and evening. During the day the
+flexed position should be maintained and the arm carried in a sling;
+during the night the limb is fixed to a pillow in the extended
+position. The patient is allowed to use the joint cautiously within a
+fortnight.
+
+_Old-standing Fracture._--When union fails to take place, the interval
+between the fragments tends to increase by the contraction of the
+triceps gradually stretching the intermediate fibrous tissue, so that
+a wide gap comes to separate the fragments. It is quite common that
+the function of the arm is all that can be desired in spite of a gap
+between the fragments, but, if this is not the case, the fragments may
+be united by operation.
+
+#Fracture of the coronoid process# is rare except as a complication of
+backward dislocation of the elbow. It may be produced by direct
+violence, as well as by muscular action. As the fracture is usually
+within a quarter of an inch of the tip, the fibres of insertion of the
+brachialis prevent displacement. The ordinary evidence of fracture is
+often absent, and the diagnosis is seldom completed without the aid of
+the X-rays. The treatment consists in flexing the elbow and supporting
+the forearm in a sling. In some cases associated with dislocation,
+however, the small fragment has been so far displaced as to become
+attached to the back of the humerus (Annandale).
+
+
+FRACTURE OF THE UPPER END OF THE RADIUS
+
+Intra-capsular fracture of the #head of the radius# may result from
+direct violence, from a fall on the pronated hand, or from forcible
+pronation or abduction--that is, deviation of the forearm to the
+radial side. It may accompany dislocation of the elbow or fracture of
+adjacent bones. The head may be completely separated, or may be split
+into two or more fragments. Up to the seventeenth year, the
+_epiphysis_, which is entirely intra-articular, may be separated.
+
+The _clinical features_ are localised pain, crepitus, interference
+with pronation and supination, while the elbow can be almost fully
+extended and flexed, and in some cases the fragment may be felt
+through the skin, although it usually continues to move with the shaft
+in pronation and supination.
+
+Union generally takes place satisfactorily, but in some cases the
+fragments form new attachments resulting in impaired movement at the
+elbow, and necessitating operative interference.
+
+Fracture of the #neck of the radius# between the capsule and the
+tubercle is rare.
+
+#Avulsion of the tubercle# may occur from forcible contraction of the
+biceps, or, in children, from traction made on the forearm (A. L.
+Hall).
+
+These injuries are treated with the elbow in the flexed position, and
+massage and movement are carried out as already described.
+
+
+DISLOCATION OF THE ELBOW
+
+Dislocations of the elbow-joint may involve one or both bones of the
+forearm, and may be complete or incomplete.
+
+#Dislocation of both bones backward# is the most common of all
+dislocations of the elbow, and is the only dislocation that is
+frequently met with in children. It usually results from a fall on the
+outstretched hand, causing hyper-extension of the joint with
+abduction--that is, deviation towards the radial side; but it may
+follow a direct blow on the back of the humerus, a fall on the elbow,
+or a twist of the forearm.
+
+[Illustration: FIG. 36.--Backward Dislocation of Elbow, in a boy æt.
+10, caused by a fall off a wall, landing on the elbow.]
+
+_Morbid Anatomy._--All the ligaments of the elbow, except the annular
+(orbicular), are torn or stretched. The radius and ulna pass backward,
+the coronoid process coming to rest opposite the olecranon fossa
+behind the humerus, and the head of the radius behind the lateral
+condyle. The condyles of the humerus bear their normal relations to
+one another. The olecranon and the triceps tendon form a marked
+prominence on the back of the elbow, the tip of the olecranon lying
+above and behind the condyles. The lower end of the humerus lies in
+the flexure of the joint with the biceps tendon tightly stretched over
+it. The coronoid process is often broken, or the tendon of the
+brachialis torn. The median and ulnar nerves may be stretched or torn.
+Not infrequently the bones of the forearm are displaced towards the
+medial side as well as backward.
+
+Occasionally, as a sequel to the dislocation, processes of bone
+develop in relation to the insertion of the brachialis and interfere
+with the movements of the joint. These outgrowths are due to
+displacement of bone-forming elements, either at the time of the
+original injury or as a result of forcible efforts at reduction.
+According to D. M. Greig, they do not develop in the tendon of the
+brachialis, but under it, and are not of the nature of myositis
+ossificans. In from four to six weeks after reduction of the
+dislocation, the movements begin to be restricted, and a hard mass can
+be felt in the cubital fossa, which with the X-rays is seen to be a
+bony outgrowth springing from the quadrilateral space on the front of
+the elbow below the coronoid process (Fig. 37). This gradually
+increases in size and leads to fixation of the joint. In most cases
+the effects reach their maximum in about six months, and then
+reabsorption of the mass begins.
+
+[Illustration: FIG. 37.--Bony Outgrowth in relation to insertion of
+Brachialis Muscle, following Backward Dislocation of Elbow.
+
+(Sir Robert Jones' case. Radiogram by Dr. D. Morgan.)]
+
+If the disability shows no sign of abatement within a year, or if the
+bony outgrowth is producing pressure effects on the median nerve, it
+should be removed by operation.
+
+It is important not to mistake this condition for the effects of a
+fracture which has complicated the dislocation and been overlooked at
+the time of the accident.
+
+[Illustration: FIG. 38.--Radiogram of Incomplete Backward Dislocation
+of Elbow.]
+
+_Clinical features._--The elbow is held fixed at an angle of about
+120°, pronated or midway between pronation and supination. Any attempt
+at movement causes great pain, and is followed by an elastic rebound
+to the abnormal position. The antero-posterior diameter of the joint
+is increased, and the forearm, as measured from the lateral epicondyle
+to the tip of the styloid process of the radius, is shortened to the
+extent of about an inch. If examined before swelling ensues, the
+outlines of the articular surfaces may be recognised in their abnormal
+positions, but swelling usually comes on rapidly, and, by obscuring
+the bony landmarks, renders the diagnosis difficult.
+
+This injury has to be diagnosed from supra-condylar fracture with
+backward displacement of the lower fragment and from separation of the
+lower humeral epiphysis. A general anæsthetic is often necessary to
+enable an accurate diagnosis to be made. When the deformity is once
+reduced, there is no tendency to its reproduction unless the
+coronoid process is also fractured. In a considerable number of
+cases--according to E. H. Bennett, in the majority--this dislocation
+is _incomplete_, the coronoid process resting at the level of the
+trochlea, and the backward projection of the olecranon being scarcely
+appreciable. The head of the radius, however, is unduly prominent. In
+such cases the lesion is liable to be overlooked, and therefore to go
+untreated, leading to permanent stiffness at the elbow.
+
+#Dislocation forward# is much less common than the backward variety.
+It is produced by severe force acting from behind on the flexed elbow,
+the ulna being driven forward, tearing the ligaments of the joint and
+the muscles attached to the condyles. The olecranon is frequently
+fractured at the same time (Fig. 39). When it remains intact, it may
+rest below the condyles (incomplete or first stage of dislocation), or
+may pass in front of them, especially if the triceps is ruptured
+(complete or second stage). The forearm is lengthened, the elbow
+slightly flexed, the posterior aspect of the joint flattened, and the
+condyles, in their abnormal relationship, can be palpated from behind.
+
+#Medial and Lateral Dislocations.#--Dislocation towards the ulnar side
+is always incomplete, some portion of the articular surface of the
+bones of the forearm remaining in contact with the condyles.
+
+The dislocation to the radial side is also incomplete as a rule,
+although cases have been recorded in which complete separation had
+taken place.
+
+These forms of dislocation are rare, that towards the ulnar side being
+more frequently observed. Each form is often combined with other
+injuries in the vicinity.
+
+The most common cause of these dislocations is a fall on the
+outstretched hand, the forearm at the moment being strongly pronated.
+Forced abduction favours the displacement to the ulnar side; adduction
+to the radial side. The limb is held flexed and pronated, and the
+facility with which the bony points can be palpated renders the
+diagnosis easy.
+
+In a few cases _diverging dislocations_ have been met with, the radius
+and ulna being separated from one another, the annular (orbicular)
+ligament being torn and no longer holding them together.
+
+#Treatment of Dislocations of Elbow.#--The chief obstacle to reduction
+is the spasmodic contraction of the muscles passing over the joint,
+and, in the backward variety, the hitching of the coronoid process
+against the edge of the olecranon fossa. In recent cases, to effect
+reduction the patient is seated on a chair, while the surgeon grasps
+the humerus and wrist, and places his knee in the bend of the elbow.
+The limb is first fully extended, or even hyper-extended, to relax the
+triceps and free the coronoid process. Traction is then made in
+opposite directions upon the forearm and arm, the surgeon's knee
+meanwhile making pressure, in a backward direction, upon the lower end
+of the humerus. The joint is next slowly flexed, and the bones slip
+into position, often with a distinct snap. If the patient be
+anæsthetised, these manipulations must be adapted to the recumbent
+position.
+
+When some days have elapsed before reduction is attempted, forcible
+manipulations are to be deprecated as they greatly increase the risk
+of ossification occurring in relation to the brachialis (D. M. Greig);
+and recourse should be had to open operation, and the tearing or
+bruising of the soft parts should be reduced to a minimum.
+
+After reduction, the limb is flexed to rather less than a right angle
+and supported by a sling. Massage and movement are commenced at once.
+
+Fracture of the coronoid process predisposes to recurrence of the
+dislocation; when this complication exists, therefore, the limb should
+be fixed at an acute angle, and movements of full extension postponed
+for a fortnight. Massage and limited movements, however, may be
+carried out from the first.
+
+If there is a fracture of the olecranon, the treatment must be
+modified accordingly (p. 87).
+
+[Illustration: FIG. 39.--Forward Dislocation of Elbow, with Fracture
+of Olecranon.
+
+(Sir Robert Jones' case. Radiogram by Dr. D. Morgan.)]
+
+Comminuted and compound injuries usually call for operative treatment,
+the fractured bones being wired after reduction of the dislocation, or
+the loose fragments removed.
+
+The _forward dislocation_ is reduced by fully flexing the elbow, and
+then pushing the bones of the forearm backward, while the humerus is
+pulled forward.
+
+_Old-standing Dislocations._--No attempt should be made to reduce by
+manipulation a dislocation of the elbow which has remained displaced
+for five or six weeks, especially when it has been complicated by a
+fracture. The joint surfaces become welded together by adhesions, and
+separated fragments often form attachments which lock the joint.
+Attempts to break these down are attended with considerable risk of
+re-fracturing the bone or of tearing the soft parts. In such cases it
+is best to expose the joint, and if reduction is not easily effected a
+sufficient amount of the lower end of the humerus should be removed to
+provide a movable joint.
+
+#Dislocation of the ulna alone# is a rare injury, and is usually
+associated with fracture of one or other of its processes or of the
+inner condyle.
+
+#Dislocation of the radius alone#, on the other hand, is comparatively
+common, especially as a concomitant of fracture of the upper third of
+the shaft of the ulna (Fig. 40).
+
+The injury may result from a blow on the back of the upper end of the
+radius, a fall on the outstretched hand, or, in children, from
+forcible traction on the forearm while in the pronated position. The
+displaced head usually passes _forward_, and rests on the anterior
+edge of the capitellum, thus preventing complete flexion and
+supination of the limb.
+
+The limb is held partly flexed and pronated. The displaced head of the
+radius can be felt to rotate with the shaft in its abnormal position,
+and the articular facet on the head of the radius may also be felt;
+there is a depression posteriorly below the lateral epicondyle where
+the head should be. The radial side of the forearm is slightly
+shortened. The superficial and deep (posterior interosseous) branches
+of the radial nerve are liable to be pressed upon or torn by the
+displaced head of the radius, especially if the ulna is fractured,
+leading to disturbances in the area of their distribution.
+
+[Illustration: FIG. 40.--Radiogram of Forward Dislocation of Head of
+Radius, with Fracture of Shaft of Ulna.]
+
+In a few cases the displacement of the head has been _backwards_ or
+_laterally_.
+
+_Treatment._--To effect reduction, the forearm should be alternately
+flexed and extended, while traction is made upon it from the wrist,
+and the head of the radius is pressed backward with the thumb in the
+fold of the elbow. When reduction is prevented by the interposition
+of a portion of the torn ligaments between the bones, it is sometimes
+necessary to open the joint to ensure accurate adjustment. The joint
+is fixed in acute flexion to relax the biceps, to allow of union of
+the torn ligaments, and to prevent recurrence.
+
+In old-standing cases, to obtain a useful joint, or to remove pressure
+from the branches of the radial nerve, resection of the head of the
+radius may be necessary.
+
+#Sub-luxation of the head of the radius#, or "dislocation by
+elongation," is a comparatively common injury in children between the
+ages of two and six. It almost invariably results from the child being
+lifted or dragged by the hand or forearm. The traction and torsion
+thus put upon the radius causes the front part of its head to pass out
+of the annular ligament, the edge of which slips between the bones.
+
+The person holding the child may feel a click at the moment of
+displacement. The child complains of pain in the region of the elbow:
+the arm at once becomes useless, and is held flexed, midway between
+pronation and supination. All movements are painful, but especially
+movements in the direction of supination. The deformity is slight, but
+the head of the radius may be unduly prominent in front. From the way
+in which the injury is produced the wrist also is often swollen, and
+in some cases the patient is brought to the surgeon on account of the
+condition of the wrist, and attention is not directed to the elbow.
+
+_Treatment._--Reduction frequently takes place spontaneously or during
+examination, the function of the arm being at once completely
+restored. In other cases it is necessary, under anæsthesia, to
+manipulate the head of the bone into position. This is usually easily
+done by flexing the elbow, making slight traction on the forearm, and
+alternately pronating and supinating it. After reduction, a few days'
+massage is all that is necessary, the joint in the intervals being
+kept at rest in a sling.
+
+#Sprain# of the elbow is comparatively common as a result of a fall on
+the hand or a twist of the forearm. The point of maximum tenderness is
+usually over the radio-humeral joint, the radial collateral and
+annular ligaments being those most frequently damaged. Effusion takes
+place into the synovial cavity, and a soft, puffy swelling fills up
+the natural hollows about the joint. The bony points about the elbow
+retain their normal relationship to one another--a feature which aids
+in determining the diagnosis between a sprain and a dislocation or
+fracture. In children it is often difficult to distinguish between a
+sprain and the partial separation of an epiphysis. Sprains of the
+elbow are treated on the same lines as similar lesions elsewhere--by
+massage and movement.
+
+The condition known as _tennis elbow_ is characterised by severe pain
+over the attachment of one or other of the muscles about the elbow,
+particularly the insertion of the pronator teres during the act of
+pronation, and is due to stretching or tearing of the fibres of that
+muscle, and of the adjacent intermuscular septa. A similar
+injury--_sculler's sprain_--occurs in rowing-men from feathering the
+oar. The treatment consists in massage and movement, care being taken
+to avoid the movement which produced the sprain.
+
+
+FRACTURE OF THE FOREARM
+
+The _shafts_ of the bones of the forearm may be broken separately, but
+it is much more common to find both broken together.
+
+#Fracture of both bones# may result from a direct blow, from a fall on
+the hand, or from their being bent over a fixed object. The line of
+fracture is usually transverse, both bones giving way about the same
+level. The common situation is near the middle of the shafts. In
+children, greenstick fracture of both bones is a frequent result of a
+fall on the hand--this indeed being one of the commonest examples of
+greenstick fracture met with (Fig. 41).
+
+[Illustration: FIG. 41.--Greenstick Fracture of both Bones of the
+Forearm, in a boy.]
+
+The _displacement_ varies widely, depending partly upon the force
+causing the fracture, partly on the level at which the bones break,
+and on the muscles which act on the respective fragments. It is common
+to find an angular displacement of both bones to the radial or to the
+ulnar side. In other cases the four broken ends impinge upon the
+interosseous space, and may become united to one another, preventing
+the movements of pronation and supination. There may be shortening
+from overriding of fragments.
+
+When the radius is broken above the insertion of the pronator teres,
+its upper fragment may be supinated by the biceps and supinator
+muscles, while the lower fragment remains in the usual semi-prone
+position. If union takes place in this position, the power of complete
+supination is permanently lost.
+
+The usual _symptoms_ of fracture are present, and there is seldom any
+difficulty in diagnosis.
+
+The _prognosis_ must be guarded, especially with regard to the
+preservation of pronation and supination. These movements are
+interfered with if union takes place in a bad position with angular or
+rotatory deformity of one or both bones, or if callus is formed in
+excess and causes locking of the bones. In some cases the callus fuses
+the two bones across the interosseous space, and pronation and
+supination are rendered impossible.
+
+Persistent angular deformity of the forearm is also liable to ensue,
+either from failure to correct the displacement primarily, or from
+subsequent bending due to ill-applied splints or slings. Want of
+union, or the formation of a false joint in one or both bones, is
+sometimes met with, particularly in children, and, like the
+corresponding fracture of the leg, is liable to prove intractable.
+
+A considerable number of cases of gangrene of the hand after simple
+fracture of the forearm are on record. This is sometimes attributable
+to damage inflicted upon the blood vessels by the fractured bones, or
+to the force that caused the fracture, but is oftener due to a roller
+bandage applied underneath the splints strangulating the limb, to
+injudiciously applied pads, or to too tight bandaging over the
+splints. Volkmann's ischæmic contracture occasionally develops after
+fractures of the forearm.
+
+In uncomplicated cases, union takes place in from three to four
+weeks.
+
+_Treatment._--To ensure accurate reduction and coaptation, a general
+anæsthetic is usually necessary. In the greenstick variety the bones
+must be straightened, the fracture being rendered complete, if
+necessary, for this purpose.
+
+To retain the bones in position, anterior and posterior splints are
+then applied. These are made to overlap the forearm by about half an
+inch on each side, to avoid compressing the forearm from side to side,
+and so making the fractured ends encroach upon the interosseous space.
+The dorsal splint is usually made to extend from the olecranon to the
+knuckles, and the palmar one from the bend of the elbow to the flexure
+in the middle of the palm, a piece being cut out to avoid pressure on
+the ball of the thumb (Fig. 42). The splints are applied with the
+elbow flexed to a right angle, and, except when the radius is broken
+above the level of the insertion of the pronator teres, with the
+forearm midway between pronation and supination. The limb is placed in
+a sling, so adjusted that it supports equally the hand and elbow in
+order to avoid angular deformity. The use of special interosseous pads
+is to be avoided.
+
+[Illustration: FIG. 42.--Gooch Splints for Fracture of both Bones of
+Forearm. (These are applied with the wooden side towards the skin.)]
+
+When the fracture of the radius is above the insertion of the pronator
+teres, the forearm should be placed in the position of complete
+supination, with the elbow flexed to an acute angle, and retained in
+this position by a moulded posterior splint, and the arm fixed to the
+side by a body bandage. Great care is necessary in the adjustment of
+the apparatus to prevent pronation.
+
+Massage and movement should be carried out from the first. It is
+usually necessary to continue wearing the splints for about three
+weeks.
+
+In cases of _mal-union_, especially when the bones are ankylosed to
+one another across the interosseous space, operation may be necessary,
+but it is neither easy in its performance nor always satisfactory in
+its results. The seat of fracture should be exposed by one or more
+incisions so placed as to enable the muscles to be separated and to
+give access to the callus. When the limb is straight, it is only
+necessary to gouge away the exuberant callus that interferes with
+rotatory movements; but when there is an angular deformity the bones
+must, in addition, be divided and re-set, and, if necessary,
+mechanically fixed in good position. In comparatively recent cases it
+is sometimes possible, without operation, to re-fracture the bones and
+to set them anew.
+
+_Un-united fracture_ of both bones of the forearm is not uncommon and
+is treated on the usual lines; the gap between the fragments of the
+radius is bridged by a portion of the fibula, that should be long
+enough to overlap by at least an inch at either end; it is rarely
+necessary to bridge the gap in the ulna, unless it alone is the seat
+of non-union.
+
+#Fracture of the shaft of the radius alone# may be due to a direct
+blow; to indirect violence, such as a fall on the hand; or to forcible
+pronation against resistance, as in wringing clothes. It is rare in
+comparison with fracture of both bones. When broken above the
+insertion of the pronator teres, the upper fragment is flexed and
+supinated by the biceps and supinator, while the lower fragment
+remains semi-prone, and is drawn towards the ulna by the pronator
+quadratus.
+
+When the fracture is below the pronator teres, the displacement
+depends upon the direction of the force and the obliquity of the
+fracture. In fractures of the lower third of the shaft, the hand may
+be flexed toward the radial side, and the styloid lies at a higher
+level, as in a Colles' fracture. From the frequency with which this
+fracture occurs while cranking a motor-car, it is conveniently
+described as _Chauffeur's fracture_; we have observed in doctors, who
+have sustained this fracture in their own persons, that they were
+under the impression that they had sustained a trivial sprain of the
+wrist.
+
+In addition to the ordinary signs of fracture, there is partial or
+complete loss of pronation and supination. The head of the radius as a
+rule does not move with the lower part of the shaft, but may do so if
+the fracture is incomplete or impacted.
+
+#Fracture of the shaft of the ulna alone# is also comparatively rare.
+It is almost always due to a direct blow sustained while protecting
+the head from a stroke, or to a fall on the ulnar edge of the forearm,
+as in going up a stair.
+
+The upper third is most frequently broken, and this injury is often
+associated with dislocation of the head of the radius (Fig. 40), or
+some other injury implicating the elbow-joint. On account of the
+superficial position of the bone, this fracture is frequently
+compound.
+
+The displacement depends on the direction of the force, the fragments
+being usually driven towards the interosseous space. There is seldom
+marked deformity unless the head of the radius is dislocated at the
+same time. The diagnosis is, as a rule, easy.
+
+The _treatment_ is the same as for fracture of both bones, but the
+splints may be discarded at the end of a fortnight.
+
+For some unexplained reason, a fracture of the upper third of the
+shaft of the ulna frequently fails to unite.
+
+
+
+
+CHAPTER V
+
+INJURIES IN THE REGION OF THE WRIST AND HAND
+
+
+Surgical Anatomy--FRACTURE OF LOWER END OF RADIUS: _Colles' fracture_;
+ _Chauffeur's fracture_; _Smith's fracture_; _Longitudinal
+ fracture_; _Separation of epiphysis_--FRACTURE OF LOWER END OF
+ ULNA: _Shaft_; _Styloid process_; _Separation of
+ epiphysis_--FRACTURE OF CARPAL BONES--DISLOCATION: _Inferior
+ radio-ulnar joint_; _Radio-carpal joint_; _Carpal bones_;
+ _Carpo-metacarpal joint_--SPRAINS--INJURIES OF FINGERS:
+ _Fractures_; _Dislocations_; _Mallet finger_.
+
+
+INJURIES IN THE REGION OF THE WRIST
+
+These include fractures of the lower ends of the bones of the forearm
+and separation of their epiphyses; sprains and dislocations of the
+inferior radio-ulnar, and of the radio-carpal articulations; and
+fractures and dislocations of the carpus.
+
+#Surgical Anatomy.#--The most important landmarks in the region of the
+wrist are the styloid processes of the radius and ulna. The tip of the
+radial styloid is palpable in the "anatomical snuff-box" between the
+tendons of the long and short extensors of the thumb, and it lies
+about half an inch lower than the ulnar styloid. The ulnar styloid is
+best recognised on making deep pressure a little below and in front of
+the head of the ulna, which forms the rounded subcutaneous prominence
+seen on the back of the wrist when the hand is pronated.
+
+The tubercle of the navicular (scaphoid) and the greater multangular
+(trapezium) can be felt between the radial styloid and the ball of the
+thumb, a little below the radial styloid; and the pisiform and hook of
+the hamatum (unciform) are palpable, slightly below and in front of
+the ulnar styloid.
+
+In examining an injured wrist, the different bony points should be
+located, and their relative positions to one another and to the
+adjacent joints noted; and the shape, position, and relations of any
+unnatural projection or depression observed, using the wrist on the
+other side as the normal standard for comparison. The power and range
+of movement--active and passive--at the various joints should also be
+tested.
+
+
+FRACTURE OF THE LOWER END OF THE RADIUS
+
+#Colles' Fracture.#--This injury, which was described by Colles of
+Dublin in 1814, is one of the commonest fractures in the body, and is
+especially frequent in women beyond middle age. It is almost
+invariably the result of a fall on the palm of the hand, in the
+three-quarters pronated position, the force being received on the ball
+of the thumb, and transmitted through the carpus to the lower end of
+the radius which is broken off, the lower fragment being driven
+backwards.
+
+The fracture takes place through the cancellated extremity of the
+bone, within a half to three-quarters of an inch of its articular
+surface (Fig. 45). It is usually transverse, but may be slightly
+oblique from above downwards and from the radial to the ulnar side. In
+a considerable proportion of cases it is impacted, and not
+infrequently the lower fragment is comminuted, the fracture extending
+into the radio-carpal joint.
+
+[Illustration: FIG. 43.--Colles' Fracture showing radial deviation of
+hand.]
+
+[Illustration: FIG. 44.--Colles' Fracture showing undue prominence of
+ulnar styloid.]
+
+When impaction takes place, it is usually reciprocal, the dorsal edge
+of the proximal fragment piercing the distal fragment, and the palmar
+edge of the distal fragment piercing the proximal. The periosteum is
+usually torn and stripped from the palmar aspect of the fragments,
+while it remains intact on the dorsum.
+
+In the majority of cases the styloid process of the ulna is torn off
+by traction exerted through the medial ulno-carpal (internal lateral)
+ligament, and in a considerable proportion there is also a fracture of
+one of the carpal bones.
+
+The resulting _displacement_ is of a threefold character: (1) the
+distal fragment is displaced backwards; (2) its carpal surface is
+rotated backwards on a transverse diameter of the forearm; while (3)
+the whole fragment is rotated so that the radial styloid comes to lie
+at a higher level than normal.
+
+[Illustration: FIG. 45.--Radiogram showing the line of fracture and
+upward displacement of the radial styloid in Colles' Fracture.]
+
+_Clinical Features._--In a typical case there is a prominence on the
+dorsum of the wrist, caused by the displaced distal fragment, with a
+depression just above it (Fig. 43); and the wrist is broadened from
+side to side. The natural hollow on the palmar aspect of the radius is
+filled up by the projection of the proximal fragment. The carpus is
+carried to the radial side by the upward rotation of the distal
+fragment, and the radial styloid is as high, or even higher, than that
+of the ulna. The lower end of the ulna is rendered unduly prominent by
+the flexion of the hand to the radial side. The fingers are partly
+flexed and slightly deviated towards the ulnar side; and the patient
+supports the injured wrist in the palm of the opposite hand, and
+avoids movement of the part. Occasionally the median nerve is bruised
+or torn, causing motor and sensory disturbances in its area of
+distribution.
+
+The general outline of the wrist and hand has been compared not
+inaptly to that of "an inverted spoon." Pronation and stipulation are
+lost, the joint is swollen, and there is tenderness on pressure,
+especially over the line of fracture. Tenderness over the position of
+the ulnar styloid may indicate fracture of that process, although it
+is sometimes present without fracture. No attempt should be made to
+elicit crepitus in a suspected case of Colles' fracture as the
+manipulations are painful, and are liable to increase the
+displacement.
+
+_Treatment._--It cannot be too strongly insisted upon that success in
+the treatment of Colles' fracture with displacement and impaction
+depends chiefly upon complete and accurate reduction, and to enable
+this to be effected a general anæsthetic is almost essential. The
+surgeon grasps the patient's hand, as if shaking hands with him, and,
+resting the palmar surface of the wrist on his bent knee, makes
+traction through the hand, and counter-extension through the forearm,
+with lateral movements, if necessary, to undo impaction. When the
+fragments are freed from one another, the wrist is flexed, and the
+hand carried to the ulnar side, while the lower fragment is moulded
+into position by the thumb of the surgeon's disengaged hand. When
+reduction is complete, the deformity disappears, and the two styloid
+processes regain their normal positions relative to one another.
+
+As there is no tendency to re-displacement and no risk of non-union,
+no retentive apparatus is required, but, if it adds to the patient's
+sense of security, a bandage or a poroplastic wristlet may be applied.
+In severe cases, however, anterior and posterior splints, similar to
+those used for fracture of both bones of the forearm, or a dorsal
+splint padded so as to flex the wrist to an angle of 45°, but somewhat
+narrower, may be employed. The hand and forearm are in any case
+supported in a sling.
+
+To avoid the stiffness that is liable to follow, massage and movement
+of the wrist and fingers should be carried out from the first, the
+range of movement being gradually increased until the function of the
+joints is perfectly restored. If splints are used, they should be
+discarded in a week, and the patient is then encouraged to use the
+wrist freely.
+
+The various special splints recommended for the treatment of Colles'
+fracture, such as Carr's, Gordon's, the "pistol splint," and many
+others, are all designed to correct the deformity as well as to
+control the fragments. It has already been pointed out that if
+reduction is complete there is no deformity to correct, and if it is
+not complete the deformity cannot be corrected by any form of splint.
+
+_Unreduced Colles' Fracture._--When union has been allowed to take
+place without the displacement having been reduced, an unsightly
+deformity results. In young subjects whose occupation is likely to be
+interfered with, and in women for æsthetic reasons, the fracture is
+reproduced and the displacement of the lower fragment corrected. This
+is conveniently done by means of Jones' wrench, which grasps the
+distal fragment and affords sufficient leverage to break the bone.
+
+#Chauffeur's Fracture.#--A fracture of the lower end of the radius
+frequently occurs from the recoil of the crank, "by back firing," in
+starting the engine of a motor-car. The injury may be produced either
+by direct violence, the handle as it recoils striking the forearm, or
+by indirect violence, from forcible hyper-extension of the hand while
+grasping the handle. The fracture may pass transversely through the
+lower end of the radius, as in Colles' fracture, but is more often met
+with two or three inches above the wrist (Fig. 46). It is treated on
+the same lines as Colles' fracture.
+
+[Illustration: FIG. 46.--Radiogram of Chauffeur's Fracture.]
+
+A fracture of the lower end of the radius _with forward displacement
+of the carpal fragment_, was first described by R. W. Smith of Dublin
+(_Colles' fracture reversed_, or #Smith's fracture#) (Fig. 47). It is
+nearly always due to forcible flexion, as from a fall on the back of
+the hand. Like Colles' fracture, it may be transverse or slightly
+oblique, impacted, or comminuted. The deformity is characterised by an
+elevation on the dorsum running obliquely upwards from the ulnar to
+the radial side of the wrist, and caused by the head of the ulna,
+which remains in position, and the distal end of the proximal
+fragment. Below this, over the position of the distal radial fragment,
+is a gradual slope downwards on to the dorsum of the hand. Anteriorly
+there is a prominence in the flexure of the wrist, and the distal
+fragment may be felt under the flexor tendons. The hand deviates to
+the radial side, and thereby still further increases the prominence
+caused by the lower end of the ulna. The radial styloid is displaced
+forward, upward, and to the radial side, and the ulnar styloid may be
+torn off.
+
+[Illustration: FIG. 47.--Radiogram of Smith's Fracture.
+
+(Sir George T. Beatson's case.)]
+
+When the deformity is not well marked, this injury may be mistaken for
+forward dislocation of the wrist, for fracture of both bones low down,
+or for sprain of the joint.
+
+The _treatment_ is carried out on the same lines as in Colles'
+fracture.
+
+_Longitudinal fractures_ of the lower end of the radius opening into
+the joint usually result from the hand being crushed by a heavy weight
+or in machinery. They are often compound and comminuted.
+
+#Separation of the lower epiphysis# of the radius, which is on the
+same level as that of the ulna and lies above the level of the
+synovial membrane of the wrist-joint, is comparatively common between
+the ages of seven and eighteen, especially in boys, and is caused by
+the same forms of violence as produce Colles' fracture.
+
+Although clinically the appearances in these two injuries bear a
+general resemblance to one another, separation of the epiphysis may
+usually be identified by the directly transverse line of the dorsal
+and palmar projections, the folding of the skin observed in the palmar
+depression, the absence of abduction of the hand and the ease with
+which muffled crepitus can be elicited (E. H. Bennett). The deformity
+is readily reduced, and the fragments are easily retained in position.
+
+This injury is often complicated with fracture of the shaft or styloid
+process of the ulna, or with dislocation of the radio-ulnar joint, and
+it is not infrequently compound, the lower end of the shaft being
+driven through the skin on the palmar aspect immediately above the
+wrist. Impairment of growth in the radius seldom occurs; when it does,
+it results in a valgus condition of the hand (Fig. 48), calling for
+resection of the lower end of the ulna.
+
+[Illustration: FIG. 48.--Manus Valga following separation of lower
+radial epiphysis in childhood.
+
+(Mr. H. Wade's case.)]
+
+The _treatment_ is the same as for Colles' fracture.
+
+#Fracture of the Lower End of the Ulna.#--The lower end of the _shaft_
+of the ulna is seldom fractured alone. The _styloid process_, as has
+already been pointed out, is frequently broken in association with
+Colles' and other fractures of the lower end of the radius.
+
+Separation of the _lower epiphysis_ of the ulna sometimes occurs, and
+in rare cases results in arrest of the growth of the bone, leading to
+a varus condition of the hand and bending of the radius. Sometimes the
+separated epiphysis fails to unite, and although this gives rise to no
+disability, it is liable to lead to errors in the interpretation of
+skiagrams.
+
+The _treatment_ is similar to that for the corresponding injuries of
+the radius.
+
+Simultaneous separation of the _epiphysis of both radius and ulna_
+sometimes occurs, and, as a result of severe violence, may be
+compound, the lower ends of the diaphyses projecting through the skin
+on the palmar aspect above the wrist.
+
+#Fracture of Carpal Bones.#--The use of the Röntgen rays has shown
+that fracture of individual carpal bones is commoner than was
+previously supposed, and that many cases formerly looked upon as
+severe sprains are examples of this injury.
+
+The _navicular_ (scaphoid) and _lunate_ (semilunar) are those most
+commonly fractured, usually by indirect violence, by forced
+dorsiflexion from a fall on the extended hand. The clinical features
+are: localised swelling on the radial side of the wrist, increase in
+the antero-posterior diameter of the carpus, marked tenderness in the
+anatomical snuff-box when the hand is moved laterally, especially in
+the direction of adduction, and, rarely, crepitus. The median nerve is
+sometimes over-stretched or partly torn. In many cases, however, the
+symptoms are so obscure that an accurate diagnosis can only be made by
+the use of the X-rays (Fig. 49). Codman recommends taking pictures of
+the navicular by placing the two wrists of the patient in adduction,
+and of the lunate, in abduction.
+
+[Illustration: FIG. 49.--Radiogram showing Fracture of Navicular
+(Scaphoid) Bone.]
+
+The _treatment_ of simple fractures consists in massage and movement.
+Codman and Chase recommend excision of the proximal half of the
+fractured bone, through a dorsal incision to the lateral side of the
+extensor digitorum communis. When the fracture is compound, the loose
+fragments should be removed.
+
+
+DISLOCATIONS IN THE REGION OF THE WRIST
+
+Dislocation may occur at the inferior radio-ulnar, the radio-carpal,
+mid-carpal, inter-carpal, or carpo-metacarpal joints, but the strong
+ligaments of these articulations, the comparatively free movement at
+the various joints, and the relative weakness of the lower end of the
+radius whereby it is so frequently fractured, render dislocation a
+rare form of injury.
+
+Dislocation of the #inferior radio-ulnar# articulation may complicate
+fracture of the lower end of the radius, or accompany sub-luxation of
+the head of the radius. The head of the ulna usually passes backward.
+
+In children, the commonest cause is lifting the child by the hand, and
+the displacement is only partial. In adults, it may result from
+forcible efforts at pronation or supination, as in wringing clothes,
+or from direct violence, the separation being frequently complete, and
+sometimes compound.
+
+The head of the ulna is unduly prominent, and there is a depression on
+the opposite aspect of the joint. The hand is generally pronated, the
+rotatory movements at the wrist are restricted and painful, while
+flexion and extension are comparatively free.
+
+Reduction is effected by making pressure on the displaced bone and
+manipulating the joint, especially in the direction of supination. If
+the ligaments fail to unite, the head of the ulna tends to slip out of
+place in pronation and supination--_recurrent dislocation_.
+
+Dislocation at the #radio-carpal# articulation, usually spoken of as
+_dislocation of the wrist_, is attended by tearing of the ligaments
+and displacement of tendons, and is frequently compound. The carpus
+may be displaced backward or forward, and the articular edge of the
+radius towards which it passes may be chipped off.
+
+_Backward_ dislocation is commonest, the injury resulting from a
+severe form of violence, such as a fall from a height on the palm
+while the hand is dorsiflexed and abducted. The clinical appearances
+closely simulate those of Colles' fracture, or of separation of the
+lower radial epiphysis, but the unnatural projections, both in front
+and behind, are lower down, and end more abruptly (Fig. 50). The hand
+is more flexed, and the palm is shortened. The styloid processes
+retain their normal relations to one another, and the carpal bones lie
+on a plane posterior to the styloids, the articular surfaces may be
+recognised on palpation. The forearm is not shortened.
+
+_Forward_ dislocation of the carpus may result from any form of forced
+flexion, such as a fall on the back of the hand, or from direct
+violence. The displaced carpus forms a marked projection on the palmar
+aspect of the wrist, and there is a corresponding depression on the
+dorsum. The attitude of the hand and fingers is usually one of
+flexion.
+
+In both varieties reduction is readily effected by making traction on
+the hand and pushing the carpus into position. A moulded poroplastic
+splint, which keeps the hand slightly dorsiflexed, adds to the comfort
+of the patient, but this should be removed daily to admit of movement
+and massage being employed.
+
+[Illustration: FIG. 50.--Dorsal Dislocation of Wrist at Radio-carpal
+Articulation, in a man, æt. 24, from a fall.]
+
+#Dislocation of Carpal Bones.#--The two rows of carpal bones may be
+separated from one another, or any one of the individual bones may be
+displaced. These injuries are rare, and result from severe forms of
+violence, usually from a fall on the extended hand. Pain, deformity,
+and loss of function are the ordinary symptoms. The treatment consists
+in making direct pressure over the displaced bone, while traction is
+made on the hand, which is alternately flexed and extended.
+
+Of these injuries that most frequently observed is displacement of the
+_head of the capitate bone_ (_os magnum_) from the navicular
+(scaphoid) and lunate (semilunar) bones. Frequently these bones are
+fractured, and fragments accompany the displaced os magnum. In full
+palmar flexion of the wrist the displaced head of the os magnum forms
+a prominence on the dorsum opposite the base of the third metacarpal,
+which temporarily disappears when the hand is dorsiflexed. There is an
+increase in the antero-posterior diameter of the wrist, situated on a
+lower level than that which accompanies fracture of the lower end of
+the radius; flexion and extension of the wrist are limited; and in
+some cases there are symptoms referable to pressure on the median
+nerve. By keeping the hand in the dorsiflexed position for a week or
+ten days, the bone may become fixed in its place and the function of
+the wrist be restored, but it is often necessary to excise the bone.
+
+The _lunate_ may be displaced forward by forcible dorsiflexion of the
+hand, and forms a projection beneath the flexor tendons; there is
+usually loss of sensibility in the distribution of the ulnar nerve in
+the hand. The most satisfactory treatment is removal of the bone.
+
+In a few cases the _navicular_ has been displaced (Fig. 51), and has
+had to be subsequently replaced by operation. Separation of any of the
+other bones is rare.
+
+[Illustration: FIG. 51.--Radiogram showing Forward Dislocation of
+Navicular (Scaphoid) Bone.]
+
+#Carpo-metacarpal Dislocations.#--Any or all of the metacarpal bones
+may be separated from the carpus by forced movements of flexion or
+extension. The commonest displacement is backward. The thumb seems to
+suffer oftener than the other digits. These injuries, however, are so
+rare, and the deformity is so characteristic, that a detailed
+description is unnecessary.
+
+#Sprain of the wrist# is a common injury, and results from a fall on
+the hand, a twist of the wrist, or from the back-firing of a
+motor-crank dorsiflexing the hand. The marked swelling which rapidly
+ensues may render it difficult to distinguish a sprain from the other
+injuries that are liable to result from similar causes--Colles'
+fracture, separation of the lower radial epiphysis, dislocation of the
+wrist, and fractures and dislocations of the carpal bones.
+
+In a sprain the normal relations of the styloid processes and other
+bony points about the wrist are unaltered, and there is no radial
+deviation of the hand, as in Colles' fracture. The most marked
+swelling is over the line of the articulation on the anterior and
+posterior aspects of the joint. There is usually some effusion into
+the sheaths of the tendons passing over the joint, and in some cases
+on moving the fingers a peculiar creaking, which may simulate
+crepitus, can be elicited. There is marked tenderness on making
+pressure over the line of the joint, as well as over one or other of
+the collateral ligaments, depending upon which ligament has been
+over-stretched or torn. Movements that tend to put the damaged
+ligaments on the stretch also cause pain. It has to be borne in mind,
+however, that in many cases of Colles' fracture there is extreme
+tenderness on pressing over the ulnar styloid and medial ulno-carpal
+ligament, as these structures are frequently injured as well as the
+radius, but the point of maximum pain and tenderness is over the seat
+of fracture of the radius. In all doubtful cases the X-rays should be
+employed to establish the diagnosis.
+
+The _treatment_ consists in the immediate employment of massage and
+movement, supplemented by alternate hot and cold douches, on the same
+lines as in sprains of other joints.
+
+
+INJURIES OF THE FINGERS
+
+#Fracture.#--_Fractures of the metacarpals of the fingers_ are
+comparatively common. When they result from direct violence, such as
+a crush between two heavy objects, they are often multiple and
+compound. Indirect violence, acting in the long axis of the bone and
+increasing its natural curve, such as a blow on the knuckle in
+striking with the closed fist, usually produces an oblique fracture
+about the middle of the shaft, the proximal end of the distal fragment
+projecting towards the dorsum. Apart from this there is little
+deformity, as the adjacent metacarpals act as natural splints and tend
+to retain the fragments in position. A sudden sharp pain may be
+elicited at the seat of fracture on making pressure in the long axis
+of the finger; and unnatural mobility and crepitus may usually be
+detected. These fractures are readily recognised by the X-rays. Firm
+union usually results in three weeks.
+
+The shaft of the _metacarpal of the thumb_ is frequently broken by a
+blow with the closed fist. The fracture is usually transverse, and
+situated near the proximal end of the shaft; frequently it is
+comminuted, and in some instances there is a longitudinal split.
+
+_Treatment._--When the fracture is transverse, and especially when it
+implicates the middle or ring fingers, the most convenient method is
+to make the patient grasp a firm pad, such as a roller bandage covered
+with a layer of wool, and to fix the closed fist by a figure-of-eight
+bandage. In this way the adjoining metacarpals are utilised as side
+splints. Active and passive movements must be carried out from the
+first, and the bandage may be dispensed with at the end of a week or
+ten days.
+
+In oblique fractures with a tendency to overriding of the fragments,
+especially in the case of the index and little fingers, it is
+sometimes necessary to apply extension to the distal segment of the
+digit, by means of adhesive plaster, to which elastic tubing is
+attached and fixed to the end of a bow splint, reaching well beyond
+the finger-tips (Fig. 52). This should be worn for a week or ten days.
+
+[Illustration: FIG. 52.--Extension apparatus for Oblique Fracture of
+Metacarpals.]
+
+#Bennett's Fracture of the Base of the First Metacarpal
+Bone.#--Bennett of Dublin described an injury of the thumb which,
+although comparatively common, is often mistaken for a sub-luxation
+backward of the carpo-metacarpal joint, or a simple "stave of the
+thumb." It consists in an "oblique fracture through the base of the
+bone, detaching the greater part of the articular facet with that
+piece of the bone supporting it which projects into the palm" (Fig.
+53). We have frequently observed the fracture extend for a
+considerable distance along the palmar aspect of the shaft.
+
+[Illustration: FIG. 53.--Radiogram of Bennett's Fracture of Base of
+Metacarpal of Right Thumb.]
+
+It usually results from severe force applied directly to the point of
+the thumb, driving the metacarpal against the greater multangular bone
+(trapezium), and chipping off the palmar part of the articular
+surface, but it may result from a blow with the closed fist. The rest
+of the metacarpal slips backward, forming a prominence on the dorsal
+aspect of the joint. The pain and swelling in the region of the
+fracture often prevent crepitus being elicited, and as the deformity
+is not at once evident, the nature of the injury is liable to be
+overlooked. The fracture is recognised by the use of the X-rays.
+Unless properly treated this injury may result in prolonged impairment
+of function, full abduction and fine movements requiring close
+apposition of the thumb being specially interfered with.
+
+The _treatment_ consists in reducing the fracture by extension in the
+attitude of full abduction and applying an accurately fitting pad over
+the extremity of the displaced bone, maintained in position by a light
+angular splint. This splint is first fixed to the extended and
+abducted thumb, and while extension is made by pushing it downwards
+the upper end is fixed to the wrist (Fig. 54 A). The apparatus is worn
+for three weeks, being carefully readjusted from time to time to
+maintain the extension and abduction. A moulded poroplastic splint
+added on the same principle may be employed, and is more comfortable
+(Fig. 54 B). Excellent results are obtained after reduction of the
+displacement, by massage and movement from the first, and the support
+merely of a figure-of-eight bandage (Pirie Watson).
+
+[Illustration: FIG. 54.--A. Splint applied as used by Bennett. B.
+Poroplastic Moulded Splint for Bennett's Fracture.]
+
+#Fractures of phalanges# usually result from direct violence, and on
+account of the superficial position of the bones, are often compound,
+and attended with much bruising of soft parts. Force applied to the
+distal end of the finger may also fracture a phalanx. The proximal
+phalanges are broken oftener than the others. The deformity is usually
+angular, with the apex towards the palm, and if union takes place in
+this position, the power of grasping is interfered with. Unnatural
+mobility and crepitus can usually be recognised, but, on account of
+the swelling and tenderness, the fracture is apt to be overlooked.
+Firm union takes place in two or three weeks. In oblique and
+comminuted fractures, union may take place with overlapping, producing
+a deformity which may prevent the wearing of a glove or of rings. In
+compound fractures, non-union sometimes occurs, and causes persistent
+disability. In doubtful cases radioscopy renders valuable aid, as the
+parts are readily seen with the screen.
+
+_Treatment._--Early movement and massage are all-important. The
+contiguous fingers may be utilised as side splints, and a long palmar
+splint projecting beyond the fingers is applied. In oblique and
+comminuted fractures it may be necessary to anæsthetise the patient to
+effect reduction. When it is particularly desirable to avoid
+deformity, an open operation may be advisable.
+
+#Dislocation.#--_Dislocation of the Metacarpo-phalangeal Joint of the
+Thumb._--The commonest dislocation at this joint is a _backward_
+displacement of the proximal phalanx, which may be complete or
+incomplete. Its special clinical importance lies in the fact that much
+difficulty is often experienced in effecting reduction.
+
+This dislocation is usually produced by extreme dorsiflexion of the
+thumb, whereby the volar accessory (palmar) and the collateral
+ligaments are torn from their metacarpal attachments, the phalanx
+carrying with it the volar accessory ligament and sesamoid bones. The
+head of the metacarpal passes forward between the two heads of the
+short flexor of the thumb, and the tendon of the long flexor slips to
+the ulnar side. The phalanx passes on to the dorsum of the metacarpal,
+where it is held erect by the tension of the abductor and adductor
+muscles.
+
+The attitude of the thumb is characteristic. The metacarpal is
+adducted, its head forming a marked prominence on the front of the
+thenar eminence, and the phalanges are displaced backwards, the
+proximal being dorsiflexed and the distal flexed towards the palm.
+
+Many explanations of the difficulty so often experienced in reducing
+this variety of dislocation have been offered, but the consensus of
+opinion seems to be that it is due to the interposition of the volar
+accessory ligament and the sesamoid bones between the phalanx and the
+metacarpal, and that this is most frequently the result of ill-advised
+efforts at reduction. In some cases the tension of the long flexor
+tendon may be a factor in preventing reduction, but the
+"button-holing" by the short flexor is probably of no importance.
+
+Reduction is to be effected by flexing and abducting the metacarpal
+while the phalanx is hyper-extended and pushed down towards the joint
+and levered over the head of the metacarpal.
+
+When this manipulation fails, the volar accessory ligament should be
+divided longitudinally through a puncture made with a tenotomy knife
+on the dorsal aspect of the joint, so as to separate the sesamoid
+bones and permit the passage of the head between them. An open
+operation is seldom necessary.
+
+Dislocation _forward_ is rare. It results from forced flexion of the
+thumb with abduction, tearing the posterior and medial collateral
+ligaments. The deformity is characteristic: the rounded head of the
+metacarpal projecting behind the level of the joint, while the base of
+the phalanx forms a prominence among the muscles of the thenar
+eminence.
+
+Reduction is easily effected by making traction on the phalanges and
+carrying out movements of flexion and extension. The deformity,
+however, is liable to be reproduced unless a retentive apparatus is
+securely applied.
+
+Dislocation of the thumb to one or other side is rare.
+
+Dislocations of the _metacarpo-phalangeal joint of the fingers_ may be
+backward or forward. They are less common than those of the thumb, but
+present the same general characters. In the backward variety the same
+difficulty in reduction occurs as is met with in the corresponding
+dislocation of the thumb, and is to be dealt with on the same lines.
+
+_Inter-phalangeal Dislocation._--The second and the ungual phalanges
+may be displaced backwards, forwards, or to the side. The clinical
+features are characteristic, and the diagnosis, as well as reduction,
+is easy. These dislocations are frequently the result of machinery
+accidents, and being compound and difficult to render aseptic, often
+necessitate amputation.
+
+_Persistent flexion of the terminal phalanx_ of the thumb or fingers
+(_drop_ or _mallet finger_) may result from violence applied to the
+end of the digit when in the extended position--as, for example, in
+attempting to catch a cricket-ball. The terminal phalanx is flexed
+towards the palm, and the patient is unable to extend it voluntarily.
+A palmar splint is applied securing extension of the distal joint for
+three or four weeks. If the deformity has been allowed to occur it can
+only be corrected by an open operation, suturing or tightening the
+extensor tendon at its insertion into the base of the terminal
+phalanx.
+
+
+
+
+CHAPTER VI
+
+INJURIES IN THE REGION OF THE PELVIS, HIP-JOINT, AND THIGH
+
+
+FRACTURES OF PELVIS: _Varieties_--INJURIES IN REGION OF HIP: Surgical
+ anatomy; _Fracture of head of femur_; _Fracture of neck of femur_;
+ _Fracture below lesser trochanter_--DISLOCATION OF HIP:
+ _Varieties_--Sprains--Contusions--FRACTURE OF SHAFT OF FEMUR.
+
+
+FRACTURE OF THE PELVIS
+
+For descriptive as well as for practical purposes, it is useful to
+divide fractures of the pelvis into those that involve the integrity
+of the pelvic girdle as a whole, and those confined to individual
+bones.
+
+In all, the prognosis depends upon the severity of the visceral
+lesions which so frequently complicate these injuries, rather than
+upon the fractures themselves.
+
+#Fractures implicating the pelvic girdle as a whole# usually result
+from severe crushing forms of violence, such as the fall of a mass of
+coal or a pile of timber, or the passage of a heavy wheel over the
+pelvis. The force may act in the transverse axis of the pelvis, or in
+its antero-posterior axis. The pelvic viscera may be lacerated by the
+tearing asunder of the bones, or perforated by sharp fragments, or
+they may be ruptured by the same violence as that causing the
+fracture.
+
+As a rule, more than one part of the pelvis is broken, the situation
+of the lesions varying in different cases.
+
+_Separation of the pubic symphysis_ may result from violence inflicted
+on the fork, as in coming down forcibly on the pommel of a saddle;
+from forcible abduction of the thighs; or it may happen during
+child-birth. In some cases the two pubic bones at once come into
+apposition again, and there is no permanent displacement, the only
+evidence of the injury being localised pain in the region of the
+symphysis elicited on making pressure over any part of the pelvis. In
+other cases the pubic bones overlap one another, and the membranous
+portion of the urethra, or the bladder wall, is liable to be torn. The
+displaced bones may be palpated through the skin, or by vaginal or
+rectal examination.
+
+The _pubic portion_ of the pelvic ring is the most common seat of
+fracture. The bone gives way at its weakest points--namely, through
+the superior (horizontal) ramus of the pubes just in front of the
+ilio-pectineal eminence, and at the lower part of the inferior
+(descending) ramus (Fig. 55). The intervening fragment of bone is
+isolated, and may be displaced. These fractures are frequently
+bilateral, and are often associated with separation of the sacro-iliac
+joint, with longitudinal fracture of the sacrum (Fig. 55), or with
+other fractures of the pelvic-bones.
+
+[Illustration: FIG. 55.--Multiple Fracture of Pelvis through
+Horizontal and Descending Rami of both Pubes, and Longitudinal
+Fracture of left side of Sacrum.]
+
+Injuries of the membranous urethra and bladder are frequent
+complications, less commonly the rectum, the vagina, or the iliac
+blood vessels are damaged.
+
+Localised tenderness at the seat of fracture, pain referred to that
+point on pressing together or separating the iliac crests, and
+mobility of the fragments with crepitus, are usually present. The
+fragments may sometimes be felt on rectal or vaginal examination. In
+all cases shock is a prominent feature.
+
+_The lateral and posterior aspects_ of the pelvic ring may be
+implicated either in association with pubic fractures or
+independently. Thus a fracture of the iliac bone may run into the
+greater sciatic notch; or a vertical fracture of the sacrum or
+separation of the sacro-iliac joint may break the continuity of the
+pelvic brim. In rare cases these injuries are accompanied by damage to
+the intestine, the rectum, the sacral nerves, or the iliac blood
+vessels.
+
+[Illustration: FIG. 56.--Fracture of left Iliac Bone; and of both
+Pubic Arches.]
+
+_Treatment._--It is of importance that the patient be moved and
+handled with care lest fragments become displaced and injure the
+viscera. He should be put to bed on a firm mattress, which may be
+made in three pieces, for convenience in using the bed-pan and for the
+prevention of bed-sores.
+
+Before the treatment of the fracture is commenced, the surgeon must
+satisfy himself, by the use of the catheter and by other means, that
+the urethra and bladder are intact. Should these or any other of the
+pelvic viscera be damaged, such injuries must first receive attention.
+
+The treatment of the fracture itself consists in adjusting the
+fragments, as far as possible by manipulation, applying a firm binder
+or many-tailed bandage round the pelvis, and fixing the knees together
+by a bandage (Fig. 57).
+
+[Illustration: FIG. 57.--Many-tailed Bandage and Binder for Fracture
+of Pelvic Girdle.]
+
+When there is displacement of fragments extension should be applied to
+both legs, with the limbs abducted and steadied by sand-bags.
+
+Compound fractures, being commonly associated with extravasation of
+urine, are liable to infective complications. Loose fragments should
+be removed, as they are prone to undergo necrosis.
+
+The patient is confined to bed for six or eight weeks, and it may be
+several weeks more before he is able to resume active employment.
+
+The #acetabulum# may be fractured by force transmitted through the
+femur, usually from a fall on the great trochanter, less frequently
+from a fall on the feet or other form of violence. It may merely be
+fissured, or the head of the femur may be forcibly driven through its
+floor into the pelvic cavity, either by fracturing the bone or, in
+young subjects, by bursting asunder the cartilaginous junction of the
+constituent bones. When the femoral head penetrates into the
+pelvis--the _central dislocation of the hip_ of German writers--the
+condition simulates a fracture of the neck of the femur, but the
+trochanteric region is more depressed and the trochanter lies nearer
+the middle line. The limb is shortened, and movements of the joint are
+painful and restricted, especially medial rotation. In some cases
+there is pain along the course of the obturator nerve.
+
+On rectal or vaginal examination there is localised tenderness over
+the pelvic aspect of the acetabulum, and in some cases a convex
+projection, or even crepitating fragments can be detected. The
+diagnosis is completed by an X-ray picture.
+
+When the head of the femur penetrates the acetabulum, reduction should
+be attempted by traction and manipulation. The pelvis is held rigid,
+and the thigh is flexed and forcibly adducted, while the medial side
+of the thigh rests against a firm sand-bag; the femoral head is thus
+lifted out of the pelvis. In a recent injury the amount of force
+required is relatively slight. The head is kept in its corrected
+position by extension.
+
+Fracture of the _upper and back part of the rim_ of the acetabulum may
+accompany or simulate dorsal dislocation of the hip. Crepitus may be
+present in addition to the symptoms of dislocation, and after
+reduction the displacement is easily reproduced. The treatment is by
+extension with the limb adducted.
+
+#Fracture of Individual Bones of the Pelvis.#--_Ilium._--The expanded
+portion of the iliac bone is often broken by direct violence, the
+detached fragments varying greatly in size and position (Fig. 56).
+
+The whole or part of the _crest_ may be separated by similar forms of
+violence.
+
+When the fracture implicates the _ala_ of the bone, it usually starts
+at the triangular prominence near the middle of the crest, and runs
+backwards or forwards, passing for a variable distance into the iliac
+fossa. The displaced fragment can sometimes be palpated and made to
+move when the muscles attached to it are relaxed. This is done by
+flexing the thighs and bending the body forward and towards the
+affected side. Pain and crepitus may be elicited on making this
+examination.
+
+These fractures are treated by applying a roller bandage or broad
+strips of adhesive plaster over the seat of fracture, and by placing
+the patient in such a position as will relax the muscles attached to
+the displaced fragment--in the case of the iliac spine by flexing the
+thigh upon the pelvis; in the case of the crest or ala by raising the
+shoulders. Union takes place in three or four weeks.
+
+In young persons, the _anterior superior spine_ has been torn off and
+displaced downwards by powerful contraction of the sartorius muscle;
+and the _anterior inferior spine_ by strong traction on the
+ilio-femoral or [inverted Y]-shaped ligament. These injuries are best
+treated by fixing the displaced fragment in position by a peg or
+silver wire sutures and relaxing the muscles acting on it.
+
+Fracture of the _ischium_ alone is rare. It results from a fall on the
+buttocks, the entire bone or only the tuberosity being broken. There
+is little or no displacement, and the diagnosis is made by external
+manipulation and by examination through the rectum or vagina.
+
+A longitudinal fracture of the _sacrum_ may implicate the posterior
+part of the pelvic ring, as has already been mentioned. In rare cases
+the lower half of the bone is broken _transversely_ from a fall or
+blow, and the lower fragment is bent forward so that it projects into
+the pelvis and may press upon or tear the rectum, or the sacral nerves
+may be damaged, and partial paralysis of the lower limbs, bladder, or
+rectum result. These fractures are frequently comminuted and compound,
+and the soft parts may be so severely bruised and lacerated that
+sloughing follows. On rectal examination the lower segment of the bone
+can be felt, and on manipulating it pain and crepitus may be elicited.
+
+Fracture of the _coccyx_ may be due to a direct blow, or may occur
+during parturition. As a result of this injury the patient may have
+severe pain on sitting or walking, and during defecation. The loose
+fragment can be palpated on rectal examination. There is considerable
+difficulty in keeping the fragment in position, and if it projects
+towards the rectum it should be removed. If the lower fragment unites
+at an angle so as to cause pressure on the rectum, it gives rise to
+the symptoms of _coccydynia_, which may call for excision.
+
+
+INJURIES IN THE REGION OF THE HIP
+
+These include the various fractures of the upper end of the femur;
+dislocation and sprain of the hip-joint; and contusion of the hip.
+
+#Surgical Anatomy.#--The strength of the hip-joint depends primarily
+on its osseous elements--the rounded head of the femur filling the
+deep socket of the acetabulum, to the bottom of which it is attached
+through the medium of the ligamentum teres. The edge of the acetabulum
+is specially strong above and behind, while at its lower margin there
+is a gap, bridged over by the labrum glenoidale (cotyloid ligament).
+
+In relation to fractures of the upper end of the femur, it is to be
+borne in mind that as the antero-posterior diameter of the neck is
+less than that of the shaft, and as a considerable portion of the
+great trochanter lies behind the junction of the neck with the shaft,
+the greater part of any strain put upon the upper end of the femur is
+borne by the neck of the bone and not by the trochanter. The head and
+neck of the femur are nourished chiefly by the thick, vascular
+periosteum, and through certain strong fibrous bands reflected from
+the attachment of the capsule--the retinacular or cervical ligaments
+of Stanley. The integrity of these ligaments plays an important part
+in determining union in fractures of the neck of the femur, both by
+keeping the fragments in position and by maintaining the blood-supply
+to the short fragment. Whether it be true or not that an alteration in
+the angle of the femoral neck takes place with advancing years, it is
+generally recognised that this change is of no importance in relation
+to fractures in this region.
+
+The articular capsule of the hip is of exceptional strength. It is
+attached above to the entire circumference of the acetabulum, and
+below to the neck of the femur in such a way that while the whole of
+the anterior and inferior aspects of the neck lies within its
+attachment, only the inner half of the posterior and superior aspects
+is intra-capsular. The capsule is augmented by several accessory
+bands, the most important of which is the _ilio-femoral or [inverted
+Y]-shaped ligament_ of Bigelow, which passes from the anterior
+inferior iliac spine to the anterior inter-trochanteric line, its
+fasciculi being specially thick towards the upper and lower ends of
+this ridge. The medial limb of this ligament limits extension of the
+thigh, while the lateral limits eversion and adduction. The weakest
+part of the capsular ligament lies opposite the lower and back part of
+the joint.
+
+The hip-joint is surrounded by muscles which contribute to its
+strength, the most important from the surgical point of view being the
+obturator internus, which plays an important part in certain
+dislocations, and the ilio-psoas, which influences the attitude of the
+limb in various lesions in this region.
+
+Except in thin subjects, the constituent elements of the hip-joint
+cannot be palpated through the skin. A line drawn vertically downwards
+from the middle of Poupart's ligament passes over the centre of the
+joint, which in adults lies on the same level as the tip of the great
+trochanter. In children it is somewhat higher.
+
+For purposes of clinical diagnosis it is necessary to locate certain
+bony prominences, the most important being--(1) The _anterior superior
+iliac spine_, which is most readily recognised by running the fingers
+along Poupart's ligament towards it. (2) The _ischial tuberosity_,
+which in the extended position of the limb is overlapped by the lower
+margin of the gluteus maximus muscle, and is therefore not easily
+located with precision. By flexing the limb and making pressure from
+below upwards in the gluteal fold, the smooth, rounded prominence can
+usually be detected. (3) The quadrilateral _great trochanter_ is
+readily recognised on the lateral aspect of the hip. Its highest point
+or _tip_ can best be felt by pressing over the gluteal muscles from
+above downwards.
+
+_Clinical Tests._--If a line is drawn from the anterior superior iliac
+spine to the most prominent part of the ischial tuberosity, it just
+touches the tip of the great trochanter. This is known as _Nélaton's
+line_ (Fig. 58).
+
+[Illustration: FIG. 58.--Nélaton's Line.]
+
+_Bryant's test_ (Fig. 59) is applied with the patient lying on his
+back, and consists in dropping a perpendicular AB from the anterior
+superior iliac spine, and drawing a line CD from the tip of the great
+trochanter to intersect the perpendicular at right angles. This is
+done on both sides of the body, and the length of the lines CD
+compared. Shortening on one side indicates an upward displacement of
+the trochanter, lengthening a downward displacement. The third side AC
+of the triangle indicates the distance between the anterior spine and
+the tip of the trochanter.
+
+[Illustration: FIG. 59.--Bryant's Line.]
+
+_Chiene's test_, which is simpler than either of these, consists in
+applying a strip of lead or tape across the front of the body at the
+level of the anterior superior iliac spines, and another touching the
+tips of the two trochanters. Any want of parallelism in these lines
+indicates a change in the position of one or other trochanter.
+
+
+FRACTURE OF THE UPPER END OF THE FEMUR
+
+The fractures of the upper end of the femur that are liable to be
+confused with one another and with dislocations of the hip, include
+fractures of the head, the neck, the trochanters, and separation of
+the upper epiphyses, and fracture of the shaft just below the
+trochanters.
+
+Fracture of the #head of the femur# is rare, and is usually a
+complication of backward dislocation of the hip. It takes the form of
+a split of the articular surface caused by impact against the edge of
+the acetabulum, and is analogous to the indentation fracture of the
+head of the humerus, which may accompany dislocation of the shoulder.
+
+The #epiphysis of the head#, which lies entirely within the capsule
+of the joint (Fig. 60), is occasionally separated, and the symptoms
+closely simulate those of fracture of the narrow part of the neck. If
+the condition is overlooked or imperfectly treated, it may in course
+of time be followed by coxa vara.
+
+[Illustration: FIG. 60.--Section through Hip-Joint to show epiphyses
+at upper end of femur, and their relation to the joint.
+
+ _a_, Epiphysis of head.
+ _b_, Epiphysis of great trochanter.
+ _c_, Epiphysis of small trochanter.
+ _d_, Capsular ligaments.
+
+(After Poland.)]
+
+
+FRACTURE OF THE NECK
+
+It has long been customary to divide fractures of the neck of the
+femur into two groups--"intra-" and "extra-capsular"; but as in a
+considerable proportion of cases the line of fracture falls partly
+within and partly without the capsule, this classification is wanting
+in accuracy. It is more correct to divide these fractures into (1)
+those occurring _through the narrow part of the neck_, which are
+nearly always purely intra-capsular; and (2) those occurring _through
+the base of the neck_ in which the line of fracture lies inside the
+capsule in front, but outside of it behind.
+
+It is of considerable importance to distinguish between fractures in
+these two positions. The first group occurs almost exclusively in old
+persons as a result of slight forms of indirect violence, and it is
+liable, on account of the feeble vascular supply to the upper
+fragment, to be followed by absorption of the neck, which delays or
+may even entirely prevent union (Fig. 61). The second group usually
+occurs in robust adults, and results from severe forms of violence
+applied to the trochanter. In this group firm osseous union usually
+takes place.
+
+[Illustration: FIG. 61.--Fracture through Narrow Part of Neck of Femur
+on section. The Neck of the bone has undergone absorption.]
+
+#Fracture of the Narrow Part of the Neck# or #Intra-capsular
+Fracture#.--This fracture is most frequently met with in elderly
+persons, especially women, and is usually produced by comparatively
+slight forms of indirect violence--such, for example, as result from
+the foot catching on the edge of a carpet, a stumble in walking, or
+missing a step in going downstairs.
+
+The line of fracture, which is usually transverse but may be oblique
+or irregular, lies for the most part within the capsule, and the
+posterior part of the neck is more comminuted than the anterior. The
+distal fragment, which includes the base of the neck, the
+trochanters, and the shaft, is usually displaced upward and rotated
+laterally. If the periosteum and the retinacular ligaments remain
+intact, displacement is prevented and union favoured.
+
+Impaction is less common than in fracture through the base of the
+neck; it usually results from the patient falling on the trochanter,
+the distal fragment being driven as a wedge into the proximal (Fig.
+62).
+
+[Illustration: FIG. 62.--Impacted Fracture through Narrow Part of Neck
+of Femur.]
+
+_Clinical Features._--In non-impacted cases the limb is at once
+rendered useless, and the patient is unable to rise. There is pain and
+tenderness in the region of the hip on making the slightest movement;
+and a specially tender spot may be localised, indicating the seat of
+fracture.
+
+On placing the pelvis as square as possible, and comparing the
+measurements of the limbs from the anterior superior spine to the
+medial malleolus, shortening of the injured limb to the extent of from
+1 to 3 inches may be found. On applying Nélaton's, Bryant's, or
+Chiene's test, the tip of the great trochanter will be found elevated.
+It is also farther back and less prominent than normal.
+
+The whole limb is usually everted to a greater or less degree, and is
+slightly abducted. In some cases, when the impaction is of the
+anterior portion of the neck, the limb is inverted. On comparing the
+ilio-tibial band of the fascia lata on the two sides, it is found to
+be relaxed on the side of the injury.
+
+The violence being as a rule indirect, there is at first little or no
+discoloration in the vicinity of the hip, but this may appear a few
+days later.
+
+Crepitus is not a constant sign, and should not be sought for, as the
+necessary manipulations are liable to disengage the fragments and to
+increase the deformity. For the same reason rotatory movements are to
+be avoided.
+
+In all cases in which the diagnosis is uncertain, the patient should
+be put to bed, and treated as for a fracture. In the course of a few
+days it is nearly always possible to make an accurate diagnosis.
+
+In examining an old person who has sustained an injury in the region
+of the hip, it should be borne in mind that the limb may be shortened
+and everted as a result of arthritis deformans, and that the symptoms
+of that disease may simulate those of fracture. In arthritis
+deformans, however, the ilio-tibial band of the fascia lata is not
+relaxed as it is in fracture.
+
+[Illustration: FIG. 63. Fracture of Neck of Right Femur, showing
+shortening, abduction, and eversion of limb.]
+
+In some cases, and particularly in those in which the periosteum of
+the neck and the retinacular ligaments remain intact, the shortening
+does not become apparent till a few days after the accident. As the
+other symptoms are correspondingly obscure, the condition is apt to be
+mistaken for a bruise. In all doubtful cases the part should be
+examined from day to day, and, if possible, the X-rays should be used.
+
+In _impacted_ cases the signs of fracture are often obscure, and the
+patient may even be able to walk after the accident. The skin over the
+trochanter is generally discoloured from bruising. Eversion is usually
+present, but there may be little shortening. Crepitus is absent. In
+old people it is never advisable to undo impaction, as the
+interlocking of the bones favours the occurrence of osseous union.
+
+_Prognosis._--A fracture of the neck of the femur in an old person is
+always attended with danger to life, a considerable proportion of the
+patients dying within a few weeks or months of the accident from
+causes associated with it. In some cases the mental and physical shock
+so far diminishes the vitality of the patient that death ensues within
+a few days. It is possible that fat embolism may account for death in
+some of the more rapidly fatal cases. In others, the continued dorsal
+position induces hypostatic congestion of the lungs, or, owing to the
+difficulties of nursing, bed-sores may form and death result from
+absorption of toxins. Frequently the prolonged confinement to bed, the
+continuous pain, and the natural impairment of appetite wear out the
+strength. In many cases the patient becomes peevish, irritable, or
+mentally weak.
+
+Osseous union is the exception in intra-capsular fracture, especially
+when the periosteum and the retinacular ligaments have been completely
+torn, but in sub-periosteal and in impacted fractures it sometimes
+occurs. As a rule, however, the neck of the femur becomes absorbed and
+disappears, the head of the bone comes to lie in contact with the base
+of the trochanter, and a false joint forms (Fig. 64). Chronic changes
+of the nature of arthritis deformans may occur in and around such
+false joints.
+
+[Illustration: FIG. 64.--Fracture of Narrow Part of Neck of Femur. The
+neck has become absorbed, the head has not united, and a false joint
+has formed.]
+
+When osseous union fails to take place, although the patient may
+eventually be able to get about, he can do so only with the aid of a
+stick or crutch, and as there is marked shortening, he walks with a
+decided limp. There is considerable antero-posterior thickening of
+the neck of the femur, and the femoral vessels may be pushed forward
+in Scarpa's triangle.
+
+_Treatment._--In treating a fracture through the narrow part of the
+neck, it is necessary to consider the age and general condition of the
+patient; whether the fracture is impacted or not; and the site of the
+fracture--whether in the narrow part of the neck or at its base. "The
+first indication is to save life, the second to get union, and the
+third to correct or diminish displacements" (Stimson).
+
+In old and debilitated patients, bony or even firm fibrous union
+seldom takes place, and it is generally advisable to get them out of
+bed as speedily as possible. For the first few days the patient may be
+kept on his back, the limb massaged daily, and in the interval
+steadied by sand-bags; but on the first sign of respiratory or cardiac
+trouble he should be propped up in bed, and as soon as possible lifted
+into a chair. In all such cases care should be taken to avoid undoing
+impaction.
+
+When the general condition of the patient permits of it, an attempt
+should be made to secure bony union.
+
+_Extension_ is applied by one or other of the methods described for
+fracture of the shaft (p. 149), so modified as to maintain the limb
+_in the abducted position_, which ensures the most accurate apposition
+of the fragments (Royal Whitman). This position may be maintained by a
+hinged long-splint, an adaptation of Thomas' hip splint. The fragments
+may be fixed to one another by a long steel peg introduced through the
+skin over the great trochanter, and passed so as to transfix them; or
+they may be exposed by operation and sutured together. Albe uses a
+bone peg.
+
+#Fracture of the Neck of the Femur in Children.#--The use of the
+X-rays has shown that this fracture is comparatively common in
+children, as a result of a fall or a forcible twist of the leg. The
+fracture is most frequently of the greenstick variety; when complete,
+it is usually impacted. There is shortening to the extent of a half or
+three-quarters of an inch, a slight degree of eversion, the movements
+of the hip are restricted, and there is some pain. The patient is
+often able to move about after the accident, but walks with a limp.
+Unless the use of the X-rays reveals the fracture, the condition is
+liable to be overlooked.
+
+When the lesion is diagnosed, the deformity should be completely
+corrected, any impaction that exists being undone; and the limb is put
+up in a wide abduction splint (p. 221) or in a plaster-of-Paris case
+in the position of extreme abduction.
+
+If the condition is not recognised and treated, it is liable to be
+followed by the development of coxa vara (Royal Whitman) (Fig. 65).
+
+[Illustration: FIG. 65.--Coxa Vara following Fracture of Neck of Femur
+in a child.]
+
+#Fracture through the Base of the Neck.#--This fracture is usually
+produced by a fall on the great trochanter, although it is
+occasionally due to a fall on the feet or knees.
+
+[Illustration: FIG. 66.--Non-impacted Fracture through Base of Neck.]
+
+Although often spoken of as "extra-capsular," the line of fracture is
+generally partly within and partly without the capsule. The fracture
+usually lies close to the junction of the neck with the shaft, and in
+the great majority of cases is accompanied by breaking of one or both
+trochanters. This is due to the neck being driven as a wedge into the
+trochanters, splitting them up. When the fragments remain interlocked,
+the fracture is of the _impacted_ variety (Fig. 67).
+
+[Illustration: FIG. 67.--Fracture through Base of Neck of Femur with
+Impaction into the Trochanters.]
+
+_Clinical Features._--Although this fracture is commonly met with in
+strong adults, it may occur in the aged.
+
+The lateral aspect of the hip shows marks of bruising, and there is
+severe pain and a considerable degree of shock. The limb lies
+helpless; there is generally marked eversion, with shortening, which,
+in _non-impacted_ cases, may amount to 1-1/2 or 2 inches, and is
+evident immediately after the accident; it is due to the distal
+fragment being drawn up by the muscles inserted into the great
+trochanter and upper end of the shaft. In a limited number of cases
+the distal fragment lies in front of the proximal, and there is
+inversion of the limb.
+
+[Illustration: FIG. 68.--Non-impacted Fracture through Base of Neck.
+Union has occurred with diminution of angle of neck--Coxa Vara.]
+
+On applying the various tests, the great trochanter is found to be
+displaced upwards, there is some antero-posterior broadening of the
+trochanteric region, and the ilio-tibial band is relaxed. On pressing
+the fingers into the lateral part of Scarpa's triangle, a mass
+consisting of the bony fragments may be felt, and is tender on
+pressure. Unnatural mobility with crepitus may be elicited.
+
+In the _impacted variety_, the shortening seldom exceeds one inch; the
+eversion is less marked; there is some power of voluntary movement;
+and crepitus is absent. The broadening of the trochanteric region is
+greater, and the great trochanter is approximated to the acetabulum.
+
+_Prognosis._--The risks to life in the aged are similar to those of
+intra-capsular fracture. In youths and healthy adults the chief danger
+is that the limb may be shortened and its function thereby impaired.
+
+As the periosteum and retinacular ligaments which transmit the blood
+vessels to the proximal fragments are intact, bony union is the rule.
+There is always, however, considerable thickening in the region of the
+trochanter due to displaced fragments and callus, and in a certain
+number of cases, even with the greatest care in treatment, there is a
+varying degree of shortening and eversion of the limb. In cases in
+which the distal fragment lies in front of the proximal there is
+permanent inversion.
+
+_Treatment._--As this fracture usually occurs in robust patients,
+there is no danger from prolonged confinement to bed; and as union
+without deformity can be attained in no other way, this is always
+advisable. When the shortening and eversion are excessive, they should
+be completely corrected under anæsthesia before the retentive
+apparatus is applied, any impaction that exists being undone. When the
+deformity resulting from impaction is slight, however, it is best to
+leave it, as it facilitates speedy and firm union.
+
+Extension is obtained by the same appliances as are used in fracture
+of the shaft, and the limb should be kept in the abducted position.
+
+Fracture of the #greater trochanter# occurring apart from fracture of
+the neck usually results from direct violence, but may be due to
+muscular action. The trochanter is displaced by the gluteal muscles,
+causing broadening of the lateral aspect of the hip. In young persons
+the _epiphysis_ of the great trochanter may be separated, but this is
+rare. The treatment consists in retaining the fragments in position by
+keeping the limb abducted between sand-bags, or by pegs driven in
+through the skin.
+
+#Fracture immediately below the lesser trochanter# may be produced by
+direct or by indirect violence, and the displacement depends largely
+on whether the line of fracture is transverse or oblique. The proximal
+fragment is kept tilted forward, rotated laterally, and abducted by
+the ilio-psoas muscle and the lateral rotators inserted in the region
+of the great trochanter. The lower fragment passes upward, and is
+rotated laterally by the weight of the limb; the displacement is
+aggravated by the contraction of the flexor and adductor muscles. The
+tilting of the proximal fragment may be increased by the displaced
+distal fragment pushing it forward.
+
+On account of the difficulty of controlling the short proximal
+fragment, union is liable to take place with considerable shortening
+and deformity (Fig. 69).
+
+[Illustration: FIG. 69.--Fracture of the Femur just below the Small
+Trochanter united, showing flexion and lateral rotation of upper
+fragment.]
+
+_Treatment._--When it is found, under an anæsthetic, that the
+displacement can be completely reduced, and does not tend to recur,
+this fracture is treated on the same lines as fracture of the shaft of
+the bone.
+
+In cases in which the proximal fragment cannot be brought into line
+with the distal one, however, it is necessary to flex, evert, and
+abduct the thigh in order to get the fragments into apposition and
+into line. A Hodgen's splint (Fig. 77) is applied with the highest
+sling under the upper end of the lower fragment and with sufficient
+extension to correct overriding. The upper end is then strongly lifted
+by a counter-weight of about 15 lbs. This secures apposition of the
+fragments with slight forward angulation at the seat of fracture. By
+the end of a month sufficient callus has formed to prevent
+re-displacement, and if the counter-weight is gradually diminished the
+two fragments sag back together into a normal alignment (J. N. J.
+Hartley). A double-inclined plane (Fig. 70), with extension applied in
+the axis of the thigh, gives satisfactory results.
+
+[Illustration: FIG. 70.--Adjustable Double-inclined Plane.]
+
+
+DISLOCATION OF THE HIP
+
+It is unnecessary for our present purpose to attempt a comprehensive
+classification of the numerous varieties of dislocation that have been
+met with at the hip-joint. It will suffice if we divide them into
+those in which the head of the femur passes backward, and comes to
+rest on the dorsum ilii, or in the vicinity of the great sciatic
+notch; and those in which it passes forward and comes to rest in the
+obturator foramen, or on the pubes (Fig. 71).
+
+[Illustration: FIG. 71.--Diagram of the most common Dislocations of
+the Hip.]
+
+The backward are much more common than the forward dislocations, in
+contrast to what obtains at the shoulder, where the forward varieties
+predominate.
+
+On account of the great strength of the hip-joint, dislocation is by
+no means a common injury. It occurs most frequently in strong adults
+after the epiphyses have ossified, and before the bones have commenced
+to become brittle; and it is much more common in men than in women. It
+is invariably the result of severe violence, the limb at the moment
+being in such a position that the ligaments are on the stretch and the
+muscles taken at a disadvantage. The head of the femur usually leaves
+the joint at the lower and back part, where the socket is most shallow
+and the ligaments weakest. The ligamentum teres is almost always torn
+from its femoral attachment, and one or more of the muscles inserted
+in the region of the trochanters may be ruptured. The [inverted
+Y]-shaped ligament, on the other hand, is seldom torn, and so long as
+it remains intact the dislocation belongs to one or other of the types
+above named. All atypical dislocations, such as the supra-cotyloid,
+infra-cotyloid, ilio-pectineal, are due to rupture of some part of the
+[inverted Y]-ligament, and are so rare as not to call for individual
+description. The central dislocation of German authors, in which the
+head is driven through the floor of the acetabulum, is described on
+page 126.
+
+Like other dislocations, those of the hip may be complicated by
+laceration of muscles, blood vessels, or nerves, or by fracture of one
+or other of the bones in the vicinity.
+
+#Dislocation on to the Dorsum Ilii.#--This, the commonest form of
+dislocation of the hip, is usually the result of the patient falling
+from a height, or receiving a heavy weight on the back while stooping
+forward with the thigh flexed, slightly adducted, and rotated
+medially. It is also said to have occurred from muscular action. The
+shaft of the femur acts as the long limb of a lever of which the neck
+is the short limb, the femoral attachment of the [inverted Y]-ligament
+forming the fulcrum. The head, thus brought to bear upon the lower and
+back part of the capsule, tears it and leaves the socket, passing
+upwards and coming to rest on the dorsum of the ilium, above and
+anterior to the tendon of the obturator internus (Fig. 73). The
+articular surface is directed backward, while the trochanter looks
+forward.
+
+[Illustration: FIG. 72.--Dislocation of Right Femur on to Dorsum
+Ilii.]
+
+_Clinical Features._--The affected limb is flexed, adducted, and
+inverted, so that the knee crosses the lower third of the opposite
+thigh, and the ball of the great toe lies on the dorsum of the sound
+foot. There is shortening to the extent of from 1-1/2 to 2 inches, the
+trochanter being displaced above Nélaton's line, and lying nearer to
+the anterior superior iliac spine than on the normal side. The patient
+is unable to move the limb or to bear weight upon it; abduction and
+lateral rotation are specially painful; and traction fails to restore
+the limb to its proper length. On making these attempts a
+characteristic elastic resistance is felt.
+
+The head of the femur in its new position may sometimes be felt
+through the fibres of the gluteus maximus, but swelling of the soft
+parts often obscures this sign. The normal depression behind the
+great trochanter is lost, the gluteal fold is raised, and there is
+often a degree of lordosis which compensates for the flexion. The
+fingers can be pressed more deeply into Scarpa's triangle on the
+dislocated than on the normal side--a point in which this injury
+differs from fracture of the base of the neck of the femur.
+
+In a certain number of cases the lateral limb of the [inverted
+Y]-ligament is ruptured and the limb is everted--_dorsal dislocation
+with eversion_.
+
+[Illustration: FIG. 73.--Dislocation on to Dorsum Ilii. Note relation
+of neck of femur to tendons of obturator internus and gemelli
+(diagrammatic).]
+
+#Dislocation into the Vicinity of the Great Sciatic Notch#, or
+"_dislocation below the tendon_."--This variety of backward
+dislocation is less common than that on to the dorsum, although
+produced in the same way. The head of the femur passes beneath the
+obturator internus, and this tendon, catching on its neck, checks its
+upward movement (Fig. 74).
+
+The _clinical features_ are the same as those of the dorsal variety,
+but, on the whole, are less marked.
+
+_Differential Diagnosis._--Backward dislocation of the hip is usually
+easily recognised. When dislocation below the tendon occurs in a stout
+person, however, it is liable to be overlooked on account of the
+difficulty of feeling the displaced bone, and of the comparatively
+slight amount of deformity present. The nature of the accident, the
+absence of broadening of the trochanter, and the adduction and
+inversion of the limb are usually sufficient to prevent a dislocation
+being mistaken for an impacted extra-capsular fracture.
+
+#Dislocation into the Obturator Foramen# (Fig. 71).--This dislocation
+is produced by great force applied from behind while the thigh is
+flexed and abducted, as when a weight falls on the back of a man
+stooping forward with the legs wide apart. It may also result from
+violent abduction by wide separation of the thighs.
+
+The capsule gives way at its medial and lower part, and the head of
+the femur comes to rest on the surface of the external obturator
+muscle, its articular surface looking forward, while the trochanter
+looks backward.
+
+_Clinical Features._--In the standing position the thigh is slightly
+flexed and abducted, with the foot pointing directly forward or a
+little outward. The body is bent forward to relax the ilio-psoas
+muscle and the [inverted Y]-ligament, the foot is advanced and the
+heel drawn up. It is not uncommon for the patient to be able to walk
+after the accident, and only to seek advice some time later on account
+of inability to adduct and extend the limb. There is apparent
+lengthening of the limb due to tilting of the pelvis downward on the
+affected side. The hip is flattened, the trochanter less prominent
+than usual, and the head of the bone may sometimes be felt in its
+abnormal position.
+
+[Illustration: FIG. 74.--Dislocation into the vicinity of the
+Ischiatic Notch. Note relation of neck of femur to tendons of
+obturator and gemelli, "Dislocation below the tendon" (diagrammatic).]
+
+#Dislocation on to the pubes# is a further degree of the obturator
+form (Fig. 71). It is usually produced by forcible hyper-extension and
+lateral rotation of the hip, such as occurs when the body is bent back
+while the thigh remains fixed.
+
+The capsule is torn farther forward than in the other varieties, and
+the head rests on the horizontal ramus of the pubes against the
+ilio-pectineal line.
+
+_Clinical Features._--There is marked eversion, flexion, and
+abduction, but the shortening is inconsiderable. The ilio-psoas and
+[inverted Y]-ligament are tense. The head of the femur may be felt in
+the groin, with the femoral vessels over, or to one or other side of
+it. There is sometimes pain and numbness in the distribution of the
+femoral (anterior crural) nerve. The prominence of the great
+trochanter is lost.
+
+#Treatment of Dislocation of the Hip.#--For the reduction of a
+dislocation of the hip complete anæsthesia is necessary, and the
+patient should be placed on a firm mattress on the floor to give the
+surgeon the best possible purchase upon the limb. The surgeon grasps
+the ankle with one hand, while the other is placed behind the head of
+the tibia, the leg being held at right angles to the thigh. An
+assistant meantime steadies the pelvis by making firm pressure over
+the iliac crests.
+
+As the chief obstacle to reduction is the tension of the ilio-femoral
+ligament, the first indication is to relax this structure by flexing
+the hip _to its fullest extent_.
+
+In the _backward_ varieties (dorsal and sciatic) the [inverted
+Y]-ligament is relaxed by flexing the thigh upon the pelvis in the
+position of adduction. The thigh is then fully abducted, to cause the
+head of the bone to retrace its steps forwards towards the rent in the
+capsule; and at the same time rotated laterally to relax the rotator
+muscles. This combined movement tends also to open up the rent in the
+capsule. Finally, the limb is quickly extended to cause the head to
+enter the socket. This object is often aided by making vertical
+traction or lifting movements on the abducted and laterally rotated
+limb before extending.
+
+For the reduction of the _forward_ varieties (obturator and pubic),
+the thigh is first fully flexed on the pelvis, but in the abducted
+position. The limb is then strongly rotated medially and abducted, and
+finally extended. Lifting movements may be found useful in these cases
+also.
+
+All methods of reduction by forcible traction on the extended limb are
+to be avoided, as they fail to meet the primary indication of relaxing
+the [inverted Y]-ligament.
+
+After reduction, the limb is steadied by sand-bags; massage is carried
+out from the first, and movement after a few days. The range of
+movement is gradually increased, and the patient is allowed to use the
+limb with caution in from two to three weeks.
+
+When the rim of the acetabulum has been fractured, the patient must be
+confined to bed with extension for six to eight weeks, to avoid the
+risk of re-dislocation.
+
+Changes of the nature of chronic arthritis are liable to occur in and
+around the joint in old and rheumatic subjects; and atrophy or
+paralysis of muscles may follow, if their nerves are implicated.
+
+#Old-standing Dislocation.#--It is impossible to lay down any
+time-limit for attempting reduction in old-standing dislocations of
+the hip. Manipulation may succeed in cases of some months' standing,
+and may fail when the bone has been out only a few weeks. In certain
+cases, even after reduction has been effected, there is a marked
+tendency to re-displacement. In any case, the attempt does good by
+breaking down adhesions, provided no undue force is employed such as
+may damage the sciatic nerve or vessels, or fracture the neck of the
+femur, and success may attend on a second or even a third attempt at
+intervals of from three to five days. If manipulation fails, and if
+the deformity is great and the usefulness of the limb seriously
+impaired, an attempt may be made to effect reduction by operation; the
+operation, however, is one of considerable difficulty, and in the
+event of failure the head of the bone should be excised. If the head
+has formed a new socket for itself and there is a fairly useful joint,
+the condition should be left alone.
+
+_Congenital dislocation of the hip_ is described with Deformities of
+the Extremities.
+
+#Sprain# of the hip is comparatively rare. It results from milder
+degrees of the same forms of violence as produce dislocation. The
+ligaments are stretched or partly torn, and there is effusion of fluid
+into the joint. Pressure over the joint elicits tenderness; and the
+limb assumes the position of slight flexion, abduction, and lateral
+rotation, but there is no alteration in length. Such injuries, unless
+carefully treated by massage and movement from the outset, are apt to
+be followed by the formation of adhesions, resulting in stiffness of
+the joint.
+
+#Contusion# in this region, on the other hand, is not uncommon. It is
+produced by a fall on the trochanter, and gives rise to symptoms which
+simulate to some extent those of fracture of the neck. The limb lies
+in the position of slight flexion, but the bony points retain their
+normal relationship to one another, and there is no shortening. The
+swelling and tenderness often prevent a thorough examination being
+made, and when any doubt remains as to the diagnosis, the patient
+should be kept in bed till the doubt is cleared up by the use of the
+X-rays. If the bone has been broken, this will reveal itself in the
+course of a few days by the occurrence of shortening and other
+evidence of fracture.
+
+In elderly patients, contusion of the hip may be followed by changes
+in the joint of the nature of arthritis deformans; and it has been
+stated, although proof is wanting, that absorption of the neck of the
+femur sometimes occurs. These injuries are treated by rest in bed,
+massage, and the other measures already described as applicable to
+sprains and contusions.
+
+
+FRACTURE OF THE SHAFT OF THE FEMUR
+
+This group includes all fractures between that immediately below the
+lesser trochanter and the supra-condylar fracture.
+
+_In adults_, when due to direct violence, the fracture is usually
+transverse, and may be attended with comparatively little
+displacement. Indirect violence, on the other hand, usually produces
+an oblique fracture, which is frequently comminuted and often
+compound. The break is most commonly situated a little above the
+middle of the shaft, the obliquity being downward, forward, and
+medially, and of such a nature that the fragments tend to override one
+another (Fig. 75). The most serious forms are those associated with
+gun-shot wounds.
+
+[Illustration: FIG. 75.--Longitudinal section of Femur showing recent
+Fracture of Shaft with overriding of Fragments.]
+
+The direction and nature of the displacement depend more upon the
+fracturing force, the weight of the lower part of the limb, and the
+action of the muscles attached to the respective fragments, than upon
+the direction of the obliquity. As a rule, the proximal fragment
+passes forward and laterally, and is maintained in this position by
+the ilio-psoas and glutei muscles, while the distal fragment is
+displaced upward and medially and is rotated outward by the combined
+action of the weight of the limb, the longitudinal muscles, and the
+adductors.
+
+_Clinical Features._--The limb is at once rendered useless, and there
+is great swelling from effusion of blood in the region of the
+fracture. This, together with the muscularity of the part, often
+renders an accurate diagnosis as to the site and direction of the
+fracture exceedingly difficult. The shortening varies from 1/2 inch to
+3 or 4 inches--averaging about 1 inch in adults--and eversion is
+always marked. Mobility may be detected and crepitus elicited without
+disturbing the patient, by placing the hand under the seat of fracture
+and gently attempting to raise the limb; or by fixing the proximal
+fragment by one hand placed in front of it while the distal part of
+the limb is carefully lifted. It will be found that the great
+trochanter does not rotate with the lower segment of the femur. These
+tests must be employed with great caution lest the deformity be
+increased or the fracture rendered compound.
+
+In many fractures of the thigh, and especially in those produced by
+indirect violence, the knee is sprained, and there is a considerable
+effusion into the joint, and this may lead to stiffness unless massage
+is employed from the outset.
+
+_Treatment._--Fracture of the shaft of the femur is one of the most
+difficult fractures in the body to treat successfully. In cases of
+oblique fracture, the patient should be warned that shortening to the
+extent of from 3/4 to 1 inch is liable to result, however carefully
+the treatment may be carried out. This does not necessarily imply a
+permanent limp, as by tilting the pelvis he may be enabled to walk
+quite well; if this is not sufficient to equalise the length of the
+limbs, the sole of the boot may be raised. A general anæsthetic is
+necessary to ensure accurate reduction, and extension must be applied
+to maintain the fragments in apposition and prevent shortening. The
+splint which has been found most generally useful is the Thomas' knee
+splint, the ring of which rests against the ischial tuberosity. To
+admit of flexion at the knee the Thomas' splint should have a hinged
+attachment on which the leg is supported. This leaves the knee free
+and allows of movement being made to prevent stiffness. The limb is
+suspended by broad strips of flannel or linen, fixed to the side bars
+of the splint by means of safety pins or strong spring paper clips.
+
+In simple fractures extension may be obtained by means of broad strips
+of adhesive plaster applied to each side of the thigh and reaching
+well above its middle. The plaster is secured by a bandage, and to its
+lower ends are attached broad tapes which are buckled to a stirrup
+through which traction is made by means of a cord passing over a
+pulley fixed to an upright at the foot of the bed.
+
+The lower end of the splint is suspended, and the counter-extension is
+obtained by pressing the ring against the ischial tuberosity. To
+prevent the ring overriding the tuberosity and pressing on the soft
+tissues of the buttock, it is slung by the rope to a cross-bar above
+the bed, _e.g._ the Balkan frame (Fig. 81).
+
+In compound fractures the presence of a wound may prevent adhesive
+plaster being used, and it is necessary to take the extension directly
+through the bone. A posterior gutter splint is applied to prevent
+sagging. After pulling the skin upward, a small incision is made over
+the upper expanded border of each condyle, and the points of an
+ice-tong calliper are made to grip the bone without penetrating into
+the cancellous tissue. A cord attached to the handles of the calliper
+passes over a pulley and supports the weight necessary to give the
+desired amount of traction (Fig. 81).
+
+An alternative method of exerting traction directly through the bone
+is by means of Steinmann's apparatus (Fig. 76). In a moderately
+muscular adult, a weight of from 12 to 15 pounds by means of strips of
+plaster applied to the skin, or 10 to 25 pounds by direct traction on
+the bone, should be applied in the first instance. The correct weight
+to employ is that which maintains the length of the limb at its
+normal, and is therefore liable to revision from time to time.
+
+[Illustration: FIG. 76.--Radiogram of Steinmann's Apparatus applied
+for Direct Extension to the Femur.]
+
+_Hodgen's splint_ is a comfortable and efficient means of treating
+these fractures, as it allows the patient a certain amount of
+movement, admits of the part being massaged, and facilitates nursing.
+
+It consists of a wire frame (Fig. 77) to one side of which a series of
+strips of flannel about 4 inches wide are attached. Extension
+strapping is first applied, and then the frame, which extends from the
+level of Poupart's ligament to well beyond the sole, is placed over
+the front of the limb, and the loose ends of the flannel strips
+brought round behind the limb, and fixed to the other side of the
+frame, convert it into a sling. The tapes attached to the extension
+strapping are now tied to the end of the frame. By suspending the limb
+in this splint by means of cords passing obliquely over a pulley
+attached to an upright at the foot of the bed, the weight of the limb
+is made to act as the extending force.
+
+[Illustration: FIG. 77.--Hodgen's Splint.]
+
+The retentive apparatus should be worn for from six to eight weeks,
+after which the patient is allowed up with crutches, which he usually
+requires to use for three or four weeks longer, before he can bear his
+weight upon the limb. The old dictum of Nélaton, that the treatment of
+fracture of the thigh should last for a hundred days, is a safe
+working-rule. In fractures of the shaft an ordinary Thomas' knee
+splint, or a "walking calliper splint" which is fixed to the heel of
+the boot, may be worn when the patient gets up.
+
+Union may be exceedingly slow in fracture of the femur, and may even
+be delayed for months. Mal-union sometimes occurs, the fracture
+uniting with an angular deformity outward and forward.
+
+Re-fracture is liable to occur if the patient falls or twists the limb
+within a few months of the original injury. It has happened not
+infrequently just after the retentive apparatus has been removed from
+the nurse raising the limb by the foot in order to wash it.
+
+_Liston's long splint_ is only employed as a temporary expedient for
+immobilising the fragments during transport; a Thomas' splint, if
+available, is better for this purpose.
+
+[Illustration: FIG. 78.--Long Splint with Perineal Band.]
+
+_Operative treatment_ is sometimes called for when simpler measures
+fail to reduce the displacement, and in cases of un-united fracture or
+of vicious union. The incision, which must be free, is preferably
+placed in the line of the lateral intermuscular septum; the
+periosteum is interfered with as little as possible. The application
+of extension by the calliper method is often of great service, during
+the operation, in enabling the operator to get the fragments into
+position; sometimes no fixation is required, but, if necessary,
+recourse is had to plating or pegging, or an intra-medullary pin. The
+extension apparatus is retained for three or four weeks. The
+after-treatment is carried out on the same lines as for simple
+fracture, but the retentive apparatus must be worn for a considerably
+longer period.
+
+[Illustration: FIG. 79.--Fracture of Thigh treated by Vertical
+Extension.]
+
+#Fracture of the Femur in Children.#--In children, especially below
+the age of ten, this fracture is quite common. It is often of the
+greenstick variety, or, if complete, is transverse and sub-periosteal,
+and as it is accompanied by few symptoms and but little deformity, is
+liable to be overlooked.
+
+When there is displacement, the deformity is similar to that in
+adults, and the treatment is carried out on the same lines.
+
+In young children the nursing is greatly facilitated by applying
+vertical extension to one or both lower extremities (Fig. 79). If the
+fracture is transverse and shows little tendency to displacement, the
+local Gooch splints may be dispensed with; in any case, massage should
+be employed from the first.
+
+The patient may be allowed out of bed in from three to four weeks,
+wearing a retentive apparatus.
+
+The shaft of the femur is sometimes fractured _during delivery_,
+particularly in breech cases. The simplest and most efficient means of
+controlling the fracture is by extension strapping fixed to the lower
+end of a Thomas' knee splint.
+
+
+
+
+CHAPTER VII
+
+INJURIES IN THE REGION OF THE KNEE AND LEG
+
+
+_Surgical Anatomy_--FRACTURE OF LOWER END OF FEMUR: _Supra-condylar_;
+ _T- or Y-shaped_; _Separation of epiphysis_; _Either
+ condyle_--FRACTURE OF UPPER END OF TIBIA: _Of head_; _Separation
+ of epiphysis_; _Avulsion of tubercle_--DISLOCATIONS OF KNEE:
+ _Dislocations of superior tibio-fibular joint_--INTERNAL
+ DERANGEMENTS OF KNEE--INJURIES OF PATELLA: _Fractures_;
+ _Dislocations_--INJURIES OF LEG: _Fracture of both bones_;
+ _Fracture of tibia alone_; _Fracture of fibula alone_.
+
+
+INJURIES IN THE REGION OF THE KNEE
+
+These include the supra-condylar fracture of the femur, the T- or
+Y-shaped fracture opening into the joint, separation of the lower
+femoral epiphysis; fracture of the head of the tibia, and separation
+of its upper epiphysis; the various sprains and dislocations of the
+knee, as well as its internal derangements; and fractures and
+dislocations of the patella.
+
+#Surgical Anatomy.#--Of the two epicondyles the medial is the more
+prominent and palpable. The adductor tubercle, which is situated on
+the upper and back part of the medial epicondyle, gives attachment to
+the round tendon of the adductor magnus, and marks the level of the
+epiphysial line and of the upper limit of the trochlear surface of the
+femur. Between the medial condyle of the femur and the medial condyle
+(tuberosity) of the tibia, when the limb is in the flexed position,
+the line of the joint can be recognised as a groove or cleft, and this
+is made use of in measuring the length of the tibia. The lateral
+condyle (tuberosity) of the tibia can also be palpated, and must not
+be mistaken for the head of the fibula, which lies farther back and at
+a slightly lower level, and can readily be identified by tracing to it
+the tendon of the biceps. The tuberosity of the tibia, into which the
+quadriceps extensor tendon is inserted, lies on the same level as the
+head of the fibula. In the extended position of the limb, the patella
+is loose and movable on the front of the trochlear surface of the
+femur, while in the flexed position it sinks between the condyles,
+resting chiefly on the lateral one and becoming fixed.
+
+The popliteal artery and vein and the tibial (internal popliteal)
+nerve lie in close relation to the posterior aspect of the joint; and
+the common peroneal (external popliteal) nerve passes behind and to
+the medial side of the biceps tendon.
+
+The knee is an example of a joint which depends for its strength
+chiefly on its ligaments. Not only are the tibial and fibular
+collateral (external and internal lateral) ligaments and the posterior
+part of the capsular ligament particularly strong, but the cruciate
+ligaments and the menisci (semilunar cartilages) inside the cavity of
+the joint further add to its stability. The powerful tendon of the
+quadriceps extensor muscle, in which the patella is developed as a
+sesamoid bone, protects and strengthens the front of the joint and
+functionates as the anterior ligament of the joint. In the attitude of
+complete extension in which the joint is locked, no demand is made on
+the quadriceps apparatus; with the commencement of flexion, the
+stability of the joint, and the weight-bearing capacity of the limb as
+a whole, depend largely on the controlling influence of the
+quadriceps muscle; this becomes evident on going down an incline and
+more markedly on going down stairs. Hence it is, that in recurrent
+sprains of the knee, including under this term the various forms of
+internal derangement of the joint, the wasting with loss of tone of
+the quadriceps is an important factor in aggravating the disability of
+the limb and in retarding and preventing recovery. In the treatment of
+recurrent sprains of the knee, therefore, special attention must be
+directed towards the wasting of the quadriceps by means of massage and
+appropriate exercises.
+
+The synovial cavity extends from the level of the head of the tibia to
+an inch or more above the trochlear surface of the femur, passing
+slightly higher on the medial aspect of the joint than on the lateral
+(Fig. 80). The large bursa between the quadriceps muscle and the femur
+(_sub-crural bursa_) generally communicates with the cavity of the
+joint. The synovial cavity of the superior tibio-fibular articulation
+is usually distinct from that of the knee-joint, but may communicate
+with it through the popliteal bursa.
+
+[Illustration: FIG. 80.--Section of Knee-joint showing extent of
+Synovial Cavity.
+
+ _a_, Pre-patellar bursa.
+ _b_, Infra-patellar bursa.
+ _c_, Ligamentum mucosum.
+ _d_, Ligamentum patellæ.
+ _e_, Posterior cruciate ligament.
+ _f_, Medial semilunar meniscus.
+
+(After Braune.)]
+
+A large bursa (_pre-patellar_) lies over the lower part of the patella
+and upper part of the ligamentum patellæ; and a smaller one separates
+the ligamentum patellæ from the tuberosity of the tibia. Several
+important bursæ are found in the popliteal space, one of which--the
+semi-membranosus bursa--sometimes communicates with the knee-joint.
+
+
+FRACTURE OF THE LOWER END OF THE FEMUR
+
+Fractures involving the lower end of the femur, especially the
+supra-condylar and T-shaped fractures, are to be looked upon as
+serious injuries, on account of the difficulties attending their
+treatment, and the risk of damage to the popliteal vessels and of
+impairment of the usefulness of the knee-joint.
+
+#Supra-condylar# fracture is usually the result of a fall on the feet
+or knees, or of direct violence, and is most common in adult males.
+The line of fracture is generally irregularly transverse, or it may be
+slightly oblique from above downwards and forwards, so that the
+proximal fragment passes forward towards the patella, while the distal
+is rotated backward on its transverse axis by the gastrocnemius
+muscle.
+
+_Clinical features._--Soon after the accident a copious effusion of
+blood and synovia takes place into the cavity of the knee-joint,
+adding to the swelling caused by the displaced bones, and rendering it
+difficult to recognise the precise nature of the lesion. As it is
+important to make an accurate diagnosis, the X-rays should be employed
+if possible, and a general anæsthetic should be given when necessary.
+
+The proximal end of the distal fragment is usually palpable in the
+popliteal space, while the proximal fragment is unduly prominent in
+front. By flexing the knee the fragments may be brought into
+apposition and crepitus elicited. In oblique fractures, the pointed
+lower end of the proximal fragment may transfix the quadriceps
+extensor muscle and may be felt under the skin, or it may perforate
+the skin and thus render the fracture compound. It should be
+disengaged by fully flexing and making traction on the knee. The thigh
+is shortened to the extent of from 1/2 to 1 inch.
+
+The popliteal vessels lie so close to the bone that they are liable to
+be torn by the displaced distal fragment, giving rise to the usual
+signs of ruptured artery. Sometimes, owing to the feeble state of the
+circulation from shock, the bleeding does not take place at the time
+of the accident, but ensues some hours later. The vessels may merely
+be pressed upon by the displaced bone, but the nutrition of the limb
+beyond is endangered and gangrene may ensue if early reduction be not
+effected.
+
+_Treatment._--The small size of the distal fragment, its depth from
+the surface, and the accompanying effusion into and around the joint,
+render its control difficult. In the majority of cases the two
+fragments can only be brought into apposition when the knee is flexed
+on the thigh and the thigh on the pelvis, and it is almost always
+necessary to carry out the reduction under anæsthesia.
+
+In the few cases in which the fragments can be accurately approximated
+in the extended position of the limb, retention may be effected by
+means of a box splint reaching well up the thigh (p. 180).
+
+In the majority, however, flexion is necessary, and a Thomas' knee
+splint with flexion attachment bent to an angle of 30° (Fig. 81) and
+extension by means of ice-tong callipers secures the best apposition.
+If this apparatus is not available the limb must be fixed on a
+double-inclined plane, so constructed that the angle of flexion can be
+adjusted to meet the requirements of the individual case (Fig. 70).
+
+[Illustration: FIG. 81.--Extension applied by means of ice-tong
+callipers for Fracture of Femur.]
+
+Hodgen's splint, bent nearly to a right angle, may also be employed.
+
+A careful watch must be kept on the circulation of the limb during the
+first few days, lest it be interfered with by the pressure of the
+apparatus.
+
+In a considerable number of cases these means of retaining the
+fragments in apposition prove ineffectual, and it is necessary to have
+recourse to operative measures for mechanical fixation. Division of
+the tendo calcaneus (Achillis) is not to be recommended as a means of
+combating the backward tilting of the distal fragment.
+
+In all cases the retentive apparatus must be worn for about four
+weeks, after which the limb is flexed over a pillow; but massage and
+movement should be employed as soon as possible, as persistent
+stiffness of the knee is one of the most troublesome sequelæ of these
+injuries.
+
+Compound and complicated fractures are dealt with on the general
+principles governing the treatment of such injuries. Amputation may
+become necessary should gangrene ensue from injury to the popliteal
+vessels, or if infective complications threaten the life of the
+patient.
+
+Operative interference may be called for to rectify deformities
+resulting from mal-union.
+
+The #T- or Y-shaped fracture# is, as a rule, produced by direct
+violence, the force first breaking the bone above the condyles and
+then causing the proximal fragment to penetrate the distal and split
+it up into two or more pieces. The fracture implicates the articular
+surface, and the main fissure is usually through the inter-condylar
+notch; the lower end of the bone is sometimes severely comminuted.
+
+The knee is broadened, and pain and crepitus are readily elicited on
+moving the condyles upon one another or on pressing them together. On
+moving the patella transversely, it may be felt to hitch against the
+edge of one or other of the fragments. The shortening may amount to
+one or two inches.
+
+The treatment is carried out on the same lines as in supra-condylar
+fracture, but as the joint is implicated there is greater risk of
+subsequent impairment of its functions.
+
+#Separation of the lower epiphysis# is a comparatively common injury.
+It is seldom pure, a portion of the diaphysis usually being broken
+off and remaining attached to the epiphysis. It occurs usually in boys
+between the ages of thirteen and eighteen, from severe violence such
+as results from the limb being caught between the spokes of a
+revolving wheel, or from hyper-extension of the knee. It has also been
+produced in attempting forcibly to rectify knock-knee and other
+deformities in this region, and in making traction on the limb to
+correct deformities following recovery from tuberculous disease of the
+knee. As a rule, there is little displacement of the loose epiphysis,
+but it may pass in any direction, forward being much the most common
+(Fig. 82), and when displaced it is difficult to reduce and to
+maintain in position. The age of the patient, the mode of injury, the
+finding of the smooth broad end of the diaphysis in the popliteal
+space or on the front of the thigh, according to the displacement,
+usually serve to establish the diagnosis. The X-rays afford reliable
+information as to the position of the fragments. Pressure on the
+popliteal vessels is a serious aggravation of the injury, and adds
+greatly to the difficulties of treatment.
+
+[Illustration: FIG. 82.--Radiogram of Separation of Lower Epiphysis of
+Femur, with backward displacement of the diaphysis; pressure on
+popliteal vessels caused sloughing of calf.]
+
+[Illustration: FIG. 83.--Separation of Lower Epiphysis of Femur, with
+fracture of lower end of diaphysis.]
+
+The treatment is the same as for supra-condylar fracture, but, owing
+to the serious disability that follows on incomplete reduction, it may
+be necessary to have recourse to operation. After an epiphysial
+separation, the growth of the limb is sometimes, although not always,
+interfered with.
+
+#Either condyle# may be broken off without the continuity of the shaft
+being interrupted, by a direct blow or fall on the knee, or by violent
+twisting of the leg. The separated condyle may not be displaced, or it
+may be pushed upwards or rotated on its transverse axis.
+
+There is broadening of the knee but no shortening of the thigh, and
+the ecchymosis, crepitus, and pain are localised to the affected side
+of the joint; the knee can usually be moved towards the injured side
+in a way that is characteristic. If allowed to unite with the condyle
+displaced, the articular surface is oblique and bow- or knock-knee
+results.
+
+If there is difficulty in replacing the broken condyle and maintaining
+it in position, it may be fixed by means of a steel nail inserted
+through the skin.
+
+
+FRACTURE OF THE UPPER END OF THE TIBIA
+
+#Fracture of the head of the tibia# is a comparatively rare injury. It
+may result from a direct blow, such as the kick of a horse, or from
+indirect forms of violence, and the line of fracture may be
+transverse or oblique. Occasionally the distal fragment is impacted
+into the proximal and comminutes it. In oblique fracture a gliding
+displacement is liable to occur and cause bow- or knock-knee.
+Transverse fracture of the head of the fibula sometimes accompanies
+fracture of the head of the tibia, and there is always considerable
+effusion into the knee-joint. One or other of the condyles may be
+chipped off by forcible adduction or abduction at the knee.
+
+[Illustration: FIG. 84.--Radiogram of Fracture of Head of Tibia and
+Upper Third of Fibula.]
+
+The ordinary clinical features of fracture are well marked, and the
+diagnosis is easy. From some unexplained cause this fracture may take
+a long time, sometimes several months, to consolidate.
+
+#Separation of the upper epiphysis# of the tibia, which includes the
+tongue-like process for the tubercle and the facet for the fibula, is
+also rare. It usually occurs between the ages of three and nine. The
+displacement of the epiphysis is almost always forward or lateral, and
+is accompanied by the usual signs of such lesions. The growth of the
+limb is sometimes arrested, and shortening and angular deformity may
+result.
+
+_Treatment._--After reduction under an anæsthetic these fractures are
+usually satisfactorily treated in a box splint (Fig. 91), carried
+sufficiently high to control the knee-joint. When the head of the
+tibia is comminuted or split obliquely, weight-extension--direct from
+the bone, the ice-tong callipers grasping the malleoli or the
+calcaneus--may be used. Massage and movement are employed from the
+outset.
+
+Avulsion of the #tuberosity of the tibia# occasionally occurs in
+youths, from violent contraction of the quadriceps--as in jumping. The
+limb is at once rendered powerless; the osseous nodule can be felt,
+and on moving it crepitus is elicited.
+
+This is best treated by pegging the tuberosity in position, and fixing
+the extended limb on an inclined plane to relax the quadriceps muscle.
+
+In young, athletic subjects, the tongue-like process of the epiphysis
+(Fig. 85), into which the ligamentum patellæ is inserted, may be
+partly or completely torn away, giving rise to localised swelling, and
+pain which is aggravated by any muscular effort--_Schlatter's disease_
+or "rugby knee." It has been frequently observed in cadets as a result
+of kneeling at drill. The treatment consists in rest and massage, but
+the symptoms are slow to disappear.
+
+[Illustration: FIG. 85.--Radiogram illustrating Schlatter's disease.]
+
+The condition is liable to be mistaken for some chronic inflammatory
+condition of the bone, such as tubercle, unless an X-ray examination
+is made.
+
+The #upper end of the fibula# is seldom broken alone. The chief
+clinical interest of this fracture lies in the fact that it may
+implicate the common peroneal nerve, and cause drop-foot.
+
+
+DISLOCATIONS OF THE KNEE
+
+Dislocation of the knee is a rare injury, and occurs as a result of
+extreme degrees of violence, especially of a wrenching or twisting
+character.
+
+Rupture of the popliteal vessels, or pressure exerted on them by the
+displaced bones, may lead to gangrene of the limb, and necessitate
+amputation. The common peroneal nerve is frequently damaged. When the
+lesion is compound, also, amputation may become necessary on account
+of infective complications.
+
+The varieties of dislocation are named in terms of the direction in
+which the tibia passes: forward, backward, medial, and lateral.
+
+#Dislocation forward# is the most common variety, and results from
+sudden hyper-extension of the knee, tearing the collateral and
+cruciate ligaments. The leg remains fully extended, and lies on a
+plane anterior to that of the thigh. The condyles of the femur are
+palpable posteriorly, and the skin is tightly stretched over them, or
+may even be torn, rendering the dislocation compound. The patella is
+projected forward, the quadriceps tendon is lax, and the skin over it
+is thrown into transverse folds. The limb is shortened by two or three
+inches.
+
+#Dislocation backward# is usually due to a direct blow driving one of
+the bones past the other. The leg remains hyper-extended, the head of
+the tibia occupies the popliteal space, while the lower end of the
+femur projects forward with the patella either in front or to one side
+of it.
+
+The #medial and lateral dislocations# are generally incomplete, and
+are liable to be mistaken for separation of the lower epiphysis of the
+femur. When the tibia passes _medially_, the lateral condyle of the
+femur forms a prominence, and there is a depression below it. The head
+of the tibia projects on the medial side, and the medial condyle is in
+a depression.
+
+When the tibia is displaced _laterally_, the relative position of the
+prominences and depressions is reversed.
+
+_Treatment._--In dislocations of the knee no special manipulations are
+necessary to restore the displaced bone to its place, and reduction is
+not accompanied by a distinct snap.
+
+If, while the patient is fully anæsthetised, traction is made on the
+leg and counter-traction on the thigh with the knee in the flexed
+position, the bones can usually be replaced by manipulation.
+
+After reduction has been effected, in antero-posterior dislocations,
+the limb should be flexed and placed on a pillow, massage and movement
+being employed from the first. The patient is usually able to walk
+within a month.
+
+In medial and lateral dislocations there is at first considerable
+tendency to re-displacement, and it is therefore necessary to secure
+the joint in a box splint, specially padded, for about fourteen days,
+massage being employed from the first, and movement commenced when the
+splint is removed. It is usually about six weeks before the patient
+can use the limb with freedom.
+
+In compound dislocations, and in those complicated by injury to the
+popliteal vessels, the question of amputation may have to be
+considered.
+
+#Dislocation of the Superior Tibio-Fibular Articulation.#--This joint
+may be dislocated by twisting forms of violence applied to the foot or
+leg, or by forcible contraction of the biceps muscle. The displacement
+may be forward or backward, and the head of the fibula can be felt in
+its new position with the prominent tendon of the biceps attached to
+it. The movements of the knee are quite free, but the patient is
+unable to walk on account of pain. Reduction and retention are, as a
+rule, easy, and the ultimate result satisfactory. We have frequently
+met with this injury accompanying compound fractures of both bones of
+the leg resulting from railway and similar accidents.
+
+By applying direct pressure over the displaced bone with the knee
+flexed, the dislocation is easily reduced. It is kept in position by a
+firm bandage or a light rigid splint.
+
+#Total Dislocation of Fibula.#--Very rarely the fibula is separated
+from the tibia at both ends and displaced upwards. Bennett of Dublin
+has pointed out that in some persons the upper end of the fibula does
+not reach the facet on the tibia--a condition which might be mistaken
+for a dislocation.
+
+
+INJURIES OF THE SEMILUNAR MENISCI
+
+The semilunar menisci are two crescentic plates of white
+fibro-cartilage, which lie upon the upper end of the tibia, and serve
+to deepen the articular surface for the condyles of the femur. Each
+cartilage is firmly attached to the tibia by its anterior and
+posterior ends, and, through the medium of the coronary ligaments, is
+loosely attached along its peripheral, convex edge to the head of the
+tibia, the medial meniscus being connected also to the capsular
+ligament of the joint. The tendon of the popliteus muscle intervenes
+between the lateral meniscus and the capsule. The central, concave
+edges of the menisci are thin and unattached.
+
+The cartilages enjoy a limited range of movement within the joint,
+passing backwards during flexion, and forwards again when the limb is
+extended; under normal conditions the lateral moves more freely than
+the medial. While the limb is partly flexed, a slight degree of
+rotation of the leg at the knee is possible, and during this movement
+the cartilages glide from side to side, and the tibia rotates below
+them.
+
+Any abnormal laxity of the ligaments of the joint may render the
+cartilages unduly mobile, so that they are liable to be displaced from
+comparatively slight causes, and when so displaced it is not uncommon
+for one or other to be torn by being nipped between the femur and the
+tibia. It is convenient to consider these "internal derangements of
+the knee-joint" separately, according to whether the meniscus is
+merely abnormally mobile, or is actually torn.
+
+#Mobile Meniscus--Displacement of Medial Semilunar Cartilage# (Fig.
+86).--The _medial_ meniscus exhibits undue mobility much more
+frequently than the lateral, and the condition is usually met with in
+adult males who engage in athletics, or who follow an employment which
+entails working in a kneeling or squatting position for long periods,
+with the toes turned outwards--for example, coal-miners. The tibial
+collateral ligament, and through it the coronary ligament, are thus
+gradually stretched, so that the cartilage becomes less securely
+anchored, and is rendered liable to be displaced towards the centre of
+the joint during some sudden movement which combines flexion of the
+knee with medial rotation of the femur upon the tibia, as, for
+example, in rising quickly from a squatting position, or turning
+rapidly and pushing off with the foot, in the course of some game such
+as football or tennis. It may occur also from tripping on a loose
+stone or slipping off the kerbstone.
+
+[Illustration: FIG. 86.--Diagram of Longitudinal Tear of Posterior End
+of Right Medial Semilunar Meniscus.]
+
+What actually happens when the meniscus is displaced would appear to
+be, that the combined flexion and abduction of the knee opens up the
+medial side of the joint by separating the medial condyles of the
+femur and tibia, and that the medial meniscus in its movement backward
+during flexion slips under the femoral condyle and is caught between
+it and the tibia. It may even slip past the condyle and into the
+intercondyloid notch, and come to lie against the cruciate ligaments.
+
+The mechanism by which this lesion is produced doubtless explains the
+greater frequency with which the _left_ knee is affected, as most
+sudden movements are made from right to left, thus throwing the strain
+upon the left knee.
+
+_Clinical Features._--When seen immediately after the accident, the
+patient usually gives the history that while making a sudden movement
+he was seized with an intense sickening pain in the knee, accompanied,
+it may be, by a sensation of something giving way with a distinct
+crack, and followed by locking of the joint. He may fall to the
+ground and be unable to rise. On examination, the knee is found to be
+fixed in a slightly flexed position; and while the surgeon may be able
+to carry out movements of flexion to a considerable extent without
+increasing the pain, any attempt to extend the joint completely is
+extremely painful. Tenderness may be elicited on making pressure to
+the medial side of the ligamentum patellæ in the groove between the
+femur and the tibia, but the meniscus cannot be recognised by
+palpation. Considerable effusion rapidly takes place into the synovial
+cavity.
+
+The condition is liable to be mistaken for a sprain of the joint,
+particularly one implicating the tibial collateral ligament, but
+whereas in the lesion of the meniscus the maximum tenderness is in the
+interval _between_ the bones, in the sprain of the ligament the
+maximum tenderness is over its attachment to the bone, usually the
+tuberosity of the tibia.
+
+_Treatment._--To reduce the displacement, the patient is placed on a
+couch, and, after the knee is fully flexed, the leg is rotated
+laterally and abducted, to separate the medial femoral condyle from
+the tibia, and while the rotation and abduction are maintained the leg
+is quickly extended. The return of the meniscus to its place is
+sometimes attended with a distinct snap, but in other cases reduction
+is only recognised to have taken place by the fact that the joint can
+be completely extended without causing pain.
+
+Alternate flexion and extension combined with rotatory movements is
+sometimes successful. Several attempts are often necessary, and a
+general anæsthetic may be called for. After reduction, the limb is
+fixed with sand-bags, and massage and movement are employed to get rid
+of effusion, care being taken that no rotatory movement at the knee is
+permitted. Rest and support are necessary to allow of repair of the
+torn ligaments, and when the patient begins to use the limb he must be
+careful to avoid movements which throw strain on the damaged
+ligaments.
+
+In a considerable proportion of cases no recurrence takes place, and
+in the course of a month or two the patient is able to resume an
+active life with a perfectly useful joint. In other cases there is a
+tendency to recurrence of the displacement.
+
+#Recurrent Displacement.#--In cases of recurrent displacement, each
+attack is accompanied by symptoms similar in kind to those above
+described, but less severe, and the patient usually learns to carry
+out some manipulation by which he is able to return the meniscus into
+position. He seeks advice with a view to having something done to
+prevent displacement occurring, and to restore the stability of the
+joint, which, in many cases, is impaired, preventing him following his
+occupation. There persists a variable amount of fluid in the joint,
+the ligaments are stretched and slack, and the quadriceps muscle is
+markedly wasted.
+
+The symptoms closely resemble those of a "loose body," and it is often
+difficult to differentiate between them. In the case of a body free in
+the cavity of the joint, the site of the pain varies in different
+attacks, and the body can sometimes be palpated. Loose bodies wholly
+or partly composed of bone may be identified with the X-rays.
+
+Attempts may be made to retain the meniscus in position by pads,
+bandages, or other forms of apparatus, so arranged as to prevent
+rotation and side-to-side movement at the knee. In the majority of
+cases, however, the best results are obtained by opening the joint and
+excising the meniscus in whole or in part, as may be necessary.
+
+The limb is flexed on a splint until the wound has healed, after which
+massage should be employed and movement of the joint commenced. At the
+end of two or three weeks the patient is allowed up, wearing an
+elastic bandage. In most cases the use of the joint is completely
+regained in from four to six weeks. As an indication of the perfect
+recovery of the functions of the joint after removal of the meniscus,
+professional football players are often able to resume their
+occupation.
+
+#Displacement of the lateral meniscus# is comparatively rare. It is in
+every way comparable to displacement of the medial meniscus, and is
+treated on the same lines.
+
+#Torn or Lacerated Meniscus.#--In a large proportion of cases of
+displaced meniscus in which the condition assumes the recurrent type,
+it is found, on opening the joint, that, in addition to being unduly
+mobile, the meniscus is torn or lacerated. The experience of surgeons
+varies regarding the nature of the laceration. In our experience the
+most common form is a longitudinal split, whereby a portion of the
+inner edge of the cartilage is separated from the rest and projects as
+a tag towards the centre of the joint (Fig. 86). As a rule, it is the
+anterior end that is torn, less frequently the posterior end.
+Sometimes the meniscus is split from end to end, the outer crescent
+remaining in position, while the inner crescent passes in between the
+condyles and lies curled up against the cruciate ligaments.
+Occasionally the anterior end is torn from its attachment to the
+tibia, less frequently the posterior end. In one case we found the
+meniscus separated at both ends and lying between the bones and the
+capsule.
+
+The _clinical features_ are similar to those of mobile meniscus with
+displacement, and as a rule the exact nature of the lesion is only
+discovered after opening the joint.
+
+The _treatment_ consists in excising the loose tag or the whole
+meniscus, according to circumstances. The recovery of function is
+usually complete. It is not advisable to attempt to stitch the torn
+portion in position.
+
+#Rupture of the Cruciate Ligaments.#--A few cases have been recorded
+in which, as a result of severe twisting forms of violence, the
+cruciate ligaments have been torn from their attachments, leaving the
+joint loose and unstable, so that the tibia and the femur could be
+moved from side to side on one another. When the disability persists,
+the joint may be opened and the ligaments sutured in position (Mayo
+Robson).
+
+#Sprains# of the knee are comparatively common as a result of sudden
+twisting or wrenching of the joint. In addition to the stretching or
+tearing of ligaments, there is usually a considerable effusion of
+fluid into the synovial cavity, and examination with the X-rays
+occasionally reveals that a portion of bone has been torn away with
+the ligament--_sprain-fracture_. The swelling fills up the hollows on
+either side of the patella, and extends for some distance in the
+synovial pouch underneath the quadriceps. The patella is raised from
+the front of the femur by the collection of fluid in the
+joint--"floating patella"--and, if firmly pressed upon, it may be made
+to rap against the trochlear surface.
+
+A sprain is to be diagnosed from separation of one or other of the
+adjacent epiphyses, fracture involving the articular ends of the
+bones, and displacement of the semilunar menisci. On account of the
+swelling, which obscures the outline of the part, the differential
+diagnosis is often difficult, but as the swelling goes down under
+massage it becomes easier. Chief reliance is to be placed upon the
+bony points retaining their normal relationships, and upon the fact
+that the points of maximum tenderness are over the attachments of one
+or other of the collateral ligaments. As the tibial collateral
+ligament suffers most frequently, the most tender spot is usually over
+its attachment to the medial aspect of the head of the tibia--less
+frequently over the medial condyle of the femur.
+
+Unless efficiently treated, a sprain of the knee is liable to result
+in weakness and instability of the joint from stretching of the
+ligaments, and this is often associated with effusion of fluid in the
+synovial cavity (_traumatic hydrops_). This is more likely to occur if
+the joint is repeatedly subjected to slight degrees of violence, such
+as are liable to occur in football or other athletic exercises--hence
+the name "footballer's knee" sometimes applied to the condition.
+
+A further cause of disability, following upon sprains of the knee, is
+_wasting of the quadriceps muscle_. The stability of the joint,
+whenever the position of full extension has been departed from, is
+largely dependent upon its capacity of controlling the amount of
+flexion, notably in descending a stair or in walking on uneven ground,
+hence it is that with a wasted quadriceps there is increasing
+liability to a repetition of the sprain. With each repetition of the
+sprain, there is an addition to the fluid in the joint, stretching of
+ligaments, and further wasting of the quadriceps. A form of vicious
+circle is established in which there is at the same time increased
+liability to sprain and diminished capacity of recovering from it.
+Even after the repair of the damaged ligament or the removal of the
+mobile or torn meniscus, wasting of the quadriceps remains a source of
+weakness and disability and calls for treatment by massage and
+electricity.
+
+_Treatment._--In recent and severe cases the patient must be confined
+to bed, and firm pressure applied over the joint by means of cotton
+wool and a bandage. This may be removed once or twice a day to admit
+of the joint being douched, and at the same time it should be massaged
+and moved to promote absorption of the effusion and prevent the
+formation of adhesions.
+
+Chronic effusion into the joint is most rapidly got rid of by rest and
+blistering. If the patient is unable to lie up, massage should be
+systematically employed, and a firm elastic bandage worn. A patient
+who has once had a severe sprain of the knee, or who has developed the
+condition of "footballer's knee," must give up violent forms of
+exercise which expose him to further injuries, otherwise the condition
+is liable to be aggravated and to result in permanent impairment of
+the stability of the joint.
+
+
+INJURIES OF THE PATELLA
+
+#Fracture of the patella# is a comparatively common injury in adult
+males. Most frequently it is due to _muscular action_ the patella
+being snapped across the lower end of the femur by a sudden and
+forcible contraction of the quadriceps extensor muscle while the limb
+is partly flexed--as, for example, in the attempt to avoid falling
+backward. The bone is then broken as one breaks a stick by bending it
+across the knee, and the line of fracture, which is transverse or
+slightly oblique, crosses the bone a little below its middle.
+Fractures produced in this way are almost never compound.
+
+[Illustration: FIG. 87.--Radiogram of Fracture of Patella.]
+
+The degree of displacement of the fragments depends upon the extent to
+which the expansion of the quadriceps tendon is lacerated. As a rule,
+it is but slightly torn, so that the separation of the fragments does
+not exceed an inch. In other cases it is widely torn, and the
+contraction of the quadriceps muscle is then able to separate the
+fragments by three or four inches, and sometimes causes tilting of the
+upper fragment. The blood effused into the joint tends still further
+to increase the separation. As the periosteum is usually torn at a
+level lower than the fracture, its free margin hangs as a fringe from
+the proximal fragment, and by getting between the broken ends may form
+a barrier to osseous union (Macewen).
+
+_Clinical Features._--Immediately the bone breaks, the patient falls,
+and he is unable to rise again, as the limb is at once rendered
+useless, and in attempting to do so we have known him to fracture the
+patella of the other limb. The power of extending the limb is lost,
+and the patient is unable to lift his foot off the ground. The
+knee-joint is filled with blood and synovia, which usually extend into
+the bursa under the quadriceps. The two fragments can be detected,
+separated by an interval which admits of the finger being placed
+between them, and which is increased on flexing the knee. On relaxing
+the quadriceps, the fragments may be approximated more or less
+completely.
+
+_Prognosis._--In cases with little displacement, if the fragments have
+been kept in perfect apposition, osseous union may take place, but in
+the great majority of cases the union is fibrous. The shortening of
+the quadriceps and the gradual stretching and thinning of the
+connecting fibrous band may allow of further separation of the
+fragments (Fig. 88), which to a variable extent interferes with the
+stability and functions of the limb. The proximal fragment sometimes
+becomes attached to the front of the femur, and moves with it, and the
+fibrous band between the two fragments gradually becomes stretched.
+After bony union has occurred, it is not uncommon for the patella to
+be fractured again by a fall within a month or two of the original
+accident.
+
+[Illustration: FIG. 88.--Fracture of Patella, showing wide separation
+of fragments, which are united by a fibrous band.
+
+(Anatomical Museum of the University of Edinburgh.)]
+
+_Treatment._--It is probably true that the best functional results are
+most speedily obtained by operative measures. The laceration of the
+aponeurosis of the quadriceps, the tilting of the fragments, and the
+interposition of the torn periosteum between them, can in no other way
+be rectified with certainty. The operation, however, should only be
+undertaken by those who are familiar with wound technique, and who
+have the means at their disposal for carrying it out. Operative
+treatment is specially indicated in young subjects who lead an active
+life, and in labouring men, particularly those who follow dangerous
+employments necessitating stability of the knee.
+
+As soon as the wound is healed,--in a week or ten days,--massage and
+movement of the limb are commenced, and the patient is encouraged to
+move his limb in bed. At the end of another week he may be allowed up
+with sticks or crutches.
+
+_Non-operative Treatment._--In the majority of cases occurring in
+patients who do not follow a laborious occupation or otherwise lead an
+active life, a satisfactory result can be obtained without having
+recourse to operation. We have reason to be satisfied with the
+following method: the patient is kept in bed for a few days, the
+injured region being supported on a pillow and massaged daily, and the
+patella moved from side to side as a whole to prevent adhesion to the
+femur. About the fourth day he is allowed to get about with crutches.
+As osseous union of the fragments is not essential to a good
+functional result, and as fibrous union does not necessarily entail
+any material interference with the usefulness of the limb, no attempt
+need be made to approximate the fragments, but every effort must be
+made to maintain the function of the quadriceps muscle and the
+mobility of the joint.
+
+If it is desired to bring the fragments into contact and to secure
+osseous union, the limb should be placed upon an inclined plane to
+relax the quadriceps muscle, and means taken to arrest effusion and to
+diminish the swelling by systematic massage and a supporting bandage.
+When, in the course of a few days, this has been accomplished, the
+attempt is made to approximate the fragments, by fixing a large
+horseshoe-shaped piece of adhesive plaster to the front of the thigh,
+embracing the proximal fragment. Extension is made upon this by means
+of rubber tubing, which is fixed to the foot-piece of the splint. The
+bandage which binds the limb to the splint should make upward pressure
+on the distal fragment, or this may be done by a special piece of
+adhesive plaster with elastic tubing pulling in an upward direction.
+
+The retentive apparatus is kept on for about three weeks, and a rigid,
+but easily removable, apparatus is thereafter applied, and the patient
+allowed up on crutches, the limb being massaged and exercised daily to
+improve the tone of the muscles.
+
+When the fracture is caused by _direct violence_, such as a fall on
+the knee or the kick of a horse, it may be transverse, oblique, or
+vertical, but in many cases it is stellate, the bone being broken into
+several irregular pieces. These comminuted fractures are frequently
+compound. In transverse and oblique fractures, the displacement
+depends upon the same causes as in fracture by muscular action. In
+vertical and stellate fractures, unless the knee has been forcibly
+flexed after the bone has been broken, there is little or no
+displacement. The treatment is governed by the same considerations as
+in fractures by muscular action.
+
+_Old-standing Fracture._--As fibrous union, even with an interval of
+several inches between the fragments, is not incompatible with a
+useful limb, it is not often necessary to operate for this condition,
+but when the usefulness of the limb is seriously impaired, operative
+treatment is indicated. The operation is carried out on the same lines
+as for recent fracture, the ends of the bones being rawed and
+adhesions divided. When the proximal fragment has become attached to
+the femur, it should be separated and a layer of fascia interposed; it
+is sometimes necessary to lengthen the quadriceps muscle by making a
+number of V-shaped incisions through its substance; or a flap may be
+turned down from the rectus and stitched to the patella and the
+ligamentum patellæ.
+
+When operative treatment is contra-indicated, the patient should be
+fitted with a firm apparatus which will limit flexion of the knee and
+support the fragments.
+
+#Dislocation of the patella# is rare. It results from exaggerated
+muscular movements when the limb is in the fully extended position, or
+from a blow on one or other edge of the bone. Laxity of the ligaments
+and knock-knee are predisposing factors. It is sometimes associated
+with fracture of the edge of the trochlear surface, which renders
+retention in position difficult.
+
+The _lateral_ is the most common variety--the _medial_ being rare.
+Either may be complete or incomplete. Sometimes the bone is rotated so
+that its edge rests on the front of the femur--_vertical_ dislocation;
+and in a few cases it has been completely turned round, so that the
+articular surface is directed forwards.
+
+_Clinical Features._--The joint is fixed, usually in a position of
+slight flexion, and the displaced patella can readily be palpated. The
+deformity is a striking one, and at first sight suggests a much more
+serious injury. Although easily reduced, the dislocation is liable to
+recur.
+
+To effect reduction, the quadriceps must be thoroughly relaxed by
+extending the leg upon the thigh and flexing the thigh upon the
+pelvis; the patella is then tilted by making firm pressure on that
+edge which lies farthest from the middle of the joint, and at the same
+time pushing towards the middle line. The limb is placed on a
+posterior splint, and firm elastic pressure made on the joint to
+prevent or diminish effusion. Massage and movement are carried out
+from the first.
+
+As the displacement is liable to recur, the patient should wear a firm
+elastic bandage or a strong knee-cap.
+
+_Permanent and recurrent dislocation of the patella_ will be described
+later.
+
+
+FRACTURE OF THE BONES OF THE LEG
+
+The bones of the leg may be broken together or separately.
+
+#Fracture of both Bones.#--The features of this injury depend to a
+large extent upon the nature of the violence producing it. In fracture
+by _direct_ violence, such as the passage of a wheel over the limb or
+a severe blow, the bones give way at the point of impact, and the line
+of fracture tends to be transverse, both bones being broken at the
+same level (Fig. 89). There is little or no displacement, and such as
+there is is angular, and is determined by the direction of the
+fracturing force.
+
+[Illustration: FIG. 89.--Radiogram of Transverse Fracture of both
+Bones of Leg by direct violence.]
+
+When the violence is _indirect_, as from a fall on the feet, or a
+twist of the leg, the tibia usually gives way at the junction of its
+lower and middle thirds, and the fibula at a higher level (Fig. 90).
+Torsion of the tibia is probably the most important factor in the
+production of the fracture, the distal fragment being fixed by the
+pressure of the foot upon the ground, while the proximal fragment is
+rotated by the impetus of the body. Both fractures are usually
+oblique--that in the tibia running from above downward, forward, and
+medially, and it is generally found that the obliquity of the fibular
+fracture corresponds with that in the tibia.
+
+[Illustration: FIG. 90.--Radiogram of Oblique Fracture of both Bones
+of Leg by indirect violence.]
+
+There is usually considerable displacement, the weight of the lower
+portion of the limb causing it to fall backwards and to roll away from
+the middle line, and the traction of the calf muscles pulling up the
+heel and pointing the toes. The proximal fragment forms a projection
+on the front of the limb.
+
+On account of the superficial position of the tibia and the pointed
+character of the fragments, this fracture is frequently rendered
+compound by the bone being forced through the skin. The projecting
+piece of bone is usually the distal end of the proximal fragment. This
+fracture is often comminuted. It has been observed that when the line
+of fracture forms the letter V on the subcutaneous surface of the
+tibia, there is invariably a fissure passing down along the back of
+the bone into the ankle-joint--a complication which adds to the risk
+of subsequent stiffness and impaired usefulness of the limb. Apart
+from this, the ankle is usually sprained in fractures by indirect
+violence, and we have frequently found the superior tibio-fibular
+articulation torn open in severe fractures of both bones of the leg
+from indirect violence.
+
+_Clinical Features._--The tibial fracture is readily recognised by
+detecting an irregularity on running the fingers along the crest of
+the shin, and at this point abnormal mobility, tenderness, and
+crepitus can usually be elicited. It is often difficult to detect the
+fibular fracture, and it is not always advisable to attempt to do so,
+especially if the manipulations cause pain or tend to increase the
+displacement. The condition of the fibula is usually to be inferred by
+noting the amount of displacement and the extent of mobility of the
+tibial fragments. Not infrequently the seat of fracture may be
+recognised by locating a point at which pain is elicited on making
+pressure over the bone at a distance--pain on distal pressure.
+
+On account of the close connection of the skin to the periosteum on
+the subcutaneous aspect of the tibia, the tension caused by
+extravasated blood is often extreme; blisters frequently form over the
+area of ecchymosis, and when these become infected, sloughing of the
+skin may take place and the fracture thus be rendered compound.
+
+The vessels and nerves of the leg are seldom seriously damaged.
+
+_Treatment._--If there is marked displacement, reduction is most
+satisfactorily accomplished under anæsthesia. Traction is made upon
+the foot and the fragments are manipulated into position, the pointing
+of the toes and the outward rotation of the foot being at the same
+time corrected. The normal outline of the foot in relation to the leg
+is restored when the ball of the great toe, the medial malleolus, and
+the medial edge of the patella are in the same vertical plane. As in
+other fractures of the lower extremity, the limb should be placed in
+the natural position of slight eversion: not with the toes pointing
+straight forward.
+
+The retentive apparatus to be applied depends upon the tendency to
+re-displacement, the degree of swelling, and the extent of the damage
+to the skin.
+
+In the average case, the leg is supported between sand-bags, and
+massage and movements are employed from the outset. When there is a
+tendency to re-displacement, the limb may be immediately enclosed in a
+rigid apparatus, such as lateral poroplastic splints retained in
+position by an elastic bandage, or a Cline's splint, which can readily
+be removed to admit of massage. When the fracture is in the lower
+third of the leg, the ambulatory splint gives excellent results, and
+is of special service in hospital practice (Fig. 95).
+
+As an emergency appliance, for example for purposes of transport, the
+_box splint_ (Fig. 91) is simple and efficient. We have not found it
+effectual in controlling the fragments, particularly in oblique
+fractures, and it requires constant supervision and readjustment. It
+consists of two pieces of wood extending from above the knee to an
+inch or two beyond the sole, and a little broader than the maximum
+diameter of the leg. These are rolled into the opposite ends of a
+folded sheet, so as to form two sides of a box, of which the sheet
+constitutes a third side. It is found advantageous to insert another
+board, fitted with a foot-piece, between the folds of the sheet
+forming the third side of the box, to add to the rigidity of the
+splint, and to aid in controlling the foot. By folding one side of the
+sheet somewhat obliquely, the box is made a little wider at the knee
+than at the ankle, and so fits the limb more accurately.
+
+[Illustration: FIG. 91.--Box Splint for Fractures of Leg.]
+
+The limb is placed in this box, the sides of which have been carefully
+padded. Ring pads are applied to take pressure off the condyles, the
+head of the fibula, the malleoli, and the prominence of the heel, and
+a large supporting pad is placed behind the tendo calcaneus. A folded
+towel is laid over the front of the leg, forming a lid to the box, and
+the whole is bound to the limb by three slip-knots. Finally, the foot
+is fixed at right angles to the leg and slightly abducted by a
+figure-of-eight bandage or a piece of elastic webbing. Sand-bags
+placed alongside serve to steady the limb. In fractures of the lower
+third of the leg, the box splint may stop short of the knee and the
+limb may then be suspended in a Salter's cradle, which allows the
+patient to move about more freely in bed.
+
+[Illustration: FIG. 92.--Box Splint (applied).]
+
+To prevent shortening in oblique fractures and in those near the
+ankle-joint, where it is often difficult to control the lower
+fragment, extension, applied by weight and pulley, or through a
+Thomas' knee splint, may be of service. The strapping may be applied
+only to the distal fragment, but we prefer to carry it to the upper
+third of the leg. If the overriding of the fragments persists,
+extension may be taken directly from the bone, the ice-tong callipers
+gripping the malleoli or the calcaneus.
+
+When the skin is damaged, as it so frequently is on the medial aspect
+of the tibia, means must be taken to prevent infection.
+
+Massage is carried out daily, and, to prevent stiffness, the ankle is
+moved from the first. In the course of three weeks, lateral
+poroplastic splints retained by an elastic bandage may be substituted,
+and the patient allowed up on crutches. In simple fractures without
+displacement, union is usually complete in from six to eight weeks,
+but when the fracture is oblique, comminuted, or compound, union is
+often delayed, and the functions of the limb may not be fully regained
+for three or even four months after the accident.
+
+_Operative Treatment._--When overriding cannot otherwise be corrected,
+it is advisable to replace the fragments by operation. A curved
+incision with its convexity backward is made over the medial side of
+the tibia, exposing the fragments, which are then levered into
+position and if necessary plated or otherwise fixed according to
+circumstances. It is seldom necessary to deal separately with the
+fibula. A box splint is applied till the wound has healed, after which
+a poroplastic splint is substituted and massage commenced.
+
+We do not share in the dissatisfaction expressed by some surgeons,
+notably Arbuthnot Lane, as to the results obtained by non-operative
+means in the common fractures of the leg, and do not recommend a
+systematic resort to operative treatment.
+
+_Un-united fracture_ of the bones of the leg is sometimes met with. It
+is treated on the same lines as in other situations, but may prove
+extremely intractable, especially in children, in whom, indeed, it is
+sometimes incurable.
+
+_Mal-union_, on account of the disability it entails, may call for
+operative treatment in the form of osteotomy of one or both bones.
+
+_Compound fractures_ of the leg are common, and are treated on the
+lines already laid down for the treatment of compound fractures in
+general (p. 25).
+
+#Fracture of the tibia alone#, when due to direct violence, is usually
+transverse, there is little displacement, and as the fibula retains
+the fragments in position, union usually takes place rapidly and
+without deformity. Oblique and spiral fractures result from indirect
+violence.
+
+#Fracture of the fibula alone# may result from direct violence, and,
+on account of the support given by the tibia, is usually unattended by
+displacement. Bennett of Dublin has pointed out that it is common to
+meet with an oblique fracture of the upper third of the fibula as the
+result of an outward twist of the ankle while the foot is extended. It
+is characterised by pain localised at the seat of the break, on moving
+the foot in such a way as to bring the talus to bear against the
+fibula. Local pressure also may make the fibula yield and may elicit
+crepitus. In some cases this fracture is associated with sprain of the
+ankle-joint. It is often overlooked, and from want of proper treatment
+may result in prolonged impairment of usefulness.
+
+Fractures of the tibia or fibula alone are treated on the same lines
+as fractures of both bones, and splints are rarely necessary. The
+ambulant method is useful in these cases (Fig. 95).
+
+
+
+
+CHAPTER VIII
+
+INJURIES IN REGION OF ANKLE AND FOOT
+
+
+Surgical Anatomy--FRACTURES: _Pott's fracture_; _Converse of Pott's
+ fracture_; _Separation of lower epiphysis_; _Fracture of talus_;
+ _Fracture of calcaneus_; _Fractures of other tarsal bones_;
+ _Fractures of metatarsal bones_; _Fractures of
+ phalanges_--DISLOCATIONS: _Of ankle joint_; _Of inferior
+ tibio-fibular joint_; _Complete dislocation of talus_; _Sub-taloid
+ dislocation_; _Medio-tarsal dislocation_; _Tarso-metatarsal
+ dislocation_; _Dislocations of toes_.
+
+The fractures in this region include Pott's fracture, and its
+converse; separation of the lower epiphysis of the tibia; fractures of
+the talus, calcaneus, and other tarsal bones; and fractures of the
+metatarsals and phalanges. Various dislocations also occur, the most
+important being those of the ankle joint, of the talus, and the
+sub-taloid dislocation.
+
+#Surgical Anatomy.#--For the study of injuries in the region of the
+ankle-joint it is of importance to define the terms employed in
+describing the movements of the foot. Thus by _flexion_ or
+_dorsiflexion_ is meant that movement which approximates the dorsum of
+the foot to the front of the leg; while _extension_ or _plantar
+flexion_ means the drawing up of the heel so that the toes are
+pointed. In _inversion_ the medial edge of the foot is drawn up so
+that the sole looks towards the middle line of the body, an attitude
+which is analogous to supination of the hand. In _eversion_ the
+lateral edge of the foot is drawn up, the sole looking away from the
+middle line--analogous to pronation of the hand. _Adduction_ indicates
+the rotation of the foot so that the toes are turned towards the
+middle line of the body; while in _abduction_ the toes are turned away
+from the middle line.
+
+The most prominent bony landmarks in the region of the ankle are the
+two _malleoli_, the lateral lying slightly farther back, and about
+half an inch lower than the medial. On the medial side of the foot
+from behind forward may be felt the _medial process (internal
+tuberosity)_ of the calcaneus; the _sustentaculum tali_, which lies
+about 1 inch vertically below the tip of the malleolus; the _tubercle
+of the navicular_, about 1 inch in front of the malleolus, and at a
+slightly lower level; the _first (internal) cuneiform_, and the base,
+shaft, and head of the _first metatarsal_.
+
+On the lateral side may be recognised the _lateral process (external
+tuberosity)_ of the calcaneus; the _trochlear process (peroneal
+tubercle)_ on the same bone; the _cuboid_; and the prominent base of
+the _fifth metatarsal_.
+
+The talo-navicular joint lies immediately behind the tuberosity of the
+navicular, and a line drawn straight across the foot at this level
+passes over the calcaneo-cuboid joint.
+
+The _ankle-joint_, formed by the articulation of the tibia and fibula
+with the talus, lies about half an inch above the tip of the medial
+malleolus, and is so constructed that when the foot is at a right
+angle with the leg it is only possible to flex and extend the joint.
+When the toes are pointed, however, slight side-to-side and rotatory
+movements are possible. The chief seat of side-to-side movement of the
+foot is at the talo-navicular and calcaneo-cuboid articulations--"the
+mid-tarsal or Chopart's joint."
+
+The ankle-joint owes its strength chiefly to the malleoli and the
+collateral ligaments, and to the inferior tibio-fibular ligaments,
+which bind together the lower ends of the bones of the leg. The
+numerous tendons passing over the joint on every side also add to its
+stability.
+
+The synovial membrane of the ankle-joint passes up between the bones
+of the leg to line the inferior tibio-fibular joint; but it is
+distinct from that of the intertarsal joints, which communicate with
+one another in a complicated manner. The epiphysial cartilage at the
+lower end of the fibula lies on the level of the talo-tibial
+articulation, while that of the tibia is about half an inch higher
+(Fig. 93).
+
+[Illustration: FIG. 93.--Section through Ankle-Joint showing relation
+of epiphyses to synovial cavity.
+
+ _a_, Lower epiphysis of tibia.
+ _b_, Lower epiphysis of fibula.
+ _c_, Talus.
+ _d_, Calcaneus.
+
+(After Poland.)]
+
+
+FRACTURES IN THE REGION OF THE ANKLE
+
+#Pott's Fracture.#--It must be understood that various lesions
+occurring in the region of the ankle-joint are included under the
+clinical term "Pott's fracture." Although of a similar nature, and
+produced by the same forms of violence, these vary considerably in
+their anatomy and clinical features. They are all the result of
+_combined eversion and abduction_ of the foot--produced, for example,
+by slipping off the kerbstone, or by jumping from a height and landing
+on the medial side of the foot.
+
+When forcible _eversion_ is the chief movement, the tightening of the
+deltoid (internal lateral) ligament usually tears off the medial
+malleolus across its base. The talus is then brought to bear on the
+lateral malleolus, and the force continuing to act, the lower end of
+the fibula is pressed laterally, and breaks close above the
+malleolus. The tibio-fibular interosseous ligament may rupture, or the
+outer portion of the tibia, to which it is attached, may be avulsed.
+This form is sometimes called _Dupuytren's fracture_. When the bones
+are widely separated in Dupuytren's fracture the talus may be forced
+up between them.
+
+When the movement of _abduction_ predominates, the deltoid ligament is
+usually ruptured, or the anterior edge or tip of the medial malleolus
+torn off. The tibio-fibular interosseous ligament usually resists, and
+an oblique fracture of the fibula 2 or 4 inches above its lower end
+results.
+
+_Clinical Features._--In a considerable proportion of cases--in our
+experience in the majority--this fracture is not accompanied by any
+marked deformity of the foot, and the patient is often able to walk
+after the injury with only a slight limp.
+
+In others, however, the deformity is marked and characteristic (Fig.
+94). The foot is everted, its inner side resting on the ground. The
+medial malleolus is unduly prominent, stretching the skin, which may
+give way if the patient attempts to walk. The foot, having lost the
+support of the malleoli, is often displaced backward, and the toes are
+pointed by the contraction of the calf muscles. There is abnormal
+mobility--both from side to side and antero-posteriorly--and crepitus
+may be elicited. The points of tenderness are over the deltoid
+ligament or medial malleolus, the inferior tibio-fibular joint, and at
+the seat of fracture of the fibula. Distal pressure over the shaft of
+the fibula, or on the extreme tip of the malleolus, may elicit pain
+and crepitus at the seat of fracture. There is usually considerable
+ecchymosis and swelling in the hollows below and behind the malleoli;
+and the malleoli appear to be nearer the level of the sole. In
+Dupuytren's fracture, when the talus passes up between the tibia and
+fibula, there is great broadening of the ankle.
+
+[Illustration: FIG. 94.--Radiogram of Pott's Fracture with lateral
+displacement of foot.]
+
+There is often considerable difficulty in distinguishing a _sprain_ of
+the ankle from a fracture without displacement, as both forms of
+injury result from the same kinds of violence, and are rapidly
+followed by swelling and discoloration of the overlying soft parts. In
+a sprain, the point of maximum tenderness is over the ligaments and
+tendon sheaths that have been damaged, while in fracture the site of
+the break is the most tender spot. The X-rays are useful in the
+diagnosis of doubtful cases.
+
+_Treatment._--In those cases of fracture of the lower end of the
+fibula in which there is no marked displacement,--and they constitute
+a considerable proportion,--the limb should be massaged and laid on a
+pillow between sand-bags, or placed in a box splint for two or three
+days, until the swelling subsides. Some form of rigid apparatus, such
+as side poroplastic splints fixed in position with an elastic bandage,
+which will allow the patient to get about with crutches, is then
+applied. This is removed daily to permit of massage and movement being
+carried out--a point of great practical importance, because, if this
+is neglected, not only does union take place more slowly, but the
+stiffness of the ankle and oedema of the leg and foot which ensue,
+prolong the period of the patient's incapacity and endanger the
+usefulness of the limb.
+
+It is in cases of this kind that the _ambulatory method_ of treatment
+yields its best results. When, in the course of two or three days, the
+swelling has subsided, a plaster-of-Paris case (Fig. 95) is applied in
+such a way that when the patient walks the weight is transmitted from
+the condyles of the tibia through the plaster case to the ground, no
+weight being borne by the bones at the seat of fracture. The apparatus
+is applied as follows: A boracic lint bandage is applied to the limb
+as far as the knee, and protecting pads or rings of wool are placed
+over the condyles of the tibia, the head of the fibula, and the
+malleoli. A pad of wool about 3 inches thick is then placed under the
+sole and fixed in position by a plaster-of-Paris bandage, which is
+carried up the limb in the usual way. The case is made specially
+strong on the sole, around the ankle, up the sides of the leg, and at
+the bearing-point at the head of the tibia. After the plaster has
+thoroughly set, the patient is allowed to walk about with a stick,
+crutches being unnecessary. In the course of three weeks the plaster
+case may be removed and the limb massaged. It is usually found that
+the movements of the ankle are scarcely interfered with, and the
+patient is generally able to resume work within a month of the
+accident.
+
+[Illustration: FIG. 95.--Ambulant Splint of plaster of Paris.]
+
+When there is marked eversion of the foot, it may be necessary to
+administer a general anæsthetic to reduce the deformity; and to
+prevent recurrence of the displacement _Dupuytren's splint_ (Fig. 96)
+may be used. This splint, which is of the same shape as Liston's long
+splint, but on a small scale, is applied to the medial side of the leg
+extending from just below the knee to well beyond the sole of the
+foot. A large pad is placed in the hollow above the medial malleolus,
+and it must be thick enough to carry the splint so far from the limb
+that when the foot is fully inverted it does not touch the splint. The
+upper end of the splint having been fixed to the leg at the level of
+the condyles of the tibia, a bandage is applied to correct the
+eversion of the foot, and at the same time to support the heel, and,
+as far as possible, to overcome the pointing of the toes. Care must be
+taken to avoid carrying the turns of this bandage over the seat of
+fracture. The limb may then be slung in a cradle, or placed on a
+pillow resting on its lateral side with the knee flexed. In the course
+of a few days, a poroplastic splint may be substituted and massage
+commenced.
+
+[Illustration: FIG. 96.--Dupuytren's Splint applied to correct
+eversion of foot.]
+
+When backward displacement of the heel is the prominent deformity,
+_Syme's horse-shoe_ or _stirrup splint_ (Fig. 97) may be employed. It
+is applied to the anterior aspect of the limb, which is carefully
+padded to prevent undue pressure on the edge of the shin bone. After
+the upper end of the splint has been fixed, the heel is pulled forward
+by a few turns of bandage passed over the prongs at the lower end of
+the splint. The foot is then inverted and brought up to a right angle
+by a few supplementary turns of the bandage. In a few days this
+appliance may be replaced by a poroplastic splint.
+
+[Illustration: FIG. 97.--Syme's Horse-shoe Splint applied to correct
+backward displacement of foot.]
+
+_Operative Treatment._--If the displacement is not completely
+corrected by the measures described, the fibular fracture is exposed
+by a free incision and the fragments are levered into position, and if
+necessary fixed by lashing with catgut or by other mechanical means.
+
+Mal-union of Pott's fracture may necessitate re-fracture by means of a
+Jones' wrench, used in the same manner as for club-foot, or the parts
+are exposed by operation; the bone is divided by means of an
+osteotome, the foot forcibly inverted, and the limb put up in the same
+way as in a recent fracture.
+
+#The Converse of Pott's Fracture--sometimes called "Pott's Fracture
+with Inversion."#--This injury is fairly common, and results from
+forcible inversion of the foot. The lateral malleolus is broken across
+its base, or, in young subjects, along the epiphysial line. The medial
+malleolus alone may be carried away, or a portion of the broad part of
+the tibia may accompany it.
+
+The foot is inverted, the heel falls back, and the toes are pointed.
+In other respects it corresponds to the typical Pott's fracture, and
+is treated on the same principles. When Dupuytren's splint is
+required, it is, of course, applied to the lateral side of the leg.
+
+#Separation of the lower epiphysis of the tibia# is not common. It
+occurs most frequently between the ages of eleven and eighteen, as a
+result of forcible eversion or inversion of the foot. It is usually
+accompanied by fracture of the diaphysis of the fibula (Fig. 98), and
+is not infrequently compound. When the epiphysis is displaced to one
+side, the deformity is characteristic. In rare cases the growth of the
+tibia is arrested, the continued growth of the fibula causing the foot
+to become inverted. The treatment is the same as for Pott's fracture.
+
+[Illustration: FIG. 98.--Radiogram of Fracture of lower end of Fibula,
+with separation of lower epiphysis of Tibia.]
+
+#Fracture of the talus# usually occurs as a result of a fall from a
+height, the bone being crushed between the tibia and the calcaneus. It
+is usually associated with other fractures, and is sometimes
+impacted, the foot assuming the position of equino-varus. The
+diagnosis is only to be made by exclusion, or by the use of the
+Röntgen rays. In interpreting radiograms of injuries in this region,
+care must be taken not to mistake the _os trigonum tarsi_ for a
+fracture. In uncomplicated cases, the treatment consists in
+immobilising the foot and leg in a poroplastic splint and applying
+massage. In comminuted and in impacted fractures with persistent
+deformity, complete excision of the bone yields good results.
+
+The #calcaneus# is most frequently broken by the patient falling from
+a height and landing on the sole of the foot, and the injury may occur
+simultaneously in both feet.
+
+The primary fracture is usually longitudinal, passing through the
+facets for the talus and cuboid, and from this various secondary
+fissures radiate; the cancellated tissue is much crushed, so that the
+whole bone is flattened out. In spite of the great comminution, it is
+often impossible to elicit crepitus, as the fragments are held
+together by the investing soft parts. In other cases the foot may feel
+like "a bag of bones." The lesion is often mistaken for a fracture of
+the lower end of the fibula, or is not diagnosed at all. The chief
+clinical feature is pain on movement of the foot, or on attempting to
+walk; the foot appears flat, and the hollows on either side of the
+tendo Achillis are filled up. In many cases there is a persistent
+tenderness which delays restoration of function for some months, but
+the ultimate result is usually satisfactory.
+
+_Treatment._--In simple comminuted fractures the patient should be
+anæsthetised, and the foot moulded into position, care being taken to
+restore the arch in order to avoid any tendency to flat foot. The foot
+is supported on a pillow, and to prevent stiffness, massage and
+movements of the ankle and tarsal joints should be commenced without
+delay.
+
+Compound fractures confined to the calcaneus may be treated on
+conservative lines, but if associated with other injuries of the foot
+they may necessitate amputation.
+
+_The tuberosity of the calcaneus_, into which the tendo Achillis is
+inserted, is sometimes separated by forcible contraction of the calf
+muscles, or from a fall on the ball of the foot. The separated
+fragment may be pulled up for a distance of 1 or 2 inches, and the
+rough surface from which it has been torn may be recognisable. The
+patient may be able to walk immediately after the accident, although
+with difficulty; or he may have pain for many months.
+
+A good functional result is usually obtained by relaxing the calf
+muscles and fixing the foot in the position of extreme plantar flexion
+with the knee flexed, but in some cases it is advisable to peg the
+fragments, either through the skin or after exposing them by
+operation.
+
+The #other bones of the tarsus# are rarely fractured separately. The
+_tuberosity of the navicular_ is sometimes torn away by violent
+traction on the ligaments attached to it.
+
+#Fractures of the metatarsals and phalanges# usually result from
+direct violence, such as a crush of the foot, in which the soft parts
+are severely damaged. The use of the Röntgen rays has shown, however,
+that certain painful conditions in the foot following comparatively
+slight injuries, such as kicking a stone, are due to a fracture of one
+of the metatarsals or phalanges.
+
+When simple, these injuries are often overlooked, on account of the
+difficulty of eliciting the signs of fracture from the swelling which
+accompanies them. They are best treated in a moulded splint.
+
+Compound fractures are more common, and are to be treated on the same
+principles as govern such injuries elsewhere.
+
+_A fracture of the base of the fifth metatarsal_ has been described by
+Sir Robert Jones. It is produced by the patient coming down forcibly
+on the lateral edge of the foot while the foot is inverted and the
+heel raised--as, for example, in dancing. There is a localised
+swelling over the base of the fifth metatarsal, and pain when the
+patient puts weight on the foot. There is no crepitus or deformity.
+The fracture is readily recognised by the Röntgen rays. Massage and
+movement are employed from the first.
+
+
+DISLOCATIONS IN THE REGION OF THE ANKLE
+
+#Dislocation of the Ankle-Joint.#--In describing dislocation of the
+talus from the tibio-fibular socket, the varieties are named according
+to the direction in which the foot passes--backward, forward,
+medially, laterally, or upward.
+
+All of them may be complete, but they are more frequently incomplete,
+and are liable to be rendered compound, either from tearing of the
+skin at the time of the injury, or by its sloughing later. Although as
+a rule there is little difficulty in effecting reduction by
+manipulation, these injuries are liable to be followed by stiffness
+and impaired usefulness of the joint.
+
+The _backward_ dislocation is the most common, and results from
+extreme plantar flexion of the foot, as from a fall backwards while
+the foot is fixed, wedging the talus between the tibia and fibula.
+The collateral ligaments are torn, and one or both malleoli may be
+broken, or the posterior part of the articular edge of the tibia
+chipped off (Fig. 99).
+
+[Illustration: FIG. 99.--Radiogram of Backward Dislocation of Ankle.
+
+(Professor Chiene's case.)]
+
+The foot appears shortened, the heel is unduly prominent behind, and
+the lower ends of the tibia and fibula project in front, sometimes
+coming through the skin. The tendons around the joint are stretched or
+torn.
+
+_Forward_ dislocation results from extreme dorsal flexion at the
+ankle-joint. The foot appears lengthened, the heel is less prominent
+than normal, and the hollows on each side of the tendo Achillis are
+obliterated. The talus is felt in front of the tibia, and the malleoli
+appear to be displaced backwards and to lie nearer the sole.
+
+_Medial_ or _lateral_ dislocation is only possible after fracture of
+one or both malleoli, and may be looked upon as a complication of
+these injuries.
+
+In cases in which the interosseous ligament is ruptured, and in severe
+cases of Dupuytren's fracture, the talus may be driven _upwards_
+between the bones of the leg. There is great broadening in the region
+of the ankle, and the malleoli are unduly prominent under the skin,
+which is tightly stretched over them. They are also nearer to the sole
+than normally. The movements of the ankle-joint are lost.
+
+Dislocation of the _inferior tibio-fibular joint_ is exceedingly rare,
+except in association with fractures of the lower ends of the bones of
+the leg, particularly Dupuytren's fracture, or with dislocation of the
+ankle-joint proper.
+
+_Treatment of Dislocation of Ankle._--The patient having been
+anæsthetised, the foot is extended and the knee and hip joints flexed
+to relax the calf muscles as completely as possible. Traction is then
+made upon the foot, while counter-extension is applied to the leg, and
+the bones are manipulated into position. Reduction usually takes place
+gradually without the characteristic snap which accompanies reduction
+of most dislocations. It is sometimes necessary to divide the tendo
+Achillis, particularly in cases of forward dislocation.
+
+When the talus passes upwards between the tibia and fibula, it is
+sometimes impossible to effect reduction by manipulation, and the best
+results are then obtained by operation.
+
+The after-treatment consists in keeping the leg on a pillow between
+sand-bags, and carrying out the usual massage and movement.
+
+In compound dislocations which have become infected, primary
+amputation may be indicated, but in young and healthy subjects an
+attempt may be made to save the foot.
+
+#Dislocation of the talus# from its articulations with the bones of
+the leg above and the calcaneus and navicular below, is a
+comparatively common injury, and results from a violent wrench of the
+foot. It may be incomplete or complete. When the foot is plantar
+flexed at the moment of injury, the displacement is generally
+_forward_ with a tendency outward. The talus comes to rest on the
+third cuneiform and cuboid bones, the foot being abducted, inverted,
+and displaced medially. In a large proportion of cases the
+dislocation is compound, more or less of the talus being forced
+through the skin (Fig. 100).
+
+[Illustration: FIG. 100.--Compound Dislocation of the Talus.]
+
+When the foot is dorsiflexed at the moment of injury the displacement
+is _backward_, but this is rare, as is also _dislocation to one or
+other side_, and _dislocation by rotation_, in which the talus is
+rotated in its socket. In all these injuries the body of the talus
+loses its normal relationship with the malleoli.
+
+An attempt should be made to reduce the dislocation under anæsthesia,
+the limb being placed in the same position as for reduction of
+dislocation of the ankle. While traction is made upon the foot, an
+assistant presses directly on the displaced bone and endeavours to
+manipulate it into position. In incomplete dislocations this usually
+succeeds, but it not infrequently fails in those which are complete,
+and under these circumstances it may be necessary to chisel through
+the lateral malleolus to admit of reduction, or to excise the talus.
+In most cases of compound dislocation also, this bone should be
+removed.
+
+#Sub-taloid Dislocation.#--In this dislocation, which results from the
+same kinds of violence as the last, the talus retains its position in
+the tibio-fibular socket, and the calcaneus and navicular, with the
+rest of the foot, are carried away from it. The body of the talus,
+therefore, maintains its normal relationship with the malleoli--a
+point of importance in the differential diagnosis between this injury
+and dislocation of the talus. The displacement is usually incomplete,
+and the foot may either pass backward and medially, or backward and
+laterally. When the foot passes _backward and medially_, the head of
+the talus projects on the outer part of the dorsum, resting on the
+cuboid. The dorsum of the foot is shortened, the heel lengthened, the
+toes adducted, and the medial border of the foot raised. The lateral
+malleolus is unduly prominent, and reaches nearly to the sole.
+
+[Illustration: FIG. 101.--Radiogram of Fracture-Dislocation of Talus.]
+
+In the _backward and lateral_ variety, the medial malleolus and head
+of the talus project unduly towards the medial side of the foot, which
+is abducted and everted.
+
+In neither variety is there any mechanical obstacle to movement at the
+ankle-joint.
+
+The _treatment_ is carried out on the same lines as for dislocation of
+the talus, reduction being effected without difficulty in most cases.
+If this fails, as it occasionally does, it may be necessary to excise
+the talus.
+
+#Mid-tarsal or transverse tarsal dislocation#--that is, at the
+talo-navicular and calcaneo-cuboid articulations--is extremely rare.
+The distal segment of the foot is usually displaced towards the sole;
+the foot is foreshortened, the malleoli raised from the sole, the
+arch of the foot is lost, and the first row of tarsal bones projects
+on the dorsum. The treatment consists in reducing the displacement by
+manipulation, after which massage and movement are employed.
+
+#Tarso-metatarsal Dislocations.#--One, several, or all of the
+metatarsals may be separated from the distal row of tarsal bones--the
+usual cause being a fall from a horse, the foot being fixed in the
+stirrup. The bases of the metatarsal bones are displaced laterally and
+towards the dorsum. The base of the second metatarsal and the first
+cuneiform are sometimes fractured. Reduction by manipulation is
+generally easy in dorsal dislocations, but may be difficult when the
+bones are displaced laterally. This may be due to fragments of bone or
+soft parts getting between the bones, and may necessitate operative
+interference. In old-standing dislocations, operation is to be advised
+only when locomotion is seriously interfered with.
+
+#Dislocation of the Toes.#--The great toe may be dislocated at its
+metatarso-phalangeal joint, the base of the proximal phalanx passing
+towards the dorsum (Fig. 102). Diagnosis and reduction are alike easy.
+
+[Illustration: FIG. 102.--Radiogram of Dislocation of Toes.
+
+(Sir Montagu Cotterill's case.)]
+
+#Inter-phalangeal# dislocations are rare and are easily reduced.
+
+
+
+
+CHAPTER IX
+
+DISEASES OF INDIVIDUAL JOINTS
+
+
+THE SHOULDER-JOINT
+
+The shoulder is seldom the seat of disease, and most affections of the
+joint are met with in adults. In young subjects, infective processes
+result chiefly from extension of disease from the upper epiphysial
+junction of the humerus, which is partly included within the limits of
+the synovial cavity. The synovial membrane, in addition to lining the
+capsular ligament, is prolonged down the inter-tubercular (bicipital)
+groove around the long tendon of the biceps, and pus may escape from
+the joint by this diverticulum and gravitate down the arm; we have
+also observed loose bodies of synovial origin in this diverticulum.
+There is frequently a communication between the joint and the
+sub-deltoid bursa. There is no attitude characteristic of disease of
+the shoulder-joint, but the girdle is usually elevated, the upper arm
+held close to the side and rotated medially, while the elbow is
+carried a little backwards. In the later stages, the head of the
+humerus may be drawn upwards and medially towards the coracoid
+process. Fixation of the shoulder-joint is largely compensated for by
+movement of the scapula on the thorax, so that when testing for
+rigidity the scapula should be fixed with one hand while passive
+movements of the arm are carried out with the other. The deltoid is
+usually atrophied, allowing the acromion, coracoid, and great
+tuberosity of the humerus to stand out prominently beneath the skin.
+Swelling is rarely a prominent feature, except when there is a
+collection of synovial fluid or of pus in the bursa beneath the
+deltoid.
+
+#Tuberculous Disease# is usually met with in young adults, and is more
+common in the right shoulder. The prominent features are pain,
+rigidity, and wasting of the deltoid and scapular muscles. The pain is
+sometimes severe, shooting down the arm and interfering with sleep,
+and it may be associated with tenderness on pressure over the upper
+end of the humerus. In cases with carious destruction of the
+articular surfaces there are starting pains, and the arm is shortened.
+If a cold abscess forms in the bursa underneath the deltoid, the pus
+may burrow and appear at the anterior or posterior boundary of the
+axilla or in the axillary space. Pus formed in the joint tends to
+gravitate along the inter-tubercular groove. The axillary glands may
+be infected.
+
+The primary lesion is either a caseating focus in one of the
+bones--most often in the upper end of the humerus--or it is of the
+nature of caries sicca. The greater part of the head may disappear,
+and the upper end of the shaft be drawn against the socket. In
+exceptional cases, portions of the glenoid or humerus are found
+separated as sequestra, or the disease involves parts outside the
+joint, such as the acromion or coracoid process. Hydrops with
+melon-seed bodies is rare. In young subjects, destruction of the
+tissues at the ossifying junction may result in considerable
+shortening of the arm.
+
+The _diagnosis_ is to be made from (1) arthritis deformans, in which
+the movements are less restricted, and are attended with grating and
+cracking; (2) paralysis involving the deltoid and scapular muscles--by
+the absence of pain, and the flail-like character of the movements;
+(3) disease in the sub-deltoid bursa--by the absence of rigidity and
+other evidence of implication of the articular surfaces; and (4)
+sarcoma of the upper end of the humerus--by the history of the case,
+the use of the X-rays or an exploratory incision. Injuries in the
+region of the upper epiphysis resulting in loss of movement, may, in
+the absence of a reliable history, be mistaken for tuberculous
+disease.
+
+While the _prognosis_ is favourable on the whole, recovery is usually
+attended with fibrous ankylosis and incapacity to raise the arm above
+the level of the shoulder. The disease often progresses slowly, and
+may last for years.
+
+_Treatment._--The limb should be immobilised in the position of
+abduction with the forearm and hand directed forwards; the most
+efficient apparatus is a plaster spica embracing the thorax and the
+upper limb down as far as the wrist. If the articular surfaces are
+affected and the disease is likely to lead to ankylosis, the arm
+should be abducted to a right angle. The severe pain of caries sicca
+may be relieved by blistering or by the application of the cautery. To
+inject iodoform, the needle is introduced either immediately outside
+the coracoid process, or just below the junction of the acromion
+process and spine of the scapula. When the disease does not yield to
+conservative measures, or the X-rays show a gross lesion in the bone,
+excision of the joint should be performed; a close fibrous ankylosis
+usually results, and the arm is quite a useful one provided the
+abducted position has been maintained throughout.
+
+#Pyogenic Diseases.#--The shoulder-joint may be infected by extension
+of suppurative osteomyelitis from the upper end of the humerus, or
+from suppuration in the axilla, or through the blood stream by
+ordinary pus organisms, pneumococci, typhoid bacilli, or gonococci.
+Extension should be applied to the arm abducted at a right angle. When
+it is necessary to open the joint, the incision should be placed
+anteriorly in the line of the inter-tubercular groove; if a
+counter-opening is required it is made on the posterior aspect by
+cutting on the point of a dressing forceps introduced through the
+anterior incision.
+
+#Arthritis Deformans.#--The shoulder is seldom affected alone, except
+when the arthritis is a sequel to injury, such as a fracture of the
+neck of the humerus. The common type of lesion is a dry arthritis with
+fibrillation and eburnation of the articular surfaces. The long tendon
+of the biceps is usually destroyed, the head of the bone is drawn
+upwards, and, after wearing through the capsule, rubs on the under
+surface of the acromion, which also becomes eburnated. The clinical
+features are pain, stiffness, and cracking on movement, and as these
+symptoms may also be caused by loose bodies in the joint, an X-ray
+picture should be taken to differentiate between them.
+
+#Neuro-arthropathies# of the shoulder are met with chiefly in
+syringomyelia. In some cases there is a large fluctuating and
+painless swelling; in others marked and rapid wasting of the deltoid
+and scapular muscles with flail-like movements of the joint associated
+with disappearance of the upper end of the humerus (Fig. 104).
+
+[Illustration: FIG. 103.--Arthropathy of Shoulder in Syringomyelia.
+The upper end of the humerus has disappeared and the movements are
+flail-like (cf. Fig. 104).]
+
+[Illustration: FIG. 104.--Radiogram of specimen of Arthropathy of
+Shoulder in Syringomyelia. The head of the humerus has disappeared and
+masses of new bone have formed in the surrounding muscles (cf. Fig.
+103).]
+
+#Loose bodies# are rare in the shoulder; we have met with a case in
+which the joint-cavity was distended with loose bodies of synovial
+origin, and as most of these had undergone ossification, the X-ray
+appearances were highly characteristic. They were removed through an
+anterior incision.
+
+#Ankylosis# is not so disabling at the shoulder as at other joints, as
+the mobility of the scapula on the chest wall largely compensates for
+the fixation of the joint.
+
+
+THE ELBOW-JOINT
+
+In disease of the elbow, the usual attitude is that of flexion with
+pronation of the hand. Swelling of the joint, whether from effusion of
+fluid or from thickening of the synovial membrane, is observed chiefly
+on the posterior aspect, above and on either side of the olecranon,
+because the synovial sac is here nearest the surface. The free
+communication between the elbow and the superior radio-ulnar joint
+should be borne in mind.
+
+[Illustration: FIG. 105.--Radiogram showing Multiple partially
+ossified Cartilaginous Loose Bodies in Shoulder-joint. The lowest one
+is in the synovial prolongation along the tendon of the biceps.]
+
+#Tuberculous disease# is the most common and important affection (Fig.
+106). It usually occurs in patients under twenty, but may be met with
+at any age; in children the age-incidence is earlier than in the other
+large joints, a considerable proportion being met with in the first
+two years of life (Stiles). When the disease is confined to the
+synovial membrane, its onset is insidious, there is little or no pain,
+and no interference with any movement except complete extension. The
+chief evidence of disease is a white swelling on either side of and
+above the olecranon, obscuring the bony landmarks. The further
+progress is attended with wasting of the triceps, symptoms of
+involvement of the articular surfaces, and with abscess formation.
+
+[Illustration: FIG. 106.--Diffuse Tuberculous Thickening of Synovial
+Membrane of Elbow (white swelling) in a boy æt. 12.]
+
+The occurrence of articular caries without swelling of the synovial
+membrane is exceptional, and is associated with a good deal of pain
+and considerable restriction of movement. Rigidity from muscular
+contraction occurs late, and is rarely complete. Tuberculous foci in
+the bones are met with chiefly in the lower end of the diaphysis of
+the humerus; in children, the epiphyses are so small that the
+ossifying junction is intra-articular. Foci are also met with in the
+upper end of the ulna. The grosser osseous lesions cause enlargement
+of the bone, and are readily demonstrated by skiagraphy. Abscess
+formation most commonly occurs beneath the triceps, and the abscess
+points at one or other edge of that muscle. A subcutaneous abscess
+may form over the upper end of the ulna or over the radio-humeral
+joint. Tuberculous hydrops with melon-seed bodies is rare.
+
+[Illustration: FIG. 107.--Contracture of Elbow and Wrist following a
+burn in childhood. Treated by resection of both joints, and the
+insertion, on the palmar aspect of each, of a flap from the abdominal
+wall.]
+
+_Treatment._--Conservative measures are persevered with so long as
+there is a prospect of securing a movable joint. The limb is placed in
+a light form of splint reaching from the axilla to the wrist, flexed
+to rather less than a right angle and with the hand semi-pronated and
+dorsiflexed. To inject iodoform or other anti-tuberculous agent, the
+needle of the syringe is easily introduced between the lateral condyle
+and the head of the radius. A localised focus of disease in one or
+other of the bones may be eradicated without opening into the synovial
+cavity.
+
+If the articular surfaces are so involved that recovery is likely to
+be attended with ankylosis, the disease should be removed by
+operation, and cure with a useful and movable joint may then be
+reasonably anticipated within two or three months. When the patient's
+occupation is such that a strong stiff joint is preferable to a weaker
+movable one, bony ankylosis at rather less than a right angle should
+be aimed at.
+
+#Arthritis deformans# occurs as a hydrops with hypertrophy of the
+synovial fringes and loose bodies, or as a dry arthritis with
+eburnation and lipping of the articular margins.
+
+#Neuro-arthropathies# are met with chiefly in syringomyelia, and are
+attended with striking alterations in the shape of the bones and with
+abnormal mobility.
+
+#Pyogenic diseases# result from staphylococcal osteomyelitis--chiefly
+of the humerus or ulna--and from gonorrhoea.
+
+The remaining diseases at the elbow include syphilitic disease in
+young children, bleeder's joint, hysterical affections, and loose
+bodies, and do not call for special description.
+
+#Ankylosis# of the elbow-joint, if interfering with the livelihood of
+the patient, may be got rid of by resecting the articular ends of
+the bones, or by inserting between them a flap of fascia and
+subcutaneous fat derived from the posterior aspect of the upper
+arm--_arthroplasty_.
+
+
+THE WRIST-JOINT
+
+The close proximity of the flexor sheaths to the carpal articulations
+permits of infective processes spreading readily from one to the
+other. The arrangement of the synovial membranes also favours the
+extension of disease throughout the numerous articulations in the
+region of the wrist.
+
+#Tuberculous disease# is met with chiefly in young adults, but may
+occur at any age. It usually originates in the synovial membrane, but
+foci are frequently present in the carpal bones, and less commonly in
+the lower ends of the radius and ulna, or in the bases of the
+metacarpals. The clinical features are almost invariably those of
+white swelling, which is most marked on the dorsum where it obscures
+the bony prominences and the outlines of the extensor tendons. Wasting
+of the thenar and hypothenar eminences, and filling up of the hollows
+above and below the anterior annular ligament, render the appearance
+on the palmar aspect characteristic.
+
+The attitude is one of slight flexion with drooping of the hand and
+fingers. The fingers become stiff as a result of adhesions in the
+tendon sheaths, and the power of opposing the thumb and fingers may be
+lost. Pain is usually absent until the articular surfaces become
+carious. Softening of the ligaments may permit of lateral mobility,
+and sometimes partial dislocation occurs. Abscess may be followed by
+sinuses and infection of the tendon sheaths, especially those in the
+palm.
+
+The localisation of disease in individual bones or joints can be
+determined by the use of the X-rays.
+
+_Treatment._--Conservative measures may be persevered with over a
+longer period than in most other joints. The forearm, wrist, and
+metacarpus are immobilised in the attitude of dorsal flexion, while
+the fingers and thumb are left free to allow of passive movements. It
+may be necessary to give an anæsthetic to obtain the necessary degree
+of dorsiflexion. To inject iodoform, the needle is inserted
+immediately below the radial or the ulnar styloid process. Sometimes
+the carpal bones are so soft that the needle can be made to penetrate
+them in different directions. Operative treatment is indicated in
+cases which resist conservative measures, or when the general health
+calls for speedy removal of the disease.
+
+_Other diseases of the wrist_ are comparatively rare. They include
+pyogenic affections, such as those resulting from infective conditions
+in the palm of the hand, different types of gonorrhoeal, rheumatic,
+and gouty affections, and arthritis deformans. An interesting feature,
+sometimes met with in arthritis deformans, consists in eburnation of
+the articular surfaces of the carpal bones, although the range of
+movement is almost nil.
+
+
+THE HIP-JOINT
+
+Owing to the depth of this joint from the surface, it is not possible
+to detect the presence of effusion or of synovial thickening as
+readily as in other joints, hence in the recognition of hip disease we
+have to rely largely upon indirect evidence, such as a limp in
+walking, an alteration in the attitude of the limb, or restriction of
+its movements.
+
+The whole of the anterior and fully one-half of the posterior aspect
+of the neck of the femur is covered by synovial membrane, so that
+lesions not only of the epiphysis and epiphysial junction, but also of
+the neck of the bone, are capable of spreading directly to the
+synovial membrane and to the cavity of the joint. Conversely, disease
+in the synovial membrane may spread to the bone in relation to it.
+Infective material may escape from the joint into the surrounding
+tissues through any weak point in the capsule, particularly through
+the bursa which intervenes between the capsule and the ilio-psoas, and
+which in one out of every ten subjects communicates with the joint.
+
+
+TUBERCULOUS DISEASE
+
+Tuberculous disease of the hip, morbus coxæ, or "hip-joint disease,"
+is especially common in the poorer classes. It is a frequent cause of
+prolonged invalidism, and of permanent deformity, and is attended with
+a considerable mortality. It is essentially a disease of early life,
+rarely commencing after puberty, and almost never after maturity.
+
+#Pathological Anatomy.#--Bone lesions bulk more largely in hip disease
+than they do in disease of other joints--five cases originating in
+bone to one in synovial membrane being the usual estimate. The upper
+end of the femur and the acetabulum are affected with about equal
+frequency.
+
+In addition to primary tuberculous lesions, secondary changes result
+from the inflamed and softened bones pressing against one another
+subsequent to the destruction of their articular cartilages. The head
+of the femur undergoes absorption from above downwards, becoming
+flattened and truncated, or disappearing altogether. In the acetabulum
+the absorption takes place in an upward and backward direction,
+whereby the socket becomes enlarged and elongated towards the dorsum
+ilii. To this progressive enlargement of the socket Volkmann gave the
+suggestive name of "wandering acetabulum" (Fig. 108). The
+displacement of the femur resulting from these secondary changes is
+one of the causes of real shortening of the limb.
+
+[Illustration: FIG. 108.--Advanced Tuberculous Disease of Acetabulum
+with caries and perforation into pelvis.
+
+(Anatomical Museum, University of Edinburgh.)]
+
+#Clinical Features.#--It is customary to describe three stages in the
+progress of hip disease, but this is arbitrary and only adopted for
+convenience of description.
+
+_Initial Stage._--At this stage the disease is confined to a focus in
+the bone which has not yet opened into the joint or to the synovial
+membrane. The onset is insidious, and if injury is alleged as an
+exciting cause, some weeks have usually elapsed between the receipt of
+the injury and the onset of symptoms. The child is brought for advice
+because he has begun to limp and to complain of pain. There is a
+history that he has become pale and has ceased to take food well, that
+his sleep has been disturbed, and that the pain and the limp, after
+coming and going for a time, have become more pronounced. On walking,
+the affected limb is dragged in such a way as to avoid movement at the
+hip, and to substitute for it movement at the lumbo-sacral junction.
+The child throws the weight of the trunk as little as possible on to
+the affected limb, and inclines to rest on the balls of the toes
+rather than on the sole. There is usually some wasting of the muscles
+of the thigh and flattening of the buttock. Diminution or loss of the
+gluteal fold indicates flexion at the hip which might otherwise escape
+notice. Pain is complained of in the hip, or is referred to the medial
+side of the knee, in the distribution of the obturator nerve.
+Sometimes the pain is confined to the knee, and if the examination is
+restricted to that joint the disease at the hip may be overlooked. At
+this stage the attitude of the limb is not constant; at one time it
+may be natural, and at another slightly flexed and abducted.
+Tenderness of the joint may be elicited by pressing either in front or
+behind the head of the bone, but is of little diagnostic importance.
+Pain elicited on driving the head against the acetabulum may
+occasionally assist in the recognition of hip disease, but the
+diagnostic value of this sign has been overrated and, in our opinion,
+this test should be omitted.
+
+Most information is gained by testing the functions of the joint, and
+if this is done gently and without jerking, it does not cause pain.
+The child should lie on his back, either on his nurse's knee or on a
+table; and to reassure him the movements should be first practised on
+the sound limb. On slowly flexing the thigh of the affected limb, it
+will be found that the range of flexion at the hip is soon exhausted,
+and that any further movement in this direction takes place at the
+lumbo-sacral junction. The child is next made to lie on his face with
+the knees flexed in order that the movements of rotation may be
+tested. The thigh is rotated in both directions, and on comparing the
+two sides it will be found that rotation is restricted or abolished on
+the side affected, any apparent rotation taking place at the
+lumbo-sacral junction. These tests reveal the presence of _rigidity_
+resulting from the involuntary contraction of muscles, which is the
+most reliable sign of hip disease during the initial stage, and they
+possess the advantage of being universally applicable, even in the
+case of young children.
+
+_Second Stage._--This probably corresponds with commencing disease of
+the articular surfaces, and progressive involvement of all the
+structures of the joint. The child complains more, and usually
+exhibits the attitude of abduction, eversion, and flexion (Fig. 109).
+
+[Illustration: FIG. 109.--Early Tuberculous Disease of Right Hip-joint
+in a boy æt. 14, showing flexion, abduction, and apparent lengthening
+of the limb.]
+
+At first the attitude is maintained entirely by the action of muscles;
+but when it is prolonged, the muscles, fasciæ, and ligaments undergo
+shortening, so that it becomes fixed.
+
+On looking at the patient, the abnormal attitude may not be at once
+evident, as he usually restores the parallelism of the limbs by
+lowering the pelvis on the affected side and adducting the sound limb.
+This obliquity or tilting of the pelvis causes _apparent lengthening_
+of the diseased limb, and is best demonstrated by drawing one straight
+line between the anterior iliac spines, and another to meet it from
+the xiphoid cartilage through the umbilicus; if the pelvis is in its
+normal position, the two lines intersect at right angles; if it is
+tilted, the angles at the point of intersection are unequal. The
+flexion may be largely compensated for by increasing the forward curve
+of the lumbar spine (lordosis), and by flexing the leg at the knee.
+There may also be an attempt to compensate for the eversion of the
+limb by rotating the pelvis forwards on the affected side.
+
+[Illustration: FIG. 110.--Disease of Left Hip: position of ease
+assumed by patient, showing moderate flexion and lordosis.]
+
+[Illustration: FIG. 111.--Disease of Left Hip: disappearance of
+lordosis on further flexion of the hip.]
+
+To demonstrate the lordosis, the patient should be laid on a flat
+table; in the resting position the lordosis is moderate, when the hip
+is flexed it disappears, when it is extended the lordosis is
+exaggerated, and the hand or closed fist may be inserted between the
+spine and the table (Fig. 112).
+
+[Illustration: FIG. 112.--Disease of Left Hip: exaggeration of
+lordosis produced by extending the limb.]
+
+When the functions of the joint are tested, it will be found that
+there is rigidity, and that both active and passive movements take
+place at the lumbo-sacral junction instead of at the hip. While
+rigidity is usually absolute as regards rotation, it may sometimes be
+possible with care and gentleness to obtain some increase of flexion.
+For diagnostic purposes most stress should therefore be laid on the
+presence or absence of rotation.
+
+If the sound limb is flexed at the hip and knee until the lumbar spine
+is in contact with the table, the real flexion of the diseased hip
+becomes manifest, and may be roughly measured by observing the angle
+between the thigh and the table (Fig. 113). This is known as "Thomas'
+flexion test," and is founded upon the inability to extend the
+diseased hip without producing lordosis.
+
+[Illustration: FIG. 113.--Thomas' Flexion Test, showing angle of
+flexion at diseased (left) hip.]
+
+_Swelling_ is seen on the anterior aspect of the joint; it may fill up
+the fold of the groin and push forward the femoral vessels. It is
+doughy and elastic, but may at any time liquefy and form a cold
+abscess. Swelling about the trochanter and neck of the bone may be
+estimated by measuring the antero-posterior diameter with callipers,
+and comparing with the sound side. Swelling on the pelvic aspect of
+the acetabulum can sometimes be discovered on rectal examination.
+
+_Third Stage._--This probably corresponds with caries of the articular
+surfaces, since pain is now a prominent feature, and there are usually
+startings at night. The attitude is one of adduction, inversion,
+flexion, and apparent or real shortening of the limb (Fig. 114). The
+_flexion_ is usually so pronounced that it can no longer be concealed
+by lordosis, so that when the patient is recumbent, although the spine
+is arched forwards, the limb is still flexed both at the hip and at
+the knee; with the spine flat on the table, the flexion of the thigh
+may amount to as much as a right angle. The _adduction_ varies greatly
+in degree; when it is slight, as is most often the case, the toes of
+the affected limb rest on the dorsum of the sound foot. When moderate,
+it is compensated for by raising the pelvis on the affected side, with
+_apparent shortening_ of the limb, this being the result of an effort
+on the part of the patient to restore the normal parallelism of the
+limbs, the sound limb being abducted to the same extent as the
+affected limb is adducted. It is important to recognise the cause of
+this shortening, as it can be corrected by treatment. As a result of
+the obliquity of the pelvis, the patient, when erect, exhibits a
+lateral curvature of the spine with the dorso-lumbar convexity to the
+sound side.
+
+[Illustration: FIG. 114.--Tuberculous Disease of Left Hip: third
+stage, showing adduction and shortening.]
+
+When adduction is pronounced, the patient is unable to restore the
+normal parallelism of the limbs, and the knee on the affected side may
+cross the sound limb. There is a deep groove at the junction of the
+perineum and thigh, great prominence of the trochanter, and the pelvis
+may be tilted to such an extent that the iliac crest comes into
+contact with the lower ribs.
+
+As a result of the pressure of the carious articular surfaces against
+one another, the acetabulum is enlarged and the upper end of the femur
+is drawn gradually upwards and backwards within the socket.
+Examination will then reveal the existence of a variable amount of
+_actual shortening_; it will also be found that the trochanter is
+displaced above Nélaton's line, while above and behind the trochanter
+there is a prominent hard swelling corresponding to the enlarged
+acetabulum.
+
+There may, therefore, be a combination of real and apparent shortening
+together amounting to several inches (Fig. 115).
+
+[Illustration: FIG. 115.--Advanced Tuberculous Disease of Left
+Hip-joint in a girl æt. 14, showing flexion, adduction, shortening,
+and iliac abscess.]
+
+In cases of long standing, beginning in childhood, the shortening is
+still further added to by deficient growth in length of the femur, and
+it may be of all the bones of the limb; even the foot is smaller on
+the affected side.
+
+The most reasonable explanation of the attitudes assumed in hip
+disease is that given by König. If the patient walks without crutches,
+as he is usually able to do at an early stage of the disease, the
+attitude of abduction, eversion, and slight flexion enables him to
+save the limb to the utmost extent; on the other hand, if he uses a
+crutch, as he is obliged to do at a more advanced stage, he no longer
+uses the limb for support, and therefore draws it upwards and medially
+into the position of adduction, inversion, and greater flexion.
+Similarly, if he is confined to bed, he lies on the sound side, and
+the affected limb sinks by gravity so as to lie over the normal one in
+the position of adduction, inversion, and flexion. König's explanation
+accords with the fact that in the exceptional cases which begin with
+adduction and inversion we have usually to deal with a severe type of
+the disease, associated with grave osseous lesions--precisely those
+cases in which the patient is compelled from the outset to lie up or
+to adopt the use of crutches. Further, the transition from the
+abducted to the adducted position usually follows upon such an
+aggravation of the symptoms that the patient is no longer able to walk
+without the assistance of a crutch.
+
+During the third stage the other signs and symptoms become more
+pronounced; the patient looks ill and thin, he is usually unable to
+leave his bed, his sleep is disturbed by startings of the limb, and
+the rigidity of the joint and the wasting of the muscles are well
+marked. The temperature may rise slightly after examination of the
+limb, or after a railway journey.
+
+#Abscess Formation in Hip Disease.#--The formation of abscess is not
+related to any stage of the disease; it may occur before there is
+deformity, and it may be deferred until the disease is apparently
+cured. Its importance lies in the fact that if a mixed infection with
+pyogenic organisms occurs, the gravity of the condition is greatly
+increased.
+
+An abscess may appear _in the thigh_ in front or behind the joint. The
+_anterior abscess_ emerges on one or other side of the psoas muscle;
+from the resistance offered by the fascia lata, the pus may gravitate
+down the thigh before perforating the fascia. It has occasionally
+happened that when such an abscess has been opened and become infected
+with pyogenic organisms, the femoral vessels have been eroded, and
+serious or even fatal hæmorrhage has resulted. The _posterior abscess_
+appears in the buttock and may make its way to the surface through the
+gluteus maximus; more often it points at the lower border of this
+muscle in the region of the great trochanter, or it may gravitate down
+the thigh.
+
+Abscesses which form _within the pelvis_ originate either in
+connection with the acetabulum or in relation to the psoas muscle
+where it passes in front of the joint. Those that are directly
+connected with disease of the acetabulum may remain localised to the
+lateral wall of the pelvis, or may spread backwards towards the hollow
+of the sacrum. They may open into the bladder or rectum, or may ascend
+into the iliac fossa and point above Poupart's ligament (Fig. 115), or
+descend towards the ischio-rectal fossa. The abscess which develops in
+relation to the psoas muscle may be shaped like an hour-glass, one sac
+occupying the iliac fossa, the other filling up Scarpa's triangle, the
+two sacs communicating with each other through a narrow neck beneath
+Poupart's ligament.
+
+So long as the skin is intact, the abscess is unattended with
+symptoms, and may escape notice. If it bursts externally, pyogenic
+infection is almost inevitable, and the patient gradually passes into
+the condition of hectic fever or chronic toxæmia; he loses ground from
+day to day, may become the subject of waxy disease in the viscera, or
+may die of exhaustion, tuberculous meningitis, or general
+tuberculosis.
+
+#Dislocation# is a rare complication of hip disease, and is most
+likely to occur during the stage of adduction with inversion. It has
+been known to take place during sleep, apparently from spasmodic
+contraction of muscles. In the dorsal dislocation, which is the most
+common form, adduction and inversion are exaggerated, the trochanter
+projects above and behind Nélaton's line, and the head of the bone may
+be felt on the dorsum ilii. It is a striking fact that after
+dislocation has occurred there is less complaint of pain or of
+startings than before, and passive movements may be carried out which
+were previously impossible.
+
+#Diagnosis of Hip Disease.#--The diagnosis is to be made not only from
+other affections of the joint, but also from morbid conditions in the
+vicinity of the hip, as in any of these the patient may seek advice on
+account of pain and a limp in walking. The patient should be stripped,
+and if able to walk, his gait should be observed. He is then examined
+lying on his back, and attention is directed to the comparative length
+of the limbs, to the attitude of the limbs and pelvis, and to the
+movements at the hip-joint, especially those of rotation. When there
+is any doubt as to the diagnosis, the examination should be repeated
+at intervals of a few days. In children, there are three non-febrile
+conditions attended with a limp and with shortening of the limb, which
+may be mistaken for hip disease,--_congenital dislocation_, _coxa
+vara_, and _paralysis following poliomyelitis_--but in all of these
+the movements are not nearly so restricted as they are in disease of
+the joint.
+
+In tuberculous disease of the _sacro-iliac joint_, while the pelvis
+may be tilted, and the limb apparently lengthened, the movements at
+the hip are retained. In tuberculous disease of the _great
+trochanter_, or of either of the _bursæ_ over it, while there may be
+abduction, eversion, impairment of mobility, and swelling in the
+region of the trochanter followed by abscess formation, the movements
+are less restricted than in disease of the joint.
+
+In _psoas abscess_ associated with spinal disease, or in _disease of
+the bursa underneath the psoas_, the limb is flexed and everted, there
+may be lordosis, and the patient may limp in walking, but the
+movements at the hip are restricted only in the directions of
+extension and inversion, while in hip disease they are restricted in
+all directions.
+
+_New-growths_ in the vicinity of the hip--especially central sarcoma
+of the upper end of the femur--are difficult to differentiate from hip
+disease without the help of the X-rays.
+
+Among other conditions which by interfering with the free mobility of
+the hip may simulate hip disease, are appendicitis, inflammation of
+the glands in the groin, staphylococcal disease of the upper end of
+the femur, and sciatica.
+
+The diagnosis _from other diseases of the hip-joint_ is made by
+careful consideration of the history, symptoms, and X-ray appearances.
+
+#Prognosis.#--The prognosis in hip disease is more serious than in
+tuberculosis of other joints, excepting only those of the spine, and
+it is most unfavourable when there are gross lesions of the bones and
+infected sinuses.
+
+Whatever the stage of the disease, recovery is a slow process, and
+even in early and mild cases it seldom takes place in less than one or
+two years, and is liable to be attended with some impairment of
+function. During the process of cure, complications are liable to
+occur, and after apparent recovery relapses are not uncommon. When
+arrested during the initial stage, recovery may be complete; but when
+there has been destruction of the articular surfaces, there is apt to
+be ankylosis of the joint and shortening of the limb.
+
+In cases which terminate fatally, death usually results from
+meningeal, pulmonary, or general tuberculosis, or from pyogenic
+complications and waxy degeneration.
+
+#Treatment.#--A large proportion of cases recover under conservative
+treatment, and the functional results are so much better than those
+following operative interference that unless there are special
+indications to the contrary, conservative measures should always be
+adopted in the first instance.
+
+_Conservative Treatment._--The first essential is to take the weight
+off the limb and secure its fixation in the attitude of almost
+complete extension and moderate abduction. When the symptoms are well
+marked, the child is kept in bed and the limb is extended with a
+weight and pulley.
+
+_Extension by Weight and Pulley_ (Fig. 116).--The weight employed
+varies from one to four pounds in children, to ten or more pounds in
+adolescents and adults, and must be adjusted to meet the requirements
+of each case. If pain returns after having been relieved, it is due to
+stretching of the ligaments, and the weight should be diminished or
+removed for a time. If there is deformity, the line of traction should
+be in the axis of the displaced limb until the deformity is got rid
+of. The extension should be continued until pain, tenderness, and
+muscular contraction have disappeared, and the limb has been brought
+into the desired attitude.
+
+[Illustration: FIG. 116.--Extension by adhesive plaster and Weight and
+Pulley.]
+
+In restless children, in addition to the extension, a long splint is
+applied on the sound side and a sand-bag on the affected one; or,
+better still, a double long splint and cross-bar, the long splint on
+the affected side being furnished with a hinge opposite the hip to
+permit of varying the degree of abduction (Fig. 117).
+
+[Illustration: FIG. 117.--Stiles' Double Long Splint to admit of
+abduction of diseased limb.]
+
+When the deformed attitude does not yield rapidly to extension, it
+should be corrected under an anæsthetic, and if the adductor tendons
+and fasciæ are so contracted that this is difficult, they should be
+forcibly stretched or divided.
+
+The immediate correction of deformed attitudes under anæsthesia has
+largely replaced the more gradual method by extension with weight and
+pulley; and in hospital practice it is usually followed by the
+application of a plaster case. The plaster bandages are applied over a
+pair of knitted drawers; the pelvis and both thighs, the diseased one
+in the abducted position, are included. The case may be strengthened
+by strips of aluminium, and should be renewed every six weeks or two
+months.
+
+_Ambulant Treatment._--When the patient is able to use crutches, the
+affected limb is prevented from touching the ground by fixing a patten
+on the sole of the boot on the sound side. This may suffice, or, in
+addition, the hip-joint is kept rigid by a Thomas' (Fig. 118) or a
+Taylor's splint. The Thomas' splint must be fitted to the patient
+under the supervision of the surgeon, who must make himself familiar
+with the construction of the splint, and its alteration by means of
+wrenches.
+
+[Illustration: FIG. 118.--Thomas' Hip Splint applied for disease of
+Right Hip. Note patten under sound foot. The foot on the affected side
+is too near the ground.]
+
+In children who are unable to use crutches, a double Thomas' splint is
+employed; the child thereby is converted into a rigid object, capable
+of being carried from one room to another and into the open air.
+Personally we have obtained satisfaction from the double Thomas'
+splint employed for spinal disease, which extends from the occiput to
+the soles of the feet.
+
+The fixation of the hip-joint and the taking of the weight off the
+limb by one or other of the above methods, should, as a general rule,
+be continued for at least a year.
+
+Should an abscess develop, it is treated on the usual lines.
+
+_Operative Interference._--Widely diverse opinions are held on the
+question as to whether or not recourse should be had to operative
+interference.
+
+Some surgeons are opposed to operative interference, on the grounds
+that however advanced the disease may be it will yield to conservative
+measures if judiciously and perseveringly carried out. Other surgeons
+advocate operative treatment in all cases which do not speedily show
+improvement under conservative treatment. An intermediate attitude may
+be adopted which recommends operation in cases in which the disease
+progresses in spite of conservative treatment, and in which periodic
+examination with the X-rays shows that there are progressive lesions
+in the upper end of the femur or in the acetabulum.
+
+It is claimed by those who advocate operation under these conditions
+that pain and suffering are at once got rid of, sleep is restored,
+appetite returns, and there is a marked improvement in the general
+health, and that this result is obtained in months instead of years,
+and that the cure is more likely to be permanent. It is certainly
+unwise to delay operation until sinuses have formed, as such a course
+is largely responsible for the bad results which formerly followed
+excision of the joint.
+
+_Amputation_ for tuberculous disease of the hip has become one of the
+rarest of operations, but is still required in cases which have
+continued to progress after excision, and when there is disease of the
+pelvis or of the shaft of the femur, with sinuses, albuminuria, and
+hectic fever.
+
+#The Correction of Deformity resulting from Antecedent Disease of the
+Hip.#--From neglect or from improper treatment, deformity may have
+been allowed to persist, while the disease has undergone cure. It is
+associated with ankylosis of the joint, or contracture of the soft
+parts or both. The contracture of the soft parts involves specially
+the tendons, fasciæ, and ligaments on the anterior and medial aspects
+of the joint, and is usually present to such a degree that, even if
+the joint were rendered mobile, these shortened structures would
+prevent correction of the deformity. The usual deformity is a
+combination of shortening, flexion, and adduction.
+
+#Bilateral Hip Disease.#--Both hip-joints may become affected with
+tuberculous disease, either simultaneously or successively, and
+abscesses may form on both sides. The patient is necessarily confined
+to bed, and if the disease is recovered from, his capacity for walking
+may be seriously impaired, especially if the joints become fixed in an
+undesirable attitude. The most striking deformity occurs when both
+limbs are adducted so that they cross each other--one variety of the
+"scissor-leg" or "crossed-leg" deformity--in which the patient, if
+able to walk at all, does so by forward movements from the knees. An
+attempt should be made by arthroplasty to secure a movable joint at
+least on one side.
+
+
+OTHER DISEASES OF THE HIP-JOINT
+
+#Pyogenic Diseases# are met with in childhood and youth as a result of
+infection with the common pyogenic organisms, gonococci, pneumococci,
+or typhoid bacilli. While the organisms usually gain access to the
+tissues of the joint through the blood stream, a direct infection is
+occasionally observed from suppuration in the femoral lymph glands or
+in the bursa under the ilio-psoas.
+
+The _clinical features_ are sometimes remarkably latent and are much
+less striking than might be expected, especially when the hip
+affection occurs as a complication of an acute illness such as scarlet
+fever. It may even be entirely overlooked during the active stage, and
+only noticed when the head of the femur is found dislocated, or the
+joint ankylosed. In the acute arthritis of infants also, the clinical
+features may be comparatively mild, but as a rule they assume a type
+in which the suppurative element predominates. The limb usually
+becomes flexed and adducted, and a swelling forms in front of the
+joint at the upper part of Scarpa's triangle; the upper femoral
+epiphysis may be separated and furnish a sequestrum.
+
+The flexion and adduction of the limb favour the occurrence of
+dislocation. A child who has recovered with dislocation on to the
+dorsum ilii is usually able to walk and run about, but with a limp or
+waddle which becomes more pronounced as he grows up. The condition
+closely resembles a congenital dislocation, but the history, and the
+presence of gross alterations in the upper end of the femur as seen
+with the X-rays, should usually suffice to differentiate them.
+
+_Treatment._--In the acute stage the limb is extended by means of the
+weight and pulley, and kept at rest with the single or double long
+splint, or by sand-bags. If there is suppuration, the joint should be
+aspirated or opened by an anterior incision, and Murphy's plan of
+filling the joint with formalin-glycerine may be adopted. In children,
+it is remarkable how completely the joint may recover.
+
+If there is dislocation, the head of the femur should be reduced by
+manipulation with or without preliminary extension; it has been
+successful in about one-half of the cases in which it has been
+attempted. Preliminary tenotomy of the shortened tendons is required
+in some cases. When reduction by manipulation is impossible, the joint
+structures should be exposed by operation and the head of the bone
+replaced in the acetabulum. When the upper end of the femur has
+disappeared, the neck should be implanted in the acetabulum, and the
+limb placed in the abducted position.
+
+#Arthritis Deformans.#--This disease is comparatively common at the
+hip, either as a mon-articular affection or simultaneously with other
+joints.
+
+[Illustration: FIG. 119.--Arthritis Deformans, showing erosion of
+cartilage and lipping of articular edge of head of femur.]
+
+_The changes in the joint_ are characteristic of the dry form of the
+disease, and affect chiefly the cartilage and bone. The atrophy and
+wearing away of the articular surfaces are accompanied by new
+formation of cartilage and bone around their margins. The head of the
+femur may acquire the shape of a helmet, a mushroom, or a limpet
+shell, and from absorption of the neck the head may come to be sessile
+at the base of the neck, and to occupy a level considerably below that
+of the great trochanter (Fig. 120). These changes sometimes extend to
+the upper part of the shaft, and result in curving of the shaft and
+neck, suggesting a resemblance to a point of interrogation (Fig. 121).
+The acetabulum may "wander" backwards and upwards, as in tuberculous
+disease. It is usually deepened, and its floor projects on the pelvic
+aspect; its margins may form a projecting collar which overhangs the
+neck of the femur, or grasps it, so that even in the macerated
+condition the head is imprisoned in the socket and the joint locked.
+There is eburnation of the articular surfaces in those areas most
+exposed to friction and pressure.
+
+[Illustration: FIG. 120.--Upper End of Femur in advanced Arthritis
+Deformans of Hip. The shaft is curved and the head of the bone is at a
+lower level than the great trochanter.]
+
+[Illustration: FIG. 121.--Femur in advanced Arthritis Deformans of Hip
+and Knee Joints. The upper end of the bone shows the condition of coxa
+vara; the lower end shows enlargement of the medial condyle and
+alteration in the axis of the articular surface.]
+
+These changes are necessarily associated with restriction of movement,
+and in advanced cases with striking deformity, which consists in
+shortening of the limb, usually with eversion and displacement of the
+trochanter upwards and backwards in relation to Nélaton's line.
+
+The _clinical features_ are usually so characteristic that there is
+little difficulty in diagnosis. Restriction of the movements of
+abduction and adduction, the presence of cracking and of grating of
+the articular surfaces, and the aggravation of the pain and stiffness
+after resting the limb, are characteristic of arthritis deformans. The
+prominence of sciatic pain may lead to the disease being regarded as
+sciatica.
+
+The greatest difficulty is met with in cases in which the disease
+occurs as mon-articular affection in adolescents, for the resemblance
+to tuberculous disease of the hip and to coxa vara may be close.
+Skiagrams do not always enable one to differentiate between them.
+
+_Treatment_ is conducted on the same lines as in other joints. The
+normal movements are maintained by suitable exercises, and an effort
+is made to diminish the pressure on the articular surfaces in walking
+by the use of sticks or crutches.
+
+Shortening of the limb may be compensated by raising the sole of the
+boot. When the X-rays show that the disability is mainly due to new
+bone locking the head of the femur, such new bone may be removed by
+operation, _cheilotomy_ (Sampson Handley). Excision of the joint has
+in some cases yielded satisfactory results; it is indicated in young
+patients who are otherwise healthy, and who are unable to walk on
+account of pain and deformity.
+
+#Osteo-chondritis Deformans Juvenilis.#--Under this term Perthes
+describes an affection of the hip in children which differs in many
+respects from the juvenile form of arthritis deformans. Islands of
+cartilage appear in the epiphysis of the head of the femur, and the
+epiphysis itself becomes flattened without involvement of the
+articular surface or of the acetabulum.
+
+The disease is met with in children between five and ten; there is a
+limp in walking without pain or sensitiveness, so that the child
+continues to take part in games. Abduction is markedly restricted and
+the trochanter is elevated and prominent. There is no crepitation on
+movement or other signs of involvement of the articular surfaces. The
+X-rays show the deformity of the head and clear areas in the interior
+of the upper epiphysis corresponding to the islands of cartilage;
+these clear areas resemble those due to caseous foci in tuberculous
+coxitis.
+
+The disease runs a chronic course, and in the course of a year or two
+the limp and the restriction of abduction disappear, so that no active
+treatment is called for.
+
+#Neuro-Arthropathies.#--_Charcot's disease_ is usually met with in men
+over thirty who suffer from tabes dorsalis. One or both hip-joints may
+be affected. Sometimes the first manifestation is a hydrops and a
+fluctuating swelling in the upper part of Scarpa's triangle. In many
+of the recorded cases, however, attention has first been directed to
+the disease by the deformity and limp associated with disappearance of
+the head of the femur, or by the occurrence of pathological
+dislocation. The absence of pain and tenderness is characteristic.
+When dislocation has occurred, the limb is short, and the upper end of
+the femur is freely movable on the dorsum ilii. When both hips are
+dislocated, the attitude and gait are similar to those observed in
+bilateral congenital dislocation. The rotation arc of the great
+trochanter may be much reduced as a result of the disappearance of the
+head of the femur. There may be considerable formation of new bone,
+giving rise to large tumour-like masses in relation to the capsular
+ligament and the muscles surrounding the joint.
+
+The _treatment_ consists in protecting and supporting the joint. When
+the affection is unilateral, advantage may be derived from a Thomas'
+or other form of splint, along with a patten and crutches; in
+bilateral cases, from the use of crutches alone.
+
+_Loose bodies in the hip_ are mostly the result of hypertrophy of
+synovial fringes in arthritis deformans and in Charcot's disease, and
+do not figure in the clinical features of these affections; Caird has
+observed a case in which the cavity of the joint and the bursa beneath
+the psoas were filled with loose bodies, many of which had undergone
+ossification and gave a characteristic picture with the X-rays.
+
+_Hysterical affections_ of the hip resemble those in other joints.
+
+
+THE KNEE-JOINT
+
+The knee is more often the seat of disease than any other joint in the
+body.
+
+The synovial membrane extends beneath the quadriceps extensor as a
+cul-de-sac, which either communicates with the sub-crural bursa, or
+forms with it one continuous cavity. When the joint is distended with
+fluid, this upper pouch bulges above and on either side of the
+patella, and this bone is "floated" off the condyles of the femur.
+When there is only a small amount of fluid, it is most easily
+recognised while the patient stands with his feet together and the
+trunk bent forwards at the hip-joints, and the quadriceps completely
+relaxed; the fluid then bulges above and on each side of the patella,
+and its presence is readily detected, especially on comparison with
+the joint of the other side.
+
+On account of the great extent of the synovial membrane, a large
+quantity of serous effusion may accumulate in the joint in a
+comparatively short time, as a result either of injury or disease. The
+villous processes and fringes may take on an exaggerated growth, and
+give rise to pedunculated and other forms of loose body.
+
+The bursæ in the popliteal space, especially that between the
+semi-membranosus and the medial head of the gastrocnemius, as well as
+the sub-crural bursa, frequently communicate with the synovial cavity
+of the knee and may share in its diseases.
+
+As the epiphyses at the knee are mainly responsible for the growth in
+length of the lower extremity, and are late in uniting with their
+respective shafts--twenty-one to twenty-five years--serious shortening
+of the limb may result if their functions are interfered with, whether
+by disease or injury. The epiphysial cartilages lie beyond the limits
+of the synovial cavity, so that infective lesions at the ossifying
+junctions are less likely to spread to the joint than is the case at
+the hip or shoulder, where the upper epiphysis lies partly or wholly
+within the joint; disease in the lower end of the femur is more likely
+to implicate the knee-joint than disease in the upper end of the
+tibia.
+
+One of the commonest causes of prolonged disability and feeling of
+insecurity in the knee, is to be found in the wasting and loss of tone
+in the quadriceps extensor muscle; the feeling of insecurity is most
+marked in coming down stairs. The instability of the joint is often
+added to by stretching of the ligaments and lateral mobility. As a
+result of both of these factors the joint is liable to repeated
+slight strains or jars which irritate the synovial membrane and tend
+to keep up the effusion and excite the overgrowth of its tissue
+elements.
+
+
+TUBERCULOUS DISEASE
+
+While tuberculous disease of the knee is specially common in childhood
+and youth, it may occur at any period of life, and is not uncommon in
+patients over fifty. The disease originates in the synovial membrane
+and in the bones respectively with about equal frequency.
+
+When the synovial membrane is diseased, it tends to grow inwards over
+the articular surfaces (Fig. 122), shutting off the supra-patellar
+pouch and fixing the knee-cap to the femur, and diminishing the area
+of the articular surfaces. The ingrowth of synovial membrane may fill
+up the cavity of the joint, or may divide it up into compartments.
+Ulceration of the cartilage and caries of the articular surfaces are
+common accompaniments.
+
+[Illustration: FIG. 122.--Tuberculous Synovial Membrane of Knee,
+spreading over articular surface of femur.]
+
+The femur and tibia are affected with about equal frequency, and the
+nature and seat of the bone lesions are subject to wide variations.
+Multiple small foci may be found beneath the articular cartilage of
+the tibia, or along the margins of the femoral condyles--especially
+the medial. Caseating foci are comparatively rare, but they sometimes
+attain a considerable size--especially in the head of the tibia, where
+they may take the form of a caseous abscess. Sclerosed foci, which
+form sequestra, are comparatively common (Fig. 123).
+
+[Illustration: FIG. 123.--Lower End of Femur from an advanced case of
+Tuberculous Arthritis of the Knee. Towards the posterior aspect of the
+medial condyle there is a wedge-shaped sequestrum, of which the
+surface exposed to the joint is polished like porcelain.
+
+(Anatomical Museum, University of Edinburgh.)]
+
+#Clinical Types.#--(1) _Hydrops_ usually arises from a purely synovial
+lesion, but the joint may suddenly become distended with fluid when an
+osseous focus ruptures into the synovial cavity.
+
+It is met with chiefly in young adults. As the fluid accumulates it
+gradually stretches the capsule, and pushes the patella forwards, so
+that it floats. There is little pain or interference with function;
+the patient is usually able to walk, but is easily tired. The amount
+of fluid diminishes under rest, and increases after use of the limb.
+In a certain number of cases it may be possible to recognise localised
+thickening of the synovial membrane, or the presence of floating
+masses of fibrin or melon-seed bodies. This is best appreciated if the
+knee is alternately flexed and extended by the patient while the
+surgeon grasps and compresses it with both hands. If the joint is
+opened, fibrinous material, often in the form of melon-seed bodies,
+may be found lining the synovial membrane.
+
+Tuberculous hydrops is to be diagnosed from the effusion that results
+from repeated sprain, from the hydrops of loose body, gonorrhoea,
+arthritis deformans, Charcot's disease, and Brodie's abscess in the
+adjacent bone, and from the hæmarthrosis met with in bleeders.
+
+(2) _Papillary or Nodular Tubercle of the Synovial Membrane._--This is
+a condition in which there is a fringy, papillary, or polypoidal
+growth from the synovial membrane. It is most often met with in adult
+males. The onset and progress are gradual, and the chief complaint is
+of stiffness and swelling which are worse after exertion. Sometimes
+there are symptoms of loose body, such as occasional locking of the
+joint, with pain and inability to extend the limb; but the locking is
+easily disengaged, and the movements are at once free again. The
+patient may give a history of several years' partial and intermittent
+disability, with lameness and occasional locking, although he may have
+been able to go about or even to continue his occupation.
+
+There is a moderate degree of effusion into the joint, and when this
+has subsided under rest it may be possible to feel ill-defined cords,
+or tufts, or nodular masses, and to grasp between the fingers those in
+the supra-patellar pouch. There is little wasting of muscles, and it
+is exceptional to have signs of disease of the articular surfaces or
+of cold abscess.
+
+On opening the joint, there may escape fluid and loose bodies similar
+to those described under hydrops, and if the finger is introduced into
+the cavity, the upper pouch is felt to be occupied by fringes or
+polypoidal processes derived from the synovial membrane.
+
+The diagnosis is to be made from arthritis deformans, and in some
+cases from loose body of other than tuberculous origin.
+
+(3) _Cold abscess_ or _empyema_ of the knee is a rare condition, in
+which the joint becomes filled with pus. It usually results from a
+primary tuberculosis of the synovial membrane occurring in children
+reduced in health and the subject of tuberculosis elsewhere.
+
+(4) _Diffuse Thickening of the Synovial Membrane--White Swelling._--So
+long as this form of the disease remains confined to the synovial
+membrane, the chief feature is that of an indolent elastic swelling in
+the area of the joint. The swelling tapers off above and below, so
+that it acquires a fusiform shape, and from the wasting of the muscles
+it appears greater than it really is. The range of movement is
+moderately restricted.
+
+At first the patient limps, keeps the knee slightly flexed, and
+complains of tiredness and stiffness after exertion. As the articular
+surfaces become affected, there is pain, which is readily excited by
+jarring of the limb, or by any attempt at movement; the joint is held
+rigid, and there may be startings at night. If untreated, flexion
+becomes more pronounced--it may be to a right angle--the leg and foot
+are everted, and, in children, the tibia may be displaced backwards
+(Fig. 124). The wasting of muscles continues, the part becomes hot to
+the touch, the swelling increases, and may show areas of softening or
+fluctuation from abscess formation.
+
+[Illustration: FIG. 124.--Advanced Tuberculous Disease of Knee, with
+backward displacement of Tibia.]
+
+White swelling is to be differentiated from peri-synovial gummata,
+from myeloma and sarcoma of the lower end of the femur, and from
+bleeder's knee. In the first of these the swelling is nodular and less
+uniform, and there may be tertiary ulcers or depressed scars in the
+neighbourhood of the patella. In tumours the swelling is more marked
+on one side of the joint, it is uneven or nodular, it does not
+correspond to the shape of the synovial membrane, and may extend
+beyond the limits of the joint, and it involves the bone to a greater
+extent than is usual in disease of the joint. Skiagrams show expansion
+of the bone in central tumours, or abundant new bone in ossifying
+sarcoma. The diagnosis of bleeder's knee is to be made from the
+history.
+
+(5) _Primary Tuberculous Disease in the Bones of the Knee._--So long
+as the foci are confined to the interior of the bone, it is impossible
+to recognise their existence, unless they are of sufficient size to
+cause enlargement of the bone or to be discernible in a skiagram.
+
+#The formation of peri-articular abscess# takes place in rather more
+than fifty per cent. of cases. When left to themselves, such abscesses
+tend to spread up the thigh, or down the back of the leg between the
+superficial and deep layers of calf muscles, and numerous sinuses may
+result from their rupture through the skin.
+
+#Attitudes of the Limb in Knee-Joint Disease.#--The attitude most
+often assumed is that of _flexion_, with or without _eversion of the
+leg and foot_. The flexion is explained by its being the resting
+attitude of the joint, and that which affords most ease and comfort to
+the patient. Once the joint is flexed, the involuntary contraction of
+the flexor muscles maintains the attitude, and if the patient is able
+to use the limb in walking, the weight of the body is a powerful
+factor in increasing it. The eversion of the leg is probably
+associated with contraction of the biceps muscle. _Backward
+displacement of the tibia_ is met with chiefly in neglected cases of
+chronic disease of the knee when the child has walked on the limb
+after it has become flexed.
+
+In certain cases, _genu valgum_ or abduction of the leg is present
+along with a slight degree of flexion. The valgus attitude is
+associated with slight lateral displacement of the patella, with
+prominence and apparent enlargement of the medial condyle, with
+depression of the pelvis on the diseased side and apparent lengthening
+of the limb.
+
+#Treatment of Tuberculous Disease of the Knee.#--Conservative measures
+are always indicated in the first instance, and are persevered with so
+long as there is a prospect of obtaining a movable joint.
+
+_Conservative Treatment._--If the joint is sensitive and tends to be
+flexed, the patient is confined to bed, the limb is secured to a
+posterior splint, and extension with weight and pulley persevered with
+until these symptoms have disappeared; during this time, from three to
+six weeks, methods of inducing hyperæmia and other anti-tuberculous
+procedures are employed. If it is proposed to inject iodoform or other
+drug, the needle is inserted into the interval between the bones on
+the medial side of the ligamentum patellæ or into the upper pouch when
+this is distended with fluid.
+
+If there is no pain or tendency to flexion, or when these have been
+overcome, the limb is put up in a Thomas' splint (Fig. 125) and the
+patient allowed to go about. The splint is worn for a period varying
+from six to twelve months; before being discarded it may be left off
+at night; it is ultimately replaced by a bandage.
+
+[Illustration: FIG. 125.--Thomas' Knee Splint applied. Note extension
+strapping applied to affected leg, and patten under sound foot.]
+
+The indications for _operative treatment_ are: (1) marked symptoms of
+destruction of the articular cartilages; (2) a deformed attitude
+incapable of being rectified without operation; (3) a condition of the
+general health which requires that the disease should be got rid of as
+speedily as possible; (4) progress or persistence of the disease in
+spite of conservative treatment. When there is no prospect of recovery
+with a movable joint it is a waste of time and a possible source of
+danger to persevere with conservative measures. Operation permits of
+the disease being eradicated and the restoration of a useful limb
+within a reasonable time, averaging from three to six months.
+
+In adults, the operation consists in excising the joint; in children
+the aim is to remove the diseased tissues without damaging the
+epiphysial cartilages.
+
+Amputation is performed when the disease has relapsed after excision
+and there is persistent suppuration, and when life is threatened by
+the occurrence of tuberculosis in the lungs or elsewhere.
+
+#Treatment of Deformities resulting from Antecedent Diseases of the
+Knee.#--Flexion is the commonest of these; when due to contracture of
+the soft parts, these are either stretched by degrees, the limb being
+encased in plaster after each sitting, or they are divided by open
+dissection in the popliteal space. If there is fibrous or osseous
+ankylosis, the choice lies between arthroplasty, the removal of a
+wedge of bone which includes the joint, or, in patients who are still
+growing, of a wedge from the femur above the level of the epiphysial
+cartilage. Backward displacement of the tibia, genu recurvatum, and
+genu valgum also require operative treatment.
+
+
+OTHER DISEASES OF THE KNEE-JOINT
+
+#Pyogenic diseases# result from infection through the blood stream,
+from one of the adjacent bones, or from a penetrating wound of the
+joint. The commoner types include the _synovitis_ associated with
+disease in the adjacent bone, _acute arthritis of infants_, joint
+suppuration in _pyæmia_, _pyogenic arthritis_ following upon
+penetrating wounds, and the affections which result from _gonorrhoeal_
+or _pneumococcal_ infection.
+
+_Treatment._--The limb is immobilised on a posterior splint so padded
+as to allow slight flexion at the knee, and extension applied with
+sufficient weight to relieve the pain; it is also of benefit to induce
+hyperæmia by one or other of the methods devised by Bier. To tap the
+joint, the needle is introduced obliquely into the supra-patellar
+pouch, and if it is necessary to open the joint, the incision is made
+on one or on both sides of the patella, and Murphy's plan of inserting
+formalin-glycerine may be employed. If the infection progresses and
+threatens the life of the patient, it may be necessary to lay the
+joint freely open from side to side, sawing across the patella, and,
+the limb being flexed, the whole wound is left open and packed with
+gauze. As the infection subsides, the limb is gradually straightened.
+If these methods fail, amputation through the thigh may be the only
+means of saving life.
+
+#Arthritis deformans# affects the knee more frequently than any of the
+other large joints. The changes related to the synovial membrane here
+attain their maximum development, and may assume the form of hydrops
+with or without fibrinous bodies, or of overgrowth of the synovial
+fringes and the formation of pedunculated loose bodies. It is
+suggested that these synovial changes follow upon repeated sprains or
+upon a previous pyogenic infection of the joint. The effusion and
+stretching of the ligaments that follow upon a sprain are incompletely
+recovered from; the synovial membrane becomes puckered, the quadriceps
+atrophies and no longer puts the ligamentum mucosum on the stretch;
+and the infra-patellar pad of fat, not undergoing the normal
+compression during extension, is readily nipped between the femur and
+tibia. Each nipping implies a fresh sprain, with return of the
+effusion, and so a vicious circle is set up which terminates in what
+has been called a _villous arthritis_, with fringes and loose bodies;
+in time, the articular cartilage at the line of the synovial
+reflection undergoes fibrillation and conversion into connective
+tissue, and the process spreading to the articular surfaces, the
+picture of a rheumatoid arthritis is complete. Fibrillation of the
+cartilage imparts a feeling of roughness when the joint is grasped
+during flexion and extension, and lipping of the margins of the
+trochlear surface of the femur may be felt when the joint is flexed;
+it is also readily seen in skiagrams. When a portion of the "lipping"
+is broken off, it may give rise to a loose body. In advanced cases
+with destruction of the cartilages, there may be movement from side to
+side, with grating of the articular surfaces.
+
+In the early stages, treatment consists in limiting the movements of
+extension by means of a splint provided with a hinge that locks at
+thirty degrees from full extension and vigorous massage of the
+quadriceps. In the dry, creaking forms of arthritis, the symptoms are
+relieved by introducing liquid vaseline into the joint. When the
+symptoms are due to the presence of fringes and loose bodies, these
+may be removed by operation. When the disease is of a severe type, and
+is confined to one knee, the question of excising the joint may be
+considered.
+
+_Bleeder's knee_, _Charcot's disease_, _hysterical knee_, and _loose
+bodies_ in the joint have already been described.
+
+
+THE ANKLE-JOINT
+
+There is a common synovial cavity for the ankle and the inferior
+tibio-fibular joints. The epiphysial cartilage of the tibia lies above
+the level of this synovial cavity, but that of the fibula is included
+within its limits (Fig. 93). The talus is related to three
+articulations--the ankle above, the talo-navicular joint in front, and
+the calcaneo-taloid joint below. The tendon sheaths, especially those
+of the peronei and of the tibialis posterior, are liable to be
+infected by the spread of infective disease from the joint.
+
+#Tuberculous Disease.#--Tuberculous disease at the ankle is met with
+at all ages. In the majority of cases the disease affects both bone
+and synovial membrane. Gross lesions in the bones are comparatively
+rare, and are chiefly met with in the head or neck of the talus.
+
+_Primary synovial disease_ usually exhibits the features of white
+swelling, projecting beneath the extensor tendons on the dorsum, and,
+posteriorly, filling up the hollows on either side of the tendo
+Achillis and below the malleoli (Fig. 126). The foot may retain its
+normal attitude, or the toes may be pointed and adducted. The calf
+muscles are wasted, there is little complaint of pain, and the
+movements of the joint may be so little interfered with that the
+patient can walk without a limp. When the disease involves the
+articular surfaces, there is pain and sensitiveness, the movements are
+restricted or abolished, and the patient is unable to put the foot on
+the ground.
+
+[Illustration: FIG. 126.--Tuberculous Disease in a man æt. 35, of six
+weeks' duration.]
+
+_A primary focus in the bone_ causes localised pain and tenderness,
+and a limp in walking, but the first sign may be the formation of
+abscess or the rapid development of articular symptoms. In such cases
+skiagrams afford valuable information.
+
+Abscess formation is an early and prominent feature, whether the
+disease is of osseous or synovial origin, and sinuses are liable to
+form around the joint. Outlying abscesses and sinuses are usually the
+result of infection of the tendon sheaths in the neighbourhood.
+
+_Diagnosis._--When teno-synovitis occurs independently of disease of
+the ankle, the swelling is confined to one aspect of the joint. In
+sarcoma of the lower end of the tibia, the swelling lacks the uniform
+distribution of that met with in joint disease. In Brodie's abscess of
+the lower end of the tibia there may be swelling of the ankle, but
+there is an area of special tenderness on percussion over the bone.
+
+_Treatment._--The foot is immobilised at a right angle to the leg by
+splints or plaster of Paris; if articular symptoms are absent or have
+subsided, a Thomas' knee splint should be applied to enable the
+patient to move about without bearing his weight on the affected foot
+(Fig. 125). To inject iodoform, the point of the needle is inserted
+below either malleolus, and is then pushed upwards alongside of the
+talus. If localised disease in one of the bones is recognised before
+the joint is infected, it should be eradicated by operation.
+
+When the disease is diffuse and resists conservative treatment,
+excision should be performed, the articular surfaces of the
+constituent bones being removed, and if necessary the whole of the
+talus.
+
+Amputation is only called for in adults with rapidly progressing
+disease and diffuse suppuration, and in cases which have relapsed
+after excision.
+
+The other diseases of the ankle include _pyogenic_, _gonorrhoeal_,
+_rheumatic_, _gouty_, and _hysterical_ affections, _arthritis
+deformans_, and _Charcot's disease_. The last-named is generally
+associated with a rapid and painless disintegration of the bones of
+the ankle and tarsus, resulting in great deformity and loss of the
+arch of the foot--sometimes associated with perforating ulcer of the
+sole.
+
+Tuberculous disease in the #tarsus#, #metatarsus#, and #phalanges# has
+been considered in the chapter on Diseases of Bone.
+
+
+
+
+CHAPTER X
+
+DEFORMITIES OF THE EXTREMITIES
+
+
+The origin of deformities: (1) Those arising before birth; (2) those
+ produced during birth; and (3) those acquired after birth.
+
+Palsies of children: _Anterior Poliomyelitis_. Cerebral palsies:
+ _Spastic paralysis_.
+
+THE LOWER EXTREMITY: Congenital dislocation of hip--Snapping
+ hip--Paralytic deformities--Contracture and ankylosis of hip--Coxa
+ vara and coxa valga--Congenital dislocation of knee and
+ patella--Genu recurvatum--Paralytic deformities--Contracture and
+ ankylosis of knee--Genu valgum and genu varum--Congenital
+ deformities of leg--Bow-leg--Club-foot: _Talipes equino-varus_;
+ _Pes equinus_; _Pes calcaneus_; _Pes calcaneo-valgus and varus_;
+ _Pes cavus_; Flat-foot and pes valgus--Painful affections of
+ heel--Metatarsalgia--Hallux valgus and bunion--Hallux
+ varus--Hallux rigidus and flexus--Hammer-toe--Hypertrophy of
+ toes--Supernumerary toes--Webbed toes.
+
+THE UPPER EXTREMITY: Congenital absence of clavicle--Elevation of
+ scapula--Winged scapula--Congenital paralytic deformities of
+ shoulder--Deformities of elbow--Club-hand--Deformities of
+ wrist--Madelung's deformity--Deformities of fingers--Dupuytren's
+ contraction--Polydactylism.
+
+The surgery of the extremities is so largely concerned with the
+correction of deformities that it is necessary at the outset to refer
+briefly to some points relating to the time and mode of origin of
+these.
+
+1. _Congenital deformities_--that is, those which originate _in utero_
+and are present at birth--are comparatively common and may be due to a
+variety of causes. Some result from errors of development--for
+example, supernumerary fingers or toes, and deficiencies in the bones
+of the leg or forearm. A larger number are to be attributed to a
+persistent abnormal attitude of the foetus, usually associated with
+want of room in the uterus--for example, the common form of club-foot
+and congenital dislocation of the hip. Less frequently amniotic bands
+so constrict the digits or the limbs as to produce distortion, or even
+to sever the distal part--_intra-uterine amputation_. Lastly, certain
+diseases of the foetus, and particularly such as affect the
+skeleton--for example, achondroplasia--cause congenital deformities.
+
+2. _Deformities originating during birth_ are all traceable to the
+effects of injuries sustained in the course of a difficult labour.
+Examples of these are: wry-neck resulting from rupture of the
+sterno-mastoid; lesions of the shoulder-joint and brachial plexus due
+to hyper-extension of the arm; a spastic condition of the lower
+limbs--Little's disease--resulting from tearing of blood vessels on
+the surface of the brain with hæmorrhage and interference with the
+function of the cortical motor area.
+
+3. _Deformities acquired after birth_ arise from widely different
+causes, of which diseases of bone, including rickets, diseases of
+joints, and affections of the nervous system attended with paralysis,
+are amongst the commonest. Other deformities are produced by
+unsuitable clothing, such as a tight corset, or ill-fitting shoes
+distorting the toes, prolonged standing in growing subjects
+overstraining the mechanism of the foot and giving rise to the common
+form of flat-foot.
+
+The part played by the palsies of children in the surgical affections
+of the extremities necessitates a short description of their more
+important features.
+
+#Anterior poliomyelitis# is the lesion underlying what was formerly
+known as _infantile paralysis_--a name to be avoided, because the
+condition is not confined to infants and it is not the only form of
+paralysis met with in young children. Anterior poliomyelitis is
+characterised by an illness attended with fever, in which the child is
+found to have lost the power of one, less frequently of both lower
+extremities; or, it may be, of one or both arms. After a period,
+varying from six weeks to three months, the paralysis tends to
+diminish both in extent and degree, and in the majority of cases it
+ultimately persists only in certain muscles or groups of muscles. At
+the onset of the paralysis the affected limb is helpless and relaxed,
+the reflexes are lost, the muscles waste, and those that are paralysed
+exhibit the reaction of degeneration. In severe cases, and especially
+if proper treatment is neglected, the nutrition of the limb is
+profoundly affected; its temperature is subnormal, the skin is bluish
+in cold weather and readily becomes the seat of pressure sores. In
+course of time the limb lags behind its fellow in growth, and tends to
+assume a deformed attitude, which at first can easily be corrected,
+but later becomes permanent.
+
+[Illustration: FIG. 127.--Female child showing the results of
+Poliomyelitis affecting the left lower extremity; the limb is short
+and poorly developed, the pelvis is tilted and the spine is curved.]
+
+When the acute stage of the illness is past, the chief question is to
+what extent recovery of function can be looked for in the paralysed
+muscles.
+
+It would appear to be established that if a muscle reacts to faradism
+it will recover, but the contrary proposition does not follow. It was
+formerly accepted that a muscle which exhibits the reaction of
+degeneration is incapable of recovery, but observation has shown that
+this is not the case. Complete destruction of the motor cells in the
+anterior horn of grey matter as a result of poliomyelitis is now known
+to be exceptional; as a matter of fact, damage to the nerve cells is
+usually capable of being repaired. The muscles governed by these cells
+may appear to be completely paralysed, but with appropriate treatment
+their functional activity can be restored. As functional disability is
+frequently due to the affected muscle being _over-stretched_, it is of
+the first importance, when the acute symptoms are on the wane, that
+every care should be taken to prevent the weak muscular groups being
+put upon the stretch, and the greatest attention should be paid to
+_the posture of the limb during convalescence_. For example, if the
+child is allowed to lie with the wrist flexed, the flexor muscles
+undergo shortening, and the extensors are over-stretched and are
+therefore placed at a mechanical disadvantage. As the inflammatory
+changes in the anterior horn of the cord subside, the flexor tendons,
+from their position of advantage, are in a condition to respond to the
+first stimuli that come from their recovering motor cells, while the
+extensors are not in a position to do so. If, on the other hand, the
+wrist and fingers are maintained in the attitude of extreme
+dorsiflexion, the extensors become shortened, and, relieved of strain,
+they soon begin to respond to the stimuli sent them from the
+recovering nerve cells. Similarly in the lower extremity, when, for
+example, the muscles innervated through the peroneal (external
+popliteal) nerve are paralysed, if the foot is allowed to remain in
+the attitude of inversion with the heel drawn up--paralytic
+equino-varus--an attitude which is rendered more pronounced by the
+pressure of the bedclothes, the chance of the muscles recovering their
+function is seriously diminished. Another potent factor in preventing
+recovery, especially in the lower limbs, is _erroneous deflection of
+the body weight_. If, for example, there is weakness in the tibial
+group of muscles, and the child is allowed to walk, the eversion of
+the foot will steadily increase, the tibial muscles will be more and
+more stretched, the opposing peroneal muscles will shorten, and, in
+time, the bones of the tarsus will undergo structural alterations
+which will perpetuate the deformity. If, on the other hand, by some
+alteration of the boot, the foot is maintained in the attitude of
+inversion, the weakened or paralysed tibial muscles are placed in a
+much more favourable condition for recovery.
+
+It must be emphasised that no operation should be performed in these
+cases until the question whether it be possible or not to restore the
+apparently paralysed muscle is settled. The clinical test of the
+recoverability of a muscle is to keep it for a long period--six or
+even twelve months--in a condition of relaxation. This test should be
+made, no matter how many months or years the muscle may have been
+paralysed.
+
+The first stage in the treatment, therefore, is the correction of
+existing deformity, after which the limb should be kept immovable
+until the ligaments, muscles, and even the bones have regained their
+normal length and shape. The slightest stretching of a muscle which is
+in process of recovery disables it again.
+
+The age of the patient influences the method of treatment. In young
+children in whom the structures are soft and yielding, gradual
+correction of the deformity is to be preferred to the more rapid
+methods employed in older children. The proper sequence consists in
+correcting the deformity, providing the simplest apparatus to keep the
+limb in good position, preventing erroneous deflection of body weight
+during walking, and then allowing the child to grow and develop until
+he has reached the age of five before considering such an operation as
+transplanting tendons, and the age of ten before deciding to ankylose
+a flail-like joint.
+
+_Reposition, Manipulations, Supports._--An attempt is made to correct
+the deformity by manipulation, and the proper attitude is maintained
+by a mechanical support. If the foot has become rotated so that the
+sole looks laterally, the medial side of the boot must be raised, and
+an iron worn which extends from the knee down the lateral side of the
+leg, to end, without a joint, in the heel of the boot. In pes equinus,
+the iron is let into the back of the heel and extends forwards into
+the waist of the boot, to keep the foot at right angles to the leg and
+to relax the weak extensor muscles.
+
+_Division of Contractions._--Bands of fascia and contracted tendons
+which prevent correction of deformity may have to be divided or
+lengthened. This is best done by the open method.
+
+_Removal of Skin._--To assist in maintaining the desired attitude,
+Jones recommends the plan of excising an area of the redundant skin on
+the weaker aspect of the limb; in equinus, the skin is taken from the
+dorsum; in equino-varus, from the front and lateral aspect of the
+foot. When the edges of the gap have united, the foot is maintained in
+the desired attitude for some months, even if parents carelessly
+remove the iron support to let the child run about.
+
+_Tendon transplantation_, a procedure introduced by Nicoladoni, is to
+be considered in children of five and upwards. It may be employed for
+different purposes: (1) To reinforce a weak muscle by a healthy
+one--for example, by transplanting a hamstring tendon into the patella
+to reinforce a weak quadriceps, or reinforcing the weak invertors of
+the foot by a transplanted extensor hallucis longus. (2)
+Transplantation may also be performed to replace a muscle which is
+quite inactive and does not show any sign of recovery--for example,
+the tibiales being paralysed, the peroneus longus may be implanted
+into the navicular or first metatarsal to act as an invertor of the
+foot.
+
+Wherever possible a tendon should be transplanted directly into bone,
+as, if it is attached to soft parts it rarely holds firmly enough. The
+bone should if possible be tunnelled, and the tendon passed through
+the tunnel and securely fixed. When bringing a tendon to its new point
+of attachment, it should pass in as straight a line as possible,
+avoiding any bend or angle which might impair its action. Fat is the
+best medium for the transplanted tendon to traverse, as it acts as a
+sheath and prevents the formation of adhesions which would interfere
+with the function of the new tendon. All deformity must be corrected
+before transferring the tendon; if the tendon is too short to admit of
+this, it can be lengthened by means of silk threads (Lange).
+
+According to Jones, the most successful transplantations are the
+following, in order: (1) The tibialis anterior into the lateral tarsus
+in paralysis of the peronei; (2) the peroneus longus into the
+navicular in paralysis of the tibial group; (3) the extensor hallucis
+longus into any part of the foot where it may be wanted; (4) the
+hamstrings into the patella, to reinforce the quadriceps, provided the
+strictest after-treatment can be secured; (5) deflection of part of
+the tendo Achillis to one or other side of the foot.
+
+_Arthrodesis._--This operation, first performed by Albert in 1877,
+consists in removing the cartilage covering the articular surfaces of
+bones with the object of producing a firm ankylosis. The procedure is
+most successful in the ankle and mid-tarsal joints, and as a result of
+it there is obtained a secure and firm base of support in walking.
+Before performing arthrodesis, the surgeon must decide whether the
+patient will be better off with a stiff joint or with a weak and
+movable ankle supported by apparatus. This is often a matter of social
+position; in the poor, an ankylosed joint is more useful and less
+expensive. An arthrodesis should seldom be performed at the ankle
+until the child has passed his eighth year, or at the knee until he
+has reached his twentieth year. There is plenty to be done during the
+period of waiting, and if this is done well, it is possible that the
+operation may not be required. The existing deformities, for example,
+will have to be corrected, areas of skin removed to relieve
+functionless muscles of strain, the body weight appropriately
+deflected, and the child must be taught to walk with the aid of a
+support, swinging his limb about, and using it effectively in a
+correct position. Such exercise is a powerful agent in promoting
+physiological and functional development.
+
+_Nerve anastomosis_, which seeks to provide a new channel for the
+transmission of motor impulses to the paralysed muscles, has as yet a
+restricted field of application--for example, the tibial and peroneal
+nerves may be anastomosed when the muscles supplied by one of them are
+paralysed. Stoffel of Heidelberg lays stress on regard being paid to
+the anatomical arrangement of the nerve bundles within the nerve-trunk
+so that motor fibres may be joined to motor ones and not to sensory.
+It is necessary also to cut across some of the fibres of the healthy
+nerve in order that they may grow into the nerve which is degenerated.
+
+In extreme cases in which the limb is hopelessly paralysed and
+useless, it may be _amputated_ to admit of an artificial limb being
+worn; it must be borne in mind, however, that such limbs furnish poor
+stumps, usually quite unable to bear pressure.
+
+#Cerebral Palsies of Childhood--Spastic Paralysis.#--These may be due
+to arrest of development of the brain, to injuries of the head at
+birth, to meningeal hæmorrhage, or to other lesions of the brain, with
+secondary degenerative changes in the spinal cord. The commonest cause
+is hæmorrhage occurring during child-birth from the veins which ascend
+from the middle part of the convexity of the hemisphere to open into
+the superior sagittal (superior longitudinal) sinus. The blood is
+poured out beneath the dura on one or on both sides of the falx
+cerebri, and as it accumulates near the vertex, the damage to the
+motor centres for the legs is usually more extensive than that to the
+centres for the arms. The paralysis may affect one side of the
+body--_hemiplegia_, or both sides--_diplegia_; less commonly one
+extremity alone is involved--_monoplegia_. In diplegia, in which both
+arms and both legs are affected in the first instance, the arms may
+recover while the lower extremities remain in a spastic state, a
+condition known as _Little's disease_. The mental functions may be
+normal but more frequently they are imperfectly developed, the
+impairment in some cases amounting to idiocy. The affected limbs
+exhibit muscular rigidity or spasm, which is aggravated on movement
+but disappears under an anæsthetic; the reflexes are exaggerated, and
+sometimes there are perverted involuntary movements (_athetosis_). The
+growth of the limb is impaired, and contracture deformities may
+supervene (Fig. 131). The amount of power in the limb is often
+astonishing, in marked contrast to what is observed to follow upon
+anterior poliomyelitis. The degree of natural improvement is by no
+means great, and normal function is almost never regained.
+
+The _treatment_ is concerned in the first place with improving the
+condition of the muscles by methodical exercises and massage. When
+reflex irritability of the muscles with consequent spasm is a
+prominent feature, the reflex arc may be interrupted by _resection of
+the posterior nerve roots_ corresponding to the part affected. This
+operation, first suggested by Spiller but chiefly popularised by
+Foerster, has yielded the best results in cases of Little's disease,
+in which there still remains a considerable amount of voluntary
+movement, and yet there is inability to walk on account of involuntary
+spasm. In the case of the lower extremities, three or more of the
+lumbar and one or more of the sacral nerve roots are resected within
+the vertebral canal. Sensation is diminished but not abolished in the
+area of skin involved. Massage and exercises and, it may be, splints
+or apparatus are essential factors in promoting the recovery of
+function. It has not yet been decided whether the results of the
+resection of nerve roots justify the risk.
+
+Apart from Foerster's operation, or when it has failed, the spasm of
+any individual muscle or group of muscles may be got rid of by
+diminishing the nerve supply to the muscle or by lengthening the
+tendon. Diminishing the nerve supply was suggested by Stoffel; it
+consists in exposing the motor nerve as it enters the muscle and
+resecting one-third or one-half of the fibres so as to reduce the
+innervation to the required degree. The method is still on its trial.
+
+_Lengthening the Tendons._--In spastic paraplegia, for example, Jones
+resects the origins of the adductors longus and brevis, lengthens the
+tendo Achillis, divides the popliteal fascia and hamstrings, and
+transplants the biceps into the quadriceps; after which the limbs are
+put up in the attitude of wide abduction for six weeks. It is
+important that the patient should begin to walk with the legs wide
+apart and learn to balance himself without any feeling of insecurity;
+he should be taught to look at an object straight in front of him
+rather than on the ground.
+
+
+THE LOWER EXTREMITY
+
+
+CONGENITAL DISLOCATION OF THE HIP
+
+This is the commonest of all congenital dislocations. Its frequency
+varies in different countries, being greater on the continent of
+Europe than in this country. It is more often unilateral than
+bilateral (about 4 to 1), and is about three times more common in
+girls than in boys.
+
+The dislocation takes place in the early months of intra-uterine life,
+and may be associated with deficiency of the liquor amnii.
+
+#Pathological Anatomy.#--_In the infant_, the anatomical changes in
+the joint are less marked than they are after the child has borne its
+weight on the limb. The acetabulum, never having been occupied by the
+head of the femur, is imperfectly developed; it remains flat and
+shallow, is partly filled with fibro-fatty tissue derived from the
+synovial membrane, and is always too small for the head of the femur.
+The cotyloid ligament being broader and thicker than usual, makes the
+osseous portion of the socket appear deeper than it really is. In
+unilateral cases the affected half of the pelvis is contracted, so
+that the pelvic basin is narrowed and oblique. The head of the femur
+is small, flattened, and, in some cases, conical; and the angle formed
+by the neck with the shaft is altered, sometimes diminished, it may be
+to a right angle--_coxa vara_ (Fig. 129); sometimes increased--_coxa
+valga_. There is also a variable degree of torsion of the neck,
+ante-torsion being of practical importance as it increases the
+difficulty of retaining the head in the socket. The capsule is lax and
+admits of the head passing upwards for a variable distance on to the
+dorsum ilii. In unilateral cases the ligamentum teres is elongated and
+thickened; in bilateral cases it is frequently absent.
+
+[Illustration: FIG. 128.--Radiogram of Double Congenital Dislocation
+of Hip in a girl æt. 4.]
+
+[Illustration: FIG. 129.--Innominate Bone and upper end of Femur from
+a case of Congenital Dislocation of Hip.]
+
+In _children who have walked_, the head of the femur is pushed farther
+upwards on the dorsum ilii; the capsule becomes lengthened by
+supporting the weight of the body. That part of the capsule which
+arises from the lower margin of the acetabulum stretches across the
+socket and partly shuts it off from the rest of the joint cavity. In
+course of time the capsule becomes greatly thickened, and may present
+an hour-glass constriction about its middle, which may prove a serious
+obstacle to reduction. The socket becomes small and triangular, and
+there is almost no ledge against which the head of the femur can rest.
+A superficial depression may form on the ilium where it is pressed
+upon by the head of the femur, covered by the capsule; and in the
+course of years, as the head changes its position, several secondary
+sockets may be formed. No proper new bony socket forms like that in
+traumatic dislocations that remain unreduced because in the congenital
+variety the thickened capsule intervenes between the head of the bone
+and the dorsum ilii. The displacement of the head is most frequently
+backwards (dorsal luxation), and as the point of support thus falls
+behind the acetabulum the pelvis tilts forwards, and the lumbar spine
+becomes unduly concave (lordosis). The muscles of the hip and thigh
+alter in consequence of the changed relations; the gemelli,
+obturators, and piriformis are lengthened, the adductors, hamstrings,
+and ilio-psoas are shortened, while the glutei and quadriceps are but
+little altered. In rare cases the head is displaced upwards and lies
+immediately above the acetabulum.
+
+[Illustration: FIG. 130.--Congenital Dislocation of Left Hip in a girl
+æt. 8. The patient is putting the whole weight on the dislocated
+limb.]
+
+_Clinical Features._--The condition rarely attracts attention until
+the child begins to walk, but sometimes the unusual breadth of the
+pelvis, the presence of a lump in the buttock, snapping about the hip,
+or a peculiar way of holding the limb, leads the parents to seek
+advice early. In _unilateral cases_, when the child has learned to
+walk at the late age of two, three, or it may even be four years, it
+is noticed that the back is hollow and the buttocks unduly prominent,
+and that there is a peculiar and characteristic limp; each time the
+weight of the body is put upon the affected limb, the trunk makes a
+sudden dip towards that side. There is no pain on walking. The
+affected limb is shortened, as is shown by the projection of the great
+trochanter above Nélaton's line; the shortening gradually increases,
+and in time may amount to several inches. It is partly compensated for
+by resting the affected limb on the balls of the toes and flexing the
+knee on the sound side. The gluteal fold is shorter, deeper, and
+higher than on the healthy side, and on account of the obliquity of
+the pelvis the spine shows a lateral curvature, with its concavity to
+the affected side. The movements at the hip-joint are free in all
+directions except abduction; on practising external rotation it is
+often found to be abnormally free; lastly, in young children, if the
+pelvis is fixed, the head of the bone may be made to glide up and down
+on the ilium.
+
+_In bilateral cases_ the trunk appears well grown in contrast to the
+short lower limbs, the hollow of the back is exaggerated, the abdomen
+protrudes, the perineum is broadened, and the buttocks are unduly
+prominent. The gait is waddling like that of a duck, the trunk
+lurching from one side to the other with each step. In untreated cases
+the deformity and disability become more pronounced as the capsular
+and round ligaments are further stretched, the shortening and limp
+become more marked, the patient is easily fatigued by walking or
+standing, and is usually unfitted for earning a living. We have had
+under observation, however, an adult male with bilateral dislocation
+and extroversion of the bladder, who efficiently performed the duties
+of a carrier for many years.
+
+Except in fat infants, the _diagnosis_ is not difficult; the absence
+of pain and tenderness, the freedom of motion and the absence of the
+head of the femur from its normal position, differentiate the
+condition from tuberculous disease of the joint, and from coxa vara
+and other deformities in the region of the hip. _Trendelenburg's test_
+consists in noting the relative level of the buttocks when the patient
+stands on the affected leg. Normally the buttocks remain on the same
+level when the patient stands on one leg; in congenital dislocation
+the buttock of the limb raised from the ground drops to a lower level;
+in coxa vara it rises higher.
+
+In paralytic conditions at the hip there may be considerable
+resemblance to dislocation, but the muscles are slack and wasted, and
+the normal attitude can easily be restored by pulling on the limb. The
+most certain means of diagnosis is by the X-rays, which show the
+position of the head of the bone in relation to the acetabulum, and
+any torsion of the neck of the femur that may be present. This last
+point is determined by taking a series of skiagrams in different
+positions of the limb; these are also useful in correcting erroneous
+impressions as to the angle of the neck of the femur.
+
+_Treatment._--We are indebted to Paci, Schede, Calot, Lorenz, and
+Hoffa for the rational treatment which seeks to reduce the dislocation
+by manipulation.
+
+#Reduction by Manipulation# (_Method of Lorenz_).--The child is
+anæsthetised and placed on its back with the legs over the end of the
+table. While an assistant steadies the pelvis, the surgeon pulls on
+the limb so as to bring the trochanter down to Nélaton's line; this is
+followed by forced rotation outwards and inwards and forcible
+abduction to a right angle, and by kneading the adductors till they
+are stretched and torn. The next step is to stretch the hamstrings,
+and this is done by raising the foot, without bending the knee, until
+the front of the thigh meets the abdomen, and the toes the face. To
+stretch the anterior muscles, the patient is turned on the side or
+face, and the hip is hyper-extended both in the straight and in the
+abducted position. The stage is now reached at which attempts at
+reduction may be made; the child is again laid on its back, the
+surgeon grasps the knee, flexes the thigh to a right angle, rotates
+laterally, and slowly flexes and abducts, while the thumb pushes from
+behind on the trochanter, trying to guide and lift it over the rim of
+the socket as the hip reaches the over-abducted position. Lorenz uses
+a wedge of wood padded with leather about 3 inches high to rest the
+trochanter upon while attempting to lift it forward. When reduction
+takes place, there is generally a sound and a sudden jump, as in
+reducing a traumatic dislocation.
+
+To keep the head in the socket, the limb must be maintained in the
+position of right-angled abduction and external rotation (90°) by a
+plaster case, which includes the lower part of the trunk and both
+limbs down to the knee. Under the plaster, stockinette drawers are
+worn, and the bony prominences are padded with cotton wool. The
+plaster should overlap the costal margin. The first case is worn for
+two months or more, and is then renewed at shorter intervals, the
+degree of abduction being diminished at each renewal until the limbs
+are nearly parallel. The child is only kept in bed for a week or two,
+and is then allowed up, being provided with a boot and high sole on
+the affected side, but should not use crutches. At the end of six
+months, by which time the capsule has become tightened up round the
+head of the femur, the plaster is given up and massage and exercises
+are employed.
+
+_In bilateral cases_ both dislocations are reduced at one sitting if
+possible, and a plaster case applied with both thighs abducted and
+flexed to a right angle, the so-called "frog position."
+
+In the event of failure to reduce a dislocation at the first attempt,
+the limb should be fixed in plaster in the abducted attitude for ten
+days or a fortnight, and then another attempt made. The greatest
+number of successes in bilateral cases is met with under five years of
+age, and in unilateral cases under seven. Reduction may sometimes be
+accomplished, however, in older children.
+
+If it is found impossible to restore the head of the femur to the
+acetabulum, an attempt should be made by similar manipulations to
+wedge it under the long head of the rectus femoris, or, failing this,
+below the anterior iliac spine under the sartorius and tensor fasciæ
+femoris. By thus converting a posterior into an anterior dislocation,
+the tilting of the pelvis and the lordosis are greatly diminished.
+This procedure, named by Lorenz _anterior transposition of the head of
+the femur_, is specially applicable to cases in which relapse has
+taken place after reduction, and to those above the age when reduction
+should be attempted.
+
+_Reduction by open operation_ may be had recourse to in cases in
+which, after several attempts, reduction has failed, or in which
+re-dislocation has occurred; it is, however, a serious operation.
+Attempts have also been made by means of pegs and other contrivances
+to fix the head of the bone and prevent it sliding upwards on the
+ilium. When reduction is impossible by any means, a stiff leather
+jacket with prolongations around the thighs may diminish the deformity
+and improve the walking.
+
+#Snapping Hip# (_Hanche à ressort_).--This is a rare affection, met
+with in children and young adults, and characterised by the occurrence
+of a sudden, snapping sound, sometimes attended with pain in the
+region of the great trochanter. This usually occurs when the limb is
+slightly flexed or adducted, and rotated either inwards or outwards.
+On palpation a cord-like structure may be felt, which slips forwards
+and backwards over the trochanter when the position of the limb is
+altered.
+
+The condition was formerly described as a voluntary dislocation of the
+hip; it is now believed to be due to a cord-like band of tissue
+slipping backwards and forwards over the trochanter. The band is
+usually derived from the fascia lata, sometimes reinforced by the
+anterior fibres of the gluteus maximus, sometimes by the tensor fasciæ
+femoris. The condition seldom gives rise to any appreciable disability
+and surgical treatment is rarely called for. In a number of cases the
+muscle has been fixed by sutures with satisfactory results. In a
+recent case, an extensive open dissection proved negative, but the
+stitching of the gluteus to the trochanter was followed by the
+disappearance of the snapping.
+
+#Paralytic Deformities of the Hip.#--In anterior poliomyelitis the
+paralysis of muscles may be so widespread that the limb is unable to
+support the weight of the body, or certain groups of muscles only are
+paralysed and the child may be able to walk with the help of
+apparatus. Even if the ilio-psoas is paralysed, flexion is still
+possible by the anterior fibres of the gluteus medius, the anterior
+adductors, and when the leg is rotated out by the tensor fasciæ and
+sartorius, the dislocation differs from the traumatic variety in that
+the head, although it leaves the socket, remains within the capsule.
+Dislocation tends to occur from the disturbance of muscular balance,
+anterior dislocation being commoner than posterior in about the
+proportion of two to one; the nature of the dislocation is best
+demonstrated by means of the X-rays. Reduction is rarely possible
+without an open operation. Tendon and nerve-transplantation are
+scarcely possible, and arthrodesis is rarely to be recommended;
+contracture deformities, however, are often benefited by tenotomy in
+young children, and in older children by osteotomy through the
+trochanter, and putting the limb up in the abducted position.
+
+In _spastic paralysis_ of cerebral origin, the tendency is towards
+contracture, usually in the attitude of flexion, with adduction and
+inversion. This may result in dislocation backwards on to the dorsum
+ilii, and may occur in patients confined to bed (Fig. 131).
+
+[Illustration: FIG. 131.--Contracture Deformities of Upper and Lower
+Limbs resulting from Spastic Cerebral Palsy in infancy.
+
+(Photograph taken after death by Dr. Thomson of Norwich.)]
+
+#Contractures and Ankyloses of the Hip.#--Various forms of contracture
+are met with as a result of cicatricial contraction, or from
+shortening of the fasciæ, muscles, and ligaments when the hip has been
+maintained in the flexed position for long periods--for example, in
+psoas abscess, chronic rheumatism, or hysteria. The majority, however,
+result from tuberculous disease of the hip-joint. In osseous
+ankylosis, an attempt may be made to restore movement by the operation
+of Murphy, which consists in chiselling through the osseous junction
+between the bones, deepening the acetabulum if necessary, and then
+interposing between the bony surfaces a portion of fat-bearing fascia
+derived from the fascia lata over the great trochanter. The operation
+of Jones consists in detaching the great trochanter (the insertions of
+the glutei into it being left intact), dividing the neck of the femur,
+and then securing the separated portion of the trochanter to the
+proximal end of the neck to prevent union of the fragments.
+
+
+COXA VARA AND COXA VALGA
+
+These deformities depend on abnormalities of the angle of the neck of
+the femur; the average or normal elevation is 125° for the adult and
+135° for the child; variations between 120° and 140° are considered
+normal. If the angle is less than 120° the condition is one of coxa
+vara; if greater than 140°, coxa valga. The angle of inclination of
+the neck of the femur is dependent upon the adjustment of certain
+forces, namely, the weight of the body, the action of muscles, and the
+resistance of the bone. The most obvious cause of deviation of the
+neck from the normal angle is some condition which causes softening
+of the bone so that it yields under weight-pressure, the most common
+being partial fractures, rickets, and other diseases of the bone.
+
+#Coxa Vara--Incurvation of the Neck of the Femur.#--There may be a
+simple adduction bend of the neck, the head sinking to, or even below,
+the level of the great trochanter (Fig. 132); or this may be combined
+with a curve of the neck, of which the convexity is upwards and
+forwards, so that the lower border of the neck is greatly shortened
+and the head approximated to the lesser trochanter. At the same time
+the shaft of the femur is adducted and rotated outwards.
+
+[Illustration: FIG. 132.--Rachitic Coxa Vara.
+
+(Sir Robert Jones' case. Radiogram by Dr. Morgan.)]
+
+_Adolescent Coxa Vara._--This, the most common clinical type, is met
+with in boys between the ages of twelve and eighteen. The _unilateral_
+form is nearly always the result of injury to the neck of the femur or
+to the epiphysial junction, although the deformity may not show itself
+for months or a year or two after the injury. The deformity may be the
+first indication, or it is preceded by pain and stiffness; the patient
+complains of being easily tired, of difficulty in kneeling and
+sitting, difficulty in riding, and of an increasing limp in walking.
+On examination, the limb is found to be shortened, the great
+trochanter is displaced upwards and backwards and is unduly prominent,
+and the muscles of the buttock and thigh are a little smaller and
+softer than on the normal side. The limb is adducted, its normal range
+of abduction, and sometimes also of flexion, is restricted, and there
+is, as a rule, some degree of lateral rotation, so that the toes point
+outwards. It should be noted that the same picture--shortening with
+eversion and stiffness at the hip--results from the common fracture of
+the neck of the bone in old people. The adduction element of the
+deformity is partly compensated for by upward tilting of the pelvis on
+the affected side and curvature of the spine with its concavity
+towards the affected limb.
+
+_When the condition is bilateral_ it is usually the result of disease
+in the bone, rickets most frequently in this country. The attitude and
+gait are highly characteristic, as the adducted and everted legs tend
+to cross each other at the knee, the deformity being of the
+scissors-like type (Fig. 134), and in extreme cases the patient is
+only able to walk with the aid of crutches.
+
+_Diagnosis._--Pain in the hip and a limp in walking suggest _hip-joint
+disease_, but while in coxa vara the movements are chiefly restricted
+in the direction of abduction, in hip disease they are restricted or
+absent in all directions. From _congenital dislocation of the hip_
+the diagnosis can usually be made by the history, the examination of
+the joint and of its movements; and by the Trendelenburg test (p.
+252). In _sacro-iliac disease_, the pain and tenderness are over the
+sacro-iliac joint and the movements at the hip are free in all
+directions. Valuable evidence is obtained from skiagrams.
+
+_Treatment._--In the early stages, especially if there is pain and
+tenderness, the patient must lie up and extension is applied in the
+abducted position of the limb; after a fortnight or so recourse is had
+to massage and exercises and the patient is allowed up for a little
+each day, attention being paid to flat-foot, which is a common
+accompaniment. When deformity is the prominent feature and interferes
+with locomotion it must be corrected. The bloodless method is to be
+preferred; under general anæsthesia, the shortened adductors are
+stretched or divided, and forcible movements are carried out in all
+directions, until the limb can be brought into an attitude of marked
+abduction and internal rotation. A plaster-case is then applied, from
+the pelvis to the middle of the calf, the knee being slightly flexed
+for greater comfort; in a week or so the patient is able to go about,
+and in a couple of months a second plaster-case is applied, this time
+leaving the knee free. After another six weeks or so a moulded splint
+is used, which can be removed at bedtime. The traumatic forms can
+nearly always be corrected by this bloodless method. In advanced cases
+the deformity can only be corrected by open operation, which consists
+in dividing the femur obliquely downwards and medially through the
+great trochanter, and, the adductor muscles having been ruptured or
+divided, the limb is put up in the abducted position along with, if
+required, powerful weight extension.
+
+[Illustration: FIG. 133.--Coxa Vara, showing adduction curvature of
+neck of femur associated with arthritis of the hip and knee.]
+
+[Illustration: FIG. 134.--Bilateral Coxa Vara, showing scissors-leg
+deformity.]
+
+In cases of traumatic origin--epiphysial separation--Sprengel has
+obtained good results by forcibly abducting and internally rotating
+the limb under an anæsthetic, and then applying a plaster-case which
+extends down to the knee.
+
+#Other Forms of Coxa Vara.#--In _rickety children_, coxa vara is most
+often associated with pronounced eversion of both lower extremities,
+without the capacity for abduction being necessarily restricted, and
+with but little impairment of function. The child should be treated
+for rickets, and put up in a double long splint with the limbs
+abducted and inverted.
+
+In _arthritis deformans_ of the hip, it is not uncommon to have
+considerable depression of the head of the bone and diminution in the
+angle of its neck, with consequent restriction of abduction. Sometimes
+the upper end of the shaft is also curved.
+
+In _osteomyelitis fibrosa_, involving the upper end of the femur, a
+gross form of coxa vara may be observed, of which a marked example is
+shown in figures on pp. 476, 478, Volume I.
+
+The _congenital variety_ of coxa vara is due to various intra-uterine
+conditions, of which the chief is defective development of the upper
+end of the femur; as it does not manifest itself until the child
+begins to walk, the resemblance to congenital dislocation of the hip
+is very close.
+
+#Coxa Valga.#--Coxa valga is the reverse of coxa vara, the angle at
+the neck of the femur being over 140°. It is not nearly so important
+in practice as coxa vara. It may result from incomplete fractures or
+epiphysial separations, rickets, or various forms of osteomyelitis,
+but it is also a frequent accompaniment of other deformities, such as
+congenital dislocation of the hip and paralysis following anterior
+poliomyelitis. It is commoner in boys than in girls, and is more often
+single than bilateral. The limb is lengthened, abducted, and rotated
+outwards; there is flattening of the buttock, and the trochanter is
+depressed so that it lies below Nélaton's line. The patient is unable
+to adduct the limb, and shows a peculiar gait, which has frequently
+caused the condition to be mistaken for unilateral congenital
+dislocation at the hip.
+
+In recent cases it may be possible under anæsthesia forcibly to adduct
+the limb and rotate it inwards, and to retain it in this position with
+a plaster bandage. In advanced cases the length of the limbs may be
+equalised by a high sole on the sound side, or by performing an
+osteotomy through the great trochanter.
+
+
+THE REGION OF THE KNEE
+
+#Congenital dislocation# at the knee-joint is rare; it is usually
+incomplete, and the patella is sometimes absent. The dislocation may
+be permanent, or may only occur from accidental movements of the limb.
+In some cases it can be produced at will by the patient or the
+surgeon. We have observed one such case in a professional cyclist in
+whom this capacity of partially dislocating the knee entailed no
+disability. When the child begins to walk, an apparatus which will
+prevent hyper-extension and lateral motion should be fitted to the
+limb.
+
+#Congenital absence of the patella# usually complicates other
+abnormalities of the knee-joint. The tubercle of the tibia is
+prominent and the extensor tendon unusually thick. In flexion the
+tendon rises on to the lateral condyle of the femur.
+
+#Congenital Dislocation of the Patella Laterally.#--This may be
+persistent or intermittent. In the _persistent form_ the dislocation
+is present from birth; the patella rests on the trochlear surface of
+the lateral condyle, and when the knee is flexed may pass farther
+outwards and become completely dislocated, lying against the lateral
+aspect of the condyle.
+
+In _the intermittent_ or _recurrent_ form the patella lies in its
+normal place, but is liable to be displaced outwards when the joint is
+flexed; the displacement occurs suddenly and unexpectedly in walking,
+and the patient may fall to the ground, suffering intense pain. The
+knee-cap is readily replaced on extending the joint, but the sprain of
+the joint is followed by effusion, and the patient is usually disabled
+for a day or two. It is met with chiefly in girls, and there may be a
+history that the child was late in walking and learned with
+difficulty. On examination, the patella is found to have an abnormal
+range of movement outwards, although it cannot be completely
+dislocated without considerable pain. If the child is brought for
+advice when there is fluid in the joint, the condition is liable to be
+mistaken for tuberculous synovitis. The observation that the undue
+mobility of the knee-cap is present in both knees is of assistance in
+arriving at a diagnosis, and also the history that the girl has
+repeatedly hurt her knee in falling.
+
+The cause of the abnormal mobility of the patella varies in different
+cases; in some there is congenital laxity of the ligaments, in others
+a faulty formation of the lower end of the femur. Bade has observed
+families in which several children were affected, and although there
+was nothing abnormal in the shape of the bones, the knee was slender
+and delicately formed.
+
+The use of a strong knee-cap may prevent falling, but as a rule an
+operation is required, and there is quite a number to choose from, the
+principle of them all being to prevent displacement of the bone
+without unduly restricting flexion of the joint. That devised by
+Goldthwait consists in exposing, by means of a vertical incision, the
+whole length of the patellar ligament, splitting it longitudinally,
+separating the lateral half from the tibia, passing it under the
+medial portion and suturing it to the periosteum; this gives the
+quadriceps a straight line of pull. We have achieved the same result
+by dividing the lax capsule and synovial membrane on the medial side
+of the patella, and overlapping the edges with a double line of catgut
+sutures.
+
+Lateral dislocation of the patella is met with in extreme forms of
+_knock-knee_, and after correction of this deformity by osteotomy, and
+its possible occurrence should be guarded against at the time of the
+operation.
+
+#Genu Recurvatum.#--In this deformity the knee is hyper-extended, the
+thigh and leg forming an angle which is open forwards; the attitude
+may be permanent or may only appear on walking. It is an extremely
+disabling and unsightly deformity.
+
+There are several varieties. In the _congenital form_, which is
+apparently due to a faulty attitude of the lower extremities _in
+utero_, the patella may be imperfectly developed or absent; the knee
+is convex backwards, and attempts to flex the joint cause pain. Other
+deformities frequently coexist. The treatment consists in flexing the
+joint to a right angle under an anæsthetic, and maintaining this
+attitude by means of plaster-of-Paris or splints until the growth of
+parts overcomes any tendency to relapse.
+
+_Acquired Forms._--The most common acquired form is the result of
+anterior poliomyelitis, and is described in the next section.
+
+The deformity may also be due to rickets which has caused a backward
+bend of the tibia immediately below its upper epiphysis--sometimes
+combined with an exaggerated forward curve of the femur. If there is
+no prospect of spontaneous rectification, the upper end of the tibia
+should be divided with the osteotome, and the limb straightened.
+
+It may result also from fracture or from separation of one of the
+epiphyses in the region of the knee, or from cicatricial contraction
+of the quadriceps. As a result of bone and joint disease, it is met
+with chiefly in neuro-arthropathies when the knee has become
+disorganised and flail-like.
+
+#Deformities of the Knee resulting from Anterior Poliomyelitis and
+from Spastic Paralysis.#--When there is paralysis of all the muscles
+acting on the knee, the joint may be so flail-like that the patient is
+unable to stand without the aid of a crutch, or when weight is put on
+the limb, it assumes the attitude of genu recurvatum. The usefulness
+of the limb may be improved by the application of a rigid apparatus
+with a lock at the joint so that it can be used in the extended
+position for walking or in the flexed position for sitting. The rigid
+knee produced by arthrodesis affords good support but is inconvenient
+in sitting.
+
+When the _quadriceps alone_ is paralysed, the patient is obliged to
+maintain the joint in the position of extreme extension, because the
+least degree of flexion results in the limb giving way under him. In
+course of time the posterior ligament is stretched, and the joint
+becomes hyper-extended, acquiring the attitude of _genu recurvatum_.
+When it is bilateral the gait is seriously impaired. The treatment
+consists in applying an apparatus which prevents hyper-extension, in
+improving the condition of the thigh muscles, and in wearing a splint
+at night which secures the flexed position. Recourse may be had to
+operative measures, such as transplanting one of the hamstrings into
+the patella, so as to compensate for the loss of power in the
+quadriceps, arthrodesis, or supra-condylar osteotomy of the femur.
+
+When the quadriceps is overcome by a _contraction of the hamstrings_,
+as in spastic paraplegia, the knee is fixed in the flexed position and
+the child is unable to walk. The flexion may be corrected by
+lengthening the hamstring tendons, bringing the divided biceps tendon
+through an opening in the vastus lateralis, and attaching it to the
+rectus and to the patella. If there is a combination of flexion and
+genu valgum, the knee-joint should be resected and ankylosed in the
+straight position.
+
+#Contracture and Ankylosis at the Knee.#--In addition to the different
+paralytic forms above described, contracture may result from
+ulceration and suppuration in the popliteal space, and from disease
+(osteomyelitis) in one of the adjacent bones. The greater number of
+contractures and ankyloses are the result of disease in the joint, and
+have already been described.
+
+
+GENU VALGUM AND GENU VARUM
+
+In the normal limb, a line drawn from the centre of the head of the
+femur to a point midway between the malleoli passes through the
+centre of the knee-joint. If the line passes outside the centre of the
+knee-joint, the condition is one of genu valgum; if inside, it is one
+of genu varum (Fig. 135).
+
+[Illustration: FIG. 135.]
+
+#Genu Valgum--Knock-knee.#--In this deformity the leg joins the thigh
+at an angle which is open outwards, and when the affection is
+bilateral, the projecting knees tend to knock against each other in
+walking; the term X-legs is sometimes applied to it.
+
+_Etiology._--The observations of Macewen and of Mikulicz, and
+information afforded by the Röntgen rays, have shown that the primary
+cause of the deformity is an inequality of growth at the ossifying
+junction of the femur or tibia or of both. This inequality of growth
+is nearly always due to rickets, and its direction is determined by a
+faulty attitude of the limbs in standing and walking. The legs being
+abducted, the weight of the body falls unequally on the medial and
+lateral parts of the ossifying junctions, and inequality of growth
+results.
+
+_Pathological Anatomy._--Examination of the femur usually shows that
+the lower third of the diaphysis is lengthened on its medial side and
+shortened on its lateral side, and that the epiphysis, itself
+unaltered, is fitted on to the diaphysis obliquely, so that the medial
+condyle appears to be increased in length and to occupy a level
+distinctly below that of the lateral condyle. In many cases the tibia
+shows corresponding alterations. On section of the bones, the
+epiphysial cartilage and the zone of ossification are found to be
+unduly broad and irregular.
+
+[Illustration: FIG. 136.--Female child with right-sided Genu Valgum,
+the result of Rickets. The pelvis is tilted, and the spine is curved.]
+
+The neck of the femur is shortened and its angle diminished. The bones
+of the leg are sometimes bent inwards in their lower thirds, and this
+compensates partly for the valgus deformity at the knee. The articular
+cartilage of the lateral condyle and the lateral meniscus are usually
+thickened. In pronounced cases the quadriceps tendon and the patella
+are displaced laterally, and this may be so pronounced that on flexion
+of the joint the patella is dislocated on to the lateral condyle of
+the femur. The biceps tendon and ilio-tibial band are shortened and
+more prominent as a result of the approximation of their attachments,
+and they are also displaced laterally. The sartorius and gracilis are
+displaced backwards, so that they descend behind instead of on the
+medial side of the knee. The popliteal artery lies on the back of the
+lateral condyle instead of in the hollow between the condyles, and the
+tibial (internal popliteal) nerve is displaced even farther outwards.
+The capsular and other ligaments are slack, so that the joint is
+unstable and easily hyper-extended. There is often some effusion into
+the joint.
+
+[Illustration: FIG. 137.--Female child with Rickety deformities of
+upper and lower extremities.
+
+(Mr. D. M. Greig's case.)]
+
+_Radiograms_ reveal the changes in the bones (Fig. 138); the shaft of
+the femur or tibia, or both, which may also be curved, is set
+obliquely on its epiphysis; and the clear zone, corresponding to the
+epiphysial cartilage, is uneven and broader than normal. There are
+also less obvious changes in the density of the shadow and in the
+arrangement of the trabecular structure of the bones.
+
+[Illustration: FIG. 138.--Radiogram of case of Double Genu Valgum in a
+child æt. 4.]
+
+_Clinical Features._--In the infantile form (Fig. 139) the knock-knee
+is commonly associated with rickets in other parts of the skeleton,
+and especially with bending of the tibia and femur, and in extreme
+cases the child may be unable to walk.
+
+[Illustration: FIG. 139.--Genu Valgum in a child æt. 4. Patient
+standing.]
+
+The deformity is about as frequently bilateral as unilateral. There
+may be knock-knee on the one side and bow-knee on the other. If, as is
+usually the case, the deformity is due to obliquity of the femur, it
+disappears on flexing the joint (Fig. 140), because in flexion the
+tibia glides behind the projecting median condyle; if the deformity
+affects the tibia only, the influence of flexion in disguising it is
+not so marked. It is usually possible to hyper-extend the joint, and,
+in the extended position, to rotate the leg outwards to a greater
+extent than is normal. In unilateral knock-knee, the affected limb is
+a little shorter than its fellow, but the patient compensates for this
+by depressing the pelvis on the affected side.
+
+[Illustration: FIG. 140.--Genu Valgum. Same patient as Fig. 139.
+Sitting, to show disappearance of deformity on flexion of knee.]
+
+_Prognosis._--In children below the age of six, the bones naturally
+tend to straighten if the child is kept off its feet. After this age,
+there is no such prospect.
+
+The _treatment of knock-knee in children_ is directed towards curing
+the rickets and preventing the child from putting its feet to the
+ground. If it cannot have the services of a nurse and the use of a
+perambulator, a light padded splint is applied on the lateral side of
+the limb, extending from the iliac crest to 3 inches beyond the foot.
+The splint is fixed above and below by bandages, and the projecting
+knee is drawn towards it by a few turns of elastic webbing. A method
+specially applicable to hospital out-patients, is to straighten the
+limbs as far as possible under anæsthesia, and apply a plaster
+bandage; the bandage is renewed at intervals of three weeks until the
+deformity is corrected. Whatever plan is adopted, it must be
+persevered with for at least six months, until the rickety changes in
+the bones have been entirely recovered from.
+
+If the child is approaching the age of five or six before it comes
+under treatment, or if the deformity does not yield to treatment by
+splints, it is better to straighten the limb by _osteotomy_.
+
+In _adolescent knock-knee_ the patient seeks advice because of the
+deformity or of pain after exertion, especially at the medial side of
+the epiphysial junctions, of being easily tired, and of incapacity for
+any occupation involving standing. The bones are coarse and badly
+formed, and there is frequently a spinous process projecting downwards
+from the medial side of the tibia about three finger-breadths below
+the joint.
+
+When the deformity is bilateral, the patient abducts the thigh and
+rotates the limb outwards at the hip to disguise the deformity, and to
+allow the projecting knees to pass each other. He usually supinates or
+inverts the foot, with the object of bringing the whole length of the
+lateral border of the sole into contact with the ground. Flat-foot is
+exceptional. The boots are usually more worn along the lateral than
+along the medial border of the sole and heel.
+
+No apparatus that allows of the patient walking is of any value. If
+the deformity is marked, there should be no hesitation in having
+recourse to operation by one or other of the various methods of
+osteotomy.
+
+In severe cases it may be found that when the deformity is corrected
+by osteotomy, the patella shows a tendency to be dislocated laterally
+on flexion of the knee. This may be prevented by putting up the limb
+in the attitude of slight genu varum.
+
+The most difficult cases to treat are those in which, owing to curving
+of the lower part of the shaft of the femur with the convexity
+forwards, the knee is permanently flexed and cannot be completely
+extended.
+
+#Other forms of genu valgum# are relatively rare. There is a
+congenital form arising from faulty position of the limbs _in utero_;
+a traumatic form following fracture or epiphysial separation in the
+region of the knee; and a paralytic form, usually combined with
+flexion, in cases of spastic paralysis. Finally, genu valgum may be a
+result of various forms of osteomyelitis of the lower end of the
+femur, or of disease in the knee-joint, such as tuberculosis,
+arthritis deformans, or Charcot's disease.
+
+#Genu Varum--Bow-knee.#--In this deformity, which is the converse of
+genu valgum, the leg joins the thigh at an angle which is open
+medially. It is almost invariably bilateral, is of rachitic origin,
+and is frequently associated with bow-legs (Fig. 141). The tibia takes
+a greater share in its production than the femur. Although an ungainly
+deformity, it is much less frequently the source of complaint than
+knock-knee, because it scarcely interferes with locomotion--as a
+matter of fact, the subjects of bow-knee, although short in stature,
+are unusually sturdy on their legs. An extreme example of the
+deformity is shown in Fig. 141.
+
+[Illustration: FIG. 141.--Bow-knee in Rickety Child.]
+
+Treatment is carried out on the same lines as in genu valgum.
+
+#Rickety Deformities of the Bones of the Leg--Bow-leg.#--These
+deformities are common in children; are nearly always bilateral and
+symmetrical, and may be associated with knock-knee or bow-knee. They
+may occur before the child is able to walk, the bones bending in the
+attitude in which the limbs are habitually placed--over the nurse's
+knee, for example, or as they are crossed underneath the child in
+sitting. In children who are able to walk, the curve is due to the
+weight of the body acting on the softened bones. In either case, the
+bending may be increased by the traction of muscles, and sometimes by
+the occurrence of greenstick fracture. The most common deformity is a
+uniform curvature of the bones laterally and forwards, or a more
+acute bend in the lower thirds of their shafts. In some cases the
+chief curvature is forwards. The ungainliness in walking may be added
+to by flat-foot. Backward curving of the upper end of the tibia has
+been already described as one of the causes of genu recurvatum. The
+most extreme deformities are met with in rickety dwarfs.
+
+_Treatment._--Under the age of six, and particularly in children, who
+are actively growing, the bones will probably straighten if the child
+is treated for rickets and kept off his feet; well-padded lateral
+splints are applied as recommended for knock-knee, and these should be
+taken off at intervals for massage and douching. Above the age of six,
+the choice lies between osteoclasis and osteotomy. In performing
+osteotomy the bone is either simply divided or a segment is resected.
+The fibula can usually be forcibly straightened, but may require to be
+divided through a separate incision. In aggravated cases it may also
+be necessary to lengthen the tendo Achillis.
+
+The deformities of the bones of the leg in _inherited syphilis_,
+_ostitis deformans_, and _osteomalacia_ have already been described.
+
+#Congenital Deficiencies of the Bones of the Leg.#--The _tibia_ may be
+absent completely or in part, more often on one side than on both
+sides. In either case the leg is short and stunted, the knee is
+flexed, the foot occupies the position of extreme equino-varus, and
+the limb is useless. The extent of the defects is demonstrated by the
+Röntgen rays. Among other defects with which it may be associated,
+absence or deficient development of the patella is the most frequent.
+When the upper end of the tibia is absent, the fibula articulates with
+the lateral condyle of the femur. The operative treatment aims at
+correcting the flexion at the knee, the equino-varus deformity of the
+foot, and at substituting the fibula for the absent tibia. The
+deficiency of the upper end may be compensated for by implanting the
+head of the fibula between the condyles of the femur, and that at the
+lower end by splitting the fibula so as to form a socket for the
+talus. Amputation should be avoided, as even a dwarfed leg and foot
+improves the service of an artificial limb. A modification of the
+O'Connor extension boot may be employed.
+
+The _fibula_ may be absent completely or in part. The clinical
+appearances depend upon the condition of the tibia. When the tibia is
+normal, the most notable feature is the absence of the lateral
+malleolus, and the extreme valgus attitude of the foot. More commonly
+the tibia makes a sharp forward bend just below its middle, and the
+overlying skin presents a dimple or scar-like depression. This has
+usually been regarded as an evidence of intra-uterine fracture, but
+the observations of Hoffa suggest that both the bend of the bone and
+the depression on the skin are due to pressure exercised upon the leg
+from without by an amniotic band or adhesion. The leg fails to grow,
+the deformity becomes more pronounced, and the toes become pointed. If
+the tibia is markedly bent, it may be straightened by osteotomy; and
+the tendons, Achillis and peronei, may require to be lengthened. If
+the ankle is unstable as a result of the absence of the lateral
+malleolus, it may be artificially ankylosed, or the lower end of the
+tibia may be split vertically so as to make a socket for the talus. In
+either case, the foot is placed in the equinus attitude to compensate
+for the shortening of the leg. Deficiency of the tibia is frequently
+associated with imperfect development of the great toe; deficiency of
+the fibula with absence of the lateral toes and their metatarsal
+bones.
+
+_Volkmann's Supra-malleolar Deformity._--This condition, which is
+closely allied to that just described, consists in a congenital
+deficiency in the development of the bones of the leg, and especially
+of the fibula, as a result of which the articular surface is oblique
+and the foot deviates to one or other side. The foot usually occupies
+a valgus position, the sole looking laterally, and only its medial
+border coming into contact with the ground. It is treated by
+supra-malleolar osteotomy.
+
+
+THE FOOT
+
+Various deformities are met with in the region of the ankle and
+tarsus. The term "talipes" is commonly used to include all these, but
+here it will be restricted to that form in which the heel is more or
+less elevated, and the foot supinated so that it rests on its lateral
+border--_talipes equino-varus_. In _pes equinus_ the foot is in the
+position of plantar-flexion, and the patient walks on the toes. In
+_pes calcaneus_ the foot is dorsiflexed so that the tip of the heel
+comes in contact with the ground; this deformity may be combined with
+eversion of the foot, _pes calcaneo-valgus_, or with inversion, _pes
+calcaneo-varus_. When the instep is unduly arched, the terms _pes
+cavus_, _pes arcuatus_ or _hollow claw-foot_ are employed; while loss
+of the arch constitutes _flat-foot_, and eversion of the sole, _pes
+valgus_.
+
+
+CLUB-FOOT
+
+#Talipes Equino-varus.#--This deformity may be congenital or
+acquired.
+
+#Congenital talipes equino-varus# (Fig. 142) is a common malformation
+which is sometimes associated with other deformities, such as hare-lip
+or spina bifida, and may be met with in several members of one family.
+It is nearly twice as common in boys as in girls, and is slightly more
+frequently bilateral than unilateral. Its etiology is obscure, and
+various hypotheses have been put forward to account for it, but no one
+is convincing. It may be pointed out, however, that the foetal foot is
+very easily moulded into abnormal attitudes by external pressure such
+as might be exercised by the wall of the uterus when the liquor amnii
+is deficient. In a number of cases there are indications of such
+pressure over the bony prominences of the foot, in the shape of
+circumscribed scar-like areas in which the skin is atrophied; and in
+the infant, the intra-uterine position can be reproduced, thus
+demonstrating its method of origin. The occurrence of club-foot in
+several generations is alleged to support the Mendelian law.
+
+[Illustration: FIG. 142.--Bilateral Congenital Club-foot in an
+infant.]
+
+_Pathological Anatomy._--In well-marked cases the foot presents a
+concavity towards the medial side, the maximum point of the curve
+being opposite the mid-tarsal joint. When the patient attempts to
+stand, only the lateral border of the foot touches the ground, and the
+weight is borne on the fifth metatarsal, the cuboid, and the greater
+process of the calcaneus.
+
+[Illustration: FIG. 143.--Radiogram of Bilateral Congenital Club-foot
+in an infant.]
+
+The individual tarsal bones, especially the talus and calcaneus, are
+altered in shape as well as in their relations to one another and to
+the tibio-fibular socket. The navicular and cuboid are rotated
+medially around the anterior ends of the talus and calcaneus
+respectively, and the tubercle of the navicular comes to lie close to
+the medial malleolus. The lower third of the tibia is twisted medially
+on its vertical axis.
+
+The changes in the soft parts follow the general law that tissues
+which are relaxed become shortened, while those that are put on the
+stretch are lengthened. All the tissues on the medial, concave side of
+the foot are shortened, the structures most affected being the medial
+and the posterior ligaments of the ankle, and the inferior
+calcaneo-navicular ligament. There is also shortening of the muscles
+inserted into the tendo Achillis, and to a less extent of the tibiales
+anterior and posterior. The extensor tendons on the dorsum are
+displaced medially.
+
+_Clinical Features._--_In children who have not walked_, the degree of
+deformity varies, sometimes being very slight; in pronounced cases,
+the foot is turned medially, and in that position forms a right angle
+with the leg; the sole looks backwards and the medial border upwards.
+The foot appears shortened because it is curved on itself, the heel is
+narrower and more vertical than normal, the medial malleolus is
+obscured by the approximation of the navicular, and the lateral
+malleolus is unduly prominent.
+
+In extreme cases, the supinated foot forms an acute angle with the
+leg, and there is frequently a deep transverse depression across the
+sole, the result of contraction of the plantar fascia--a feature which
+is distinctive of the congenital form of club-foot.
+
+_In children who have walked_, the deformity becomes aggravated. The
+dorsum of the foot is markedly uneven, partly because of the
+prominence of the individual tarsal bones, and especially of the head
+of the talus and greater process of the calcaneus, and partly because
+of a depression over the neck of the talus. Instead of resting on its
+lateral border, the foot may finally rest on the dorsum, the sole
+looking upwards and backwards. While the skin over the heel remains
+comparatively thin and delicate, that covering the lateral border and
+dorsum of the foot becomes the seat of callosities, beneath which
+adventitious bursæ are formed. These bursæ are liable to become
+inflamed, and are then a source of great suffering, and if they
+suppurate may cause persistent sinuses. The muscles of the leg and
+foot, although not paralysed, undergo atrophy from disuse. In walking,
+the patient lifts one foot over the other in an ungainly and laborious
+manner, without any spring, as if walking on stilts.
+
+_In adults_, these features are further aggravated, and there are
+permanent changes in the bones (Fig. 144).
+
+[Illustration: FIG. 144.--Congenital Talipes Equino-varus in a man æt.
+24; seen from behind.]
+
+_Treatment._--This should be commenced as soon as the viability of the
+infant is beyond question, as the younger the patient the more easily
+and completely is the deformity rectified. Manipulations to correct
+the deformity should be carried out twice or thrice daily, and the
+limbs are also massaged and douched. At the end of two or three
+months, assistance may be derived from the use of a simple lateral
+poroplastic or aluminium splint with a foot-piece, or more simply by a
+strip of rubber plaster. The foot is held in the over-corrected
+attitude and the plaster is applied so as to maintain this attitude.
+If this regime is systematically persevered with from within a few
+days after birth, by the time the child begins to walk the sole can be
+brought into contact with the ground, and the weight of the body will
+aid in correcting the deformity. If the equinus element resists
+correction, the tendo Achillis should be lengthened.
+
+The turning in of the toes may be overcome by strapping the feet at
+night to a wooden board with the whole lower limb rotated laterally so
+that the toes of each foot point directly outwards. On account of the
+tendency towards relapse, the manipulations and massage must be
+persevered with for at least a year.
+
+_Tenotomy and Forcible Correction under Anæsthesia._--In more severe
+cases we have to deal not only with the contracted soft parts, but
+with changes in the bones resulting from their having grown in
+adaptation to the deformed attitude. The majority of surgeons defer
+operative measures until the child is about a year old.
+
+The soft parts to be divided are the tendo Achillis, the medial and
+posterior ligaments of the ankle, the plantar fascia, the
+calcaneo-navicular ligaments, and the tibialis posterior tendon. The
+varus deformity may then be corrected by laying the foot on its
+lateral side on a padded triangular wooden block, and pressing
+forcibly on the anterior and posterior ends of the foot so as to undo
+the curve on its medial side and allow of abduction of the foot; this
+is usually attended with cracking as the shortened ligaments give way.
+The equinus element is next dealt with by forcibly dorsiflexing the
+foot until the deformity is over-corrected. If it is preferred to
+correct the deformity in stages instead of at one sitting, the equinus
+element is left to the last. In older children, the strength of the
+hands is usually insufficient to stretch the tissues, and mechanical
+wrenches may be employed, such as those devised by Thomas, Bradford,
+or Lorenz.
+
+_Resection of a wedge from the tarsus_ (Davies Colley, 1876) is
+reserved for the most severe cases in which the shape and rigidity of
+the bones prevent correction of the deformity by any other means. The
+base of the wedge is on the lateral aspect, and the bone removed
+includes parts of the calcaneus, cuboid, talus, and navicular.
+
+_Removal of the talus_ is an alternative operation to resection of the
+tarsus, and may yield equally good results.
+
+In children, before the tarsal bones have become completely ossified,
+Ogston's method yields good results; instead of removing a wedge from
+the tarsus, the osseous nucleus of each bone is gouged out, leaving
+the cartilaginous shell. In this way the intertarsal joints are not
+interfered with, and the cartilaginous tarsus can be moulded so that
+when ossification is completed the bones differ but little from the
+normal.
+
+After any of these operative procedures, manipulations, massage,
+exercises, electrical stimulation of the muscles, and the wearing of
+some apparatus must be persevered with for at least twelve months.
+Failures are due to not sufficiently over-correcting the deformity in
+the first instance, and to neglect of after-treatment; in hospital
+practice it is difficult to ensure continuous supervision over long
+periods.
+
+Finally, _amputation_ may be called for when other methods have
+failed, and the patient is unable to put the foot to the ground
+because of suppurating bursæ and ulceration of the skin.
+
+#Acquired Talipes Equino-varus.#--In the great majority of cases this
+condition results from anterior poliomyelitis. It especially affects
+the peronei and the extensors of the toes, and is unilateral. The
+patient is unable to dorsiflex and abduct the foot, which hangs with
+the toes pointed and the sole turned medially.
+
+At first the joints are flaccid, and the attitude can easily be
+corrected by manipulation. In course of time, however, the opposing
+muscles--those inserted into the tendo Achillis, the tibialis
+posterior, and the long flexors of the toes--become shortened, and
+there is secondary contraction of the plantar fascia and of the
+ligaments on the medial side of the foot, and the deformity is thus
+rendered permanent. The bones also are altered in their shape and
+mutual relations, the talus being rotated forwards so that a large
+portion of its trochlear surface protrudes from the tibio-fibular
+socket. The skin is cold and livid, and readily suffers from pressure
+sores. The whole limb is ill-developed, and may be shorter than its
+fellow, and the paralysed muscles are wasted and exhibit for a time
+the reaction of degeneration.
+
+A similar deformity may result from section of the peroneal (external
+popliteal) nerve, from the peroneal form of progressive muscular
+atrophy, and from peripheral neuritis.
+
+The _treatment_ of paralytic equino-varus, short of operation, has
+been referred to under anterior poliomyelitis (p. 242). If tendon
+transplantation is indicated, the tendon of the tibialis anterior is
+attached to the cuboid, and a strip of the tendo Achillis to the
+dorsal aspect of the tarsus. Jones displaces the tibialis anterior
+into the base of the fifth metatarsal.
+
+If the paralysis is widely distributed, and the joints are flail-like,
+it is better to ankylose the ankle and mid-tarsal joints. It may be
+necessary to divide in several places the plantar fascia and other
+structures that have undergone secondary shortening.
+
+As using the limb hastens the restoration of function, the child
+should be got on to his feet as soon as possible.
+
+The spastic form of talipes equino-varus is comparatively rare. The
+plantar flexors and invertors distort the foot into the equino-varus
+attitude. The heel is drawn up, the anterior part of the foot is
+adducted and inverted at the mid-tarsal joint. The muscles are tense
+and rigid, and the reflexes exaggerated. The condition is frequently
+bilateral, and is often associated with other deformities of the lower
+limb and with a characteristic spastic gait. Considerable improvement
+may be brought about by lengthening the tendons of the shortened
+muscles. In severe cases it may be necessary to resect a portion of
+the tarsus.
+
+The occurrence of #varus without equinus# is so exceptional as not to
+call for separate description.
+
+#Pes Equinus.#--This deformity, in which the foot is in the position
+of plantar-flexion with the heel drawn up and the toes pointed, is
+nearly always acquired as a result either of poliomyelitis or of
+spastic paralysis. In typical cases the patient walks on the balls of
+the toes (Fig. 145). It is seldom met with as a congenital condition.
+Occasionally it is due to nerve lesions such as peripheral neuritis,
+or to injuries and diseases in the region of the ankle, when the foot
+has been allowed to remain for long periods in the attitude of
+plantar-flexion. In a limited number of cases the equinus attitude is
+assumed to compensate for shortening of the limb.
+
+[Illustration: FIG. 145.--Bilateral Pes Equinus in a boy æt. 7, the
+result of Spastic Paralysis.]
+
+In _poliomyelitis_ the deformity is most often unilateral (Fig. 146),
+while in _spastic paralysis_ it is frequently bilateral (Fig. 145),
+and is usually accompanied by excessive arching of the foot--pes
+cavus--as a result of plantar-flexion at the mid-tarsal joint, and
+hyper-extension of the first phalanges and plantar-flexion of the
+second and third phalanges of the toes--"clawing of the toes."
+
+[Illustration: FIG. 146.--Extreme form of Pes Equinus in a girl æt. 8,
+the result of Anterior Poliomyelitis.]
+
+_Clinical Features._--In the mildest cases the patient is able to
+bring the foot to a right angle. In average cases the heel is raised
+off the ground, and the foot rests on the balls of the toes. In
+extreme cases, and especially when the extensors are completely
+paralysed, the toes may be flexed towards the sole, and the weight is
+borne on the dorsum of the foot (Fig. 146). The patient suffers from
+painful corns and callosities, and from inflammation of bursæ which
+form over the points of pressure. When unilateral, the patient
+compensates for the lengthening of the limb by flexing the knee and
+throwing the limb outwards in walking. In severe cases, especially
+when both limbs are affected, the patient may be dependent on
+crutches.
+
+The talus projects on the dorsum, the anterior part of its trochlear
+surface escapes from the tibio-fibular socket, and the calcaneus is
+drawn up so that it comes into contact with the bones of the leg (Fig.
+147).
+
+[Illustration: FIG. 147.--Skeleton of Foot from case of Pes Equinus
+due to Poliomyelitis.]
+
+Shortening of the soft parts affects chiefly the muscles inserted into
+the tendo Achillis, the posterior ligament, and posterior parts of the
+lateral ligaments of the ankle. The fasciæ, ligaments, and muscles of
+the sole of the foot are also shortened. The flexors of the toes, the
+tibialis posterior, and the peroneus longus are shortened to a less
+degree.
+
+_Treatment._--Of all the deformities of the foot, pes equinus is that
+most easily rectified. In recent cases a great deal may be done by
+regular manipulations, and by the wearing of some corrective splint or
+apparatus between times.
+
+In well-marked cases it is necessary to lengthen the shortened
+structures, and especially the tendo Achillis. When the equinus is
+corrected, the excessive arching of the foot (pes cavus) and the
+clawing of the toes usually disappear, but it may be necessary to
+lengthen the flexor tendons, especially that of the great toe, and
+also the plantar fascia.
+
+Jones divides the tendo Achillis and the flexors of the toes
+subcutaneously, and maintains the dorsiflexion by excising an oval
+flap of skin from the front of the ankle.
+
+In aggravated cases, the bones must be attacked, for example by
+excising the talus. Arthrodesis of the ankle alone or along with the
+mid-tarsal joint may be indicated when these joints are flail-like.
+Amputation is reserved for cases which are otherwise hopeless, such as
+that shown in Fig. 147.
+
+When the deformity is compensatory to shortening of the limb, it is
+usually said to be a mistake to correct the equinus. Experience shows,
+however, that in young patients growth is stimulated by walking on the
+limb after the deformity has been corrected; the sole of the boot is
+then raised to the necessary extent.
+
+#Pes Calcaneus.#--In this deformity the foot is dorsiflexed at the
+ankle-joint. It is sometimes combined with eversion of the foot--_pes
+calcaneo-valgus_, or with inversion--_pes calcaneo-varus_.
+
+Pes calcaneus may be congenital or acquired. In the _congenital form_
+the deformity is frequently bilateral. There is dorsiflexion at the
+ankle-joint, and if an attempt is made to flex the foot towards the
+sole, the extensor tendons stand out prominently. In marked cases the
+long axis of the calcaneus is vertical, the tendo Achillis lies in
+close contact with the tibia, and the hollows on either side of the
+tendon are absent. The peronei are displaced from their grooves, and
+may lie in front of the lateral malleolus.
+
+Corrective manipulations are commenced within a few days after birth,
+and a malleable splint is worn between times. When the child begins to
+walk there is a natural tendency towards recovery. In severe cases it
+may be necessary to lengthen the contracted tendons--the extensor
+digitorum, the extensor hallucis, and, it may be also, the peroneus
+tertius and tibialis anterior; the tendo Achillis may require to be
+shortened.
+
+In the _acquired form_, the appearances are different, because the
+anterior part of the foot is usually flexed towards the sole, thus
+disguising to a certain extent the dorsiflexion at the ankle. This
+form is nearly always due to poliomyelitis, but it may also result
+from accidental division of the tendo Achillis. The anterior part of
+the foot is flexed towards the sole by the contraction of the plantar
+fascia and short muscles of the sole, the balls of the toes are
+approximated to the heel, and a deep transverse groove is formed in
+the sole opposite the mid-tarsal joint. The deformity presents a
+combination of the hollow foot--pes cavus--with pes calcaneus, and
+resembles that of a Chinese lady's foot. The foot rests on the heel
+and on the balls of the great and little toes, the sole of the foot
+being so deeply hollowed that even the lateral border does not touch
+the ground.
+
+In paralysis of the calf muscles alone, the tendons of the peronei or
+flexor digitorum longus may be divided and stitched to the calcaneus,
+to take the place of the tendo Achillis. If the calf muscles are not
+completely paralysed and the tendo Achillis is merely stretched, this
+tendon may be shortened by splitting it longitudinally and making the
+ends overlap, or its insertion may be displaced downwards. When the
+ankle is flail-like, it may be necessary to perform arthrodesis.
+
+Jones gets rid of the cavus deformity by resecting a wedge with its
+base towards the dorsum from the middle of the tarsus; the foot is
+then placed in a position of extreme calcaneus, the dorsum coming into
+contact with the front of the leg. Four weeks later a wedge is taken
+from the posterior part of the talus large enough to bring the foot
+down to a right angle with the leg; the articular surfaces of the
+tibia and fibula being denuded of cartilage, ankylosis takes place in
+a good position.
+
+#Pes Calcaneo-valgus.#--This deformity, which consists in a
+combination of dorsiflexion at the ankle and eversion of the foot, is
+as common as pure calcaneus (Figs. 148 and 149); the heel is
+depressed, the sole looks laterally, and its medial border is convex.
+Although it may be congenital, it is usually acquired as a result of
+poliomyelitis. The calf muscles are paralysed while the peronei retain
+their power, and, along with the tibialis anterior and the extensors
+of the toes, become secondarily contracted. Treatment is conducted on
+the same lines as in pes calcaneus, and the valgus may be controlled
+by implanting the peroneus brevis into the navicular.
+
+[Illustration: FIG. 148.--Pes Calcaneo-valgus with excessive arching
+of foot.]
+
+[Illustration: FIG. 149.--Pes Calcaneo-valgus, the result of
+Poliomyelitis.]
+
+#Pes Calcaneo-varus.#--In this rare deformity the heel is depressed
+and the sole of the foot looks inwards.
+
+#Pes Cavus.#--In this deformity, which is known also as _hollow
+claw-foot_, _pes arcuatus_, or _pes excavatus_, the longitudinal arch
+of the foot is exaggerated as a result of the approximation of the
+balls of the toes to the heel (Fig. 150). It is most frequently met
+with as an addition to pes equinus or pes calcaneus of paralytic
+origin, and has already been described. There is a mild form which is
+congenital, and which is quite independent of paralysis; another
+variety occurs in diseases of the spinal cord, such as Friedreich's
+ataxia.
+
+The name hollow claw-foot appropriately indicates the clinical
+appearances. The arch is exaggerated and the instep abnormally high;
+there is hyper-extension of the toes at the metatarso-phalangeal
+joints, and plantar-flexion at the inter-phalangeal joints; the
+plantar fascia and muscles are shortened. The footprint shows that
+neither border of the foot touches the ground. The patient complains
+of pain in the instep, of painful corns over the heads of the
+metatarsal bones, and of difficulty in getting properly fitting
+boots.
+
+_Treatment_ should first be directed towards the equinus or calcaneus
+element of the deformity, for if these are corrected the cavus
+condition tends to disappear. Exercises and massage should be
+persevered with, and boots without heels should be worn. The
+contracted structures in the sole may require to be divided, either
+subcutaneously or by the open method, as a preliminary to forcible
+correction, and the hallucis tendon may be brought through the head of
+the first metatarsal. In aggravated cases the talus and the heads of
+the metatarsal bones may be excised.
+
+
+FLAT-FOOT--PES PLANUS AND PES VALGUS
+
+Flat-foot or splay-foot is that deformity in which there is loss of
+the arch, and the foot tends to be pronated and abducted. The term
+_pes planus_ is applicable when there is merely loss of the arch; _pes
+valgus_ when the foot is pronated and the sole looks laterally. Of all
+deformities of the foot, flat-foot is the one for which advice is most
+frequently sought; it is also a common complication of other
+disabilities of the foot and of the lower extremity. It is usually
+bilateral, and is about twice as common in the male as in the female.
+Various types are met with; they are known according to their cause,
+as static, congenital, traumatic, paralytic, rachitic, rheumatic,
+arthritic, gonorrhoeal, and tabetic.
+
+[Illustration: FIG. 150.--Pes Cavus in association with Pes Equinus,
+the result of Poliomyelitis.]
+
+[Illustration: FIG. 151.--Radiogram of Foot of adult, showing the
+changes in the bones in Pes Cavus.]
+
+#Static or Adolescent Flat-foot.#--This, by far the most common and
+important variety (Fig. 152), generally develops between the ages of
+fourteen and twenty. It is called static because the essential factor
+in its production is a disproportion between the weight of the body
+and the supporting power of the arch of the foot.
+
+[Illustration: FIG. 152.--Adolescent Flat-foot.]
+
+It is met with in rapidly growing children or adolescents of feeble
+muscular development and with long narrow feet, and those especially
+who, after leaving school, begin some occupation which entails much
+standing--such as that of a factory hand, message boy, or domestic
+servant. To enable him to stand with the least effort for long
+periods, the patient adopts an attitude which makes little demand on
+the muscles, and throws nearly all the strain of the body weight on
+the ligaments and bones of the feet. This, which has been called "the
+attitude of rest," consists in standing with the limbs apart, the
+knees slightly flexed, the legs slightly rotated laterally at the
+knee, and the feet pronated, with the toes pointing laterally. The
+most important local factors predisposing to flat-foot are weakness of
+those muscles which normally support the ankle and the tarsal arches,
+especially the tibiales; weakness of the ligaments of the foot; and
+softness of the tarsal bones. When these conditions are present and a
+faulty method of standing and walking is adopted, the undue strain to
+which the tendons and ligaments are exposed results in their being
+stretched; the bones are altered in position, and flat-foot results.
+The head of the talus is displaced medially, and is protruded between
+the calcaneus and navicular, tending to separate them from one
+another, stretching the inferior calcaneo-navicular ligament and
+causing the anterior part of the foot to be abducted. The plantar
+ligaments--especially the inferior calcaneo-navicular--are stretched
+and lengthened. In something like 80 per cent. there is the combined
+deformity--pes plano-valgus--in those who apply for treatment.
+
+[Illustration: FIG. 153.--Flat-foot, showing loss of arch.]
+
+_Clinical Features._--The patient complains of being easily tired, and
+of pain in the foot after walking or standing. There is generally more
+pain before the appearance of the deformity than when it has
+developed, and at this stage it is not so easily recognised, and is
+apt to be called "rheumatism." The most common seat of pain is at the
+medial border of the foot behind the tubercle of the navicular, and
+this is due to stretching of the inferior calcaneo-navicular ligament.
+Pain is also complained of in the middle of the dorsum across the
+instep, from stretching of the interosseous ligaments. Later, there is
+pain over the greater process of the calcaneus in front of the lateral
+malleolus, from these bones coming into contact. There may be
+nocturnal cramp in the muscles of the leg and foot.
+
+The faulty attitude of the foot in standing and walking is usually
+evident. The foot appears longer and broader than normal, and when the
+body weight is put on it, it spreads out with the toes extended until
+the entire sole is in contact with the ground. In advanced cases, the
+medial border of the foot may be actually convex. Below and in front
+of the prominent medial malleolus, the head of the talus forms a
+rounded eminence, and a little farther forwards and lower still is the
+projection of the tubercle of the navicular. The eversion of the foot
+as a whole is best seen from behind; if the central axis of the leg is
+prolonged downwards, it approaches the medial border of the heel
+instead of passing through its centre; or, stated differently, instead
+of the axis of the calcaneus being a continuation of that of the leg,
+it deviates laterally and the medial malleolus is abnormally
+prominent. When the eversion is more pronounced, the sole looks
+laterally and the tendons of the peronei stand out in relief. The
+anterior part of the foot is displaced laterally. Flat-foot is
+frequently associated with stiff great toe; the patient having lost
+the power of dorsiflexing the toe, the first phalanx and first
+metatarsal are in a straight line, instead of forming an angle open
+towards the dorsum.
+
+The muscles of the leg are flabby and poorly developed. When the
+patient is seated and asked to move the foot in different directions,
+there is a characteristic stiffness, ungainliness, and restriction in
+the range of movement. The feet are usually cold and sweat
+excessively. The gait is slouching, and there is a want of spring and
+elasticity. The lengthening of the foot results in the tendons,
+especially the flexors, being too short, hence hammer-like contraction
+of the toes may be brought about. The boots, after being worn, show a
+bulging of the instep towards the sole, greater wearing away of the
+sole along the medial border, and, when there is stiff great toe, an
+absence of the transverse crease on the dorsum opposite the balls of
+the toes. Footprints may be obtained by wetting the soles of the feet.
+The print of a normal foot shows only the heel, the lateral border of
+the foot, and the balls and tips of the toes. In flat-foot the medial
+border appears in the print to a greater or less extent (Fig. 154). If
+a record is wanted to estimate the progress of treatment, the sole of
+the foot is painted with a 5 per cent. solution of ferro-cyanide of
+potassium, and the patient stands on paper painted with the liquor of
+the perchloride of iron diluted one-half; the print appears dark blue
+on a yellow ground.
+
+[Illustration: FIG. 154.--Imprint of Normal and of Flat Foot.]
+
+_Skiagrams_ are useful for showing displacement of bones and
+differences between sitting and standing, and for recording the
+results of treatment.
+
+_Prophylaxis of Flat-foot._--Stress is to be laid on a supervised
+training of the whole muscular system, and especially of that of the
+legs. In walking and standing, the feet should be kept parallel and
+not pointed outwards, as was formally taught in schools of gymnastics
+and insisted upon by drill instructors. Children should be taught to
+walk properly, rising on the balls of the toes with each foot in
+succession. Attention should also be directed to the boots, which
+should be so fashioned that the medial side of the boot is kept
+straight and the end of the boot is opposite the big toe.
+
+_Treatment._--This is directed towards restoring and maintaining the
+arch of the foot. As the measures adopted necessarily vary with the
+extent to which the condition has progressed, it is convenient for
+purposes of treatment to recognise the following four degrees. A first
+degree, in which the arch reappears when the weight is taken off the
+foot or the patient rises on the balls of the toes; a second, in which
+the normal attitude can be restored by manipulation; a third, in which
+this is only possible under anæsthesia; a fourth, in which the bones
+are so displaced and altered in shape that correction is impossible
+without operation.
+
+_Cases of the First Degree._--If there is marked pain and tenderness,
+the patient must lie up. The general health is improved by a
+nourishing diet and by cod-liver oil and tonics; and the legs and feet
+are douched and massaged thrice daily. When pain and tenderness have
+disappeared, the patient is instructed how to walk and exercise the
+feet. In walking, the medial edges of the feet should be parallel with
+one another, first the heel should touch the ground and then the balls
+of the toes. He should neither stand nor walk long enough to cause
+fatigue, and in standing he should alter the attitude of the feet from
+time to time, and occasionally rise on the balls of the toes. The
+following exercises, devised by Ellis of Gloucester, should be
+practised: (1) Rising on the balls of the toes, the toes being
+directed straight forwards; (2) rising on the balls of the toes, with
+the points of the great toes touching each other, and the heels
+directed out, so that the medial borders of the feet meet in front at
+a right angle; (3) in the same attitude, after rising on to the balls
+of the toes, the knees are flexed and then extended before the heels
+descend again; (4) while seated in a chair, one leg crossed over the
+other, circumduction movements of the foot are carried out; (5) while
+standing, the medial border of the foot is raised off the ground
+several times, then the patient walks to and fro on the lateral border
+of the foot, and in the same attitude lifts one foot over the other.
+These exercises should be carried out slowly and deliberately, with
+the feet bare, and they should be carefully supervised until the
+patient thoroughly understands what is aimed at. The movements should
+be performed a definite number of times at regular intervals, but
+should not be pushed so as to cause pain or fatigue. The patient
+should be fitted with well-made lacing boots, with the heel and sole
+raised about half an inch on the medial side so that the foot rests
+mainly on its lateral border. The additional leather, which can be
+applied by any bootmaker, is in the form of a wedge, with its base to
+the medial side, one on the sole and one on the heel. The wedge fades
+away towards the lateral border, and also forwards towards the tip. In
+time, the limbs are further strengthened by sea-bathing, cycling,
+skipping, and other exercises.
+
+In _cases of the second degree_, the patient should be provided with a
+metal plate inside the boot. That known as Whitman's spring is the
+most popular. A plaster cast is taken of the sole while the foot is
+held in its proper position, and on this a metal plate, preferably of
+aluminium bronze, is modelled. This is covered with leather and
+inserted into the boot. We have found the supports devised by Scholl
+simple and efficient. The treatment described for cases of the first
+degree is carried out in addition.
+
+In _cases of the third degree_, the deformity is corrected under an
+anæsthetic. The foot is forcibly moved in all directions so as to
+stretch the shortened ligaments and to break down adhesions, it is
+then rotated into an extreme varus position, and fixed in
+plaster-of-Paris or to a Dupuytren's splint. It may be necessary to
+have recourse to the Thomas' wrench, employed in the correction of
+club-foot. When the reaction consequent upon this procedure has
+subsided, the question of shortening or of reinforcing the tendons
+concerned in the support of the arch of the foot may be considered;
+one of the peronei, for example, may be attached to the tubercle of
+the navicular. We have not found it necessary to employ this
+procedure.
+
+In _cases of the fourth degree_, in which the displacement and
+alterations in shape of the bones constitute an insuperable bar to
+correction, operative treatment may be considered, either resection of
+a wedge including the talo-navicular joint or forward displacement of
+the tuberosity of the calcaneus.
+
+#Spasmodic Flat-foot.#--There are cases of flat-foot in which pain and
+spasm of the peronei muscles are the predominant features. If the
+spasm is not allayed by rest in bed and hot fomentations, the foot
+should be inverted under an anæsthetic; and in this position it is
+encased in plaster-of-Paris. Jones resects an inch of each of the
+peroneal tendons about 2-1/2 inches above the tip of the lateral
+malleolus; Armour and Dunn claim to have obtained better results from
+crushing the peroneal nerve in the substance of the peroneus longus.
+
+#Paralytic Flat-foot# (Fig. 155).--In typical cases this results from
+poliomyelitis affecting the tibial muscles. When other groups of
+muscles are affected at the same time, compound deformities, such as
+pes calcaneo-valgus, are more likely to result.
+
+[Illustration: FIG. 155.--Bilateral Pes Valgus and Hallux Valgus in a
+girl æt. 15, the result of Anterior Poliomyelitis.]
+
+In paralytic valgus the medial border of the foot is depressed and
+convex towards the sole, and although the foot can readily be restored
+to the normal position by manipulation, it at once resumes the valgus
+attitude. The leg is wasted, the skin is cold and livid, and the ankle
+is flail-like. The treatment consists in reinforcing the paralysed
+tibial muscles by attaching the peronei, or a strip of the tendo
+Achillis, to the scaphoid, or in bringing about an ankylosis of the
+joints above and in front of the talus.
+
+#Traumatic flat-foot# is that form which results directly from injury.
+It is most often due to a fall from a height on to the feet; the
+ligaments supporting the arch are ruptured, and the bones are
+displaced, either at the time of the injury or later when the patient
+gets out of bed. The arch can only be restored by a wedge-resection of
+the tarsus. Loss of the arch may follow as a result of walking on the
+everted foot after injuries about the ankle, especially a badly united
+Pott's fracture; the foot may be displaced laterally and pronated, the
+sole looking laterally. This variety is very unsightly and disabling;
+it is treated by supra-malleolar osteotomy of the tibia and fibula.
+
+#Other Forms of Flat-foot.#--Flat-foot is sometimes met with in
+rickety children, in association with knock-knee or curvature of the
+bones of the leg, and is treated on the same lines as other rickety
+deformities. It may follow upon an attack of acute rheumatism or upon
+diseases in the region of the ankle and tarsus, such as gonorrhoea,
+arthritis deformans, tuberculosis, and Charcot's disease; the
+gonorrhoeal flat-foot is extremely resistant to treatment. There is a
+congenital form in which the sole is convex and the dorsum concave,
+the result of the persistence of an abnormal attitude of the foetus
+_in utero_. Lastly, there is a racial variety, chiefly met with in the
+negro and in Jews, which is inherited and developmental, and which,
+although unsightly, is rarely a cause of disability.
+
+#Pes Transverso-planus.#--Lange describes under this head a sinking or
+flattening of the anterior arch formed by the heads of the metatarsal
+bones, of which normally only the heads of the first and fifth rest on
+the ground. In this condition all may be on the same level or the arch
+is actually convex towards the sole. It may coexist along with the
+common form of flat-foot, or it may be associated with the neuralgic
+pain known as metatarsalgia.
+
+#Painful Affections of the Heel.#--These include inflammation of the
+bursa between the posterior aspect of the calcaneus and the lower end
+of the tendo Achillis, inflammation of the tendon itself and its
+sheath of cellular tissue, and the presence of a spur of bone
+projecting from the plantar aspect of the tuberosity of the calcaneus.
+The spur of bone is the source of considerable pain on standing and
+walking, and tenderness is elicited on making pressure on the plantar
+aspect of the heel; it is well demonstrated by the X-rays (Fig. 156).
+The condition is usually bilateral. Complete relief is obtained by
+removing the spur by operation.
+
+Sever of Boston calls attention to a painful condition of the heel met
+with in children, and associated with changes in the epiphysial
+junction, allied to those met with in the epiphysis of the tubercle of
+the tibia in Schlatter's disease. The changes in the epiphysial
+junction can be demonstrated in skiagrams. Treatment is conducted on
+the same lines as in teno-synovitis of the tendo Achillis.
+
+#Metatarsalgia.#--This affection, which was first described by Morton
+of Philadelphia (1876), is a neuralgia on the area of the anterior
+metatarsal arch, specially located in the region of the heads of the
+third and fourth metatarsal bones. It is most often met with in adults
+between thirty and forty, is commoner in women than in men, and is
+often combined with flat-foot. The patient complains of a dull aching
+or of intense cramp-like pain in the anterior part of the foot. The
+pain is usually relieved by rest and by taking off the boot. It may be
+excited by pressing the heads of the metatarsals together or by
+grasping the fourth metatarso-phalangeal joint between the finger and
+thumb. In advanced cases the pain may be so severe as to cripple the
+patient, so that she is obliged to use a crutch. On examination, the
+sole may be found to be broadened across the balls of the toes, and
+there may be corns over the heads of the third and fourth metatarsals.
+Skiagrams may show a downward displacement of the head of one or other
+of these bones, and prints of the foot may show an increased area of
+contact in the region of the balls of the toes. The affection is of
+insidious development, and is usually ascribed to sinking of the
+transverse arch of the foot--pes transverso-planus--the result of
+weakness or of wearing badly fitting boots. The intense pain is
+believed to be due to stretching of, or pressure upon, the
+interdigital nerves or the communicating branch between the medial and
+lateral plantar nerves; Whitman believes it is due to abnormal side
+pressure on the depressed articulations.
+
+[Illustration: FIG. 156.--Radiogram of Spur on under aspect of
+Calcaneus.]
+
+_Treatment._--Great improvement usually results from treating
+coexisting flat-foot, and pain is relieved by rest, massage, and
+douching. A tight bandage or strip of plaster applied round the
+instep before putting on the stocking may relieve pain. Boots should
+be made from a plaster cast of the foot, high and narrow at the instep
+so as to compress the bases of the metatarsals, and with the medial
+edge of the sole and heel slightly raised; a support may be worn in
+the sole, like that used for flat-foot, with both the longitudinal and
+transverse arches exaggerated. Scholl has devised a support for the
+anterior arch which we have used with benefit. When the head of one of
+the metatarsals is displaced, it may be removed through a dorsal
+incision running parallel with the tendon of the long extensor.
+
+#Hallux Valgus and Bunion.#--_Hallux valgus_ is that deformity in
+which the great toe deviates towards the middle line of the foot and
+comes to lie on the top of, or beneath, the second toe (Figs. 155,
+157). The head of the first metatarsal projects on the medial border
+of the foot, and, as a result of the pressure of the boot, an
+adventitious bursa is formed, which, when thickened by chronic
+inflammation, constitutes a prominent swelling or _bunion_. It is a
+common affection in civilised and especially in urban communities, and
+reaches its acme of development in adult women. It may occur on one or
+on both sides, and is sometimes associated with flat-foot.
+
+[Illustration: FIG. 157.--Radiogram of Hallux Valgus. The sesamoid
+bone is seen displaced towards middle line of the foot.]
+
+The deformity develops slowly, and is usually attributed to the
+wearing of stockings which are unduly tight at the toes, and of
+improperly made boots. The boot that favours the occurrence of hallux
+valgus is one which is too short and has pointed toes, with the apex
+in the middle line of the foot instead of being in line with the great
+toe. The pressure of the boot displaces the great toe into the valgus
+position, especially if a high heel is worn, as the toes are then
+driven forward into the apex of the boot. Once the great toe is
+abducted by the pressure of the boot, the deformity is increased by
+bearing unduly on the medial side of the ball of the great toe, and by
+pointing the foot outwards in walking.
+
+Arthritis deformans is rarely the cause of hallux valgus, but the
+changes characteristic of that affection are commonly present in the
+joint of the great toe. In pronounced cases, the base of the first
+phalanx is displaced on to the lateral aspect of the head of the first
+metatarsal, the exposed head of which frequently shows fibrillation
+and wearing away of the cartilage, and is often surrounded by new
+bone, sometimes amounting to an exostosis. There are also fringes from
+the synovial membrane that may be caught between the articular
+surfaces. The distal end of the first metatarsal is displaced
+medially, broadening the tread of the foot, and in severe cases its
+shaft is rotated on its long axis, so that its dorsal surface looks
+medially; the great toe is then similarly rotated (Fig. 157). The
+flexor and extensor tendons and the sesamoid bones are displaced
+laterally. The ligaments and other soft parts on the medial side are
+elongated, while those on the lateral side are contracted.
+
+In women, the chief complaint may be of the disfigurement of the boot;
+in others, of pain and disability resulting from the sensitiveness of
+the joint and of the enlarged bursa over the head of the first
+metatarsal. The inflamed bursa, which sometimes communicates with the
+joint, may suppurate, and the infection may spread to the joint.
+
+The _treatment_ varies with the severity of the deformity. In mild
+cases, a great deal can be done by wearing properly made boots and
+stockings with a separate compartment for the great toe, or a pad of
+cotton wool or tent of rubber between the great and second toes. The
+patient should practise manipulations and exercises of the toes and
+feet, and putting the foot to the ground properly in walking. In
+pronounced cases, the pain and tenderness must first be got rid of by
+rest and soothing applications. At night, the attitude of the toe may
+be corrected by a moulded splint fixed to the medial aspect of the
+foot by strips of plaster; the toe is then bandaged to the distal end
+of the splint. Scholl has devised a prop, made of rubber, to be worn
+between the great and second toes. If there is flat-foot, this must
+receive appropriate treatment.
+
+In aggravated cases, the deformity can only be corrected by an
+operation which consists in resecting the head of the metatarsal bone,
+and the tendon of the long extensor may be detached from its
+insertion and secured to the medial side of the first phalanx. A bar
+may be placed across the sole just behind the balls of the toes, and
+the boot should also comply with the anatomical shape of the foot.
+
+#Hallux Varus or Pigeon-toe# (Fig. 158).--In this deformity, which is
+extremely rare, the great toe deviates from the middle line of the
+foot; it occurs chiefly in children in conjunction with other
+deformities, and interferes with the wearing of boots. Treatment
+consists in straightening the toe and retaining it in position by a
+splint or plaster of Paris. The medial collateral ligament and the
+tendon of the abductor hallucis may require to be divided.
+
+[Illustration: FIG. 158.--Radiogram of Hallux Varus or Pigeon-toe.]
+
+#Hallux Rigidus and Hallux Flexus# (Fig. 159).--These terms indicate
+two stages of an affection of the metatarso-phalangeal joint of the
+great toe, first described by Davies Colley. In the earlier
+stage--_hallux rigidus_--the toe is stiff and incapable of being
+dorsiflexed, although plantar-flexion is, as a rule, but little
+restricted. When the joint, in addition to being stiff, is painful,
+sensitive, and swollen, the term _hallux dolorosus_ is applied.
+
+[Illustration: FIG. 159.--Hallux Rigidus and Flexus in a boy æt. 17.
+There is a suppurating corn over the head of the first metatarsal
+bone.]
+
+As the disease progresses, the toe is drawn towards the sole and
+becomes permanently flexed--_hallux flexus_--and any attempt at
+dorsiflexion is attended with pain.
+
+The condition is met with chiefly in adolescent males, is nearly
+always associated with flat-foot, and is then usually bilateral. The
+patient's gait, in addition to having the characteristic features
+associated with flat-foot, is peculiarly wooden and inelastic, as
+instead of rising on the balls of the toes with each step, he puts
+down and lifts the sole as if it were a rigid plate. The pain is
+increased by walking. The boot tends to become worn away at the point
+of the toes and at the posterior edge of the heel, and the usual
+crease across the dorsum is absent.
+
+On dissection it is found, especially in hallux flexus, that the
+inferior portions of the collateral ligaments are contracted, and that
+the cartilage of that part of the head of the metatarsal which is
+exposed on the dorsum is converted into fibrous tissue; there may also
+be other changes characteristic of arthritis deformans. Bony ankylosis
+has not been observed.
+
+_Treatment._--In early cases, great benefit results from measures
+directed towards the cure of the accompanying flat-foot, and
+especially the wearing of the support of the anterior arch devised by
+Scholl. If the joint of the big toe is painful and sensitive, absolute
+rest should be enforced until these symptoms have disappeared. The
+patient must wear a properly shaped boot with a pliable sole, and be
+instructed how to manipulate and exercise the toe. Later, when the toe
+is already rigid or flexed towards the sole, the above treatment is
+not feasible. It is then best to correct the deformity either by
+wrenching the toe into the dorsiflexed position, under anæsthesia, and
+fixing it with a plaster-of-Paris bandage; or, when this is
+impossible, by excising the articular end of the metatarsal bone and
+interposing a layer of fatty or bursal tissue between the distal end
+of the metatarsal and the base of the first phalanx. When these
+measures are impracticable, the suffering may be relieved by inserting
+in the boot a rigid metal plate which will prevent any attempt at
+dorsiflexion in walking.
+
+#Hammer-toe.#--This is a flexion-contracture which generally involves
+the second, but sometimes also other toes. It may be congenital and
+inherited, but usually develops about puberty, and is then, as a rule,
+bilateral, and often associated with flat-foot.
+
+The first phalanx is dorsiflexed, and the second is plantar-flexed,
+while the third varies in its attitude, sometimes being in line with
+the second (Fig. 160), sometimes even more plantar-flexed, and
+sometimes dorsiflexed. When the second toe alone is affected, as is
+commonly the case, it is partly buried by those on either side of it,
+only the knuckle of the first inter-phalangeal joint projecting above
+the level of the other toes (Fig. 160). The skin over the head of the
+first phalanx being pressed upon by the boot usually presents a corn,
+under which a bursa forms (Fig. 161). Both the corn and the bursa are
+subject to attacks of inflammation, which cause suffering and
+disability in walking. The soft parts at the distal extremity of the
+toe are flattened out by contact with the sole of the boot--hence the
+supposed resemblance to the head of a hammer.
+
+[Illustration: FIG. 160.--Hammer-toe.]
+
+On dissection, it is found that the contracture is maintained by
+shortening of the plantar portions of the collateral ligaments of the
+first inter-phalangeal joint and of the glenoid ligament upon which
+the head of the first phalanx rests.
+
+Hammer-toe is usually ascribed to the use of tight socks and of
+ill-fitting boots, especially those which are median-pointed and are
+too short for the feet, but in some persons there appears to be an
+inherited predisposition to the deformity.
+
+[Illustration: FIG. 161.--Section of Hammer-toe.
+
+ _a_, Corn.
+ _b_, Bursa over first inter-phalangeal joint.]
+
+While corrective manipulations, strapping, and the use of splints may
+be of service in slight cases, it is usually necessary to perform an
+operation in order to extend the toe permanently. Before operating,
+any infective condition, such as a suppurating corn or bursa, must be
+corrected. The collateral and glenoid ligaments are divided
+subcutaneously--Spitzy also divides the flexor tendons and
+capsule--and if the toe can then be straightened, the foot is secured
+to a metal splint moulded to the sole and provided with longitudinal
+slots opposite the intervals on either side of the toe affected. The
+toe is drawn down to the splint by passing a loop of cotton or elastic
+bandage round the toe and through the slots. In many cases the
+contraction of all the tissues on the plantar aspect, including the
+skin, prevents the toe being straightened even after division of the
+ligaments, and it is then necessary to remove the head and neck of the
+first phalanx through a lateral incision. This is more satisfactory
+than amputation of the affected toe at the metatarso-phalangeal
+joint, as after this the adjacent toes tend to fall together and
+favour hallux valgus. If amputation is performed, a pad of cotton wool
+or rubber prop should be worn to fill up the vacant space.
+
+The term _Gampsodactyly_ has been applied to a deformity in which all
+the toes assume the position of hammer-toe, usually from a spastic
+condition of the muscles controlling the toes.
+
+#Hypertrophy of the Toes.#--One or more of the toes may be the seat of
+hypertrophy or local giantism. This is usually present at birth or
+appears in early childhood, and may form part of an overgrowth
+involving the entire lower extremity (Fig. 162). The overgrowth may
+involve all the tissues equally, or the subcutaneous fat may be
+specially affected. The medial toes are those most commonly
+hypertrophied. In addition to being enlarged, the toe may be displaced
+from its normal axis. The hypertrophy may affect two or more toes
+which are fused together or webbed (Fig. 162). The treatment consists
+in amputating as much of the toe as will allow of an ordinary boot
+being worn.
+
+[Illustration: FIG. 162.--Congenital Hypertrophy of Left Lower
+Extremity in a boy æt. 5. The second and third toes are fused.]
+
+#Supernumerary Toes# (_Polydactylism_).--These vary from mere
+appendages of skin to fully developed toes (Fig. 163); if they
+interfere with the wearing of boots they should be removed.
+
+#Webbing of the Toes# (_Syndactylism_).--This may affect two or more
+toes, which may be united merely by a web of skin, or so completely
+fused that the individual digits are only indicated by the nails; the
+degree of fusion is shown by means of skiagrams. Unless associated
+with congenital hypertrophy, no treatment is called for.
+
+[Illustration: FIG. 163.--Supernumerary Great Toe.
+
+(Photograph lent by Sir George T. Beatson.)]
+
+
+THE UPPER EXTREMITY
+
+#Congenital Absence of the Clavicle.#--Both clavicles may be absent,
+and it is possible for the patient voluntarily to bring his shoulders
+into contact with one another in front of the chest; there is little
+or no impairment of function.
+
+#Displacements of the Scapula.#--_Congenital Elevation of the Scapula_
+(Sprengel's shoulder, 1891).--This abnormality is rare, and is not
+usually recognised till several years after birth. In one variety
+there is a bridge of bone or fibrous tissue connecting the superior
+angle of the scapula with the spinous process of one of the cervical
+vertebræ, and there may be a false joint at one end of the bridge
+permitting a certain amount of movement of the scapula. Associated
+abnormalities in the vertebræ and in the ribs are shown in skiagrams.
+In the more common type, the scapula seems to be held in its elevated
+position by shortening of the muscles attached to its body, and it is
+often rotated so that its lower angle is close to the spine and its
+axillary border nearly horizontal, or the axillary border may lie in
+close to the ribs, and the vertebral border project from the chest
+wall. The shoulder is generally higher and farther forward on the
+affected side, and there is a moderate degree of scoliosis. There is a
+want of purchase in the movements of the shoulder and upper arm.
+
+[Illustration: FIG. 164.--Congenital elevation of Left Scapula in a
+girl: also shows hairy mole over Sacrum.
+
+(Mr. D. M. Greig's case.)]
+
+When the deformity is bilateral, which is rare, the neck is short and
+thick, the chin lies close to the sternum, and the arms can scarcely
+be raised to the horizontal.
+
+Gymnastic exercises and the wearing of a brace to hold the shoulders
+back and down may be followed by some improvement, but, as a rule, it
+is necessary to mobilise the scapula by operation. An X-ray photograph
+should first be taken, because, when the scapula is connected with the
+spine by a bridge of bone, this must be resected. The muscles attached
+to the vertebral border and spine of the scapula are divided, the
+bone is drawn down to its proper position, and the parts are fixed by
+plaster bandages.
+
+_Winged Scapula._--This condition consists in a marked displacement
+backwards of the lower angle and vertebral border of the scapula, when
+the patient attempts to raise the arm from the side (Fig. 165). Under
+normal conditions, in making this movement the serratus and rhomboid
+muscles pull forward the vertebral border and inferior angle of the
+scapula, and so fix the bone firmly against the chest wall. When these
+muscles are paralysed, as a result of anterior poliomyelitis,
+neuritis, or injury of the long thoracic nerve of Bell, or of the
+fifth and sixth cervical nerve-roots through which they receive their
+supply, the patient is unable to abduct the arm, and the deltoid
+having lost its _point d'appui_, its contraction merely results in
+tilting the angle of the scapula backward (Fig. 165).
+
+[Illustration: FIG. 165.--Winged Scapula; the patient is holding the
+arms out in front.]
+
+_Treatment._--In the majority of recent cases the condition yields to
+the administration of strychnin and other muscle and nerve tonics, and
+the use of massage and the faradic current. The application of a
+carefully adjusted padded belt is sometimes useful. The method of
+treatment by stitching the latissimus dorsi over the lower angle of
+the scapula is based on the erroneous assumption that the displacement
+is due to the slipping of that muscle off the bone; at the same time,
+it must be admitted that the operation sometimes diminishes the
+deformity and adds to the patient's comfort.
+
+A more efficient method consists in detaching the clavicular portion
+of the pectoralis major from its insertion, and stitching it to the
+serratus anterior so as to make it take on the function of this
+muscle, or stitching it to the axillary border of the scapula. Success
+has also followed suture of the vertebral border of the scapula to the
+subjacent ribs (Eiselsberg).
+
+_Displacement of the scapula upwards and laterally_ has been observed
+as a result of partial paralysis of the trapezius when the nerves
+supplying it have been divided in removing tuberculous glands from the
+neck. In these acquired displacements, treatment is directed towards
+the nerve lesion and towards the improvement of the muscles by
+electricity, massage, and exercises; when the paralysis of the
+trapezius is permanent, the disability is gradually overcome by the
+compensatory hypertrophy of the levator muscle.
+
+#Congenital Dislocation of the Shoulder.#--This rare condition is
+usually bilateral, and is associated with other congenital defects.
+The glenoid cavity is deformed or absent, and the dislocation may be
+sub-coracoid, sub-acromial, or sub-spinous. The movements of the arm
+are restricted, and the development of the extremity as a whole is
+imperfect. It is sometimes possible to reduce the dislocation by
+manipulation, or, if this fails, by operation. Unilateral dislocation
+is sometimes mistaken for dislocation that has occurred during
+delivery and _vice versa_.
+
+#Habitual Dislocation# is described on p. 65.
+
+#Paralytic Deformities--Paralytic Dislocation of the Shoulder.#--The
+muscles in the region of the shoulder may have their innervation
+interfered with as a result of various conditions, of which
+poliomyelitis and injuries of the brachial plexus at birth are the
+most important. The capsular ligament of the shoulder-joint, being no
+longer kept tense by the scapular muscles--especially the deltoid and
+lateral rotators--becomes relaxed, and is gradually stretched by the
+weight of the arm. The appearances are characteristic; the muscles of
+the shoulder are wasted, the acromion is prominent, and between it and
+the upper end of the humerus there is a marked hollow into which one
+or more fingers may be inserted. The arm hangs flaccid by the side,
+rotated medially and pronated, and moves in a flail-like fashion in
+all directions, the patient having little control over it. The best
+results are obtained by the transplantation of muscles, the trapezius
+being detached from the clavicle and stitched to the surface of the
+deltoid, and the upper arm fixed in the position of horizontal
+abduction with the arm rotated laterally and supinated. Bradford
+inserts a portion of the trapezius into the humeral insertion of the
+deltoid. When these methods are impracticable, the upper arm may be
+fixed to the trunk by some form of apparatus, or arthrodesis is
+performed so that the movements of the scapula are communicated to the
+upper arm; the best attitude for ankylosis is one of abduction with
+medial rotation, so that the hand can be brought to the mouth.
+
+In cases of poliomyelitis, when all the muscles governing the elbow
+are paralysed while the muscles of the hand have escaped, it may be of
+great service to fix this joint permanently at rather less than a
+right angle. This may be effected by arthrodesis, or by removing an
+extensive diamond-shaped portion of skin from the flexor aspect of the
+joint and bringing the raw surfaces together, commencing the stitching
+at the lateral apices of the gap.
+
+[Illustration: FIG. 166.--Arrested Growth and Wasting of Tissues of
+Right Upper Extremity, the result of Anterior Poliomyelitis in
+childhood.]
+
+#Congenital Dislocations at the Elbow.#--_The head of the radius_ may
+be dislocated forwards, backwards, or laterally--usually in
+association with imperfect development of the radius and of the
+lateral condyle of the humerus. When the displaced head of the bone
+interferes with supination, or with extension, it should be removed.
+Congenital dislocation of both bones of the forearm is extremely rare.
+
+#Cubitus Valgus# and #Cubitus Varus#.--When the normal arm hangs by
+the side with the palm of the hand directed forward, the forearm and
+upper arm form an angle which is open outwards--known as the "carrying
+angle"; it is usually more marked in women in association with the
+greater breadth of the pelvis and the relative narrowness of the
+shoulders. When this angle is increased, the attitude is described as
+one of _cubitus valgus_. This deformity may be acquired as a result of
+rickets, but more commonly it is due to fracture of the lateral
+condyle of the humerus, in which the separated fragment has been
+displaced upwards.
+
+_Cubitus varus_ is the reverse of cubitus valgus. It is more common,
+is always pathological, and is nearly always a result of fracture of
+the lower end of the humerus or separation of the lower humeral
+epiphysis and subsequent interference with growth. These deformities
+may be corrected by supra-condylar osteotomy of the humerus.
+
+[Illustration: FIG. 167.--Lower end of Humerus from case of Cubitus
+Varus.]
+
+#Synostosis of the superior radio-ulnar joint# is a rare congenital
+condition, in which the hinge movements at the elbow are free, but
+supination is impossible; an attempt may be made by operation to form
+a new joint.
+
+#Volkmann's ischæmic contracture# of the muscles of the forearm,
+resulting in the production of claw-hand, is described in Volume I.,
+p. 415.
+
+#Deformities of the Forearm and Hand.#--The _radius_ may be absent
+completely or in part, frequently in combination with other
+malformations. The most evident result is a deviation of the hand to
+the radial side--one variety of _club-hand_. The forearm is
+shortened, the ulna thickened and often bent, and the thumb and its
+metacarpal bone are often absent, so that the usefulness of the hand
+and arm is greatly impaired (Fig. 171). For this condition Bardenheuer
+devised an operation which consists in splitting the lower end of the
+ulna longitudinally and inserting the proximal bones of the carpus
+into the cleft.
+
+Congenital deficiency of the _ulna_ is extremely rare.
+
+#Intra-uterine amputation# by constriction of amniotic bands sometimes
+occurs (Figs. 168, 169).
+
+[Illustration: FIG. 168.--Intra-uterine Amputation of Forearm.]
+
+[Illustration: FIG. 169.--Radiogram of Arm of patient shown in Fig.
+168.]
+
+#Drop Wrist from Anterior Poliomyelitis.#--In this condition the
+capacity of extending the fingers is deficient or absent. Recovery can
+be confidently predicted if, on still further flexing the fingers,
+they can be voluntarily extended towards the point from which they are
+flexed (Tubby and Jones). Considerable improvement may result from
+fixing the hand by means of a splint in the attitude of dorsal
+flexion. The splint is removed at frequent intervals to allow of
+massage and other treatment being carried out, and it has usually to
+be worn for a period of one to two years. In some cases recourse
+should be had to arthrodesis.
+
+[Illustration: FIG. 170.--Congenital absence of Left Radius and Tibia
+in a child æt. 8.
+
+(Mr. D. M. Greig's case.)]
+
+In _spastic paralysis_ the most pronounced deformity is flexion of the
+forearm and pronation and flexion of the hand (Fig. 166). Gradual
+extension at the wrist may be brought about by the use of a malleable
+splint, in which the angle is gradually increased, over a period of at
+least twelve months. Failing success by this method, operation may be
+had recourse to, and this consists in lengthening of tendons, and
+tendon transplantation. Tubby has devised an operation for converting
+the pronator radii teres into a supinator, and Robert Jones another in
+which the flexors of the carpus are made to take the place of the
+extensors. "These operations, combined if necessary with elongation of
+the flexors of the fingers, pave the way for diminution of the angle
+of flexion at the elbow, lessening of the pronator spasm, increase of
+the supinating power, reduction of the carpal flexion, and addition to
+the extensor power at the wrist" (Tubby and Jones).
+
+#Congenital Club-hand.#--This rare deformity corresponds to congenital
+club-foot, and probably arises in the same way. The hand and fingers
+are rigidly flexed to the ulnar or radial side, so that the patient is
+incapable of moving them. Treatment is carried out on the same lines
+as for club-foot.
+
+A deformity resembling this, _acquired club-hand_, is brought about
+when the growth of either of the bones of the forearm has been
+arrested as a result of disease or of traumatic separation of its
+lower epiphysis. The hand deviates to the side on which the growth has
+been arrested--_manus valga_ or _vara_. The treatment consists in
+resecting a portion of the longer bone.
+
+[Illustration: FIG. 171.--Club-hand, the result of imperfect
+development of radius. The thumb is absent.
+
+(Photograph lent by Sir George T. Beatson.)]
+
+#Madelung's Deformity of the Wrist.#--In 1878, Madelung called
+attention to a deformity also called sub-luxation of the hand, in
+which the lower articular surface of the radius is rotated so that it
+looks towards the palm; there is palmar displacement of the carpus,
+and the lower end of the ulna projects on the dorsum. The cause of the
+condition is obscure, but it is met with chiefly in young women with
+slack ligaments, whose laborious occupation or athletic pursuits
+subject the hand and wrist to long-continued or repeated strain. It is
+as frequently unilateral as bilateral and may recur in successive
+generations. There is a good deal of pain, the grasping power of the
+hand is impaired, and dorsiflexion is considerably restricted. The
+deformity disappears on forcible traction, but at once reappears when
+the traction is removed. A wristlet of poroplastic or leather
+extending from the mid-forearm to the knuckles is moulded to the limb
+in the corrected position, and is taken off at intervals for massage
+and exercises.
+
+When _operative treatment_ is called for, it takes the form of
+osteotomy of the radius and ulna about an inch or more above their
+articular surfaces.
+
+#Congenital dislocation of the wrist# is rare.
+
+#Deformities of the Fingers.#--Various forms of _congenital
+dislocation_ of the fingers are met with, but they are of little
+clinical importance, as they interfere but slightly with the
+usefulness of the digit affected.
+
+_Congenital lateral deviation of the phalanges_ is more unsightly than
+disabling; it is met with chiefly in the thumb, in which the terminal
+phalanx deviates to the radial or to the ulnar side in extension; the
+deviation disappears on flexion.
+
+_Congenital contraction of the fingers_ is comparatively common. It is
+an inherited deformity, and is often met with in several members of
+the same family. It most frequently affects the little or the ring and
+little fingers (Fig. 172), and is usually bilateral. The second and
+third phalanges are flexed towards the palm; the first phalanx is
+dorsiflexed, this being the reverse of what is observed in Dupuytren's
+contraction. Duncan Fitzwilliams suggests that it should be called
+"hook-finger," and that it is probably due to imperfect development of
+the anterior ligament of the first inter-phalangeal joint. He has
+observed it in association with laxity of the ligaments of the other
+joints of the body.
+
+[Illustration: FIG. 172.--Congenital Contraction of Ring and Little
+Fingers.]
+
+The affection is usually disregarded in infancy and childhood as being
+of no importance. In young children, the deformity is corrected by
+wearing a light splint fixed with strips of plaster, or a piece of
+whalebone or steel inside the finger of a glove. In older children,
+the finger may be straightened by subcutaneous division of the
+ligament over the palmar aspect of the base of the middle phalanx, or
+failing this by lengthening the flexor tendons and resecting a wedge
+from the dorsal aspect of the first phalanx close to the
+inter-phalangeal joint.
+
+#Dupuytren's Contraction.#--This is an acquired deformity resulting
+from contraction of the palmar fascia and its digital prolongations
+(Fig. 173). It is rare in childhood and youth, but is common after
+middle life, especially in men. It is often hereditary, and is said to
+occur in those who are liable to gout and to arthritis deformans.
+While it is met with in the working-classes and attributed to the
+pressure of some hard object on the palm of the hand--such as a hammer
+or shovel or whip--its greater frequency in those who do no manual
+work, and the fact that it is very often bilateral, indicate that the
+constitutional factor is the more important in its causation.
+
+[Illustration: FIG. 173.--Dupuytren's Contraction.]
+
+In the initial stage there is a localised induration in the palm
+opposite the metacarpo-phalangeal joint, and the skin over it is
+puckered and closely adherent to the underlying fascia. After a
+variable interval, the finger is gradually and progressively flexed at
+the metacarpo-phalangeal joint. The ring finger is usually the first
+to be affected, less often the fifth, although both are commonly
+involved. It is rarest of all in the index. The flexion may be
+confined to the metacarpo-phalangeal joint, or the middle and distal
+phalanges may also be flexed; and as the deformity becomes more
+pronounced, the nail of the affected finger may come into contact with
+the skin of the palm. Dissections show that the flexion of the finger
+is the result of a chronic interstitial overgrowth or fibrositis and
+subsequent contraction of the palmar fascia and of its prolongations
+on to the sides of the fingers. The digital processes of the fascia
+are thickened and shortened, and come to stand out like the string of
+a bow. The adipose tissue in the skin of the palm disappears, and the
+skin and fascia thus brought into contact become fused. The tendons
+and their sheaths are not implicated; they are found lying deeply in
+the concavity of the curve of the flexed digit. There is no pain, but
+the grasp of the hand is interfered with, the patient is unable to
+wear an ordinary glove, and he may be incapacitated from following his
+occupation.
+
+The condition is easily diagnosed from congenital contraction by the
+fact that in the latter the proximal phalanx is dorsiflexed.
+
+_Treatment._--When seen in the initial stage, contraction may be
+prevented by passive movements of the finger and by massage of the
+indurated fascia; we have observed cases in which these measures have
+held the malady in check for many years, but when flexion has already
+occurred, they are useless, and according to the social position,
+habits, or occupation of the patient, the condition is left alone or
+the deformity is corrected by operation.
+
+Adam's operation consists in multiple subcutaneous division of the
+contracted fascia in the palm and of its prolongations on to the
+finger; in addition to dividing the fascia, the tenotomy knife should
+be used also to separate the skin from the fascia. The finger is then
+forcibly extended, and a well-padded splint secured to the hand and
+forearm. The skin on the palmar aspect opposite the first
+inter-phalangeal joint may give way when the finger is extended;
+should this occur, the resulting gap may be covered by a skin graft.
+
+After healing has occurred, massage and movements must be persevered
+with, and a splint (Fig. 174) worn at night, as there is an inveterate
+tendency to recurrence of the contraction. In view of this tendency
+there is much to be said in favour of the radical operation which
+consists in removal of the fascia by open dissection. Owing to the
+long time required for healing and the sensitiveness of the scar, the
+results of excision of the fascia are sometimes disappointing. Greig
+has obtained good results by resecting the head of the metacarpal
+bone. When the little finger is completely flexed towards the palm it
+may be amputated, as it is always in the way.
+
+[Illustration: FIG. 174.--Splint used after Operation for Dupuytren's
+Contraction.]
+
+#Supernumerary Fingers (Polydactylism).#--These may coexist with
+supernumerary toes, and the condition is often met with in several
+members of the same family. Sometimes the extra finger is represented
+by a mere skin appendage, the nature of which may only be indicated by
+the presence of a rudimentary nail; sometimes it contains bone
+representing one or more phalanges, or it may be fully formed (Fig.
+175). In the majority of cases the superfluous finger should be
+removed.
+
+[Illustration: FIG. 175.--Supernumerary Thumb.
+
+(Photograph lent by Sir George T. Beatson.)]
+
+#Congenital Deficiencies in the Number of Fingers.#--One or more
+fingers may be absent, such deficiency being often associated with
+imperfect development of the radius or ulna; or they may be
+represented by short rounded stumps, which are ascribed to the
+strangulation of the digits by amniotic bands _in utero_--the
+so-called intra-uterine amputation.
+
+#Webbing of Fingers (Syndactylism).#--Congenital webbing or fusion of
+the fingers may be associated with polydactylism or with congenital
+hypertrophy, and, like other digital deformities, may affect several
+members of the same family. The degree of fusion ranges from a web of
+skin joining the fingers to a fusion of the bones, the latter being
+well seen in skiagrams. If an operation is decided upon, it should not
+be performed until the age of five or six years. In the simplest cases
+it is only necessary to divide the web and to unite the cut edges of
+skin along each finger by sutures, a skin graft being inserted into
+the angle between the fingers. An operation in which the skin is
+dissected up in the form of flaps may be required, but it should not
+be lightly entered upon, as in young children it has been known to be
+followed by gangrene of one or more of the digits.
+
+#Congenital Hypertrophy of the Fingers.#--This is a form of local
+giantism affecting one or more digits, and involving all the tissues.
+The finger is usually of abnormal size at birth, and continues to
+grow more rapidly than the others, and it may also come to deviate
+from its normal axis. Such a finger should be trimmed down or removed,
+to permit of the use of the other digits.
+
+#Trigger Finger# (Fig. 176).--This is an acquired condition in which
+movement of a finger or thumb, either in flexion or extension, is
+arrested, and is only completed with the assistance of the other hand.
+The obstacle to movement is usually overcome with a jerk or snap
+suggesting a resemblance to the trigger of a gun or the blade of a
+clasp-knife. The commonest cause is a disproportion between the size
+of the tendon and its sheath, such as may result from a localised
+thickening of the tendon. Recovery usually takes place under massage
+and passive movements. Failing this, the thickened portion of the
+tendon is pared down to its normal size; if it is the sheath of the
+tendon that is narrow, it is laid freely open.
+
+[Illustration: FIG. 176.--Trigger Finger.
+
+(Photograph lent by Sir George T. Beatson.)]
+
+#Drop# or #mallet finger# is described on p. 121.
+
+
+
+
+CHAPTER XI
+
+THE SCALP
+
+
+Surgical Anatomy--Injuries: _Contusion_; _Hæmatoma_;
+ _Cephal-hæmatoma_; _Wounds_; _Avulsion_--Diseases: _Infective
+ conditions_; Cystic and solid tumours; Air-containing swellings;
+ Vascular tumours.
+
+#Surgical Anatomy.#--The _skin_ of the scalp is intimately united to
+the _epicranial aponeurosis_ by a network of firm fibrous tissue
+containing some granular fat, and representing the subcutaneous
+connective tissue. These three layers constitute the scalp proper, and
+they are so closely connected as to form a single structure which can
+be moved to a certain extent by the action of the epicranius muscle.
+The epicranius (occipito-frontalis) muscle with its aponeurosis
+extends from the superciliary ridge in front to the superior nuchal
+(curved) line of the occipital bone behind, and laterally to the level
+of the zygoma where it blends with the temporal fascia. Between the
+scalp proper and the _pericranium_ is a quantity of loose areolar
+tissue, in the meshes of which extravasated blood or inflammatory
+products can rapidly spread over a wide area. Blood extravasated under
+the pericranium is limited by the attachments of this membrane at the
+sutures.
+
+The _blood supply_ of the frontal region is derived from the internal
+carotid arteries through their supra-orbital branches; the remainder
+of the scalp is supplied from the external carotids through their
+temporal, posterior auricular and occipital branches. The vessels,
+which run in the subcutaneous tissue, superficial to the epicranial
+aponeurosis, anastomose freely with one another and across the middle
+line. The main branches run towards the vertex, and incisions should,
+as far as possible, be directed parallel with them.
+
+The _venous return_ is through the frontal, temporal, and occipital
+veins. These have free communications, through the _emissary veins_,
+with the intra-cranial sinuses, and by these routes infective
+conditions of the scalp may readily be transmitted to the interior of
+the skull. The most important of the emissary veins are: the
+_mastoid_, _condyloid_, and _occipital_, passing to the transverse
+(lateral) sinus; the _parietal_, which enters the superior sagittal
+(longitudinal) sinus; and a branch from the nose which traverses the
+foramen cæcum and enters the anterior end of the superior sagittal
+sinus.
+
+The supra-trochlear, supra-orbital and auriculo-temporal branches of
+the trigeminal nerve, together with the greater and lesser occipital
+nerves, supply the scalp with sensation, while the muscles are
+supplied from the facial nerve.
+
+The _lymph vessels_ pass to the parotid, occipital, mastoid, and
+submaxillary groups of glands, the different areas of drainage being
+ill-defined.
+
+
+INJURIES OF THE SCALP
+
+#Subcutaneous Injuries.#--_In simple contusion_ of the superficial
+layers, owing to the density of the tissues, the blood effused is
+small in quantity and remains confined to the area directly injured,
+which is firm and tender to the touch, swollen and discoloured. The
+disappearance of the swelling may be hastened by elastic pressure and
+massage.
+
+_Hæmatoma of the scalp_ results when lacerated vessels bleed into the
+sub-aponeurotic space. Owing to the laxity of the connective tissue in
+this area, the effused blood tends to diffuse itself widely, and,
+according to the position assumed by the patient, gravitates to the
+region of the eyebrow, the occiput, or the zygoma. When a large artery
+is torn the swelling may pulsate. A hæmatoma of the scalp may readily
+be mistaken for a depressed fracture of the skull, owing to the fact
+that the margins of the effusion are often raised and of a firm
+resistant character. A differential diagnosis can usually be made by
+observing that the swelling is on a higher level than the rest of the
+skull; that the raised margin can to a large extent be dispersed by
+making firm, steady pressure over it with the finger; and that, on
+doing so, the smooth and intact surface of the skull can be
+recognised. When a fracture exists, the finger sinks into the
+depression and the irregular edge of the bone can be felt. In doubtful
+cases, if cerebral symptoms are present, an exploratory incision
+should be made.
+
+Even a large hæmatoma is usually completely absorbed, but the
+dispersion of the clot may be hastened by massage and elastic
+pressure. Any excoriation or wound of the skin must be disinfected.
+
+Sometimes a blood-cyst, consisting of a connective-tissue capsule
+filled with a yellowish-red fluid, remains, and may require to be
+emptied with a hollow needle.
+
+These effusions are to be distinguished from the _cephal-hæmatoma_, in
+which the blood collects between the pericranium and the bone. This is
+oftenest seen in newly born children as a result of pressure on the
+head during delivery, and is characterised by its limitation to one
+particular bone--usually the parietal--the further spread of the blood
+being checked by the attachment of the pericranium at the sutures.
+Occasionally a permanent thickening of the edges of the bone remains
+after the absorption of the extravasated blood. This condition is to
+be diagnosed from traumatic cephal-hydrocele (p. 390).
+
+#Wounds of the Scalp.#--So long as a scalp wound, however extensive,
+is kept free from infection, it involves comparatively little risk,
+but the introduction of organisms to even the most trivial wound is
+fraught with danger, on account of the ease and rapidity with which
+the infection may spread along the emissary veins to the meninges and
+intra-cranial sinuses.
+
+The deeper the wound, the greater is the risk. If the epicranial
+aponeurosis is divided, the "dangerous area" between it and the
+pericranium is opened, and if infection occurs, it may lead to
+widespread suppuration. Should the wound extend through the
+pericranium, infection is more liable to spread to the bone and to the
+cranial contents.
+
+The usual varieties of wounds--incised, punctured, contused, and
+lacerated--are met with in the scalp, and they vary in degree from a
+simple superficial cut to complete avulsion. For medico-legal purposes
+it is important to bear in mind that a scalp wound produced by the
+stroke of a blunt weapon, such as a stick or baton, may closely
+simulate a wound made with a cutting instrument.
+
+On account of the density of the integument and its close connection
+with the aponeurosis, scalp wounds do not gape unless the epicranial
+aponeurosis is widely divided. This facilitates union in incised
+wounds, but interferes with drainage in the long narrow tracts which
+result from punctures, and which are so liable to be infected and to
+implicate the sub-aponeurotic space, the pericranium, or even the
+bone. It also favours the inclusion in the wound of a foreign body,
+such as the broken point of a knife, or a piece of glass. The bleeding
+from scalp wounds is often profuse and difficult to control, because
+the vessels, fixed as they are in the dense subcutaneous tissue,
+cannot retract and contract so as to bring about the natural arrest of
+hæmorrhage, and it is difficult to apply forceps or ligatures to their
+cut ends, suture ligatures are more efficient. On account of the free
+arterial anastomosis in the deeper layers of the integument, large
+flaps of scalp will survive when replaced, even if badly bruised and
+torn, and it is never advisable to cut away any un-infected portion of
+the scalp, however badly it may be lacerated or however narrow may be
+the pedicle which unites it to the head.
+
+_Gun-shot wounds_ of the scalp are usually associated with damage to
+the skull and brain. A spent shot, however, may pierce the scalp, and
+then, glancing off the bone, lodge in the soft parts.
+
+_Complete Avulsion._--In women, the scalp is sometimes torn from the
+cranium as a result of the hair being caught in revolving machinery.
+The portion removed, as a rule, consists of integument and aponeurosis
+with portions of muscle attached. In a few cases the pericranium also
+has been torn away. So long as any attachment to the intact scalp
+remains, the parts should be replaced, and, if asepsis is maintained,
+a satisfactory result may be hoped for. When the scalp is entirely
+separated, recourse must be had to skin-grafting.
+
+_Treatment of recent Scalp Wounds._--To ensure asepsis, the hair
+should be shaved from the area around the wound, and the part then
+purified. Gross dirt ground into the edges of lacerated wounds is best
+removed by paring with scissors. Undermined flaps must be further
+opened up and drained--by counter-openings if necessary. When there is
+reason to suspect their presence, foreign bodies should be sought for.
+Bleeding is arrested by forci-pressure or by ligature; when, as is
+often the case, these measures fail, the hæmorrhage may be controlled
+by passing a needle threaded with catgut through the scalp so as to
+include the bleeding vessel. The wound is stitched with horse-hair or
+silk, and, except in very small and superficial wounds, it is best to
+allow for drainage. With the use of iodine as a disinfectant, it is
+often advantageous to dispense with dressings altogether.
+
+#Complications of Scalp Wounds.#--The most common complications are
+those due to infection, which not only aggravates the local condition,
+but is apt to lead to spreading cellulitis, osteomyelitis, meningitis,
+or inflammation of the intra-cranial sinuses. These dangerous sequelæ
+are liable to follow infection of any scalp wound, but more especially
+such as implicate the sub-aponeurotic area, or the pericranium. In the
+integument, a small localised abscess, attended with pain and oedema
+of surrounding parts, may form. Pus forming under the aponeurosis is
+liable to spread widely, pointing above the eyebrow, in the occipital
+region, or in the line of the zygoma. Suppuration under the
+pericranium tends to be limited by the inter-sutural attachments of
+the membrane. Necrosis of the outer table, or even of the whole
+thickness of the skull, may follow, although it is by no means
+uncommon for large denuded areas of bone to retain their vitality.
+
+The onset of infection is indicated by restlessness, throbbing pain
+and heat in the wound, a feeling of chilliness or the occurrence of a
+rigor, and tension of the stitches from oedema of the surrounding
+tissues. The oedema often extends to the eyelids and face; a puffiness
+of the eyelids, indeed, is not infrequently the first evidence of the
+occurrence of infection in the wound.
+
+_Treatment._--When suppuration ensues, the stitches should be removed,
+the wound opened up and purified with eusol, and packed. A dressing of
+ichthyol and glycerine should be employed for a few days.
+
+_Erysipelas of the scalp_ may originate even in wounds so trivial as
+to be almost invisible, or from suppurative processes in the region of
+the frontal sinuses or nasal fossæ. It tends to be limited by the
+attachments of deep fasciæ, and seldom spreads to the cheek or neck.
+Symptoms of cerebral complications, in the form of delirium or coma,
+and of meningitis may supervene. Cellulitis beneath the aponeurosis
+from mixed infection is a dangerous complication.
+
+
+DISEASES OF THE SCALP
+
+#Infective Conditions.#--It is not uncommon for _localised abscesses_
+to occur in the subcutaneous cellular tissue in delicate children, and
+such collections are not infrequently associated with pediculi,
+impetigo, or chronic dermatitis. They develop slowly and painlessly,
+and are only covered by a thin, bluish pellicle of skin. It is not
+improbable that they result from a mixed infection by pyogenic and
+tuberculous organisms. As a rule they heal quickly after incision and
+drainage, but when they are allowed to burst, tedious superficial
+ulcers may form. Localised abscesses may also form in connection with
+disease of the cranial bones. _Suppuration_ following upon injuries
+has already been referred to.
+
+_Boils and carbuncles_ are not common on the hairy part of the scalp.
+_Lupus_ rarely originates on the scalp, although it may spread thither
+from the face. _Syphilitic_ lesions are common and present the same
+characters as elsewhere. Gummata may develop in the soft parts, but
+more commonly they take origin in the pericranium or bone. _Eczema
+capitis_ is of surgical importance only in so far as it often forms
+the starting-point of infection of lymph glands by pyogenic and other
+organisms.
+
+#Cystic and Solid Tumours.#--A great variety of swellings is met with
+in the scalp.
+
+_Sebaceous cysts_ or _wens_ are of frequent occurrence, and have been
+described in Volume I.
+
+A _dermoid cyst_ is most commonly situated over the position of the
+anterior fontanelle, in the region of the occipital protuberance, or
+at the lateral angle of the orbit. As it frequently lies in a gap in
+the skull, it may be connected by a pedicle with the dura mater, and
+is liable to be mistaken for a meningocele.
+
+[Illustration: FIG. 177.--Multiple Wens.
+
+(Photograph lent by Sir George T. Beatson.)]
+
+_Serous cysts_ are occasionally found in the occipital region, and are
+believed to be meningoceles that have become shut off from the
+interior of the skull before birth.
+
+_Adenomas_ originating in the sebaceous or sweat glands are sometimes
+multiple, of a purplish colour, and the skin covering them is thin and
+glistening. They show a tendency to ulcerate and fungate, giving rise
+to a foetid discharge, and may be mistaken for epithelioma; they are
+also liable to become the seat of epithelioma. They are treated by
+excision.
+
+Large, flat _papillomas_ or warts may be single or multiple; they are
+of slow growth, and as they may also become the starting-point of
+epithelioma, they should be removed.
+
+[Illustration: FIG. 178.--Adenoma of Scalp.]
+
+The _plexiform neuroma_ forms a loose soft tumour situated in the
+course of one or more branches of the trigeminal nerve, especially
+the supra-orbital branch. In its most aggravated form the tumour hangs
+over the face or neck in large pendulous masses, and is described as a
+_pachydermatocele_ (V. Mott).
+
+A _sarcoma_ usually has its origin in the bones of the skull, and only
+implicates the scalp secondarily.
+
+_Epithelioma_ of the scalp may originate in relation to a wart, an
+ulcerated wen or sebaceous adenoma, or the cicatrix of a burn. It may
+affect comparatively young persons, may spread over a wide area, or
+pass deeply and involve the bone. Free and early removal is indicated.
+
+_Rodent cancer_ may originate on the scalp, but usually spreads
+thither from the face.
+
+In operating for extensive tumours of the scalp the hæmorrhage is
+sometimes formidable. It may be controlled by an elastic tourniquet
+applied horizontally round the head, or if, on account of the position
+of the tumour or from other causes, this is not practicable, by
+ligation or temporary clamping of the external carotid on one or on
+both sides.
+
+#Air-containing Swellings#--_Pneumatocele Capitis._--Cases have been
+recorded in which, as a result of pathological or traumatic
+perforations of the mastoid, and less frequently of the frontal cells,
+air has passed under the pericranium and given rise to a tense rounded
+tumour, resonant on percussion, and capable of being emptied by firm
+pressure. Such swellings exhibit neither pulsation nor fluctuation;
+and as they are painless, and give rise to almost no inconvenience,
+they do not call for treatment.
+
+_Emphysema of the scalp_ may follow fractures implicating any of the
+air sinuses of the skull, the air infiltrating the loose cellular
+tissue between the pericranium and the aponeurosis, and on palpation
+yielding a characteristic crepitation. It usually disappears in a few
+days.
+
+#Vascular Tumours.#--_Nævi_ on the scalp present the same features as
+elsewhere. If placed over one of the fontanelles, a nævus may derive
+pulsation from the brain, and so simulate a meningocele.
+
+_Cirsoid aneurysm_ is usually met with in the course of the temporal
+artery, and may involve the greater part of the scalp. Large,
+distended, tortuous, bluish vessels pulsating synchronously with the
+heart are seen and felt. They can be emptied by pressure, but fill up
+again at once on removal of the pressure. The patient complains of
+dizziness, headache, and a persistent rushing sound in the head.
+Ulceration of the skin over the dilated vessels, leading to fatal
+hæmorrhage, may take place.
+
+They may be treated by excision, after division and ligation of the
+larger vessels entering the swelling; or the dilated vessels may be
+cut across at several points and both ends ligated. Krogius recommends
+the introduction of a series of subcutaneous ligatures so as to
+surround the whole periphery of the pulsating tumour, and interrupt
+the blood flow. Ligation of the main afferent vessels, or of the
+external or common carotid, has been followed by recurrence, owing to
+the free anastomatic circulation in the scalp. In some cases
+electrolysis has yielded good results.
+
+_Traumatic aneurysm_ of the temporal artery was comparatively common
+in the days when the practice of bleeding from this vessel was in
+vogue, but it is seldom met with now.
+
+_Arterio-venous aneurysm_ may also occur in the course of the temporal
+artery, as a result of injury, and is best treated by complete
+extirpation of the segments of the vessels implicated.
+
+
+
+
+CHAPTER XII
+
+THE CRANIUM AND ITS CONTENTS
+
+
+Anatomy and physiology--Cerebral localisation--Lumbar puncture. HEAD
+ INJURIES--Concussion--Cerebral irritation--Compression--Contusion
+ and laceration of the brain, and traumatic intra-cranial
+ hæmorrhage: _Middle meningeal hæmorrhage_; _Hæmorrhage from
+ internal carotid and venous sinuses_--Intra-cranial hæmorrhage of
+ the newly born. Cerebral oedema--Wounds of brain--After-effects of
+ head injuries--Traumatic epilepsy and insanity--Infective
+ complications.
+
+#Anatomy and Physiology.#--The _Cranium_ is irregularly ovoid in
+shape, and its floor is broken up by various projections to form three
+separate fossæ--anterior, middle, and posterior--in which rest
+respectively the frontal, the temporal, and the occipital lobes of the
+brain; the cerebellum, pons, and medulla oblongata also occupy the
+posterior fossa.
+
+The _outer_ table is the most elastic layer of the calvarium, and it
+varies greatly in thickness in different skulls and in different parts
+of the same skull. It is nourished chiefly from the pericranium which
+is firmly bound down along the lines of the sutures. The _inner_ or
+vibreous table is thin and fragile, and its smooth internal surface is
+grooved by the middle meningeal and other arteries of the dura mater,
+and by the large venous sinuses. The intermediate layer--the
+_diploë_--is highly vascular, branches of the meningeal vessels
+anastomosing freely in its open porous substance with branches derived
+from the pericranial vessels. Some of its veins open into the external
+veins, and others into the intra-cranial sinuses, and they communicate
+with the emissary veins as these pass through the bone, which explains
+the spread of infective processes from the structures outside the
+skull to those within. The possibility of withdrawing blood from the
+interior of the skull by leeching, bleeding, or cupping depends on the
+existence of the emissary veins.
+
+_The Membranes of the Brain._--The _dura mater_ is a fibro-serous
+membrane, the outer, fibrous layer constituting the endosteum of the
+skull, the inner, serous layer forming one of the coverings of the
+brain. Between the fibrous layer and the bone the meningeal vessels
+ramify; and along certain lines the two layers split to form channels
+in which run the cranial venous sinuses. Inside the dura, and
+separated from it by a narrow space--the _sub-dural space_--lies the
+_arachno-pial membrane_, consisting of an outer (_arachnoid_) layer
+which envelops the brain but does not pass into the sulci, and a
+highly vascular inner layer--the _pia mater_--which closely invests
+the brain and lines its entire surface.
+
+The space between these layers--the _sub-arachnoid space_--is
+traversed by a network of fine fibrous strands, in the meshes of which
+the cerebro-spinal fluid circulates. Each nerve-trunk as it leaves the
+skull or spinal canal carries with it a prolongation of each of these
+membranes and their intervening spaces. The membranes gradually become
+lost in the fibrous sheaths of the nerves, and the sub-dural and
+sub-arachnoid spaces become continuous with the lymph spaces of the
+nerves.
+
+The _cerebro-spinal fluid_ is secreted by the choroid plexuses and
+fills the cerebral ventricles, the central canal of the cord, the
+sub-dural and sub-arachnoid spaces, and the sheaths of the
+intra-cerebral blood vessels. At the base of the brain, particularly
+in the posterior fossa, the sub-arachnoid space is wider than
+elsewhere, forming "cisterns" filled with cerebro-spinal fluid which
+supports the cerebral structures. Through the foramen of Magendie in
+the roof of the fourth ventricle the sub-arachnoid fluid of the
+cranial cavity communicates with that of the vertebral canal.
+
+Although it differs in its chemical constitution from true lymph, the
+cerebro-spinal fluid seems to functionate as lymph, in addition to
+acting as a lubricating agent, and playing a part in regulating the
+vascular supply of the brain. In cases of cerebral hæmorrhage,
+abscess, tumour, or depressed fracture, room is made up to a certain
+point for the extraneous matter by displacement of cerebro-spinal
+fluid.
+
+_Vascular supply._--The free anastomosis between the vessels entering
+into the formation of the circulus arteriosus (circle of Willis)
+ensures an abundant supply of blood to the brain. The larger arteries
+run in the sub-arachnoid space and give off branches which ramify in
+the pia mater before entering the cerebral substance. Within the
+brain, each artery being more or less terminal, there is no free
+anastomosis between adjacent vessels, with the result that if any
+individual artery is obstructed the vitality of the area supplied by
+it is seriously impaired. The venous arrangements are also peculiar in
+that the veins are thin-walled and valveless, and open into the rigid,
+incompressible sinuses which run between the layers of the dura mater.
+Most of the blood passes to the internal jugular vein, and any
+increase in the pressure of this vessel is immediately transmitted
+back to the cerebral veins. As the blood vessels project into a rigid
+case filled with incompressible material, and as the total _volume_ of
+blood in the brain is constant (Munro and Kelly), any alteration in
+the supply of blood to the cerebral tissue must be due to an increased
+_velocity_ of flow, and this in turn depends upon changes in the
+aortic and vena cava pressure. Thus, if the aortic pressure rises,
+more blood will enter the cerebral vessels and will move along more
+rapidly; while if the pressure in the vena cava rises there is
+obstruction to the passage of blood in the arteries and diminished
+velocity of flow. The ebb and flow of cerebro-spinal fluid in and out
+of the spinal canal may also help to control the pressure.
+
+#Nerve Elements.#--The nervous system is composed of a multitude of
+units, called _neurones_, each neurone consisting of a nucleated cell,
+with branching protoplasmic processes or _dendrites_ and one
+_axis-cylinder_ or _axon_. The nutrition of an axis cylinder depends
+on its continuity with a living cell. If the cell dies, the axis
+cylinder degenerates. If the axis cylinder is severed at any point, it
+degenerates beyond that point, and the nucleus of the nerve-cell
+disintegrates--chromatolysis.
+
+The axis cylinder of one cell ends in a number of fine filaments which
+arborise around another nerve-cell, thus bringing it into
+physiological, if not anatomical, relationship with the first cell.
+The termination is called a cell-station or _synapsis_. In this way
+the various sections of the nervous system are kept in association
+with one another and with the rest of the body.
+
+_Motor Functions and Mechanism._--The nerve centres, which together
+make up the motor area, and govern the voluntary muscular movements of
+the body, are situated in the grey matter of the præcentral or
+ascending frontal gyrus, and of the frontal aspect of the central
+sulcus (fissure of Rolando). The upper limit of the motor area reaches
+on to the mesial aspect of the paracentral lobule, and the lower limit
+stops short of the lateral cerebral fissure (fissure of Sylvius) (Fig.
+179).
+
+[Illustration: FIG. 179.--Relations of the Motor and Sensory Areas to
+the Convolutions and to Chiene's Lines.
+
+(After Cunningham.)]
+
+Each group of muscles has its own regulating centre, the size of the
+area representing any group depending upon the character and
+complexity of the movements performed by the muscles, rather than upon
+the amount of muscular tissue that is governed by the centre--for
+example, the centre for the mouth, tongue, and vocal cords is larger
+than that for the muscles of the trunk.
+
+The motor centres have been localised on the surface of the brain with
+approximate accuracy. For example, above the superior genu of the
+præcentral gyrus, the centres governing the hip, knee, and toes are
+grouped; opposite the genu are the centres for the movements of the
+trunk; between the superior and middle genua lie the centres for the
+upper extremity; opposite the middle genu, those for the neck, and
+below it, those for the face, jaws, and tongue, pharynx and larynx.
+
+#The Motor Tracts.#--It is now generally accepted that there are two
+paths by which motor impulses pass from the brain: one--the
+_rubro-spinal tract_--which controls the more elemental movements of
+the body, such as standing, walking, breathing, etc.; the other--the
+_pyramidal tract_--developed later in the evolution of the nervous
+system, and concerned with the finer and more skilled movements.
+
+The pyramidal tract is the more important clinically. From the
+pyramidal cells in the cortex of the Rolandic area, the axis cylinders
+pass through the centrum ovale towards the base of the brain. They
+converge at the internal capsule, and pass through the anterior
+two-thirds of its posterior limb (Figs. 180 and 195). The fibres for
+the eyes, face, and tongue lie farthest forward, and next in order
+from before backward, those for the arm and the leg.
+
+From the internal capsule, the motor fibres pass as the _pyramidal
+tract_ through the crusta of each crus cerebri, the pons and the
+medulla oblongata. Throughout this part of its course, numerous axons
+leave the tract, and enter the mid-brain, pons, and medulla in which
+lie the nuclei of the motor cranial nerves.
+
+At the _decussation of the pyramids_ in the lower third of the
+medulla, the main mass of the motor fibres crosses the middle line,
+and enters the lateral column of the spinal cord as the _crossed
+pyramidal tract_. The remaining fibres pass down as the _direct
+pyramidal tract_, and decussate in the cord near their termination.
+
+The fibres forming the second path pass through the red nucleus in the
+cerebral peduncle (crus cerebri) and thence by way of the rubro-spinal
+tract in the lateral column of the cord.
+
+The existence of this double motor path explains how after a
+hemiplegic stroke in which the pyramidal tract is destroyed while the
+rubro-spinal tract escapes, the patient is able to perform such
+primitive movements as are involved in walking or standing, while he
+is unable to carry out finer movements that require higher education.
+
+The pyramidal and rubro-spinal tracts, in addition to conveying motor
+impulses, convey impulses that influence muscle tonus and the deep
+reflexes. The pyramidal tract conveys impulses that inhibit muscle
+tonus, while the rubro-spinal tract is the path by which excitatory
+impulses travel. When the inhibitory influences are cut off, as in a
+lesion of the internal capsule, the paralysed muscles become spastic,
+and the deep reflexes are exaggerated. When the excitatory impulses
+are also lost, as in a total transverse lesion of the cord, the
+paralysed muscles are flaccid and the deep reflexes disappear. In
+destructive lesions of the lower neurones, the muscles are always
+flaccid.
+
+The axons passing from the cerebral cortex terminate at different
+levels in the cord by breaking up into dendrites which arborise around
+the cells on the grey matter of the posterior horns--this system of
+cells, axons, and dendritic processes forming an _upper neurone_. From
+this synapsis the _lower neurone_ proceeds, its axons travelling to
+the anterior horn and arborising around the motor cells. The axis
+cylinders pass out in the anterior nerve roots to the spinal nerves
+and are continued in them to their distribution in voluntary muscles.
+
+If the continuity of any group of these lower neurones is interrupted,
+not only do the nerve fibres degenerate, but the nutrition of the
+muscles supplied by them is interfered with and they rapidly
+degenerate and waste, and after an interval show the reaction of
+degeneration. In addition, the reflex arc is disturbed, and reflexes
+are lost. As these changes do not occur in lesions of the upper
+neurones, an appreciation of the differences enables us to distinguish
+between lesions implicating the upper and the lower neurones.
+
+#Sensory Functions and Mechanism.#--Three kinds of sensory impulses
+pass from the periphery to the brain; (1) deep, or muscular
+sensibility, (2) protopathic sensibility, and (3) epicritic
+sensibility.
+
+_Deep sensibility_ includes the recognition of (_a_) deep pressure,
+say by the blunt end of a pencil; (_b_) the position of a joint on
+passive movement (joint sense); (_c_) active muscular contraction
+(kinesthetic sense). The fibres that convey these impulses to the
+spinal cord pass in the afferent nerves from the muscles, tendons, and
+bones, and so long as these nerves are intact these sensations are
+retained, even if the surface of the skin is quite anæsthetic.
+
+_Protopathic sensibility_ is of a lower order than epicritic. It
+consists in the recognition of painful cutaneous stimuli and of
+extreme degrees of heat and cold. The fibres concerned are
+non-medullated and regenerate comparatively quickly after injury, so
+that protopathic sensibility is regained before epicritic.
+
+_Epicritic sensibility_ is the most highly specialised and permits of
+the recognition of light touch, _e.g._, with a wisp of cotton wool, of
+fine differences of temperature, and of discriminating as separate the
+points of a pair of compasses 2 cm. apart. These sensations are
+carried by medullated nerve fibres, and are slow to return after
+injury to the nerves.
+
+The sensory nerve fibres conveying these different impulses pass to
+the ganglionic cells of the posterior nerve roots. From each of these
+cells a process passes into the cord and bifurcates into an ascending
+and a descending branch. In the cord the fibres rearrange themselves
+and pass to the brain by a double path. Those that convey sensations
+of pain and of temperature pass by the spino-thalamic route by way of
+the tract of Gowers and the fillet to the optic thalamus; those that
+are concerned with the muscular sense, the joint sense, and tactile
+discrimination pass up the posterior columns in the tracts of Goll and
+Burdach to the nuclei gracilis and cuneatus in the medulla, whence
+they pass to the optic thalamus.
+
+From the cell station in the optic thalamus the fibres proceed to the
+_cortical sensory centres_, that for tactile sensation being situated
+in the post-central (ascending parietal) gyrus; that for muscular and
+stereognostic sense lying probably in the adjacent portions of the
+parietal lobe.
+
+In a unilateral lesion of the cord, pain and the temperature sense may
+be disturbed in one limb, and motor power and tactile sensibility in
+the other, as the fibres that convey impressions of pain, and those
+that subserve the discrimination of temperature, pass up and decussate
+in the cord a few segments above their point of entrance.
+
+[Illustration: FIG. 180.--Diagram of the Course of Motor and Sensory
+Nerve Fibres.]
+
+#Effects of Lesions of the Motor and Sensory Mechanisms.#--Lesions of
+the _motor mechanism_ differ in their fundamental characters according
+as they affect the upper or the lower neurones. The signs also vary
+according as the affected area is _destroyed_ or merely _irritated_,
+say by the pressure of a tumour. Irritative lesions in general produce
+muscular spasms or convulsions, while destructive lesions cause
+paralysis. The essential differences in the effects of destructive
+lesions of upper and lower neurones may be indicated thus:--
+
+ _Upper Neurone Lesion._ _Lower Neurone Lesion._
+
+ Spastic paralysis of voluntary Flaccid paralysis of voluntary
+ muscles. muscles.
+ No marked wasting of paralysed Marked wasting of paralysed
+ muscles. muscles.
+ No reaction of degeneration. Reaction of degeneration.
+ Exaggeration of reflexes. Loss of reflexes.
+
+Irritative lesions of the sensory mechanism cause numbness and
+tingling (paræsthesia); more extensive paralytic lesions produce
+anæsthesia, astereognosis, loss of muscle sense, loss of pain, or
+inability to distinguish temperature, according to the tracts that are
+affected.
+
+_Lesions of the Upper Motor Neurone_ may occur in any part of its
+course. _Localised lesions of the motor cortex_ of an irritative kind,
+for example, a patch of meningitis, a tumour, meningeal hæmorrhage, or
+a spicule of bone, produce spasms in those groups of muscles on the
+opposite side of the body that are supplied by the centres
+implicated--Jacksonian epilepsy. The cortical discharge may overflow
+into neighbouring centres and cause more widespread convulsive
+movements, or, if strong and long-continued, may even lead to general
+convulsions. Consciousness is usually lost before the whole of one
+side becomes implicated in the spasms; always before they spread to
+the opposite side. Contracture may occur in the muscles affected after
+the spasms cease.
+
+If an area of the cortex is destroyed by the lesion, paralysis is
+produced of the corresponding muscles on the opposite side of the
+body. At first the paralysed muscles are flaccid, but spasticity soon
+develops. In some cortical lesions, for reasons not yet understood,
+the paralysis remains of the flaccid type. The seat and extent of the
+paralysis depend upon the area of the cortex destroyed. In rare cases
+the whole motor area is destroyed--_cortical hemiplegia_; more
+generally the lesion affects one or more groups of muscles, and
+occasionally all the muscles of one limb are paralysed--_cortical
+monoplegia_. Lesions are often both irritative and destructive, and
+lead to paralysis of one or more groups of muscles associated with
+spasms and convulsions of the muscles governed by neighbouring areas
+of the cortex. Irritation or destruction of the sensory centres may
+also exist, giving rise to areas of paræsthesia and anæsthesia.
+
+Lesions in the _centrum ovale_, which destroy the fibres proceeding
+from the overlying cortex, produce a corresponding spastic paralysis
+on the opposite side of the body. No irritative phenomena are
+associated with such a sub-cortical lesion.
+
+Lesions in the region of the _internal capsule_ often produce complete
+spastic hemiplegia of the opposite side of the body. When the
+posterior part of the capsule is involved, there are, in addition,
+hemianæsthesia and hemianopia, and sometimes disturbances of hearing,
+smell, and taste.
+
+A lesion of the _crus_ may in like manner produce spastic hemiplegia
+and hemianæsthesia of the opposite side, often associated with a lower
+neurone paralysis of the third and fourth nerves of the same side
+(crossed paralysis). The optic tract, which crosses the crus, may also
+be affected, and hemianopia result.
+
+Lesions of the _corpora quadrigemina_ cause interference with the
+reaction of the pupil, disturbance of the functions of the oculo-motor
+nerve and of mastication, ataxia, and inco-ordination of the movements
+of the limbs.
+
+The symptoms produced by lesions of the _pons and medulla_ vary
+according to the position of the lesion. If it is unilateral, there
+may be spastic hemiplegia and hemianæsthesia of the opposite side; if
+it is situated in the lower part of the pons or in the medulla, there
+is often also a lower neurone paralysis of one or more of the cranial
+nerves on the same side as the lesion (crossed paralysis). Paralysis
+of the external rectus of one eye and of the internal rectus of the
+other (conjugate paralysis) is frequently found in pontine, and in
+cortical and internal capsule lesions.
+
+_Cerebellar_ lesions are associated with special symptoms. In ataxia,
+there is inco-ordination of muscular movements, especially of the
+coarse movements, such as walking. The gait becomes irregular and
+staggering, with a tendency to fall, sometimes to the side on which
+the lesion is situated, sometimes to the opposite side. In patients
+who cannot walk, ataxia may be tested by ordering repeated pronation
+and supination of the forearm. Paresis or asthenia may be found in the
+trunk muscles, or evidenced by weakness of the grip, or drooping of
+the head to one side. Changes in muscle tone may arise and lead to
+exaggerated or decreased reflexes, often varying from day to day.
+Vertigo and nystagmus may also be present, in addition to occipital
+headache and tenderness on percussion. When one lateral lobe is
+implicated, the symptoms are referred to the same side; when the
+median lobe is involved, they are bilateral, and there may be
+retraction of the neck with extension of the legs, probably as the
+result of the associated internal hydrocephalus.
+
+A unilateral lesion of the _spinal cord_ causes a lower neurone
+paralysis of the muscles supplied from the cord at the level of the
+lesion, with spastic paralysis of the muscles of the same side of the
+body supplied from a lower level of the cord. The sensory symptoms are
+variable. Typically there is some anæsthesia in the structures
+supplied from the damaged section of the cord--incomplete owing to the
+overlapping by other sensory nerves. Just above the lesion there is
+irritation of spinal nerves, and hyperæsthesia and pain referred to
+their distribution. On the same side below the lesion, there is a loss
+of epicritic, stereognostic and deep sensibility, and on the opposite
+side below the lesion, loss of the sense of pain and the
+discrimination between heat and cold. Ordinary tactile sensibility,
+which is governed by a double path, may or may not be lost on either
+side below the lesion.
+
+#Other Special Centres.#--The cortical centres for _vision_ lie on the
+median surfaces of the occipital lobes in the neighbourhood of the
+calcarine fissure. Each half-vision centre--for there is one in each
+occipital lobe--receives the fibres from the same side of both retinæ.
+Destruction of one half-vision centre produces the condition known as
+_homonymous hemianopia_, in which the medial (nasal) half of one
+visual field and the lateral (temporal) half of the other is affected,
+so that there is an inability to see objects situated on the side
+opposite to the lesion.
+
+_Auditory impulses_ are received in the posterior part of the superior
+temporal convolution.
+
+_Aphasia._--The use of language, spoken or written, as a means of
+expression depends upon the co-ordination of four different centres:
+the visual, the auditory, the graphic, and the articulatory. These are
+situated in different parts of the brain and are connected by
+sub-cortical association tracts, the main pathway of which lies in the
+vicinity of the upper end of the fissure of Sylvius. Marie has proved
+that aphasia results from lesions in this area.
+
+The _olfactory_ and _gustatory_ centres are situated in the uncus
+close to the pituitary fossa.
+
+Lesions of the frontal cortex anterior to the motor centres, even if
+extensive, may produce few or no symptoms, and in consequence this
+region has been called a "silent" area. Occasionally there results a
+change in temperament or intelligence, and the region is on this
+account supposed to be concerned with the higher psychical functions.
+There is evidence that the pre-frontal cortex has a centre for the
+conscious initiation of movements, and that lesions produce "apraxia,"
+_i.e._, inability to perform, or clumsiness in voluntarily performing
+fine movements such as touching the nose with the finger, though such
+movements may be perfectly carried out unintentionally. This centre is
+probably situated in the superior and middle left frontal convolutions
+in right-handed people. The fibres from the centre to the right motor
+area cross in the anterior part of the corpus callosum.
+
+#Cerebral Localisation.#--The various parts of the brain can be
+localised in relation to the surface by various methods. That devised
+by Professor Chiene has been found reliable.
+
+#Relation of Cerebral Centres to the Surface.#--Numerous attempts have
+been made to formulate rules for locating the different parts of the
+brain in relation to the surface of the head. The method devised by
+Chiene is free from many of the difficulties and fallacies common to
+most other methods, inasmuch as the results obtained do not depend
+upon making definite measurements in inches, or determining particular
+angles. Certain fixed and easily recognised bony landmarks--the
+glabella, the external occipital protuberance, the lateral angular
+process, and the root of the zygoma--are taken, and connected by
+lines, which are further subdivided--_always being bisected_. Figs.
+179 and 181 explain the method. The head being shaved, a line (GO) is
+drawn along the vertex from the glabella (G) to the external occipital
+protuberance (O). This line is bisected in M, which constitutes the
+"mid-point." The posterior half of the line MO is bisected in T,
+constituting the "three-quarters point," and the posterior half TO is
+bisected in S--"the seven-eighths point." The lateral angular process
+(E) is next connected to the root of the zygoma (P) by a line EP, and
+the root of the zygoma with the seven-eighths point by PS; the line
+EPS thus forms the base line. The lateral angular process is now
+joined to the three-quarters point by ET. The two segments of the base
+line EP and PS are bisected in N and R respectively, and these points
+connected with the mid-point (M) by lines NM and RM. These lines cut
+off a part of ET--AB, which is now bisected in C, and from C the line
+CD is drawn parallel to AM.
+
+[Illustration: FIG. 181.--Chiene's Method of Cerebral Localisation.]
+
+In this way practically all the points of the brain which are wanted
+for operative purposes may be mapped out. Thus the quadrilateral space
+MDCA contains the Rolandic area. MA represents the præcentral sulcus,
+and if it be trisected in K and L, these points will correspond to the
+origins of the superior and inferior frontal sulci. The pentagon ABRPN
+corresponds to the temporal lobe. The apex of the temporal lobe
+extends a little in front of N. The supra-marginal convolution lies in
+the triangle HBC. The angular gyrus is at B. A is over the anterior
+branch of the middle meningeal artery, and the bifurcation of the
+lateral or Sylvian fissure; AC follows the horizontal limb of the
+lateral fissure. The transverse or lateral sinus at its highest point
+touches the line PS at R (Fig. 181).
+
+The _fissure of Rolando_ or _central sulcus_ may be marked out by
+taking a point half an inch behind the mid-point (M) (Fig. 181), and
+drawing a line downwards and forwards for a distance of about three
+and a half inches, at an angle of 67.5° with the line GO. The angle of
+67.5° can be readily determined by folding a square piece of paper on
+itself so as to make a triangle. The angle at the fold equals 45°. By
+folding the paper again upon itself in the same direction, the right
+angle of the paper is divided into four angles of 22.5° each. Three of
+these angles taken together make up the 67.5°. If the straight edge of
+the paper be placed along the sagittal suture with the angle of
+folding over the upper end of the fissure of Rolando, the folded edge
+falls over the line of the fissure (Chiene).
+
+[Illustration: FIG. 182.--To illustrate the site of various operations
+on the skull.]
+
+
+LUMBAR PUNCTURE
+
+Quincke, in 1891, first suggested the withdrawal of cerebro-spinal
+fluid from the theca in the lumbar region, as a means of relieving
+excessive intra-cranial tension in tuberculous meningitis, and to
+obtain specimens of the fluid for diagnostic purposes. The scope of
+the procedure, both as a therapeutic and as a diagnostic measure, has
+since been widely extended.
+
+_Technique._--The puncture may be made with the patient either lying
+on his left side, the spine being fully flexed by approximating the
+knees and shoulders; or sitting on the table with the knees drawn up
+and the body bent forward. The upper edge of the fourth lumbar spine
+is identified by drawing a horizontal line across the back at the
+level of the highest part of the iliac crests (Fig. 183). The space
+between the fourth and fifth lumbar vertebræ being the widest, is that
+usually selected. The skin having been purified, an exploring needle,
+about three inches long, is introduced about half an inch below the
+fourth lumbar spine in the middle line, and passed for about two
+inches in a direction forwards and slightly upwards. The needle
+usually encounters some resistance as it pierces the interspinous
+ligament, and then enters the sub-arachnoid space. If bone is struck,
+the needle should be withdrawn and introduced at a different level. If
+the cerebro-spinal fluid does not escape at once, a stylet should be
+passed through the needle to clear it of blood-clot or shreds of
+tissue. When the intra-thecal tension is normal, the fluid trickles
+away drop by drop, but if it is increased, as, for example, in
+meningitis, intra-cranial tumour, hydrocephalus, or uræmia, it may
+escape in a jet.
+
+[Illustration: FIG. 183.--Localisation of site for introduction of
+needle in Lumbar Puncture.]
+
+The _normal cerebro-spinal fluid_ is clear and colourless, has a
+specific gravity of 1004-1008, and contains a trace of serum globulin
+and albumose, some chlorides, and a substance which reduces Fehling's
+solution. Microscopically, it may contain some large endothelial cells
+and a few lymphocytes, or may be entirely devoid of cells. It does not
+contain the antitoxins and opsonins which are normally found in the
+plasma and lymph, hence the liability to infective meningitis after
+injuries and operations on the central nervous system. With a view to
+diminishing these risks, hexamine, which is excreted into the
+cerebro-spinal fluid, is administered for its antiseptic properties in
+cases of head injury and before intra-cranial operations.
+
+_Diagnostic Puncture._--Examination of the fluid withdrawn has proved
+useful in diagnosis in cases of intra-cranial and intra-spinal
+hæmorrhage, in various forms of meningitis, in cerebral abscess, and
+in some cases of cerebral tumour.
+
+The first few drops should be discarded, as they may be stained with
+blood from the puncture, and about 5 c.c. collected in each of two
+sterile tubes. To determine whether blood in the fluid is due to the
+puncture or to a pre-existing intra-cranial or intra-thecal
+hæmorrhage, the fluid should be centrifugalised; in the former case
+the supernatant fluid is clear and limpid, in the latter it retains a
+yellow tinge. In extra-dural hæmorrhage there is no blood in the
+cerebro-spinal fluid.
+
+In acute meningitis the fluid is turbid, and contains an excess of
+albumin. Organisms also are present, such as the diplococcus
+intracellularis in acute cerebro-spinal meningitis; staphylococci,
+streptococci, and pneumococci, particularly in the intra-cranial
+complications of middle ear disease. In all cases of acute microbic
+infection, and especially in the suppurative forms, polynuclear
+leucocytes are found in the fluid; while in chronic affections, such
+as tubercle and syphilis, there is an excess of lymphocytes (Purves
+Stewart). The detection of the tubercle bacillus is confirmatory of a
+diagnosis of tuberculous meningitis, but, as it is often difficult to
+find, its absence does not negative this diagnosis. In tuberculous
+meningitis the clot which forms floats in the centre of the fluid, and
+is translucent, grey, and flaky; in the pyogenic forms it is yellow,
+and sticks to the side of the vessel.
+
+In a few cases of malignant tumour of the spinal cord and its
+membranes, characteristic cells have been found in the fluid after
+centrifugalising.
+
+In uræmia there is a diminution of chlorides, and an increase of
+phosphates and sulphates.
+
+The Wasserman test is sometimes positive in the cerebro-spinal fluid,
+when it is negative in the blood.
+
+_Therapeutic Puncture._--In certain cases of cerebral tumour, and of
+tuberculous meningitis associated with an excessive quantity of fluid
+in the arachno-pial space, temporary relief of such symptoms of
+increased intra-cranial tension as headache, vertigo, blindness, or
+coma, has followed the withdrawal of from 30 to 40 c.cm. of the fluid.
+Terrier and others have found this measure useful in relieving pain in
+the head, delirium, and even coma, in cases of basal fracture.
+Carrière has found it beneficial in some cases of uræmia. The quantity
+withdrawn must not exceed 40 c.cm., lest the ventricles be emptied and
+pressure be exerted directly on the basal ganglia (Tuffier). In a
+number of cases sudden death has followed the withdrawal of
+cerebro-spinal fluid.
+
+This route is sometimes selected for the induction of spinal
+anæsthesia, and for the injection of antitoxin in cases of tetanus.
+
+
+HEAD INJURIES
+
+The brain is protected from injury by moderate degrees of violence
+applied to the head, by the dense and mobile scalp, the dome-like
+shape of the skull, the elasticity of its outer table and the
+buffer-like sutural membrane between the numerous bones of which it is
+composed, and the various internal osseous projections with the
+membranes attached to them, all of which tend to diminish vibrations
+and to disperse forces so that they expend themselves before they
+reach the brain. Further protection is provided by the water-bed of
+cerebro-spinal fluid, and by the external buttresses formed by the
+zygomatic arch and the thick muscular pads related to it, as well as
+by the mobility of the skull upon the spine.
+
+In all cases of head injury, the questions that dominate the whole
+clinical outlook are, whether the brain is directly damaged or not,
+and whether it is likely to become the seat of infection.
+
+It is impossible to consider separately in their clinical aspects
+injuries of the cranium and injuries of the brain. It seldom happens
+that one is seriously damaged without the other suffering to a greater
+or less extent. Sometimes the skull suffers comparatively little,
+while the brain is severely damaged, but it is rare for a serious
+injury to the bone to be unaccompanied by definite brain lesions. In
+any case it is the damage to the brain, however slight, that gives to
+the injury its clinical importance. It is an old and a true saying
+that "no injury of the head is so trivial as to be despised or so
+serious as to be despaired of." Injuries at first sight apparently
+slight may prove fatal from hæmorrhage or infection; on the other
+hand, recovery has followed injuries of great severity--for example,
+the famous "American crowbar case," in which a bar of iron three and a
+half feet long and one and a half inches thick passed through the
+head, and yet the patient recovered.
+
+It is convenient to consider the injuries of the brain before those of
+the skull.
+
+
+TRAUMATIC LESIONS OF THE BRAIN
+
+It is probable that in all cases of injury to the head in which a
+patient loses consciousness, there is some definite damage to the
+cerebral tissue. This takes the form of a greater or less degree of
+contusion or laceration, and the lesions are usually most severe and
+dangerous when the skull is fractured and fragments are driven in upon
+the brain, but they may exist--indeed they may be very extensive--in
+the absence of fracture.
+
+Several degrees are recognised.
+
+(1) Numerous minute _petechial hæmorrhages_ may be found widely
+scattered throughout the brain substance, as a result of a diffused
+blow on the head, which has shaken up the brain and caused symptoms of
+cerebral shock or "concussion." We have found, on microscopic
+examination in such cases, in addition to these small extravasations,
+collections of colloid bodies, patches of miliary sclerosis, and
+chromatolysis and vacuolation of nerve-cells.[3]
+
+[3] Miles, _Laboratory Reports, Royal College of Physicians,
+Edinburgh_, vol. iv.
+
+(2) In more severe cases there are often several _visible areas of
+extravasation_, most commonly in the grey matter of the cortex (Fig.
+184). These foci vary in size from a split-pea to a hazel-nut, and
+consist of a dark central zone of extravasated blood, surrounded by an
+area of "red softening" of the brain matter, beyond which are numerous
+minute capillary hæmorrhages. These intra-cerebral lesions may be
+accompanied by an effusion of blood into the meshes of the
+arachno-pial membrane, and they may occur either at the part of the
+head struck, or at the opposite pole of the axis of percussion--the
+so-called point of _contre-coup_. The symptoms vary with the size and
+site of the extravasations. It is probable that the phenomena of
+"cerebral irritation" are to be explained by the occurrence of such
+hæmorrhages widely scattered through the cerebral cortex. Effusions
+into the cortical motor areas give rise to irritation or paralysis of
+the muscles governed by the affected centres. Different forms of
+aphasia and interference with vision or with hearing follow
+implication of the centres governing these functions. In the
+pre-frontal and in the lower temporal convolutions no special symptoms
+seem to follow. When the hæmorrhages are extensive and numerous,
+symptoms of compression may ensue, and these are aggravated when
+oedema of the brain is superadded.
+
+Localised hæmorrhages also occur, although less frequently, in the
+crura cerebri, the pons, the floor of the fourth ventricle, and the
+cerebellum. In these situations they usually prove fatal by causing
+rapidly advancing coma and interference with the respiratory and
+cardiac centres. The temperature immediately rises to 106° or even
+108° F., and a modified form of Cheyne-Stokes respiration is present.
+
+(3) Still more gross lesions, in the form of distinct _lacerations_,
+are comparatively common at the tips of the frontal, temporal, and
+occipital lobes, on the surface of the cerebellum, and at the base of
+the brain. These are usually associated with symptoms of compression
+in its most typical form, and as a rule prove fatal. The grey matter
+is torn, and extensive effusion of blood takes place into the brain
+substance, and on the surface, filling up the sulci, and distending
+the arachno-pial space (Fig. 184). In a compound fracture, brain
+matter may be extruded through the opening in the skull.
+
+(4) The extravasated blood may burst _into the lateral ventricles_,
+in which case the pulse becomes small and rapid--130, 160, or even
+170. The respiration also is rapid--45 to 60--and greatly embarrassed,
+and the temperature suddenly rises to 103° or 104° F., and continues
+to rise till death ensues.
+
+(5) _Traumatic Oedema._--It is not uncommon for a diffuse oedematous
+infiltration of the brain substance or of the arachno-pial membrane to
+take place in the vicinity of the injured portion of brain. This
+serous exude, on account of the natural adhesions of the arachno-pia,
+usually remains limited to the damaged area, but it may become
+generalised.
+
+_Mechanism._--The explanation of these widespread hæmorrhages is to be
+found, according to Duret, in the disturbance of the cerebro-spinal
+fluid which accompanies a severe blow on the head. This fluid not only
+surrounds the brain, but it also fills the ventricles, and permeates
+its substance in every direction in the peri-vascular and
+perilymphatic spaces. As the brain tissue is incompressible, if an
+area of the skull is momentarily depressed by a localised blow, space
+is provided for it by displacement of a quantity of cerebro-spinal
+fluid, which sets up a fluid wave, and this by hydrostatic pressure
+increases the tension of the fluid throughout the entire brain.
+Vessels may be lacerated at any point, either by the flow of this wave
+or during the ebb which follows the recoil. Hence it is that the
+lesion is not always at the seat of impact, but may be at the opposite
+side of the skull or at other remote points.
+
+[Illustration: FIG. 184.--Contusion and Laceration of Brain. Note
+limited lesion at point of impact on left side, and more extensive
+damage at point of _contre-coup_ on right.
+
+(After Sir Jonathan Hutchinson.)]
+
+_Repair._--As the disintegrated brain matter is replaced by
+cicatricial tissue, neither the nerve cells nor the fibres being
+regenerated, the loss of function of the parts destroyed is usually
+permanent. A localised extravasation of blood may become encapsulated,
+and constitute a "hæmorrhagic cyst." We have experimentally confirmed
+Duret's observations and agree with his conclusions.
+
+
+CLINICAL MANIFESTATIONS OF INJURIES TO THE BRAIN
+
+For convenience, the clinical manifestations of cerebral injury are
+usually described under the terms "concussion," "cerebral irritation,"
+and "compression," but no precise pathological significance attaches
+to these terms, they are essentially clinical. As the conditions so
+described do not occur as independent entities and may overlap or
+merge into one another their differentiation is more or less
+arbitrary, and cases are frequently met with that do not run the
+course characteristic of any of these groups.
+
+#Concussion of the Brain or Cerebral Shock.#--The symptoms associated
+with concussion of the brain are to all intents and purposes those of
+surgical shock (Volume I., p. 250), the activity of the vital centres
+being disturbed by violence acting directly upon the brain tissue
+instead of by impulses transmitted to it by way of the afferent
+nerves. Various theories have been put forward to account for the
+depression of the vital functions in concussion. According to Duret,
+with whose views we agree, the wave of cerebro-spinal fluid set in
+motion by the impact of the blow on the skull, passes, both in the
+ventricles and in the sub-arachnoid space, towards the base, where it
+impinges upon the pons and medulla, stimulating the restiform bodies
+and so inducing a fall in the blood pressure and a profound anæmia of
+the brain. The disturbance of the cerebro-spinal fluid may at the same
+time produce the microscopic lesions in the brain tissues described on
+p. 341.
+
+The symptoms of shock may be the only evidence of injury, or they may
+be superadded to those of fracture of the skull, or laceration of the
+brain.
+
+The _clinical features_ vary according to the severity of the
+violence. In the slightest cases the patient does not lose
+consciousness, but merely feels giddy, faint, and dazed for a few
+seconds. His mind is confused, but he rapidly recovers, and, perhaps
+after vomiting, feels quite well again, save for a slight shakiness in
+his limbs.
+
+In more severe cases, immediately on receiving the blow the patient
+falls to the ground unconscious. Sometimes he suffers from a general
+tetanic seizure associated with arrest of respiration, which is
+usually of short duration and is frequently overlooked, but may prove
+fatal. The pulse is slow, small, and feeble, and is sometimes
+irregular in force and frequency. The respirations are short, shallow,
+slow, and frequently sighing in character. The temperature falls to
+97° F., or even lower. The skin is cold and pallid and covered with
+clammy sweat, and the features are pinched and pale.
+
+In uncomplicated cases the pupils are usually equal, moderately
+dilated, and react sluggishly to light. The patient can be partially
+roused by shouting or by other forms of external stimulation, but he
+soon subsides again into a lethargic condition. Although voluntary
+movement and the deep reflexes are abolished, there is no true
+muscular paralysis.
+
+After a period, varying from a few minutes to several hours, he
+rallies, the first evidence often being vomiting, which is usually
+repeated. Sometimes reaction is ushered in by a mild epileptiform
+seizure. He then turns on his side, the face becomes flushed, and
+gradually the symptoms pass off and consciousness returns. The
+temperature rises to 99° or 100° F., and in some cases remains
+elevated for a few days. In most cases it falls again to 97° or 97.5°,
+and remains persistently subnormal for one or two weeks. During
+reaction the pulse becomes quick and bounding, but after a few hours
+it again becomes slow, and usually remains abnormally slow (40 to 60)
+for ten or fourteen days. There is sometimes a tendency to
+constipation, and for the bladder to become distended, although he has
+no difficulty in passing water. Very commonly the patient complains of
+pain in the head for some days after the return of consciousness.
+Children often sleep a great deal during the first few days, but
+sometimes they are very fretful.
+
+In cases complicated by gross brain lesions the symptoms of concussion
+may imperceptibly merge into those of compression or there may be a
+"lucid interval" of some hours duration.
+
+_After-Effects of Concussion._--The majority of patients recover
+completely. A number complain for a time of headache, languor,
+muscular weakness, and incapacity for sustained effort--_traumatic
+neurasthenia_. Sometimes there is a condition of mental instability,
+the patient is easily excited, and is unduly affected by alcohol or
+other stimulants. Occasionally there is permanent mental impairment.
+It is not uncommon to find that the patient has entirely forgotten the
+circumstances of the injury and of the events which immediately
+preceded it. In some instances the memory is permanently impaired. On
+the other hand, it has occurred that a patient, after concussion, has
+recovered his memory of a foreign language long since forgotten.
+
+As it is never possible to determine the precise extent of the damage
+to the brain, the immediate prognosis, even in the mildest cases of
+concussion, should always be guarded. If the patient has been actually
+unconscious, the condition should be looked upon as a serious one, and
+treated accordingly.
+
+_Treatment._--The immediate treatment is the same as that of shock.
+Absolute rest and quietness are called for. When the symptoms begin to
+pass off, the head should be raised on pillows to prevent congestion
+and to diminish the risk of bleeding from damaged blood vessels in the
+brain. The value of applying an ice-bag or Leiter's tubes with a view
+to arresting hæmorrhage inside the skull, is more than doubtful.
+Lumbar puncture, venesection, or the application of leeches over the
+temple or behind the ear may be employed with benefit. The use of
+small doses of atropin and ergotin was recommended by von Bergmann.
+The bowels should be thoroughly opened by calomel, croton oil, or
+Henry's solution, and a light milk diet given. The patient is kept in
+a shaded room, and should be confined to bed for from fourteen to
+twenty-one days. It is often difficult to convince the patient of the
+necessity for such prolonged confinement, but the responsibility for
+curtailing it must rest upon him or his friends. Reading,
+conversation, and argument must be avoided to ensure absolute rest to
+the brain.
+
+#Cerebral Irritation.#--In some cases of injury to the
+head--particularly of the anterior part and the parietal region--as
+the symptoms of concussion are passing off, the patient begins to
+exhibit a peculiar train of symptoms, which was graphically described
+by Erichsen under the name of cerebral irritation. "The attitude of
+the patient is peculiar, and most characteristic: he lies on one side
+and is curled up in a state of general flexion. The body is bent
+forwards and the knees are drawn up on the abdomen, the legs bent, the
+arms flexed, and the hands drawn in. He does not lie motionless, but
+is restless, and often, when irritated, tosses himself about. But,
+however restless he may be, he never stretches himself out nor assumes
+the supine position, but invariably maintains an attitude of flexion.
+The eyelids are firmly closed, and he resists violently every effort
+made to open them; if this be effected, the pupils will be found to be
+contracted. The surface is pale and cool, or even cold. The pulse is
+small, feeble, and slow, seldom above 70. The sphincters are not
+usually affected, and the patient will pass urine when the bladder
+requires to be emptied; there may, however, though rarely, be
+retention.
+
+"The mental state is equally peculiar. Irritability of mind is the
+prevailing characteristic. The patient is unconscious, takes no heed
+of what passes, unless called to in a loud tone of voice, when he
+shows signs of irritability of temper or frowns, turns away hastily,
+mutters indistinctly, and grinds his teeth. It appears as if the
+temper, as much as or more than the intellect, were affected in this
+condition. He sleeps without stertor.
+
+"After a period varying from one to three weeks, the pulse improves in
+tone, the temperature of the body increases, the tendency to flexion
+subsides, and the patient lies stretched out. Irritability gives place
+to fatuity; there is less manifestation of temper, but more weakness
+of mind. Recovery is slow, but though delayed, may at length be
+perfect...."
+
+The _treatment_ consists in keeping the patient quiet, in a darkened
+room, on much the same lines as for concussion.
+
+#Compression of the Brain.#--This term is used clinically to denote
+the train of symptoms which follows a marked increase of the
+intra-cranial tension produced by such causes as hæmorrhage, oedema,
+the accumulation of inflammatory exudate, or the growth of tumours
+within the skull. The only pathological idea the term conveys is that
+there is more inside the skull than it can conveniently hold.
+
+_Clinical Features._--The following description refers to compression
+due to hæmorrhage within the skull as a result of injury. In a
+majority of such cases, the symptoms of compression supervene on those
+of concussion; in certain conditions, notably hæmorrhage from the
+middle meningeal artery, there is an interval, during which the
+patient regains complete consciousness, in others the symptoms of
+concussion gradually and imperceptibly merge into those of
+compression. The rapidity of onset of the symptoms and their course
+and duration vary widely according to the nature and extent of the
+brain lesion. Death may occur in a few hours, or recovery may take
+place after the patient has been unconscious for several weeks.
+
+The first symptoms are of an irritative character--dull pain in the
+head, restlessness, and hyper-sensitiveness to external stimuli. The
+face is suffused, and the pupils at first are usually contracted. The
+temperature falls to 97°, or even to 95° F. Vomiting is not
+infrequent.
+
+As the pressure increases, paralytic symptoms ensue. The patient
+gradually loses consciousness, and passes into a condition of coma.
+The face is cyanosed, and the distension of the veins of the eyelids
+furnishes an index of the severity of the intra-cranial venous stasis
+(Cushing). The pulse becomes slow, full, and bounding. The respiration
+is slow and deep, and eventually stertorous or snoring in character
+from paralysis of the soft palate, and the lips and cheeks are puffed
+out from paralysis of the muscles of these parts. The temperature,
+which at first falls to 97° or even 95° F., in the course of three or
+four hours usually rises (100.5° or 102.5° F.). If the temperature
+reaches 104° F., or higher, the condition usually proves fatal.
+Sometimes it rises as high as 106° or 108° F.--_cerebral hyperpyrexia_
+(Fig. 185). Retention of urine from paralysis of the bladder, and
+involuntary defecation from paralysis of the sphincter ani, are
+common.
+
+[Illustration: FIG. 185.--Two Charts of Pyrexia in Head Injuries.]
+
+During the progress of the symptoms there is frequently evidence of
+direct pressure upon definite cortical centres or cranial nerves,
+giving rise to _focal symptoms_. Particular groups of muscles on the
+side opposite to the lesion may first show spasmodic jerkings or
+spasms (unilateral monospasm), and later the same groups become
+paralysed (monoplegia). The paralysis frequently affects the whole of
+one side of the body (hemiplegia) and the oculo-motor nerve is often
+paralysed at the same time.
+
+The pupils vary so widely in different cases that their condition does
+not form a reliable diagnostic sign. Perhaps it is most common for the
+pupil on the same side as the lesion to be contracted at first and
+later to become fully dilated, while that on the opposite side remains
+moderately dilated. As a rule, they are irresponsive to light.
+Ophthalmoscopic examination shows swelling of the disc, and the
+vessels of the papilla are distended and tortuous.
+
+In cases which go on to a fatal termination, the coma deepens and the
+muscular and sensory paralyses become general and complete. The vital
+centres in the medulla oblongata gradually become involved, and death
+results from paralysis of the respiratory centre. The fatal issue is
+often hastened by the onset of hypostatic pneumonia. Not infrequently
+a modified type of Cheyne-Stokes respiration is observed for some time
+before death ensues.
+
+A similar train of symptoms may ensue in cases of head injury as a
+result of _pyogenic infection_ having given rise to meningitis or
+abscess with accumulation of inflammatory exudate.
+
+_Pathology._--When any addition is made to the bulk of matter inside
+the cranial cavity, room is gained in the first instance by the
+displacement into the vertebral canal of a certain amount of
+cerebro-spinal fluid. The capacity of the spinal sheath, however, is
+limited, and as soon as the tension oversteps a certain point, the
+pressure comes to bear injuriously on the cerebral capillaries,
+disturbing the circulation, and so interfering with the nutrition of
+the brain tissue. As the intra-cranial tension still further
+increases, the pressure gradually comes to affect the cerebral tissue
+itself, and so the extreme symptoms of compression are produced. The
+vagus and vaso-motor centres are irritated, and this causes slowing of
+the pulse, contraction of the small arteries, and increase of the
+arterial tension which tends to maintain an adequate circulation in
+the vital centres in the medulla. The Cheyne-Stokes respiration is due
+to rhythmical variations in the arterial tension: during the period of
+fall the centres become anæmic and the respiration fails; during the
+rise the medulla is again supplied with blood, and breathing is
+resumed (Eyster).
+
+The parts of the brain directly pressed upon become anæmic, while the
+other parts become congested, and the nutrition of the whole brain is
+thus seriously interfered with. Different parts of the brain and cord
+show varying powers of resistance to this circulatory disturbance. The
+cortex is the least resistant part, and next in order follow the
+corona radiata, the grey matter of the spinal cord, the pons, and,
+last, the medulla oblongata. Hence it is that the respiratory and
+cardiac centres hold out longest.
+
+_Depressed Bone as a Cause of Compression._--It is more than doubtful
+whether a depressed portion of bone is of itself capable of inducing
+symptoms of compression of the brain. When such symptoms accompany
+depressed fracture, they are to be attributed either to associated
+hæmorrhage, or to interference with the circulation and consequent
+oedema which the displaced bone produces. Fragments of bone may,
+however, aggravate the symptoms by irritating the cerebral tissue on
+which they impinge.
+
+_Foreign Bodies._--The rôle of foreign bodies, such as bullets, in the
+production of compression symptoms is similar to that of depressed
+bone. That foreign bodies of themselves are not a cause of compression
+seems evident from the fact that it is not uncommon for them to become
+permanently embedded in the brain substance without inducing any
+symptoms. Not only have bullets, the points of sharp instruments, and
+other substances remained embedded in the brain for years without
+doing harm, but in many cases the patients have continued to occupy
+important and responsible positions in life.
+
+_Differential Diagnosis._--It not infrequently happens that a patient
+is found in an insensible condition under circumstances which give no
+clue to the cause of his unconsciousness. He is usually removed to the
+nearest hospital, and the house-surgeon under whose charge he comes
+must exercise the greatest care and discretion in dealing with him. In
+attempting to arrive at the cause of the condition, numerous
+possibilities have to be borne in mind, but it is often impossible to
+make a definite diagnosis. The chief of these causes are trauma,
+apoplexy or cerebral embolism, epileptic coma, alcohol and opium
+poisoning, uræmic and diabetic coma, sunstroke, and exposure to cold.
+The commonest error is to mistake a case of cerebral compression for
+one of drunkenness. It is scarcely necessary to say that a man who
+smells of alcohol is not necessarily intoxicated; the drink may have
+been given with the object of reviving him. It may be that one or
+other of the above-named conditions has caused the patient to fall,
+and in his fall he has incidentally sustained an injury to the head,
+which, however, is in no way responsible for his unconsciousness.
+Whenever there is the least doubt, therefore, the patient should be
+admitted to hospital.
+
+In the first instance, careful search should be made for any sign of
+injury, especially on the head. The discovery of a severe scalp wound
+or of a fracture of the skull, in association with the symptoms of
+concussion or compression, will in most cases raise the presumption
+that the unconsciousness is due to some traumatic intra-cranial
+lesion. Examination of the fluid withdrawn by lumbar puncture may
+furnish useful information (p. 338).
+
+In the absence of evidence of a head injury, the stomach should be
+washed out and its contents examined to see if any narcotic poison is
+present. The urine also should be drawn off and examined for albumin
+and sugar.
+
+In hæmorrhage due to the rupture of diseased cerebral arteries
+(apoplexy), or to embolism, the symptoms are essentially those of
+compression, and, in the absence of a definite history of injury to
+the head, it is seldom possible to arrive at an accurate diagnosis as
+to the cause of the condition. The history that the patient has
+previously had "an apoplectic shock," and the fact that he is up in
+years and shows signs of arterial degeneration and of cardiac
+hypertrophy which would favour such hæmorrhage, are presumptive
+evidence that the lesion is not traumatic.
+
+If a history is forthcoming that the patient is an epileptic, there is
+a strong presumption that the symptoms are those of _epileptic coma_.
+
+In _alcoholic poisoning_ the examination of the stomach contents will
+furnish evidence. The patient is not completely unconscious, nor is he
+paralysed; the pupils are usually contracted, but react; and the
+temperature is often markedly subnormal. Improvement soon takes place
+after the stomach has been emptied.
+
+In _opium poisoning_ the general condition of the patient is much the
+same as in poisoning by alcohol. The pupils, however, are markedly
+contracted, and do not react to light. When the poison has been taken
+in the form of laudanum, this may be recognised by its odour.
+
+In the _coma_ of _uræmia_ or of _diabetes_ there is no true paralysis,
+nor is there stertor. The urine contains albumin or sugar, and there
+may be oedema of the feet and legs.
+
+_Prognosis._--The prognosis depends so much on the nature and extent
+of the injury to the brain that it is impossible to formulate any
+general statements with regard to it. It may be said, however, that
+the symptoms which indicate a bad prognosis are immediate rise of
+temperature, particularly if it goes above 104° F., the early onset of
+muscular rigidity, extreme and persistent contraction of the pupils,
+with loss of the reflex to light, conjugate deviation of the eyes, and
+the early appearance of bed-sores.
+
+In the majority of cases compression ends fatally in from two to seven
+days. On the other hand, recovery may ensue after the stuporous
+condition has lasted for several weeks.
+
+The _treatment_ of compression is considered with the different
+lesions which cause it; the principle in all cases being to remove, if
+possible, the cause of the increased pressure within the skull.
+
+#Traumatic Oedema.#--In practice, cases are frequently met with,
+particularly in children, that do not conform to the classical
+description of either concussion, cerebral irritation, or compression.
+The injury may be followed by a varying degree of concussion which
+soon passes off but leaves the patient in a listless, drowsy state
+that may persist for days or even for weeks. The cerebration is
+disturbed, so that while the patient is not unconscious, he is
+apathetic and has lost his bearings and fails to recognise where or
+with whom he is. He complains of headache, there is tenderness on
+percussion over the skull, the knee jerks are diminished or absent,
+but there is no motor paralysis. In some cases there are localised
+jerkings, in others generalised convulsive attacks during which the
+patient becomes deeply cyanosed. The condition differs from
+compression due to middle meningeal hæmorrhage in that it is less
+severe and is not steadily progressive.
+
+When the symptoms are localised, the condition is probably due to
+oedematous infiltration of the injured portion of brain; when
+generalised, to increased intra-cranial tension from serous effusion
+into the arachno-pial space.
+
+The _treatment_ consists in diminishing the intra-cranial tension by
+purgation, leeches, bleeding, or lumbar puncture, or if life is
+threatened, by opening the skull over the seat of injury, or failing
+evidence of this, by a decompression operation in the temporal region.
+
+
+INTRA-CRANIAL HÆMORRHAGE
+
+Apart from the hæmorrhage that accompanies laceration of brain tissue,
+bleeding may occur inside the skull, either from arteries or from
+veins. The effused blood may collect either between the dura mater and
+the bone (_extra-dural hæmorrhage_), or inside the dura (_intra-dural
+hæmorrhage_).
+
+#Middle Meningeal Hæmorrhage.#--The commonest cause of extra-dural
+hæmorrhage is laceration of the middle meningeal artery. This
+artery--a branch of the internal maxillary--after entering the skull
+through the foramen spinosum, crosses the anterior inferior angle of
+the parietal bone, and divides into an anterior and a posterior branch
+which supply the meninges and calvaria (Fig. 186). Either branch may
+be injured in association with fractures, or from incised, punctured,
+or gun-shot wounds. The vessel may be ruptured without the skull being
+fractured, and sometimes it is the artery on the side opposite to the
+seat of the blow that is torn. The most common situations for rupture
+are at the anterior inferior angle of the parietal bone, in which case
+the anterior branch is torn (90 to 95 per cent.); and on the inner
+aspect of the temporal bone, where the posterior branch is torn (5 to
+10 per cent.).
+
+[Illustration: FIG. 186.--Relations of the Middle Meningeal Artery and
+Lateral Sinus to the surface as indicated by Chiene's Lines.
+
+(After Cunningham.)]
+
+It is probable that the size of the hæmorrhage depends on the nature,
+extent, and severity of the injury to the head. The recoil of the
+skull after the blow separates the dura from the bone, and if the
+meningeal artery is lacerated or punctured, blood is effused into the
+space thus formed (Fig. 187). A localised blow therefore results in a
+small area of separation and a correspondingly small clot; while a
+diffuse blow is followed by more extensive lesions. It is believed
+that, once the dura is partly separated, the force of the blood poured
+out from the lacerated artery is--on the principle of the hydraulic
+press--sufficient to continue the separation.
+
+[Illustration: FIG. 187.--Extra-Dural Clot resulting from hæmorrhage
+from the Middle Meningeal Artery.]
+
+_Clinical Features._--The typical characteristics of middle meningeal
+hæmorrhage are met with only when the bleeding takes place between the
+dura and the bone. Under these conditions the symptoms of concussion
+are usually most prominent at first, and those of compression only
+ensue after a varying interval, during which the patient as a rule
+regains consciousness. In some cases, indeed, he is able to continue
+his work, or to walk home or to hospital, before any evidence of
+intra-cranial mischief manifests itself. This "lucid interval" helps
+to distinguish the symptoms due to middle meningeal hæmorrhage from
+those of laceration of the brain substance, as in the latter the
+symptoms of concussion merge directly into those of compression.
+Lumbar puncture may aid in the differential diagnosis between
+extra-and intra-dural hæmorrhage, as blood is present in the fluid
+withdrawn in the latter, but not in the former.
+
+A few hours after the accident the patient experiences severe pain in
+the head, and he usually vomits repeatedly. For a time he is restless
+and noisy, but gradually becomes drowsy, and the stupor increases
+more or less rapidly until coma supervenes. The pulse usually becomes
+slow and full. The respiration is rapid (30 to 50), and becomes
+greatly embarrassed and stertorous. The temperature progressively
+rises, and before death may reach 106° F., or even higher. Monoplegia,
+usually beginning in the face or arm on the side opposite to the
+lesion, gradually comes on, and is followed by hemiplegia, from
+pressure on the motor areas, underlying the clot. The condition of the
+pupils is so variable as to have no diagnostic value; but if both are
+widely dilated and irresponsive to light, the prognosis is grave.
+Death usually ensues in from twenty-four to forty-eight hours, unless
+the pressure within the skull is relieved by operation; even after
+removal of the clot death may ensue if the brain has been lacerated,
+or if there is hæmorrhage at the base.
+
+When the hæmorrhage takes place from the anterior branch, the clot
+tends to spread towards the base, and may press upon the cavernous
+sinus, causing congestion and protrusion of the eye, with paralysis of
+the oculo-motor nerve and wide dilatation of the pupil.
+
+In some cases of middle meningeal hæmorrhage there is no gross injury
+to the brain; the area underlying the clot is merely compressed and
+emptied of blood, and, on being exposed, the brain is found flattened,
+or even deeply indented by the blood-clot, and it does not pulsate. If
+the clot is removed, the brain may regain its normal contour and its
+pulsation return. The mortality is over 50 per cent.
+
+If the fracture is compound, the blood can escape, and therefore the
+pressure symptoms are less evident or may be entirely absent.
+
+It is a fact of some medico-legal importance that hæmorrhage from the
+middle meningeal may not take place till some days, or even weeks,
+after an injury, which at the time was only attended with symptoms of
+concussion. This condition is known as _traumatic apoplexy_.
+
+_Treatment._--Immediate operation is imperatively called for, not only
+to arrest the hæmorrhage and remove the clot, but also to ward off the
+oedema of the brain, which is often responsible for the fatal issue.
+When there is no external wound, the point at which the skull is to be
+opened is determined by the symptoms; for example, paralysis of the
+arm and face on one side indicates trephining over the centres
+governing these parts on the side opposite to the paralysis.
+
+If the bleeding cannot otherwise be arrested it may be necessary to
+ligate the external carotid artery. It has been suggested by J. B.
+Murphy that, when the patient is seen while the symptoms of
+compression are coming on, instead of trephining, the hæmorrhage from
+the meningeal vessels should be arrested by applying a ligature to the
+external carotid, under local anæsthesia.
+
+Injury to the #internal carotid# artery within the skull may result
+from penetrating wounds, or may be associated with a fracture of the
+base. It is almost invariably fatal. In some cases a communication is
+established between the artery and the cavernous sinus, and an
+arterio-venous aneurysm is thus produced. Ligation of the internal
+carotid in the neck or of the common carotid is the only feasible
+treatment.
+
+Injuries of the #venous sinuses# may occur apart from gross lesions of
+the skull, but as a rule they accompany fractures and penetrating
+wounds. The transverse (lateral), superior sagittal (longitudinal),
+and cavernous sinuses are those most frequently damaged. On account of
+the low pressure in the sinuses, spontaneous arrest of extra-dural
+hæmorrhage usually takes place, and recovery ensues. In some cases,
+however, the amount of blood extravasated is sufficient to cause
+compression. If the dura mater is torn, and the blood passes into the
+sub-arachnoid space, it may spread over the whole surface of the
+brain. Sometimes the bleeding only commences after a depressed
+fracture has been elevated.
+
+In the presence of an open wound, the venous source of the bleeding is
+recognised by the dark colour of the blood and the continuous
+character of the stream. It may be arrested by pressure with gauze
+pads or by packing a strand of catgut into the sinus (Lister), or, if
+this fails, by grasping the sinus with forceps and leaving these in
+position for twenty-four or forty-eight hours. A small puncture in the
+outer wall of the sinus may be closed with sutures. Signs of
+increasing compression call for trephining and opening of the dura if
+this is necessary to admit of the clot being removed.
+
+#Intra-cranial Hæmorrhage in the Newly-Born.#--An extravasation of
+blood into the arachno-pial space frequently occurs during birth. The
+observations of Cushing seem to show that this is usually due to
+tearing of the delicate cerebral veins which pass from the cortex to
+the superior sagittal sinus, from the strain put upon them by the
+overlapping of the parietal bones, in the moulding of the head. It may
+sometimes be due to an excessive degree of asphyxia during birth. The
+extravasation is usually most marked over the central area of the
+cortex near the middle line, and it is often bilateral.
+
+This condition is most frequently met with in a first-born child--and
+more often in boys than in girls--the labour having been prolonged and
+difficult, and the presentation abnormal. There is usually a history
+that the infant was deeply cyanosed when born, and that there was
+difficulty in getting it to breathe. As a rule, there is no external
+evidence of trauma. The anterior fontanelle is tense and does not
+pulsate, the pulse is slow, and for several days the child appears to
+have difficulty in sucking and swallowing, and is abnormally still. In
+the course of a few days definite symptoms of localised pressure
+appear. It is noticed that one leg or arm, or one side of the body is
+not moved, or both sides may be affected; when the paralysis is
+bilateral, the absence of movement is more liable to be overlooked.
+The infant may suffer from convulsions; there may be paralysis of
+certain of the ocular muscles, and inequality of the pupils; sometimes
+there is blindness. Persistent rigidity of the limbs, with turning of
+the thumbs towards the palm, is present in some cases. Lumbar puncture
+may reveal the presence of blood corpuscles in the cerebro-spinal
+fluid, and increase in the tension of the fluid.
+
+If untreated, the condition is usually followed by the development of
+spastic paralysis of one or more limbs, on one or on both sides of the
+body (Little's disease), by blindness, deafness, and varying degrees
+of mental deficiency, or by Jacksonian epilepsy.
+
+_Treatment._--To obviate these after-effects the clot may be removed
+by raising an osteo-plastic flap, including nearly the whole of the
+parietal bone. The operation should be undertaken within the first
+week or two, and great care must be taken to keep up the body-warmth,
+and to prevent undue loss of blood. It may be necessary to operate on
+both sides, an interval being allowed to elapse between the two
+operations.
+
+For the immediate relief of increased intra-cranial tension, the daily
+withdrawal of 10-12 c.c. of cerebro-spinal fluid by lumbar punctures
+may be employed, or a sub-temporal decompression operation may be
+performed.
+
+
+WOUNDS OF THE BRAIN
+
+#Wounds of the Brain.#--_Incised_ wounds of the brain usually result
+from sabre-cuts, hatchet blows, or circular saws. A portion of the
+scalp and cranium may be raised along with a slice of brain matter,
+and in some cases the whole flap is severed. The extent of the injury,
+the conditions under which it is received, and the liability to
+infection, render such wounds extremely dangerous.
+
+_Punctured wounds_ may be inflicted on the vault by stabs with a knife
+or dagger, or by other sharp objects, such as the spike of a railing.
+More frequently a pointed instrument, such as a fencing foil, the end
+of an umbrella, or a knitting needle, is thrust through the orbit into
+the base of the brain. Occasionally the base of the skull has been
+perforated through the roof of the pharynx, for example, by the stem
+of a tobacco-pipe. All such wounds are of necessity compound, and the
+risk of infection is considerable, particularly if the penetrating
+object is broken and a portion remains embedded within the skull. The
+infective complications of such injuries are described later.
+
+_Bullet wounds_ have many features in common with punctured wounds.
+There is more contusion of the brain substance, disintegrated brain
+matter is usually found in the wound of entrance, and the bullet often
+carries in with it pieces of bone, cloth, or wad, thus adding to the
+risk of infection.
+
+Aseptic foreign bodies, especially bullets, may remain embedded in the
+brain without producing symptoms.
+
+The _treatment_ of punctured wounds consists in enlarging the wounds
+in the soft parts, trephining the skull, and removing any foreign body
+that may be in it, purifying the track, and establishing drainage.
+
+
+AFTER-EFFECTS OF HEAD INJURIES
+
+Various after-effects may follow injuries of the head. Thus, for
+example, _chronic interstitial changes_ (sclerosis) may spread from an
+area of cicatrisation in the brain; or _softening_ may ensue, either
+in the form of pale areas of necrosis (white softening) or of
+hæmorrhagic patches (red softening). The symptoms vary with the area
+implicated. _Adhesions_ between the brain and its membranes may
+produce severe headache and attacks of vertigo, especially on the
+patient making sudden exertion.
+
+After a head injury, the patient's whole mental attitude is sometimes
+changed, so that he becomes irritable, unstable, and incapacitated for
+brain-work--_traumatic neurasthenia_. In some cases self-control is
+lost, and alcoholic and drug habits are developed.
+
+#Traumatic epilepsy# may ensue as a result of some circumscribed
+cortical lesion, such as a spicule of bone projecting into the
+cortex, the presence of adhesions between the membranes and the brain,
+a cicatrix in the brain tissue leading to sclerosis or a hæmorrhagic
+cyst in the membranes or cerebral tissue.
+
+The convulsive attacks are of the Jacksonian type, beginning in one
+particular group of muscles and spreading to neighbouring groups till
+all the muscles of the body may be affected. The convulsions may begin
+soon after the injury, for example, when the cause is a fragment of
+bone irritating the cortex; in other cases it may be several years
+before they make their appearance. The onset is usually sudden, and
+the "signal symptom"--for example, jerking of the thumb, conjugate
+deviation of the eyes, or motor aphasia--indicates the seat of the
+lesion. At first the attacks only recur at intervals of, it may be
+weeks or months, but as time goes on they become more and more
+frequent, until there may be as many as forty or fifty in a day.
+Sometimes the patient loses consciousness during the fit; sometimes he
+remains partly conscious. In course of time the same degenerative
+changes as occur in other forms of epilepsy ensue: certain groups of
+muscles may become paralysed; the patient may pass into a state of
+idiocy, or into what is known as the "status epilepticus," in which
+the fits succeed one another without remission, the breathing becomes
+stertorous, the temperature rising, the pulse becoming very rapid;
+finally coma supervenes, and the patient dies.
+
+_Treatment._--The administration of bromides is only palliative.
+Operation is indicated only when the "signal symptom" indicates a
+limited and accessible portion of the brain as the seat of the lesion,
+or when there is a depression of the skull or other definite evidence
+of cranial injury. The more recent the injury the better is the
+prospect, as secondary changes are less likely to have taken place,
+and the peculiarly irritable state of the brain--sometimes referred to
+as the "epileptic habit"--has not developed. The operation consists in
+opening the skull freely, and removing any discoverable cause of
+irritation--depressed bone, thickened and adherent membranes, a cyst,
+or sclerosed patch of cortex; it may be necessary to interpose a layer
+of tissue, a flap of fascia lata, for example, between the bone and
+the cortex of the brain. The point at which the skull is opened is
+determined by the seat of the injury and the focal brain symptoms.
+
+The return of fits within a few days of the operation does not
+necessarily mean failure, as they often pass off again. Complete and
+permanent cure is not common, but the number and severity of the
+attacks are usually so far diminished that life is rendered bearable.
+
+#Traumatic insanity# may follow injury to any part of the brain, and
+it may come on either immediately or after an interval. It may or may
+not be associated with epilepsy. Any form of insanity may occur,
+either as a direct result of the trauma, or from the resistance of the
+brain being lowered by the injury in a patient predisposed to
+insanity. When insanity follows as a direct consequence of injury, the
+organic lesion is usually a superficial one, and the disturbance of
+brain function is generally due to reflex irritation of the dura mater
+(Duret). These facts possibly explain the immediate improvement which
+occasionally follows the opening of the skull at the point of injury
+and removal of the exciting cause. Cases occurring within a few days
+of the injury usually recover within a month or two. The later the
+condition is in developing the less obvious is the relationship
+between the trauma and the insanity, and therefore the worse is the
+prognosis.
+
+_Meningitis_, _sinus thrombosis_, and _cerebral abscess_ may follow
+upon any form of head injury attended with infection. The clinical
+features--save for the history of a trauma--correspond so closely with
+those of the same conditions occurring apart from injury, that they
+are most conveniently considered together (p. 374).
+
+
+
+
+CHAPTER XIII
+
+INJURIES OF THE SKULL
+
+
+Contusions--FRACTURES--Of the vault: _Varieties_--Of the Base:
+ _Anterior fossa_--_Middle fossa_--_Posterior fossa_.
+
+The bones of the skull may be contused or fractured. These injuries
+are not in themselves serious: their clinical importance is derived
+from the injury to the intra-cranial contents with which they are
+liable to be associated.
+
+#Contusion# of the skull may result from a fall, a blow, or a gun-shot
+injury. In the majority of cases the damage to soft parts--scalp,
+meningeal vessels, or brain--overshadows the osseous lesion, which of
+itself is comparatively unimportant.
+
+
+FRACTURES OF THE SKULL
+
+While it is convenient to consider separately fractures of the vault
+and fractures of the base of the skull, it is to be borne in mind that
+it is not uncommon for a fracture to involve both the vault and the
+base. Fractures in either situation may be simple or compound.
+
+
+FRACTURES OF THE VAULT
+
+#Mechanism.#--When the skull is broken by _direct_ violence, the
+fracture takes place at the seat of impact, and its extent varies with
+the nature of the impinging object and the degree of violence exerted.
+If, for example, a pointed instrument, such as a bayonet, a foil, or a
+spike, is forcibly driven against the skull, the weapon simply crashes
+through the bone, disintegrating it at the point of entrance, and
+cracking or splintering it for a variable, but limited, distance
+beyond. On the other hand, when the head is struck by a "blunt"
+object--for example, a batten falling from a height--the force is
+applied over a wider area and the elastic skull bends before it. If
+the limits of its elasticity are not exceeded, the bone recoils into
+its normal position when the force ceases to act; but if the bone is
+bent beyond the point from which it can recoil, a fracture takes
+place--"_fracture by bending_." The bone gives way over a wide area,
+the affected portion may be comminuted, and one or more of the
+fragments may remain depressed below the level of the rest of
+the skull. Cracks and fissures spread widely in different
+directions--often (70 to 75 per cent.) extending into the base. In
+almost all fractures of the vault the inner table splinters over a
+wider area than the outer, partly because it is more brittle and is
+not supported from within, but also because the diffusion of the force
+as it passes inwards affects a wider area. If a bullet traverses the
+cranial cavity the inner table is more widely shattered at the
+aperture of entrance, and the outer table at the aperture of exit. Von
+Bergmann reported thirty cases in which the inner table alone was
+fractured by a blow on the head.
+
+Fractures by _indirect_ violence--that is, fractures in which the bone
+breaks at a point other than the seat of impact--are almost always due
+to violence inflicted with a blunt object, and acting over a wide
+area--such, for example, as when the head strikes the pavement. Much
+discussion has taken place as to the method of their production. It
+has been shown that when the skull is depressed at one point by a
+force impinging on it, it bulges at another, so that its whole contour
+is altered. But the elasticity of the bone varies at different parts
+of the skull, owing to differences in thickness and in structure. If,
+therefore, the part which is depressed--that is, the part directly
+struck--happens to be less elastic than the part which bulges, it
+gives way, and a fracture by "bending" results; but if the bulging
+part is the less elastic, it bursts outwards--_fracture by_
+"_bursting_." The term "fracture by _contre-coup_" has been
+incorrectly applied to such fractures when the area of bulging happens
+to be opposite to the seat of impact. _Contre-coup_, properly
+so-called, is only possible in a perfectly spherical body, which, of
+course, the skull is not.
+
+When a high-velocity bullet penetrates the head, it exerts on the
+incompressible, semi-fluid brain an explosive (hydro-dynamic) force,
+which is transmitted to all points on the inner surface of the skull
+and leads to shattering of the bone.
+
+_Repair._--The repair of fractures of the skull is usually attended
+with an exceedingly small amount of callus. Except in the presence of
+infection, separated fragments live and become reunited, but they may
+unite in such a manner as to project towards the brain and, by
+irritating the cortical centres, cause traumatic epilepsy. In
+comminuted fractures, the lines of fracture remain permanently visible
+on the bone, but fissured fractures may leave no trace. Gaps left in
+the skull by injury or operation are, after a time, filled in by a
+fibrous membrane, which may undergo ossification from the periphery
+towards the centre, but unless the aperture is a small one it is
+seldom completely closed by bone. The new bone which forms is derived
+from the old bone at the margins of the opening. Permanent defects in
+the skull are chiefly injurious if they are accompanied by lesions of
+the underlying dura, such as adhesions to the brain; large gaps may
+cause giddiness on stooping, or on forcible expiration, as in blowing
+the nose or playing a wind instrument.
+
+#Varieties.#--For descriptive purposes, fractures of the vault are
+divided into the fissured, the punctured, the depressed, and the
+comminuted varieties. Clinically, however, these varieties are often
+combined. The practical importance of a given fracture depends upon
+whether it is simple or compound, rather than upon the exact nature of
+the damage done to the bone. Compound fractures which open the dura
+mater are the most serious. Simple fractures result, as a rule, from
+diffuse forms of violence, and are liable to spread far beyond the
+seat of impact. Compound fractures result from severe and localised
+violence--for example, the kick of a horse or the blow of a
+hammer--and tend to be limited more or less to the seat of impact. In
+gun-shot injuries, however, there are usually numerous fissures
+radiating from the point at which the missile enters the skull.
+
+#Fissured fractures# generally result from blows by blunt objects or
+from falls, and they usually extend far beyond the area struck, in
+most cases passing into the base. The fissure may pass through the
+bone vertically or obliquely, and it may implicate one or both tables.
+So long as the fracture is simple, it can scarcely be diagnosed except
+by inference from the associated symptoms of meningeal or cerebral
+injury. When compound, the crack in the bone can be seen and felt. It
+is recognised by the eye as a split in the bone, filled with red
+blood, which, as often as it is sponged away, oozes again into the
+gap. In fractures by bursting a tuft of hair may be caught between the
+edges of the fracture, and this adds to the difficulty of purifying
+the wound.
+
+_Diagnosis._--A normal suture may be mistaken for a fissured fracture.
+A suture, however, may generally be recognised by its position, the
+irregularity of its margins, and the absence of blood between its
+edges. At the same time, it is not uncommon, especially in children,
+for a suture to be sprung by violence applied to the head, or for a
+fissured fracture to enter a suture and, after running in it for some
+distance, to leave it again. The edges of a clean cut in the
+periosteum may be mistaken for a fissure in the bone, especially if
+reliance is placed on the probe for diagnosis. This error can be
+avoided by raising the edge of the periosteum from the bone, with the
+gloved finger. On combined auscultation and percussion a peculiar
+"hollow-cask" sound may be detected in some cases of fissured fracture
+of the vault.
+
+Fissured fractures as such call for no _treatment_. When compound, the
+wound must be disinfected; and intra-cranial complications, such as
+meningeal hæmorrhage, laceration of the brain, or infection, are to be
+treated on the lines already described.
+
+#Punctured fractures# are of necessity compound, and on account of the
+risks of infection are to be looked upon as serious injuries. They
+result from the localised impact of a sharp, and usually infected
+object the point of which is not infrequently left either in the bone
+or inside the skull. Fragments of bone are often driven into the
+brain, and short fissures frequently pass in various directions from
+the central aperture.
+
+_Diagnosis._--When the instrument impinges on the head obliquely,
+after piercing the scalp it may pass for some distance under it before
+perforating the skull, so that on its withdrawal a valvular wound is
+left, and at first sight it appears that only the scalp is involved.
+Sometimes a foreign body left in the gap so fills it up that it is
+difficult to detect the fracture with a probe or even with the finger.
+In all doubtful cases the scalp wound should be sufficiently enlarged
+to exclude such errors. We have known of a case of a man who died of
+meningitis resulting from a punctured fracture of the vault caused by
+the spoke of an umbrella, the fracture having escaped recognition
+until the meningeal symptoms developed.
+
+_Treatment._--The scalp wound must be purified, being opened up as far
+as necessary for this purpose. The infected portion of bone should be
+removed to render possible the purification of the membranes and
+brain, and to permit of drainage.
+
+#Depressed and Comminuted Fractures.#--As these varieties almost
+always occur in combination, they are best considered together. The
+terms "indentation fracture," "gutter fracture," "pond fracture," have
+been applied to different forms of depressed fracture, according to
+the degree of damage to the bone and the disposition of the fragments
+(Figs. 188, 189, 190). These fractures may be simple or compound.
+
+[Illustration: FIG. 188.--Depressed Fracture of Frontal
+Bones--involving the air sinus on both sides--with a fissured fracture
+radiating from it.
+
+(From Professor Harvey Littlejohn's collection.)]
+
+[Illustration: FIG. 189.--Depressed and Comminuted Fracture of Right
+Parietal Bone: Pond Fracture. The patient sustained the injury twenty
+years before death.]
+
+[Illustration: FIG. 190.--Pond Fracture of Left Frontal Bone, produced
+during delivery.
+
+(From a photograph lent by Mr. J. H. Nicoll.)]
+
+As a rule the whole thickness of the skull is broken, and, as usual,
+the inner table suffers most. In infants the bones may be merely
+indented, the fracture being of the greenstick variety. All degrees of
+severity are met with, from a simple, localised indentation of the
+bone, to complete smashing of the skull into fragments.
+
+_Diagnosis._--When compound, the nature of these fractures is readily
+recognised on exploring the wound, but their extent is not always easy
+to determine, and it is not uncommon for extensive fissures to pass
+into the base.
+
+A hæmatoma of the scalp may readily be mistaken for a depressed
+fracture. The condensation of the tissues round the seat of impact and
+the soft coagulum in the centre, closely simulate a depression in the
+bone; but if firm pressure is made with the finger, the irregular edge
+of the bone can be recognised, and the depressed portion is felt to be
+on a lower level. On the other hand, a depression in the bone is
+sometimes obscured by an overlying hæmatoma, and unless great care is
+taken the fracture may be overlooked.
+
+_Treatment._--All are agreed that compound depressed and comminuted
+fractures--whether associated with cerebral symptoms or not--should
+be operated on to enable the wound to be purified, and the normal
+outline of the skull to be restored by elevating or removing depressed
+or separated fragments. Except in young children, in whom considerable
+degrees of depression are frequently righted by nature, most surgeons
+recommend operative interference even in simple fractures with the
+object of elevating the depressed bone, and to anticipate subsequent
+complications such as persistent headache, attacks of giddiness,
+traumatic epilepsy, or insanity. Others, including von Bergmann and
+Tilmanns, consider that the risk of such sequelæ ensuing is not
+sufficient to justify a prophylactic operation of such severity as
+trephining.
+
+The operation is described in _Operative Surgery_, p. 93.
+
+
+FRACTURES OF THE BASE
+
+The base of the skull may be fractured by a pointed object, such as a
+fencing foil, a knitting pin, or the end of an umbrella, being forced
+through the orbit, the nasal cavities, or the pharynx. These injuries
+will be referred to in describing fractures of the anterior fossa.
+
+The majority of basal fractures result from such accidents as a fall
+from a height, the patient landing on the vertex or on the side of the
+head, or from a heavy object falling on the head. The violence is
+therefore indirect in so far as the bone breaks at a point other than
+the seat of impact.
+
+In other cases the base is broken by the patient falling from a height
+and landing on his feet or buttocks, the force being transmitted
+through the spine to the occiput, and the bone giving way around the
+foramen magnum. Sometimes the condyle of the lower jaw is driven
+through the base of the skull by a blow or fall on the chin, and
+fissures radiate into the base from the glenoid cavity. It is usual to
+describe these also as fractures by indirect violence, but as the
+skull gives way at the point where it is struck, these are really
+fractures by direct violence. Von Bergmann, Bruns, and Messerer have
+done much to elucidate the mechanism of basal fractures.
+
+In the consideration of the mode of production of basal fractures by
+indirect violence, the irregular shape of the cavity, the varying
+strength and thickness of its different parts, and the existence of
+the foramina through the bone are to be borne in mind. The force
+acting on the skull tends to increase one diameter of the cavity, and
+to diminish the opposite diameter. The resulting fracture, therefore,
+is due to bursting of the skull, and tends to take place at the part
+which has least elasticity--that is, at the base. It has been found
+that the site and direction of basal fractures bear a fairly constant
+relation to the direction of the force by which they are produced.
+When, for example, the skull is compressed from side to side, the line
+of fracture through the base is usually transverse, and it may
+implicate one or both sides (Fig. 191). On the other hand, when the
+pressure is antero-posterior, the fracture tends to be longitudinal;
+and when oblique, it tends to be diagonal.
+
+[Illustration: FIG. 191.--Transverse Fracture through Middle Fossa of
+Base of Skull.]
+
+Fractures of the base usually take the form of a single fissure, or a
+series of fissures, which, as a rule, run through the foramina in
+their track. Small portions of bone are sometimes completely
+separated. It is common for a fissure through the base to be
+continued for a considerable distance on to the vault.
+
+The fracture may involve only one fossa, but as a rule fissures
+radiate into two or all of them. Fractures of the anterior and middle
+fossæ are usually rendered compound by tearing of the mucous membrane
+of the nose, the pharynx, or the ear.
+
+Basal fractures are frequently associated with contusion and
+laceration of the brain, and also with injuries of one or more of the
+cranial nerves.
+
+#Fracture of the anterior fossa# may result from a blow on the
+forehead, nose, or face; or from a punctured wound of the orbit or of
+the nasal cavity. Often the injury is at first considered trivial, and
+it is only when infective complications, in the form of meningitis or
+cerebral abscess, develop, that its true nature is suspected. This
+fossa may also be implicated in fractures of the vault, fissures
+extending from the vertex to the orbital plate of the frontal bone, or
+to the lesser wing of the sphenoid.
+
+_Clinical Features._--Unless the fracture is compound through opening
+into the nose or pharynx, there are few symptoms by which it can be
+recognised. When compound, there may be bleeding from the pharynx or
+nose from tearing of the periosteum and mucous membrane related to the
+basi-sphenoid and ethmoid respectively. When the hæmorrhage is
+profuse, it is probable that the meningeal vessels or even the venous
+sinuses have been torn. Cerebro-spinal fluid may escape along with the
+blood, but it is seldom possible to recognise it. If the flow is long
+continued, the patient may be conscious of a persistent salt taste in
+the mouth, due to the large proportion of sodium chloride which the
+fluid contains. In very severe injuries, brain matter may escape
+through the nose or mouth.
+
+Fracture of the anterior fossa is often accompanied by extravasation
+of blood into the orbit, pushing forward the eyeball and infiltrating
+the conjunctiva (_sub-conjunctival ecchymosis_). This occurs
+especially when the orbital plate of the frontal bone is implicated.
+The blood which infiltrates the conjunctiva passes from behind
+forwards, appearing first at the outer angle of the eye and spreading
+like a fan towards the cornea. Later it spreads into the upper eyelid.
+When the orbital ridge is chipped off, without the cavity of the skull
+being opened into, the hæmorrhage shows at once both under the
+conjunctiva and in the upper lid. If the frontal sinus is opened, air
+may infiltrate the scalp.
+
+The olfactory, optic, oculo-motor, pathetic, ophthalmic division of
+the trigeminal, and the abducens nerves are all liable to be
+implicated.
+
+_Diagnosis._--It is scarcely necessary to state that bleeding from the
+nose or mouth may occur after a blow on the face without the
+occurrence of a fracture of the skull. It is only when it is long
+continued and profuse that the bleeding suggests a fracture. Similarly
+effusion of blood in the region of the orbit may be due to a simple
+contusion of the soft parts ("black eye"), or to gravitation of blood
+from the forehead or temple. Sub-conjunctival ecchymosis also may
+occur independently of a fracture implicating the anterior fossa--for
+example, in association with an ordinary black eye, or with fracture
+of the orbital ridge or of the zygomatic (malar) bone.
+
+Finally, paralysis of the cranial nerves may result from pressure of
+blood-clot, or from the nerves being torn without the skull being
+fractured.
+
+#Fracture of the middle fossa# is usually the result of severe
+violence applied to the vault, as, for example, when a man falls from
+a height, or is thrown from a horse and lands on his head.
+
+_Clinical features._--The most conclusive sign of fracture of the
+middle fossa is the escape of dark-coloured blood in a steady stream
+from the ear, followed by oozing of cerebro-spinal fluid. The bleeding
+from the ear may go on for days, the blood gradually becoming lighter
+in colour from admixture with cerebro-spinal fluid. Finally the blood
+ceases, but the clear fluid continues to drain away, sometimes for
+weeks, and in such quantity as to soak the dressings and the pillow.
+In our experience, the escape of cerebro-spinal fluid is much less
+common than is generally supposed. In most cases, on examining the ear
+with a speculum, the tympanic membrane is found to be ruptured; when
+it is intact, the blood and cerebro-spinal fluid may pass down the
+Eustachian tube into the pharynx. The escape of brain matter from the
+ear is exceedingly rare. Emphysema of the scalp sometimes results when
+the fracture passes through the mastoid cells. The facial and acoustic
+nerves and the maxillary and mandibular divisions of the trigeminal
+are frequently implicated. Deafness is a serious and not uncommon
+accompaniment of fracture of the middle fossa, as the fracture
+involves the labyrinth and is attended with hæmorrhage and the
+formation of new bone.
+
+_Diagnosis._--Care must be taken not to mistake blood which has passed
+into the ear from a scalp wound, or which has its origin in a
+fracture of the wall of the external auditory meatus or a laceration
+of the tympanic membrane, for blood escaping from a fracture of the
+base. Under these conditions the blood is usually bright red, is not
+accompanied by cerebro-spinal fluid, and the flow soon stops. It is on
+record[4] that blood and cerebro-spinal fluid may escape along the
+sheath of the acoustic nerve without the bone being broken.
+
+[4] Miles, _Edinburgh Medical Journal_, 1895.
+
+#Fracture of the posterior fossa# is produced by the same forms of
+violence as cause fracture of the middle fossa; it is specially liable
+to result if the patient falls on the feet or buttocks.
+
+_Clinical Features._--Sometimes a comparatively limited fracture of
+the occipital bone results, and in the course of a few days blood
+infiltrates the scalp in the region of the occiput and mastoid, or may
+pass down in the deeper planes of the neck. As a rule, however, there
+is no immediate external evidence of fracture. The patient is
+generally unconscious, and shows signs of injury to the pons and
+medulla, causing interference with respiration, which soon proves
+fatal. The rapidly fatal issue of these cases usually prevents the
+manifestation of any injury to the posterior cranial nerves.
+
+_Diagnosis of Basal Fractures._--In the diagnosis of fractures of the
+base, reliance is to be placed chiefly upon: (1) the nature of the
+injury; (2) the diffuse character of the cerebral symptoms; (3) the
+evidence of injury to individual cranial nerves; (4) the occurrence of
+persistent bleeding from the nose, mouth, or ear; (5) the
+extravasation of blood under the conjunctiva or behind the mastoid
+process; and (6) the presence of blood in the cerebro-spinal fluid
+withdrawn by lumbar puncture. In rare cases the diagnosis is made
+certain by the escape of cerebro-fluid or of brain matter from the
+nose, mouth, or ear.
+
+It must be admitted, however, that in a large proportion of cases
+which end in recovery, the diagnosis of fracture of the base is little
+more than a conjecture. The external evidence of damage to the bone is
+so slight and so liable to be misleading, that little reliance can be
+placed upon it. The associated cerebral and nervous symptoms also are
+only presumptive evidence of fracture of the bone. In all cases,
+however, in which there is reason to suspect that the base is
+fractured, the patient should be treated on this assumption. It is
+often found that, when there are no cerebral symptoms present, it is
+difficult to convince the patient of the necessity for undergoing
+treatment, and of the risk involved in his leaving his bed and
+resuming work.
+
+_Prognosis in Basal Fractures._--The prognosis depends upon the
+severity of the cerebral lesions, and on the occurrence of traumatic
+oedema or infective intra-cranial complications. Many cases prove
+fatal within a few hours from the associated injury to the brain, the
+patient dying from cerebral compression due to hæmorrhage. If the
+patient survives two days, the prognosis is more hopeful (Wagner). It
+is possible that the free escape of blood from the nose or ear may in
+some cases prevent compression, and to a certain extent render the
+prognosis more favourable. Punctured fractures are frequently fatal
+from infective complications--meningitis, sinus thrombosis, and
+cerebral abscess. These complications are also liable to occur in
+fractures rendered compound by opening into the nose, pharynx, or ear,
+but they are less common than might be expected.
+
+_Treatment._--The general treatment includes that for all head
+injuries. In a number of cases attended with symptoms of compression,
+benefit has followed the relief of intra-cranial tension by a
+decompression operation. The withdrawal of 30 or 40 c.c. of
+cerebro-spinal fluid by lumbar puncture has also proved beneficial in
+the same way; Quenú strongly recommends repeated puncture in serious
+cases. In a few cases this procedure has been followed by sudden
+death.
+
+Steps must be taken to prevent infection from the mucous surfaces
+implicated. This is exceedingly difficult in fractures opening into
+the pharynx and nose. Owing to the general condition of the patient,
+it is usually impossible to employ nasal douching or mouth washes, but
+spraying the cavities with peroxide of hydrogen or other antiseptics
+may be employed with benefit. In fractures of the middle fossa, the
+ear should be gently sponged out and the meatus plugged with gauze,
+retained in position by adhesive plaster or a bandage. When there is a
+persistent escape of blood or cerebro-spinal fluid, the dressing
+requires to be changed frequently.
+
+In compound fractures of the anterior fossa due to perforation through
+the orbit, the frontal bone should be trephined to admit of the
+removal of loose fragments or of any foreign body that may have
+entered the skull and to provide for drainage.
+
+
+
+
+CHAPTER XIV
+
+DISEASES OF THE BRAIN AND MEMBRANES
+
+
+Pyogenic diseases--Meningitis: _Varieties_--Abscess:
+ _Varieties_--Sinus phlebitis--Intra-cranial tuberculosis.
+ Cephaloceles--_Meningocele_--_Encephalocele_--
+ _Hydrencephalocele_--Traumatic cephal-hydrocele--Hydrocephalus;
+ _Varieties_--Micrencephaly. Cerebral tumours. Tumours of the
+ pituitary body. Epilepsy--Hernia cerebri. Surgical affections of
+ cranial nerves--Cervical sympathetic.
+
+
+PYOGENIC DISEASES
+
+The most important intra-cranial conditions that result from infection
+with pyogenic bacteria are: meningitis, abscess of the brain, and
+phlebitis of the venous sinuses.
+
+The organisms most frequently associated with these conditions are the
+staphylococcus aureus and the streptococcus, but it is not uncommon
+to meet with mixed infections in which other bacteria are
+present--particularly the pneumococcus, the bacillus foetidus, the
+bacillus coli, the bacillus pyocyaneus, and the diplococcus
+intracellularis.
+
+By far the most common source of intra-cranial infection is chronic
+suppuration of the middle ear and mastoid antrum, the organisms
+passing from these cavities to the interior of the skull directly
+through a perforation of the tegmen tympani or of the wall of the
+sigmoid groove, or being carried in the blood stream by the emissary
+veins. In some cases the infection travels along the sheaths of the
+facial and acoustic nerves.
+
+Less frequently infective conditions of the nasal cavity and its
+accessory air sinuses, and compound fractures of the skull,
+particularly punctured fractures, are followed by intra-cranial
+complications; or infection is conveyed to the inside of the skull, by
+way of the emissary veins, from wounds of the scalp, or from such
+conditions as erysipelas of the face and scalp, malignant pustule,
+carbuncles, or boils.
+
+At the bedside there is often difficulty in discriminating between the
+various pyogenic intra-cranial complications, because many of the
+symptoms are common to all the members of this group, and because
+more than one condition is frequently present. Thus a localised
+meningitis spreading to the brain may set up a cerebral abscess; a
+sinus phlebitis may give rise to a purulent lepto-meningitis; or a
+cerebral abscess bursting into the sub-arachnoid space may produce
+meningitis.
+
+
+MENINGITIS
+
+#Pachymeningitis.#--This term is applied when the infection involves
+the dura mater--a condition which is usually due to the spread of
+infection from a localised osseous lesion, such as erosion of the
+tegmen tympani in chronic suppuration of the middle ear, of the wall
+of the sigmoid groove in mastoid disease, or of the posterior wall of
+the frontal sinus in suppuration of that cavity. It also occurs in
+relation to septic lesions of the cranial bones such as a broken-down
+gumma, after operations on the cranial bones, and in cases of compound
+fracture attended with a mild degree of infection and with imperfect
+drainage. In contusion of the skull without an external wound, the
+infection may take place through the blood stream.
+
+The layer of the dura in contact with the affected portion of
+bone is inflamed, thickened, and covered with a layer of
+granulations--_external pachymeningitis_--and between it and the bone
+there is an effusion of fluid. Up to this point the process is largely
+protective in its effects, and gives rise to no symptoms, beyond
+perhaps some pain in the head.
+
+In the majority of cases, however, suppuration occurs between the dura
+and the bone--_suppurative pachymeningitis_--and leads to the
+formation of an _extra-dural abscess_ (Fig. 192). When this happens
+in association with disease in the middle ear or frontal sinus, it is
+attended with severe headache referred to the seat of the abscess, a
+sudden rise of temperature preceded by shivering, and other evidence
+of the absorption of toxins. Over the situation of the abscess, the
+scalp becomes swollen and oedematous--a condition which Percival Pott,
+in 1760, first observed to be characteristic of extra-dural
+suppuration, hence the name, _Pott's puffy tumour_, applied to it
+(Fig. 193). Under these circumstances the abscess is seldom of
+sufficient size to cause a marked increase in the intra-cranial
+tension, or to give rise to localised cerebral symptoms by pressing on
+the brain.
+
+[Illustration: FIG. 192.--Diagram of Extra-Dural Abscess.]
+
+[Illustration: FIG. 193.--Pott's Puffy Tumour in case of extra-dural
+abscess following compound fracture of orbital margin; infected with
+road-dust; operation; recovery. At the time of the photograph the man
+was unconscious.]
+
+When associated with a punctured wound implicating the skull, an
+extra-dural abscess may develop within a few days of the injury, or
+not till after the lapse of several weeks, and it may spread over a
+wide area and come to encroach on the cranial cavity sufficiently to
+raise the intra-cranial tension and cause symptoms of compression, or
+even to press upon cortical centres and produce localised paralyses.
+As discharge can escape from the wound in the scalp, the puffy tumour
+does not necessarily form.
+
+_Treatment._--When the abscess is secondary to middle ear disease, the
+mastoid must be opened, the eroded bone exposed, and sufficient of it
+removed with rongeur forceps to admit of free drainage. When the
+infection has spread from the frontal sinus, the skull is trephined in
+the frontal region, the precise site being indicated by the oedematous
+area in the scalp, and the diseased bone is removed. In cases of
+compound fracture, drainage is established by enlarging the scalp
+wound, and removing loose, depressed, or inflamed portions of bone; if
+the bone is comparatively intact, it must be trephined, and further
+bone is removed with rongeur forceps over the entire area in which the
+dura has been separated.
+
+#Lepto-meningitis.#--If the infection spreads to the adjacent
+arachno-pia (_localised lepto-meningitis_), adhesions usually form,
+and shut off the infected area from the general arachno-pial space.
+
+Pus may form among these adhesions, constituting a _sub-dural
+abscess_, and may infiltrate the superficial layers of the cortex
+(_purulent encephalitis_, or _meningo-encephalitis_) (Fig. 194). The
+symptoms are similar to those of extra-dural abscess, but may be more
+severe; and it is seldom possible to distinguish between them before
+exposing the parts by operation. The treatment is carried out on the
+same lines.
+
+[Illustration: FIG. 194.--Diagram of Sub-Dural Abscess.]
+
+_Acute General Lepto-Meningitis._--In bone lesions, particularly
+compound fractures, infection of the arachno-pia may take place
+before protective adhesions form, and a diffuse lepto-meningitis
+results. The open structure of the arachno-pial membrane favours the
+rapid spread of the infection, which may extend over the surface of
+the hemispheres, or downwards towards the base (_basal meningitis_),
+or in both directions. The process is at first attended with a copious
+effusion of cerebro-spinal fluid into the arachno-pial space and into
+the ventricles (_serous lepto-meningitis_), but this fluid tends to
+become purulent, the pus forming in a thin layer over the surface of
+the brain, and in the sulci between the convolutions (_purulent
+lepto-meningitis_). The membranes are congested and thickened, the
+veins of the arachno-pia engorged, and the superficial layers of the
+cortical grey matter may share in the process (_encephalitis_).
+
+_Clinical features._--The earliest and most prominent symptom is
+violent pain in the head, often referred to the frontal region, or, in
+cases starting from middle ear disease, to the temporal region. This
+is accompanied by a sudden rise of temperature, usually without an
+antecedent rigor; the temperature remains persistently elevated (102°
+to 105° F.), and the pulse is small, rapid, and irregular both in rate
+and force. The patient, especially if a child, is extremely irritable,
+all his sensations are hyper-acute, and he periodically utters a
+peculiarly sharp, piercing cry.
+
+Vomiting of the cerebral type--that is, unattended with nausea and not
+related to the taking of food or to gastric disturbance--is common,
+and persists through the illness. The bowels are usually constipated.
+There is an increase in the number of leucocytes in the cerebro-spinal
+fluid, and organisms also are found in the fluid. As this does not
+occur in cerebral abscess, examination of the cerebro-spinal fluid may
+be useful in differential diagnosis. There is a higher leucocytosis in
+the blood in meningitis than in cerebral abscess.
+
+When the inflammation is most marked over the cerebral hemisphere,
+there may be paralysis of the side of the body opposite to the seat of
+the original lesion; sometimes there is erratic rigidity of the limbs,
+sometimes clonic spasms of groups of muscles. The superficial reflexes
+disappear early on both sides; the abdominal reflexes being lost
+sooner than the knee-jerks. In basal meningitis, temporary squinting
+due to irritation of the ocular muscles, retraction of the head, and
+an excessively high temperature are usually prominent features. The
+pupils at first are equally contracted; later they become dilated and
+fixed. Both optic discs are oedematous and swollen.
+
+Gradually the patient becomes unconscious, shows signs of increasing
+intra-cranial tension, slowing of the pulse, and laboured respiration,
+and the condition almost always proves fatal within three or four
+days.
+
+_Treatment._--The treatment consists in removing the source of
+infection when this is possible, but as a rule little can be done to
+arrest the spread of the meningitis or to ward off its effects. In
+cases resulting from a sub-dural abscess in relation to a compound
+fracture, a sinus phlebitis, or an erosion of the tegmen tympani, an
+attempt should be made, after exposing this, to purify and drain the
+meningeal spaces. Temporary relief of symptoms sometimes follows the
+withdrawal of cerebro-spinal fluid by repeated lumbar puncture,
+bleeding by leeches or cupping, or the use of an ice-bag or Leiter's
+tubes. The bowels should be freely moved by purgatives or enemata.
+
+_Cerebro-spinal Meningitis._--This form of meningitis, which is due to
+the _diplococcus intracellularis_, may occur sporadically, but is more
+frequently met with in an epidemic form. It is attended with the
+formation of a profuse sero-purulent exudate, which covers the brain,
+the cord, the nerves, and the membranes.
+
+The clinical features are similar to those of acute general
+lepto-meningitis, and in sporadic cases the diagnosis is only
+completed by discovering the diplococcus intracellularis in the fluid
+withdrawn by lumbar puncture. Although recovery sometimes takes place,
+the disease is attended with a high mortality. In the early stages,
+before the exudate has become too thick, repeated lumbar puncture
+followed by the injection of Flexner's serum has proved beneficial.
+Recovery may be attended with paralysis of one or other of the cranial
+nerves.
+
+
+CEREBRAL AND CEREBELLAR ABSCESS
+
+#Abscess due to Middle Ear Disease.#--The most common cause of abscess
+in the brain is chronic middle ear disease, and the majority of
+cerebral abscesses are therefore situated in the temporal lobe. Some
+are due to direct spread from a collection of pus in relation to an
+erosion of the tegmen tympani, either inside or outside the dura,
+others to infection carried by the veins, and in this way the
+infective material reaches the white matter; less frequently infection
+from the middle ear takes place along the peri-vascular lymph spaces.
+Macewen has pointed out that cerebral abscess never occurs from
+pyogenic organisms passing from the middle ear by way of the internal
+auditory meatus, although lepto-meningitis may do so. Cerebral abscess
+is much more frequently met with in the white matter of the centrum
+ovale than in the cortex, and in the majority of cases the abscess is
+single.
+
+The _pus_ is often of a greenish-yellow colour, or it may be dark
+brown from admixture with broken-down blood-clot; in some cases it is
+thin and serous and contains sloughs of brain matter, and it
+frequently has a foetid odour. In quantity it varies from a few drops
+to several ounces.
+
+The _arachno-pia_ over an abscess usually has a turbid and milky
+appearance.
+
+In an acute abscess the surrounding _brain tissue_ is engorged and
+infiltrated with pus; in a chronic abscess it is condensed, and the
+pus may be encapsulated by the formation of a zone of young fibrous
+tissue round its periphery. In this condition the abscess may remain
+"latent," giving rise to no symptoms for many weeks or even months.
+
+_Clinical features._--The _initial_ formation of pus in the cerebral
+tissue is associated with the sudden onset of severe pain in the head,
+shivering and well-marked cutis anserina, and vomiting of the cerebral
+type. The discharge from the ear usually diminishes or may even cease.
+
+As a _localised abscess_ develops the patient gradually passes, into a
+stuporous condition; he does not lose consciousness, but, his
+cerebration is slow, he seems unable to sustain his attention, for any
+length of time, and he answers questions "slowly, briefly, but, as a
+rule, correctly" (Macewen). The pain in the region of the ear becomes
+less intense, but the mastoid and temporal areas on the affected side
+are tender on percussion. The temperature falls, and, as a rule,
+remains subnormal. Rigors are unusual: their occurrence usually
+indicating the development of some complication such as sinus
+phlebitis. The pulse is full, regular, and slow (40 to 60). Vomiting
+frequently occurs, and the bowels are often obstinately constipated.
+
+There is no actual paresis, but there is a "gradual diminution of the
+ability to apply his strength." The superficial reflexes are late of
+disappearing and the disturbance is unilateral. The optic discs are
+moderately swollen. "The face is expressionless, passive, and cloudy.
+It may assume a meaningless smile, with which the features are not
+lit; it is too mechanical" (Macewen).
+
+_Differential Diagnosis._--In the early stages it is often difficult
+to distinguish between meningitis and cerebral abscess. The chief
+points on which reliance is to be placed are that in meningitis the
+pulse shows an irregularity, both in rate and force, which is wanting
+in cases of uncomplicated abscess. In meningitis the temperature is
+raised, while in abscess it is persistently subnormal. The
+superficial reflexes, particularly the abdominal reflexes, disappear
+early in meningitis and the disturbance is bilateral; in abscess they
+are slower to disappear, and one side only is affected. Retraction of
+the neck, when present, is a characteristic sign of meningitis. In
+meningitis the optic discs are highly oedematous and are more swollen
+than in abscess, and the condition is equally marked on the two sides.
+
+_Localisation of Cerebral Abscess--Temporal Abscess._--The existence
+of middle ear disease is always presumptive evidence that the abscess
+is in the temporal lobe on the same side. A small abscess in this lobe
+may produce no localising symptoms; one of large size may press
+indirectly on the motor cortex, on the fibres passing through the
+internal capsule, or on individual cranial nerves.
+
+It is important to observe the order in which paralysis of the
+opposite side of the body comes on. When it begins in the face and
+passes successively to the arm and leg, the pressure is on the
+cortical centres. When the paralysis progresses in the opposite
+direction--leg, arm, face--the pressure is on the nerve fibres passing
+through the internal capsule (Fig. 195). The paralysis may be spastic
+in lesions of the cortex or internal capsule; if it is flaccid the
+lesion is almost certainly cortical.
+
+[Illustration: FIG. 195.--Diagram illustrating Sequence of Paralysis,
+caused by abscess in temporal lobe. (After Macewen.)]
+
+Motor aphasia may result from pressure on the left inferior frontal
+convolution; auditory aphasia from abscess in the posterior part of
+the superior temporal convolution. Ptosis and lateral squint, with a
+fixed and dilated pupil, indicates pressure on the oculo-motor nerve
+of the same side.
+
+Abscess in the _parietal lobe_ gives rise to paralysis of the face and
+limbs on the opposite side of the body. Abscess in the _occipital
+lobe_ produces interference with the visual functions. An abscess in
+the _frontal lobe_ may give rise to no localising symptoms, but if it
+is on the left side, the power of making co-ordinated movements may be
+lost--apraxia--or the motor speech centre may be implicated.
+
+_Terminal Stage._--If left to itself, a cerebral abscess usually ends
+fatally by causing gradually increasing stupor and coma, or by
+bursting, either into the ventricles or into the sub-arachnoid space,
+and setting up a diffuse purulent lepto-meningitis.
+
+When the _abscess bursts into the ventricles_, the patient suddenly
+becomes much worse and dies within a few hours. "The pupils become
+widely dilated, the face livid, the respiration greatly hurried, and
+either shallow or stertorous. The temperature rises within a few hours
+with a bound from subnormal to 104° to 105° F.; the pulse from 40 or
+50 per minute quickly reaches 120 and over. There are muscular
+twitchings all over the body, possibly associated with convulsions and
+tetanic seizures, and these are followed by coma and speedy death"
+(Macewen).
+
+Spontaneous evacuation of a temporal abscess may take place through
+the middle ear.
+
+#Cerebellar Abscess.#--Next to the temporal lobe, the cerebellum is
+the most common seat of abscess. Cerebellar abscess is usually due to
+spread of infection from a thrombosed sigmoid sinus, either directly
+from a sub-dural abscess formed in relation to the walls of the sinus,
+or by extension of the thrombotic process along the cerebellar veins.
+While the abscess is small, it may give rise to few symptoms, and the
+patient may be able to go about, but as it increases in size serious
+symptoms develop. There may be nystagmus, and the patient suffers from
+vertigo, and is unable to co-ordinate his movements. If he attempts to
+walk, he reels from side to side; even when sitting up in bed, he may
+feel giddy and tend to fall, usually towards the side opposite to that
+on which the abscess is situated. The head and neck are retracted, the
+pulse is slow and weak, and the temperature subnormal. There is
+frequent yawning, and the speech is slow, syllabic, and jerky. There
+may be optic neuritis and blindness. There is sometimes unilateral or
+even bilateral spastic paralysis of the limbs from pressure on the
+medulla oblongata. The respiration may assume the Cheyne-Stokes
+character, occasionally being interrupted for a few minutes, while the
+heart continues to beat vigorously. This arrest of respiration is
+especially liable to occur during anæsthesia.
+
+_Treatment._--The abscess having been localised, the skull must be
+opened and the pus removed.
+
+#Abscess from causes other than Middle Ear Disease.#--From the _nasal
+passages_, infection may spread to the interior of the skull directly
+through the walls of the frontal, ethmoidal, or sphenoidal air
+sinuses, or indirectly by way of the veins, and give rise to a
+cerebral abscess, usually in the frontal lobe. The symptoms are
+similar to those of abscess following middle ear disease, but focal
+symptoms are seldom present. When the abscess is on the left side,
+apraxia and motor aphasia may be present. Spontaneous evacuation may
+take place by the abscess bursting into the nose through the
+cribriform plate.
+
+The treatment consists in trephining through the frontal bone or
+through the temporal fossa, according to the site of the abscess and
+its seat of origin. The primary focus of infection must also be dealt
+with.
+
+In _infected compound fractures_, an abscess may form in the cortical
+grey matter within a few days of the injury from direct spread of
+infection from the bone and membranes. This is usually associated with
+a spreading lepto-meningitis, the symptoms of which predominate. The
+condition usually proves fatal, but by opening up the original wound,
+removing depressed fragments of bone, and establishing drainage, the
+patient's life may be saved.
+
+There is evidence that an abscess may form in the brain after a simple
+contusion without fracture or other external injury (Ehrenvooth).
+
+An abscess may develop in the white matter of the centrum ovale some
+weeks, or even months, after an injury, particularly if a fragment of
+bone or a foreign body has been driven into the brain. If the
+infection has spread along the track of the missile, the abscess is
+usually near to the seat of the brain injury, but if it is due to
+spread of a thrombo-phlebitis it may be a considerable distance from
+it, even on the opposite side of the head. These chronic abscesses are
+usually in the parietal or frontal lobes, and as the pus is
+encapsulated they may remain latent for long periods, during which
+they may cause some degree of headache, neuralgic pains in the
+distribution of the trigeminal nerve, and occasional rises of
+temperature. When the abscess becomes active, general symptoms similar
+to those of other forms of abscess develop, and there may be localised
+paralysis of the opposite side of the body, the distribution of which
+depends upon whether the cortical centres or the motor fibres are
+implicated.
+
+The treatment consists in opening up the original wound, removing any
+depressed bone or foreign body that may be present, and establishing
+drainage.
+
+_Bronchiectasis_ and other infective diseases of the lungs are less
+common causes of cerebral abscess, which is usually single, and may
+occur in any part of the brain.
+
+_Disease of the bones of the skull_, such as osteomyelitis or
+syphilis, may be followed by cerebral abscess.
+
+Abscesses of _pyæmic_ origin are usually multiple, and may occur both
+in the cerebrum and in the cerebellum; they are not amenable to
+surgical treatment.
+
+
+SINUS PHLEBITIS
+
+Inflammation of the intra-cranial venous sinuses is due to the spread
+of infection from a local focus of suppuration; by far the most
+frequent cause is chronic suppuration in the middle ear. Less common
+sources of infection are erysipelas of the face or scalp, infective
+conditions of the mouth or nose, and diseases of the bones of the
+skull.
+
+The organisms may reach the affected sinus directly by continuity of
+tissue, as, for instance, when the transverse (lateral) sinus becomes
+infected from a focus of suppuration in the mastoid process spreading
+through the bone to the sigmoid groove and involving the walls of the
+vessel; or they may reach it by extension of thrombosis in a tributary
+vein--for example, when the superior sagittal (longitudinal) sinus is
+infected from an anthrax pustule of the lip, which has caused
+thrombosis of the emissary vein that passes through the foramen cæcum.
+
+The pathological changes are the same as occur in the suppurative form
+of thrombo-phlebitis in the peripheral veins (Volume I., p. 285). The
+soft clot that forms adheres to the inflamed wall of the sinus, and,
+being infected with pyogenic bacteria, it soon undergoes purulent
+disintegration.
+
+The infective process may spread backward along tributary vessels, and
+so give rise to cerebral or cerebellar abscess, or to purulent
+meningitis; or it may spread into the internal jugular vein and lead
+to the development of a diffuse purulent cellulitis along its course.
+
+General pyæmic infection may take place from pus or bacteria getting
+into the circulation, either directly or by reversed flow through
+tributary veins. Infective emboli are liable to lodge in the lung or
+pleura, and set up pulmonary abscess, gangrene of the lung, or
+empyema.
+
+_Clinical Features._--In all cases, pain in the head, referred to the
+region of the affected sinus, and so severe as to prevent sleep, is an
+early and prominent feature. The patient is usually excited,
+hypersensitive, and irritable in the early stages, and becomes dull
+and even comatose towards the end. Rigors, followed by profuse
+perspiration, occur early and increase in frequency as the disease
+progresses. The temperature is markedly remittent, varying from 103°
+to 106° F. (Fig. 196). The pulse is rapid, small, and thready. Loss of
+appetite, vomiting, and diarrhoea are almost constant symptoms.
+
+[Illustration: FIG. 196.--Chart of case of Sinus Phlebitis following
+middle ear disease in a boy æt. 13.]
+
+#Phlebitis of Individual Sinuses.#--The _transverse_ (_lateral_ or
+_sigmoid sinus_), from its proximity to the middle ear and mastoid air
+cells, is that most commonly affected, especially in young adults.
+With the onset of the phlebitis the discharge from the ear stops;
+there is severe pain in the ear and violent headache. The temperature
+rises, but shows marked remissions, and rigors are common. Vomiting is
+frequently present. Turgescence of the scalp veins draining into this
+sinus, and oedema over the mastoid, are occasionally observed; but as
+these signs may accompany various other conditions, they are of little
+diagnostic value. Not infrequently phlebitis spreads to the internal
+jugular vein, which may then be felt as a firm, tender cord running
+down the neck, and the head is held rigid, sometimes in the position
+characteristic of wry-neck.
+
+Three clinical types of sinus phlebitis are recognised--pulmonary,
+abdominal, and meningeal--but it is often impossible to relegate a
+particular case to one or other of these groups. Many cases present
+symptoms characteristic of more than one of the types.
+
+In the _pulmonary type_ evidence of infection of the lungs appears
+towards the end of the second week, in the form of dyspnoea, cough,
+and pain in the side, coarse moist râles, and dark foetid sputum.
+Death usually takes place from gangrene of the lung. The brain
+functions may remain active to the end.
+
+In the _abdominal type_ the symptoms closely resemble those of typhoid
+fever, for which the condition may be mistaken. The absence of a rash
+and the coexistence of middle ear disease are important factors in
+diagnosis.
+
+When the disease is of the _meningeal type_, symptoms of general
+purulent lepto-meningitis assert themselves, and soon come to dominate
+the clinical picture. Evidence of the presence of meningitis may be
+obtained by lumbar puncture. The mind at first is clear, but the
+patient is irritable; later he becomes comatose.
+
+The _prognosis_ is always grave, on account of the risk of general
+infection.
+
+_Treatment._--The primary focus of infection must first be removed,
+and this usually involves clearing out the middle ear and mastoid
+process. The sigmoid sinus is then exposed, and after any granulation
+tissue or pus that may be in the groove has been cleared away, the
+sinus is opened and the thrombus removed. With the object of
+preventing the dissemination of infective material, a ligature should
+be applied to the internal jugular vein in the neck before the sinus
+is opened, as was first recommended by Victor Horsley. If the
+phlebitis is accompanied by other intra-cranial infections, these are,
+of course, treated at the same time.
+
+The _superior sagittal_ or _longitudinal sinus_ is liable to be
+infected from pyogenic lesions of the scalp. There are no symptoms
+that are pathognomonic, but oedema of the scalp with turgescence of
+its veins, epistaxis, and convulsions followed by paralysis, are those
+most likely to be met with.
+
+The _cavernous sinus_ is usually implicated by spread of the process
+from other sinuses--for instance, from the petrosal or transverse
+(lateral) sinuses--or from the ophthalmic veins in cases of orbital
+cellulitis. Although at first unilateral, the thrombosis usually
+spreads across the middle line to the sinus of the opposite side. The
+special symptoms--exophthalmos, oedema of the eyelids, and paralysis
+of the ocular nerves--are due to pressure on the structures entering
+the orbit.
+
+Operative interference is seldom feasible in phlebitis of the superior
+sagittal (longitudinal) or cavernous sinuses.
+
+#Intra-cranial Tuberculosis.#--_Tuberculous meningitis_ is most
+frequently met with in patients below the age of twenty, and the
+infection takes place by the blood stream from some focus elsewhere in
+the body or from the spinal membranes. In cases of tuberculous disease
+of the middle ear infection may spread to the membranes by way of the
+internal auditory meatus (Macewen). The arachno-pia, especially at the
+base, is studded over with miliary tubercles, and an excess of fluid
+collects in the arachno-pial space and in the ventricles (_acute
+hydrocephalus_).
+
+At first the _symptoms_ of irritation of the brain predominate: severe
+headache, photophobia, inequality of the pupils, stiffness of the
+neck, cutaneous hyperæsthesia, vomiting and convulsions. Kernig's
+sign--pain on flexing the hip while the knee is extended, and
+inability to extend the knee while in the sitting posture--is present.
+There is usually obstinate constipation, and the abdomen is retracted.
+Later, signs of increased intra-cranial tension develop:
+unconsciousness deepening into coma, paralysis of ocular muscles,
+rapid pulse, Cheyne-Stokes respiration, and sometimes hyperpyrexia. An
+excess of mono-nuclear lymphocytes and, sometimes, tubercle bacilli
+may be discovered in the cerebro-spinal fluid withdrawn by lumbar
+puncture. The absence of the diplococcus intracellularis helps to
+differentiate the disease from cerebro-spinal meningitis, which it may
+closely simulate.
+
+The only surgical measure that is justifiable is lumbar puncture,
+which often affords marked relief of symptoms, although the benefit is
+only temporary.
+
+_Localised tuberculous nodules_ sometimes develop in the brain and
+form definite tumours. They vary in size from a pea to a hen's egg,
+are rounded and encapsulated. Sometimes the centre is caseous,
+sometimes fibrinous or calcified. In children they are usually
+multiple; in adults they may be single--the so-called "solitary
+tubercle." They are most common in the pons, basal ganglia, and
+cerebellum, but occur also in the cerebral cortex and sometimes in the
+centrum ovale. They usually originate in the pia and invade the brain
+substance, but do not as a rule involve the dura. The membranes in the
+vicinity of the growth are often the seat of tuberculous disease.
+
+As these nodules give rise to the same symptoms as other forms of
+cerebral tumour, and as their nature can be diagnosed only in
+exceptional cases, their clinical features and treatment are described
+with tumours of the brain.
+
+#Intra-cranial Syphilis.#--_Syphilitic meningitis_ is usually
+secondary to cario-necrosis of the bones of the vault or to a
+localised gumma of the brain. When primary, it usually affects the
+inter-peduncular region of the base, and takes the form of a diffuse
+gummatous infiltration of the membranes which gives rise to symptoms
+referable to the parts pressed upon, and especially paralysis of one
+or other of the cranial nerves. As in other intra-cranial syphilitic
+lesions, the symptoms show a variability in intensity which is
+characteristic. The diagnosis is made by the history, and the
+treatment is carried out on the same lines as in other syphilitic
+lesions.
+
+_Localised gummata_ are described with tumours of the brain.
+
+
+CEPHALOCELES
+
+The term "cephalocele" is applied to a protrusion of a portion of the
+cranial contents through a congenital deficiency in the bones of the
+skull. This malformation is believed to be due to an irregularity in
+development, whereby a portion of the primary cerebral vesicle remains
+outside the mesoblastic layer of the embryo. It is usually associated
+with adhesion of the membranes in the region of the fourth ventricle,
+and with internal hydrocephalus. Cephaloceles are covered by the
+scalp, and are most commonly met with in the occipital region and at
+the root of the nose; less frequently at the anterior inferior angle
+of the parietal bone, and in the line of the sagittal suture. Very
+rarely they occur at the base of the skull and project into the
+pharynx, the mouth, or the nose, where they are liable to be mistaken
+for polypi. Cephaloceles vary greatly in size, some being so small as
+almost to escape detection, while others are larger than a child's
+head. In many cases the condition is incompatible with life.
+
+Several varieties are recognised. They are known as (1)
+_meningocele_, which consists of a protrusion of a cul-de-sac of the
+arachno-pial membrane, containing cerebro-spinal fluid; (2)
+_encephalocele_, in which a portion of the brain is protruded in
+addition to the membranes; and (3) _hydrencephalocele_, in which the
+protruded portion of brain includes a part of one of the ventricles.
+
+_Clinical Features._--The _meningocele_ is commonest in the occipital
+region, where it escapes through a cleft in the bone between the
+foramen magnum and the occipital protuberance (Fig. 197). It forms a
+tense, smooth, translucent globular swelling, which may be sessile or
+pedunculated, and is usually covered by thin, smooth skin in which the
+vessels are dilated and nævoid. The tumour does not pulsate, but
+increases in size and tension when the child cries or coughs. It may
+be diminished in size or even made to disappear by pressure, and so
+permit of the opening in the bone being felt. This manipulation,
+however, may be followed by slowing of the pulse, vomiting, loss of
+consciousness, or convulsions.
+
+[Illustration: FIG. 197.--Occipital Meningocele.
+
+(From a photograph lent by Sir George T. Beatson.)]
+
+Small meningoceles may remain stationary for a long time, or may even
+undergo spontaneous cure. Those of larger size usually progress till
+they eventually burst, and death results from the escape of the
+cerebro-spinal fluid or from meningitis. Infection may also occur
+from eczema or from excoriation of the overlying skin.
+
+_Encephaloceles_ are much commoner than meningoceles, and usually
+occur in the frontal region, where they form broad-based, elastic, and
+pulsatile tumours, which vary greatly in size.
+
+The _hydrencephalocele_ is usually met with in the occipital region,
+and is generally so large and associated with such great cerebral
+deformity as to be inconsistent with life. It does not as a rule
+pulsate (Fig. 198).
+
+[Illustration: FIG. 198.--Frontal Hydrencephalocele.
+
+(From a photograph lent by Sir George T. Beatson.)]
+
+Cephaloceles have to be diagnosed from dermoid cysts, nævi (Fig. 199),
+cephal-hydrocele, and cephal-hæmatoma. Their recognition is seldom
+attended with difficulty. If the margins of the gap in the skull can
+be distinctly felt, or the gap in the bone can be shown by the X-rays,
+the diagnosis is greatly simplified.
+
+[Illustration: FIG. 199.--Nævus at Root of Nose, simulating
+Cephalocele.
+
+(From a photograph lent by Sir George T. Beatson.)]
+
+_Treatment._--Only small cephaloceles are amenable to surgical
+treatment; those that are large and contain brain substance are best
+left alone, being merely protected from irritation and infection.
+
+While the immediate effects of operation are, on the whole,
+satisfactory, the ultimate results are disappointing, as the essential
+cause of the intra-cranial pressure persists, and the child develops
+hydrocephalus. The method of tapping the sac and injecting iodine has
+nothing to recommend it.
+
+#Traumatic Cephal-hydrocele.#--Certain rare cases of simple fracture
+of the vault occurring in early childhood have been followed by the
+development beneath the scalp of a localised fluid swelling, which
+varies in size from time to time and is partly reducible by pressure.
+The swelling results from laceration of the membranes, and sometimes
+of the brain substance, so that the cerebro-spinal fluid of the
+sub-arachnoid space, or even of the lateral ventricle, escapes through
+the opening in the skull and bulges beneath the scalp. In a majority
+the swelling pulsates synchronously with the heart, and becomes tense
+on exertion. A distinct opening in the skull may sometimes be felt.
+When associated, as it frequently is, with mental deficiency or the
+occurrence of fits, the cyst may be tapped or its neck ligated
+(Hogarth Pringle). Otherwise it should be left alone.
+
+
+HYDROCEPHALUS
+
+An excess of cerebro-spinal fluid may collect in the arachno-pial
+space surrounding the brain, or in the interior of the ventricles,
+constituting in the former case an _external_, and in the latter an
+_internal hydrocephalus_. Hydrocephalus may be acute or chronic.
+
+#Acute hydrocephalus# is practically synonymous with tuberculous
+meningitis, although it may result from other forms of meningeal
+infection. The excess of fluid is found both in the arachno-pial space
+and in the ventricles. This condition only calls for mention here as
+attempts have been made to treat it by surgical measures, such as
+lumbar puncture, or drainage through the occipital fossa. The results,
+however, have not been encouraging.
+
+#Chronic Hydrocephalus.#--_Chronic external hydrocephalus_ is rare,
+and usually results from some definite intra-cranial lesion, such as
+meningitis, tumour, or cerebral atrophy. It is not amenable to
+surgical treatment.
+
+_Chronic internal hydrocephalus_, on the other hand, is a
+comparatively common condition. It may be of congenital origin, or may
+develop in young rickety children, usually as a result of some chronic
+inflammatory process in the membranes at the base, the choroid
+plexuses, or the ependyma of the ventricles, causing obstruction to
+the outflow of blood through the internal cerebral veins of Galen. In
+the acquired form the communication between the ventricles and the
+sub-arachnoid space, by way of the foramen of Magendie, is obstructed,
+so that the cerebro-spinal fluid is pent up in the ventricles and
+gradually distends them. The pressure causes the head to enlarge, the
+fontanelles to bulge, and the bones to be separated from one another,
+the interval between the bones being occupied by a thin translucent
+membrane.
+
+The cerebral tissue is greatly thinned out, but the cerebellum and
+cranial nerves usually remain unaffected.
+
+The appearance of the patient is characteristic (Fig. 200). The
+enormous dome of the skull surmounts a puny and preternaturally old
+face; the eyes are pushed downwards and forwards by the pressure on
+the orbital plates, and the eyebrows are displaced upwards. The head
+rolls helplessly from side to side; the child moans and cries a great
+deal; and vomiting is often a prominent symptom. In most cases the
+intelligence is defective, and epileptic seizures and other functional
+disturbances of the brain may be present.
+
+[Illustration: FIG. 200.--Hydrocephalus in a child æt. 3-1/2.]
+
+In mild cases, especially when associated with rickets or syphilis,
+recovery sometimes takes place, but in the majority the condition
+progresses, and death results either from convulsions or from some
+intercurrent disease. Few hydrocephalic subjects reach adult life.
+
+_Treatment._--Hydrocephalus being a symptom rather than a disease, no
+method of treatment which does not remove the primary cause can be
+permanently curative. Anti-syphilitic treatment should be tried in the
+hydrocephalus of infants and young children. The rachitic element,
+when present, must also be treated.
+
+In congenital hydrocephalus, as there is no blocking of the passages
+at the fourth ventricle, the foramina being as a rule much larger than
+normal, no form of drainage is beneficial. Ligation of the common
+carotids, one some weeks after the other, has been successful in
+restoring the balance which normally exists between the secretion and
+absorption of the cerebro-spinal fluid (H. J. Stiles). In acquired
+hydrocephalus, puncture of the ventricles is sometimes followed by a
+remarkable improvement in the symptoms, and may even result in
+apparent cure. An exploring needle is introduced at the lateral angle
+of the anterior fontanelle, to avoid the superior sagittal
+(longitudinal) sinus, and from a half to one ounce of cerebro-spinal
+fluid withdrawn. This is repeated once a week for several weeks.
+Continuous drainage of the fourth ventricle through an opening made in
+the occipital region (Parkin), and the establishment of a
+communication between the ventricle and sub-arachnoid space
+(Watson-Cheyne), or between the sub-arachnoid space of the spinal cord
+and the peritoneal cavity, or the retro-peritoneal space (Cushing),
+have been tried, with little more than temporary benefit in the
+majority of cases. Operative treatment, if it is to do good, must be
+undertaken early, before permanent changes in the brain have taken
+place.
+
+#Micrencephaly.#--This condition is due to defective development of
+the brain, and not to premature closure of the cranial sutures and
+fontanelles, and as the subjects of it are mentally deficient, and
+often blind, deaf and dumb, the removal of segments of the skull with
+a view to enable the brain to develop have proved futile.
+
+
+CEREBRAL TUMOURS
+
+As a comparatively small proportion of tumours of the brain--using the
+term "tumour" in its widest sense--are amenable to surgical treatment,
+it is only necessary here to refer to those aspects of this subject
+that have a distinctively surgical bearing.
+
+Various forms of growth occur in the brain, the most common being
+tuberculous nodules, syphilitic gumma, endothelioma, glioma, and
+sarcoma. Less frequently fibroma, osteoma, and parasitic, hæmorrhagic,
+and other cysts are met with. The growth may originate in the brain
+tissue primarily, or may spread thence from the membranes, or from the
+skull. In relation to operative treatment, it is an unfortunate fact
+that those forms that are well defined and do not tend to infiltrate
+the brain tissue, usually occur at the base, where they are difficult
+to reach; while those that develop in more accessible regions are for
+the most part infiltrating growths of a gliomatous or sarcomatous
+nature, and are therefore irremovable.
+
+_Clinical Features._--The presence of a tumour in the brain inevitably
+results sooner or later in an increase in the intra-cranial tension,
+and to this the symptoms are chiefly due.
+
+The earliest and most prominent of the _general symptoms_ are severe
+paroxysmal headache, optic neuritis, with choked disc and limitation
+of the field for blue, amounting sometimes to blue-blindness
+(Cushing). The relative degree of neuritis in the two eyes is a
+reliable guide to the side on which the tumour is situated (Horsley).
+The symptoms are seldom absent, and are common to all forms of tumour,
+wherever situated. Vomiting, which is without relation to the taking
+of food and is usually unattended by nausea, is a characteristic
+symptom when present, but it is wanting in two-thirds of the cases
+(Cushing). Vertigo, general convulsions, and signs of mental
+deterioration are also present in a considerable proportion of cases.
+
+In addition, certain _localising symptoms_ may be present. When, for
+example, the tumour is situated in the _cortex of the Rolandic area_,
+attacks of Jacksonian epilepsy, preceded by an aura, which is usually
+referable to the centre primarily implicated, are common. The group of
+muscles first involved, and the order in which other groups become
+affected, are important localising factors. As the tumour increases in
+size, these irritative phenomena are replaced by localised paralyses.
+The tactile and muscular sensations are also disturbed, and motor and
+sensory aphasia may be present. In some cases localised tenderness on
+percussing the skull may be of assistance in indicating the site of
+the tumour.
+
+When the tumour is _sub-cortical_, that is, in the centrum ovale,
+there are no Jacksonian spasms, the motor paralysis is more
+widespread, and sensation also is lost on the opposite side of the
+body. There is no special tenderness on percussion. It is not always
+possible, however, to distinguish between cortical and sub-cortical
+tumours, and in many cases both areas are invaded.
+
+Tumours situated in the region of _the internal capsule_, and _in the
+deeper parts of the brain_, are not attended with Jacksonian spasms,
+paralysis develops more rapidly than in cortical and sub-cortical
+tumours, and there is complete loss of sensation on the opposite side
+of the body. The cranial nerve-trunks also are liable to be pressed
+upon.
+
+Tumours and cysts _in the cerebellum_ give rise to symptoms similar to
+those of cerebellar abscess (p. 381).
+
+Tumours _in the cerebello-pontine angle_, in addition to the special
+symptoms associated with cerebellar lesions, give rise to symptoms of
+interference with nerve-roots of the same side. The facial and
+acoustic nerves are most frequently affected, resulting in facial
+weakness, tinnitus, loss of perception for high-pitched notes, as
+tested by Galton's whistle, or absolute unilateral deafness. Any of
+the other cranial nerves from the fifth to the twelfth may be either
+irritated or paralysed. Pressure on the pons may produce hemiplegia of
+the opposite side, with spasticity and exaggeration of reflexes.
+Sudden death may occur from crowding of the cerebellum into the
+foramen magnum.
+
+With the growth of the tumour the symptoms become aggravated, the
+optic neuritis is followed by optic atrophy and blindness, the patient
+gradually becomes stuporous, and finally dies in a state of coma. The
+severity of the symptoms depends to a large extent on the rapidity of
+growth of the tumour; thus an osteoma growing slowly from the inner
+table of the skull and implicating the brain may reach a considerable
+size without producing cerebral symptoms, while a comparatively small
+sarcoma or syphilitic gumma of rapid growth may endanger life. A
+sudden and serious aggravation of symptoms may result from hæmorrhage
+into a soft tumour, such as glioma.
+
+The _diagnosis_ of the pathological nature of a cerebral tumour is
+generally "hardly more than a guess" (Gowers). At the same time it may
+be borne in mind that _syphilitic gummata_ occur in adults, from forty
+to sixty years of age, who have suffered from acquired syphilis, and
+who may present other evidence of the disease. They tend to increase
+somewhat rapidly. A negative Wassermann reaction does not necessarily
+exclude a diagnosis of brain syphilis. Severe nocturnal pain which
+interferes with sleep is often a prominent symptom. Gummata are
+generally situated on the surface of the brain; they often originate
+in the dura mater, and when exposed are easily enucleated. Improvement
+in the symptoms may follow the administration of iodides and mercury,
+or organic arsenical salts of the salvarsan group, but in many cases
+the growth is very resistant to anti-syphilitic treatment.
+
+_Tuberculous masses_ occur most frequently in children and
+adolescents, and other signs of tuberculosis are usually present. The
+cerebellum is a common seat of these tumours, and they are often
+multiple. Their growth may be rapid at first, and then become arrested
+for a time. Spasmodic growth of a tumour strongly suggests its
+tuberculous nature, and superadded signs of basal meningitis confirm
+the diagnosis.
+
+_Endothelioma_ grows from the dura mater, and in so far as it is a
+well-defined and non-infiltrating growth it lends itself to removal by
+operation. Unfortunately, however, it is usually located at the base
+of the brain and is not readily accessible.
+
+_Glioma_ is usually met with in the young; it tends to grow slowly at
+first, but may take on a rapid growth at any time, and hæmorrhage is
+liable to occur into the substance of the tumour, causing a sudden
+aggravation of the symptoms.
+
+_Sarcoma_ occurs between puberty and middle life; it grows slowly, and
+compresses rather than destroys the brain tissue. It is sharply
+defined from the surrounding cerebral tissue, and is therefore more
+favourable for operation than glioma.
+
+The _prognosis_ is grave in all forms of brain tumour. Even in
+syphilitic growths, although the more urgent symptoms may be
+ameliorated by the use of drugs, recurrence is liable to occur, and
+the structural changes induced in the cerebral tissue, and the
+contraction of the cicatrix which results, may permanently interfere
+with the functions of the brain, or may induce Jacksonian epilepsy.
+Tuberculous tumours also may become arrested, and may cease for a time
+to cause symptoms, but permanent cure is extremely rare. We have known
+a sarcoma to recur as late as five years after removal. Death
+sometimes occurs suddenly from hæmorrhage, from acute oedema, or from
+implication of vital centres.
+
+_Treatment._--It is to be borne in mind that gummatous growths in the
+brain are seldom influenced to any extent by anti-syphilitic remedies,
+and time should not be wasted in trying this form of treatment.
+
+The question of removal by operation arises in cases in which there is
+reason to believe that the tumour is situated near the surface of the
+brain and that it is circumscribed and of moderate size. Unfortunately
+it is only in a small proportion of cases that these conditions are
+present and can be recognised before opening the skull.
+
+In many cases in which there is no hope of being able to remove the
+tumour, it is advisable to relieve symptoms due to excessive
+intra-cranial tension, such as blindness, severe headache, and
+persistent vomiting, by performing a "decompression operation"
+(_Operative Surgery_, p. 108). The relief that follows such operations
+is often remarkable.
+
+Lumbar puncture, frequently repeated, has also been practised for the
+relief of tension in inoperable cases, but it is not free of danger
+and is not to be looked upon as a substitute for a decompression
+operation.
+
+When surgical treatment is contra-indicated, all that can be done is
+to palliate the symptoms by bromides, opium, phenacetin, caffein, and
+other drugs.
+
+#Tumours of the Pituitary Body# or #Hypophysis Cerebri#.--The tumours
+most frequently met with in the pituitary body are of the nature of
+adenoma with hyperplasia and cystic degeneration; carcinoma and
+sarcoma also occur. They develop slowly and give rise to comparatively
+slight increase in the intra-cranial tension. When the anterior lobe
+is implicated and there is a pathological increase in the functional
+activity of the gland (_hyperpituitarism_), signs of acromegaly may
+ensue. Diminution of function (_hypopituitarism_) is attended with
+infantilism, a rapid deposition of fat in the subcutaneous tissue, and
+a decrease or loss of the genital functions. In women, amenorrhoea is
+an early and constant symptom. Intense drowsiness is a marked feature
+in some cases.
+
+From their position close to the back of the optic chiasma these
+growths affect the fibres passing to the nasal half of each retina,
+and so give rise to bilateral temporal hemianopsia, and although there
+is no choked disc, the optic nerves undergo primary atrophy from
+pressure, and there is failure of sight.
+
+Marked temporary benefit has followed the administration of thyreoid
+extract. Operative treatment has been successful in a number of cases,
+but as the anterior lobe is essential to life, the operation is merely
+directed towards the relief of pressure on the optic chiasma with a
+view to preventing loss of vision. We have seen marked relief follow a
+temporal decompression operation.
+
+#Epilepsy.#--The surgical aspects of Jacksonian epilepsy following
+head injuries have already been considered (p. 358). For the cure of
+those forms of epilepsy in which there is no gross lesion of the
+brain, numerous surgical procedures have been suggested, but from none
+of these have the results been encouraging.
+
+#Hernia Cerebri.#--This term is applied to a protrusion of brain
+substance through an acquired opening in the skull and dura mater,
+such as may result from a compound fracture or a gun-shot wound. The
+protrusion is due to increased intra-cranial tension, and is almost
+invariably associated with infection of the brain and its membranes,
+and with the presence of a foreign body or fragments of bone. Other
+things being equal, a hernia is more likely to occur through a small
+than through a large opening in the skull.
+
+So long as the extruded portion of brain matter is small, it pulsates,
+but as it increases in size and is pressed upon by the edges of the
+opening through which it escapes, the pulsation ceases, and the
+herniated portion may become strangulated and undergo necrosis.
+
+In cases of compound fracture, and in other conditions associated with
+necrosis of bone, masses of redundant granulation tissue growing from
+the soft parts outside the skull may simulate a hernia cerebri.
+
+The _treatment_ consists in counteracting the septic infection by
+purifying the protruding mass, and if necessary by enlarging the
+opening in the skull with rongeur forceps to admit of the removal of
+foreign bodies or bone fragments and to relieve the inter-cranial
+tension. Steps must also be taken to prevent meningitis, which, if it
+occurs, is usually fatal. Pressure over the hernia, with the object
+of returning it to the skull, is to be avoided, and the herniated
+portion should not be cut away unless it is sloughing, or has become
+pedunculated. It may be got rid of by painting it with 40 per cent.
+formalin, which causes a dry, horny crust to form on the surface; this
+is picked off, and the formalin re-applied.
+
+After the hernia has disappeared and the wound is aseptic, steps
+should be taken to close the gap in the skull. This may be done by an
+osteo-plastic operation in which a flap, comprising a segment of the
+outer table, is raised from an adjacent part of the skull and placed
+in the gap; or by transplanting a portion of periosteum-covered bone
+from the scapula, tibia, or other suitable source. An alternative
+method is to implant a plate of celluloid, silver or other metal, or a
+portion of the fascia lata, in the gap. When a permanent hole is left
+in the bone, the patient should wear over it a leather or metal shield
+to protect the brain.
+
+The protrusion of brain resulting after a decompression operation
+deliberately performed for the relief of intra-cranial tension, unless
+it becomes infected, has nothing in common with a hernia cerebri.
+
+
+SURGICAL AFFECTIONS OF THE CRANIAL NERVE
+
+Irritation, or paralysis, of one or more of the cranial nerves may
+result from lesions implicating their centres or trunks.
+
+When the trunk of the nerve is affected, the paralysis is on the same
+side as the lesion, and is of the lower neurone type; when the
+cortical centre or the upper axons are involved, it is on the opposite
+side, and is of the upper neurone type (p. 334). The lesions of the
+cerebral centres with which nerve symptoms are most frequently
+associated are: laceration of the brain, hæmorrhage, meningitis,
+tumour, and syphilitic gumma.
+
+The nerve-trunks may be contused or torn across, especially in basal
+fractures which traverse their foramina of exit; blood may be effused
+into their sheaths as a result of injuries not attended with fracture;
+or they may be pressed upon by an inflammatory effusion, a tumour, a
+gumma, or an aneurysm invading the base of the skull. When the nerve
+is merely contused, or pressed upon by blood-clot, the paralysis tends
+to pass off in the course of a few days. When it is torn across, or
+compressed by a new growth, the paralysis is permanent. In some
+traumatic cases paralysis does not come on until a few days after the
+injury, and is then due either to gradually increasing pressure from
+blood-clot, or more probably to the onset of meningitis or of
+ascending neuritis.
+
+I. The branches of the _Olfactory Nerve_ may be ruptured as they pass
+through the cribriform plate in fractures implicating the anterior
+fossa of the skull, and there results complete and permanent loss of
+smell (_anosmia_). Hæmorrhage into the nerve sheath or contusion of
+the nerve may cause a transitory loss of smell. The trunk of the nerve
+may be implicated also in tumours and meningitis in the anterior
+fossa. In all cases in which anosmia results there is also
+interference with the power of recognising different flavours, thus
+greatly impairing the sense of taste.
+
+II. _Optic Nerve._--Temporary paralysis of one or both optic nerves is
+a comparatively common result of traumatic effusion of blood into
+their sheaths; the resulting blindness may pass off in a few days, or
+may last for some weeks. When a large effusion takes place, the
+prolonged pressure on the nerve may result in optic atrophy and
+permanent blindness. Complete severance of the nerve by a bullet, the
+point of a sharp instrument, or a fragment of bone, results in loss of
+sight in the eye on the same side. In cellulitis of the orbit,
+intra-orbital tumour, gumma and aneurysm in the region of the
+cavernous sinus, also, the optic nerve may be implicated.
+
+Lesions implicating the cortical centre for sight in the occipital
+lobe give rise to hemianopia--that is, loss of sight in the lateral
+halves of the fields of vision of both eyes--colour-blindness,
+subjective sensations of light and colour, and other eye symptoms.
+
+Double optic neuritis, followed by optic atrophy, is one of the most
+constant effects of the growth of a tumour within the skull, and is
+not uncommon in cases of cerebral abscess and meningitis. Pressure on
+the optic chiasma, for example by a tumour of the pituitary body, is
+associated with bilateral temporal hemianopsia.
+
+III. _Oculo-Motor Nerve._--One or more of the branches of this nerve
+may be compressed by extravasated blood, or be contused and lacerated
+in fractures implicating the region of the sphenoidal fissure. Fixed
+dilatation of one pupil may result from pressure by blood-clot,
+without other functional disturbance of the nerve. A tumour or an
+aneurysm growing in this region also may press upon the nerve.
+Sometimes both nerves are involved--for example, in fracture
+implicating both sides of the anterior fossa, and in tumours,
+particularly gumma, growing in the region of the floor of the third
+ventricle. In lesions of the cerebral hemispheres the third nerve is
+frequently paralysed. Its cortical centre lies in close proximity to
+the centre for the face (Fig. 179).
+
+The most prominent symptoms of complete paralysis are ptosis or
+drooping of the upper eyelid, lateral strabismus, and slight downward
+rotation of the eye with diplopia. There are also dilatation of the
+pupil from paralysis of the circular fibres of the iris, and loss of
+accommodation and reaction to light from paralysis of the ciliary
+muscle.
+
+Paralysis of the muscle supplied by the third nerve is frequently
+associated with paralysis of other ocular muscles. When all the
+muscles of the eye are paralysed, the condition is known as
+"opthalmoplegia externa"; it is usually due to syphilitic disease in
+the floor of the third ventricle.
+
+IV. The _Trochlear_ or _Patheticus Nerve_, which supplies the superior
+oblique muscle, may suffer in the same way as the oculo-motor nerve.
+When it is paralysed, there is defective movement of the eye downward
+and medially, and the patient may complain of diplopia when he looks
+downward.
+
+V. _Trigeminal Nerve._--The most important surgical affection of this
+nerve is "trigeminal neuralgia," which has already been described
+(Volume I., p. 373). One or other of the divisions of the nerve may be
+torn in fractures of the base of the skull, and there results
+anæsthesia in the area supplied by it. In fractures crossing the apex
+of the petrous portion of the temporal bone, the great and small
+superficial petrosal nerves may be ruptured, and the soft palate and
+uvula are paralysed and there is difficulty in swallowing; there are
+also painful sensations in the ear. When the ophthalmic division is
+implicated, the conjunctiva is rendered insensitive, and
+conjunctivitis, which may be followed by ulceration of the cornea,
+results from exposure to dust and other foreign bodies, which, on
+account of the anæsthetic condition of the eye, are allowed to remain
+and cause irritation.
+
+VI. _Abducens Nerve._--This nerve, which supplies the lateral rectus
+muscle, has the longest course within the skull of any of the cranial
+nerves. In spite of this fact, it is comparatively seldom torn in
+basal fractures; but it is prone to be pressed upon by tumours,
+gummas, or aneurysms in the region of the base of the brain. When it
+is paralysed, medial strabismus results.
+
+VII. _Facial Nerve._--Paralysis of the facial muscles, more or less
+complete, is the most characteristic symptom of lesions of this nerve.
+
+_Paralysis of the Cerebral Type._--When the fibres of the nerve are
+implicated in any part of their course between the cortical centre
+and the nucleus in the lower part of the pons, the paralysis is of the
+upper neurone (cerebral) type. It affects the side of the face
+opposite to that of the lesion, and the defective movement is more
+marked in the lower than in the upper half of the face.
+
+This form of facial paralysis may be due to the pressure of an
+intra-cranial tumour, abscess, or hæmorrhage, or to degenerative
+processes in the cerebral tissue, and as a rule other cranial nerves
+are also affected. Its recognition is chiefly of diagnostic and
+localising importance.
+
+_Paralysis of the Peripheral Type._--When the trunk of the nerve is
+implicated between the pontine nucleus and its peripheral
+distribution, the paralysis is of the lower neurone (peripheral) type,
+the muscles on the same side as the lesion being flaccid and
+atrophied.
+
+The majority of cases are of the so-called "rheumatic" variety, and
+are attributed to exposure to cold. Others result from fractures
+implicating the middle fossa of the skull, or are associated with
+chronic suppuration in the middle ear.
+
+In fractures passing across the petrous temporal, the nerve may be
+torn at the time of the injury, or may become pressed upon by a
+traumatic effusion or by callus later, but considering the frequency
+of these fractures it is comparatively seldom damaged.
+
+Suppurative disease of the middle ear is a more common cause of facial
+paralysis. The nerve, as it traverses the facial canal (aqueductus
+Fallopii), may be pressed upon by inflammatory effusions or
+granulations, or may be destroyed by the suppurative process,
+particularly in young children, as in them the osseous wall of the
+aqueduct is very thin. It may also be involved in tuberculous and in
+malignant disease of the middle ear.
+
+The nerve may be injured also in the course of operations on the
+mastoid or middle ear, or in the removal of tumours or glands in the
+parotid region. As the nerve breaks up into numerous branches soon
+after it leaves the stylo-mastoid foramen, the paralysis may be
+confined to one or more of its branches.
+
+Temporary paralysis may result from inflammatory conditions such as
+parotitis, or from blows or pressure over the nerve, for example by
+the forceps in delivery.
+
+_Symptoms._--In complete unilateral _facial paralysis_ (Bell's
+paralysis) the affected side of the face is expressionless and devoid
+of voluntary or emotional movement. The muscles are flaccid, the cheek
+is flattened and smooth, all its folds and wrinkles being
+obliterated. When the patient speaks or smiles, the face is drawn to
+the sound side (Fig. 201). The eye on the affected side cannot be
+closed, and on making the attempt the eyeball rolls upwards and
+outwards. The lower lid droops, the patient cannot wink, and the
+conjunctiva therefore becomes dry, and is irritated by exposure to
+cold and dust. The tears run over the cheek. From paralysis of the
+buccinator muscle there is inability to whistle or to puff out the
+cheeks and food collects between the cheek and the gums. The
+orbicularis oris being also paralysed, the patient is unable to show
+his upper teeth, and the labial consonants are pronounced
+indistinctly. The sense of taste is often impaired from involvement of
+the chorda tympani nerve.
+
+[Illustration: FIG. 201.--Patient suffering from left facial
+Paralysis. Note smoothness of left side of face, imperfect closure of
+left eye, and deviation of face to right side.
+
+(From a photograph lent by Dr. Edwin Bramwell.)]
+
+When the paralysis is bilateral, the symmetrical appearance of the
+face renders the condition liable to be overlooked.
+
+_Treatment._--In addition to removing the cause, when this is
+possible, recovery of function may be promoted by the administration
+of drugs, such as potassium iodide, strychnin, or iron, by the
+application of blisters, or by massage and electricity. These measures
+are most useful in cases due to blows or exposure to cold. When the
+nerve is accidentally divided in the course of an operation on the
+face, it should immediately be sutured. So long as the electrical
+reactions of the affected muscles indicate an incomplete lesion,
+recovery may be confidently expected (Sherren). When the reaction of
+degeneration is present and the paralysis has lasted for more than six
+months, there is little hope of recovery, and recourse should be had
+to operation, to restore the function of the nerve by grafting its
+distal end on to the trunk of the hypoglossal nerve. To prevent
+paralysis of the tongue the lingual nerve may be divided, and its
+proximal end anastomosed with the distal end of the hypoglossal.
+
+The facial may be grafted on the accessory nerve, but the associated
+movements of the face which then accompany movements of the shoulder
+often prove inconvenient.
+
+_Facial Spasm._--Clonic contraction of the facial muscles (histrionic
+spasm) occasionally results from irritative lesions in the cortex or
+pons. Sometimes all the muscles are involved, sometimes only one, for
+example the orbicularis oculi (palpebrarum)--blepharospasm. This
+condition may be induced reflexly from irrigation of the trigeminal
+nerve, notably of branches that supply the nasal cavities and the
+teeth.
+
+The _treatment_ consists in removing any source of peripheral
+irritation that may be present, in employing massage, and in
+administering nerve tonics, bromides, and other drugs. In severe
+cases, the facial nerve may be stretched with benefit, either at its
+exit from the stylo-mastoid foramen or on the face.
+
+VIII. _Acoustic_ or _Auditory Nerve_.--The acoustic nerve is liable to
+be damaged along with the facial in tumours of the cerebello-pontine
+angle, and in fractures which traverse the internal auditory meatus.
+Both nerves also may be torn across just before they enter the meatus
+in severe brain injuries apart from fracture. Complete and permanent
+deafness results. Effusion of blood into the nerve sheath, or into the
+internal or middle ear, causes transitory deafness, and the patient
+suffers from noises in the ear, giddiness, and interference with
+equilibration.
+
+IX. The _Glosso-pharyngeal Nerve_ is comparatively seldom injured.
+When it is compressed by a tumour in the region of the medulla, there
+is interference with speech and deglutition, ulcers form on the
+tongue, and oedema of the glottis may supervene.
+
+X. The _Vagus_ or _Pneumogastric Nerve_ is seldom injured within the
+cranial cavity.
+
+In the neck, it is liable to be divided or ligated in the course of
+operations for the removal of malignant or tuberculous glands, for
+goitre, or for ligation of the common carotid. Division of the nerve
+on one side, or even removal of a portion of it, is not as a rule
+followed by any change in the pulse or respiration. If it is
+irritated, however, for example by being grasped with an artery
+forceps, there is inhibition of the heart, and if it is accidentally
+ligated, there may be persistent vomiting.
+
+Division of the main trunk, or of its recurrent branch on one side,
+results in paralysis of the corresponding posterior crico-arytænoid
+muscle--the muscle that opens the glottis. This condition is known as
+unilateral _abductor paralysis_, and is accompanied by interference
+with inspiration and phonation. If both nerves are divided, bilateral
+abductor paralysis results: the vocal cords flap together, producing a
+crowing sound on inspiration and embarrassment of breathing, and
+tracheotomy may be necessary to prevent asphyxia.
+
+The vagus and recurrent nerves have been successfully sutured after
+having been divided accidentally.
+
+XI. _Accessory_ or _Spinal Accessory Nerve_.--This nerve is seldom
+damaged within the skull. It supplies the sterno-mastoid and
+trapezius; but as these muscles usually have an additional nerve
+supply from the cervical plexus, the accessory may be divided, or a
+considerable portion of it resected, as, for example, in the treatment
+of spasmodic torticollis, without any serious disablement resulting.
+It is liable to be accidentally divided in excising malignant or
+tuberculous glands in the neck. When, however, the accessory is the
+only source of supply to these muscles, its division is followed by
+considerable disablement, which appears to depend almost entirely on
+the _paralysis of the trapezius_. The head is inclined slightly
+forward, the shoulder is depressed, the arm hangs heavily by the side
+and is slightly rotated forward, the scapula is drawn away from the
+spine and rotated on its horizontal axis, and there is slight cervical
+scoliosis with the concavity towards the affected side. The trapezius
+is markedly wasted, and is, therefore, less prominent in the neck than
+normally, and the functions of the arm and shoulder are impaired,
+especially in making overhead movements. In time other muscles
+compensate in part for the loss of the trapezius.
+
+When divided accidentally, the nerve should be immediately sutured.
+Even when the paralysis has lasted for some time, secondary suture
+should be attempted; if this is impossible, the peripheral end should
+be anastomosed with the anterior primary divisions of the third and
+fourth cervical nerves (Tubby). Massage, electricity, and the
+administration of tonics are also indicated.
+
+XII. _Hypoglossal Nerve._--This nerve has been ruptured in fractures
+passing through the canalis hypoglossi (anterior condylar foramen). It
+is also liable to be divided in wounds of the submaxillary region--for
+example, in cut throat, or during the operation for ligation of the
+lingual artery, or the removal of diseased lymph glands.
+
+The paralysed half of the tongue undergoes atrophy. When the tongue is
+protruded, it deviates towards the paralysed side, being pushed over
+by the active muscles of the opposite side. Speech and mastication are
+interfered with, the tongue feeling too large for the mouth; in time
+this disability is to a large extent overcome.
+
+#The Cervical Sympathetic.#--The cervical sympathetic cord and its
+ganglia may be injured in the neck by stabs or gun-shot wounds, or in
+the course of deep dissections in the neck; and in injuries of the
+lower part of the cervical enlargement of the spinal cord (p. 417) or
+of the first dorsal nerve root.
+
+Paralysis of the cervical sympathetic is characterised by diminution
+in the size of the pupil on the affected side. The pupil does not
+dilate when shaded, nor when the skin of the neck is pinched--"loss of
+the cilio-spinal reflex." The palpebral fissure is smaller than its
+fellow, and the eyeball sinks into the orbit. There is anidrosis or
+loss of sweating on the side of the face, neck, and upper part of the
+thorax, and on the whole upper extremity of the affected side.
+
+
+
+
+CHAPTER XV
+
+DISEASES OF THE CRANIAL BONES
+
+
+Suppurative periostitis and osteomyelitis--Tuberculosis--
+ Syphilis--Tumours.
+
+#Suppurative Periostitis and Osteomyelitis.#--These conditions may be
+the result of infection through the blood stream, but as a rule they
+follow upon a breach of the surface caused by a wound, a severe burn
+as in epileptics, a tertiary syphilitic ulcer, or a compound fracture
+that has become infected. Sometimes they follow suppuration in the
+middle ear and mastoid or in the frontal sinus, and epithelioma and
+rodent cancer that has ulcerated and become infected after spreading
+from the face towards the vertex. They are occasionally associated
+with acute cellulitis of the scalp. When the infection is blood-borne
+suppuration occurs on both aspects of the bone--a point of importance
+in treatment.
+
+The illness is usually ushered in by a rigor, and this is soon
+followed by other signs of suppuration--high temperature, pain and
+tenderness, and the formation of a fluctuating swelling in relation to
+the bone. When pus forms between the bone and the dura, there is a
+characteristic oedema of the overlying area of the scalp--spoken of as
+_Pott's puffy tumour_--which is of value as indicating the extent of
+the disease in the bone, and of the collection of pus between it and
+the dura. When suppuration occurs under the pericranium, an incision
+gives exit to a quantity of pus, and exposes an area of bare bone. If
+the incision is made early, this bone may soon be covered by
+granulations and recover its vitality; but if operation is delayed, it
+usually undergoes necrosis. The sequestrum that forms includes, as a
+rule, only the outer table, but in some cases the whole thickness of
+the bone undergoes necrosis. In either case the separation of the
+sequestrum is an exceedingly slow process, and is not accompanied by
+the formation of new bone. When the whole thickness of the skull is
+lost, there may be a protrusion of the contents of the skull--hernia
+cerebri; should the patient survive, the gap becomes filled in by a
+dense fibrous membrane which is fused with the dura mater.
+
+Serious complications, in the form of meningitis, cerebral abscess,
+sinus phlebitis, and general pyæmia, are liable to develop at any time
+during the progress of the infection, and we have seen pyæmia develop
+after the suppuration in the skull had been recovered from.
+
+_Treatment._--Early, free, and, if necessary, multiple incisions are
+indicated to admit of disinfection of the affected area, and of the
+establishment of drainage. If the symptoms point to suppuration having
+occurred between the bone and the dura, the skull should be trephined
+and further bone removed with the rongeur forceps as may be required.
+
+Time may be saved by separating the sequestrum with the aid of an
+elevator or sharp spoon, or by chiselling away the dead part till
+healthy vascular bone is reached.
+
+#Tuberculosis# of the cranial vault is usually met with in children.
+The disease commences in the diploë, and results in the formation of a
+central sequestrum, around and beneath which the tuberculous process
+spreads. Granulations form between the skull and the dura, and on the
+outer aspect lifting up the pericranium. The sequestrum is slowly
+thrown off, and when separated is circular like a coin and presents
+worm-eaten edges.
+
+A circumscribed, tender swelling forms, at first yielding an obscure
+sensation of fluctuation, but later, when the pus is no longer
+confined under the pericranium, assuming the characters of a cold
+abscess, which gradually becomes superficial, and eventually bursts
+through the scalp, forming one or more sinuses.
+
+The abscess should be laid open, all tuberculous granulations scraped
+away, and the sequestrum removed, with the aid of the chisel if it has
+not already become loose. On inserting the finger through the opening,
+it appears to penetrate to an alarming extent; this is due to the
+accumulation of tuberculous material between the skull and the dura
+mater, depressing the latter. After healing is completed, a depression
+or gap in the bone remains.
+
+#Syphilis.#--Syphilitic affections occur during the tertiary period of
+the disease, and usually implicate the frontal and parietal bones
+(Fig. 202). They are described in Volume I., p. 462.
+
+[Illustration: FIG. 202.--Skull of woman illustrating the appearances
+of Tertiary Syphilis of Frontal Bone--Corona Veneris--in the healed
+condition.]
+
+#Tumours.#--_Osteoma_ of the skull has been described with diseases of
+bone (Volume I., p. 481).
+
+_Sarcoma._--All forms of sarcoma are met with, implicating the bones
+of the skull. They may originate in the pericranium, in the diploë, or
+in the dura mater, and usually involve the bones of the vault. They
+sometimes occur in children (Fig. 203).
+
+[Illustration: FIG. 203.--Sarcoma of Orbital Plate of Frontal Bone in
+a child at age of 11 months, and 18 months.
+
+(Mr. D. M. Greig's case.)]
+
+The tumour grows chiefly towards the surface, but it also tends to
+invade the cranial cavity, and may thus assume the shape of a
+dumb-bell. Its growth is usually rapid, and results in the formation
+of a diffuse soft swelling, which sometimes pulsates, and sooner or
+later fungates through the skin. On account of its rapid growth the
+tumour is liable to be mistaken for an abscess, and in some cases the
+nature of the disease is only discovered after making an exploratory
+incision, and finding that the finger passes through a softened area
+in the bone.
+
+When the cranial cavity is encroached upon, signs of compression
+ensue. After the tumour has fungated, infective complications within
+the skull are liable to develop. In all cases the prognosis is
+extremely unfavourable.
+
+If diagnosed sufficiently early, an attempt may be made to remove the
+tumour, but often the operation has to be abandoned, either on account
+of the hæmorrhage which attends it, or because of the extent of the
+disease.
+
+The bones of the skull may become the seat of _secondary growths_ by
+the direct spread of cancer from the soft parts, _e.g._ rodent cancer
+(Fig. 204), or by metastasis of cancer or sarcoma from distant parts
+of the body, or of thyreoid tumours. Metastatic cancer would appear to
+be conveyed by the blood stream; it may occur in a diffuse
+form--cancerous osteomalacia--softening the calvaria so that at the
+post-mortem examination it may be removed with the knife instead of
+the saw; or it occurs in a discrete or scattered form, and then the
+macerated skull presents a number of circular and oval perforations.
+
+[Illustration: FIG. 204.--Destruction of Bones of Left Orbit, caused
+by Rodent Cancer. The patient died of septic meningitis.
+
+(Mr. D. M. Greig's case.)]
+
+
+
+
+CHAPTER XVI
+
+THE VERTEBRAL COLUMN AND SPINAL CORD
+
+
+Surgical Anatomy--Injuries of the spinal cord: _Concussion_;
+ _Traumatic hæmatorrachis_; _Traumatic hæmatomyelia_; _Total
+ transverse lesions at different levels_; _Partial lesions_;
+ "_Railway spine_"--Injuries of the vertebral column: _Sprain_;
+ _Isolated dislocation of articular processes_; _Isolated fracture
+ of arches and spinous processes_; _Compression fracture of
+ bodies_--Traumatic spondylitis--Fracture-dislocation--Penetrating
+ wounds.
+
+#Surgical Anatomy.#--The veretebral column is the central axis of the
+skeleton, and affords a protecting casement for the spinal cord.
+
+The spine is movable in all directions--flexion, extension, lateral
+flexion, and rotation around the long axis of the column. Flexion is
+accompanied by compression of the intervertebral discs, and by a
+slight forward movement of each vertebra on the one below it. This
+forward movement is checked by the tension of the ligamenta flava
+which stretch between the laminæ.
+
+In the infant, the spine is either straight or presents one long
+antero-posterior curve with its convexity backwards. With the
+assumption of the erect posture the normal S-shaped curve is
+developed, the cervical and lumbar segments arching forward, while the
+thoracic and sacral segments arch backward.
+
+Through the skin it is often difficult to identify with certainty the
+individual spinous processes. The spine of the seventh cervical
+vertebra,--vertebra prominens--and that of the first thoracic, are
+those most readily felt. While the arm hangs by the side, the root of
+the spine of the scapula is opposite the third thoracic spine, and the
+lower angle of the scapula is on the same level as the seventh. The
+twelfth thoracic vertebra may be recognised by tracing back to it the
+last rib. A line joining the highest points of the iliac crests
+crosses the fourth lumbar spine; and the second sacral spine is on the
+same level as the posterior superior iliac spine. The bodies of the
+upper cervical vertebræ may be felt through the posterior wall of the
+pharynx. The cricoid cartilage corresponds in level to that of the
+lower border of the sixth cervical vertebræ and its transverse
+process.
+
+It is important for surgical purposes to bear in mind that most of the
+spinous processes do not lie on the same level as their corresponding
+bodies. The tips of the spines of the cervical and first two or three
+thoracic vertebræ lie, roughly speaking, opposite the lower edge of
+their respective bodies; those of the remaining thoracic vertebræ lie
+opposite the body of the vertebræ below; while the spines of the
+lumbar vertebræ lie opposite the middle of their corresponding bodies.
+
+The _vertebral canal_ contains the spinal cord so suspended within its
+membranes that it does not touch the bones, and is not disturbed by
+the movements of the vertebral column.
+
+The _membranes_ of the cord are continuous with those of the brain.
+The arachno-pia invests the cord and furnishes a sheath to each of the
+spinal nerves as it passes out through the intervertebral foramen. The
+arachno-pial space is filled with cerebro-spinal fluid, which forms a
+water-bed for the cord, continuous with that at the base of the brain.
+The dura mater constitutes the enveloping sheath of the cord. It hangs
+from the edge of the foramen magnum as a tubular sac, and is connected
+to the bones only opposite the intervertebral foramina, where it is
+prolonged on to each spinal nerve as part of its sheath. Between the
+dura and the bony wall of the canal is a space filled with loose
+areolar tissue and traversed by large venous sinuses. The dura extends
+as far as the upper edge of the sacrum.
+
+The _spinal cord_ extends from the foramen magnum to the level of the
+disc between the first and second lumbar vertebræ. The cervical
+enlargement, which includes the lower four cervical and the upper two
+thoracic segments, ends opposite the seventh cervical spine. The
+lumbar enlargement lies opposite the last three thoracic spines.
+
+One pair of spinal nerves leaves each "segment" of the cord. On
+leaving the cord the nerves incline slightly downwards towards the
+foramina by which they make their exit from the canal. The obliquity
+of the nerves gradually increases, till in the lower part of the
+canal--from the second lumbar vertebra onward--they run parallel with
+the filum terminale and together constitute the cauda equina.
+
+It is to be borne in mind that owing to the fact that the cord is
+relatively shorter than the canal, the tips of the spinous processes
+lie a considerable distance lower than the segments of the cord with
+which they correspond numerically. To estimate the level of the
+segment of the cord which is injured: in the cervical region add one
+to the number of the vertebra counted by the spines; in the upper
+thoracic region add two, in the lower thoracic region add three, and
+this will give the corresponding segment. The lower part of the
+eleventh thoracic spinous process and the space below it are opposite
+the lower three lumbar segments. The twelfth thoracic spinous process
+and the space below it are opposite the sacral segments (Chipault).
+
+_Functions._--The essential function of the spinal cord is to transmit
+motor and sensory impulses between the brain and the rest of the body.
+The general course of the fibres by which these impulses travel has
+already been described (p. 331).
+
+In the grey matter there are groups of nerve-cells--"centres"--which
+govern certain reflex movements. The most important of these--the
+centres for the rectal, the vesical, and the patellar reflexes--are
+situated in the lumbar enlargement.
+
+In the great majority of cases of spinal disease or injury coming
+under the notice of the surgeon the symptoms are bilateral, that is,
+are of the nature of paraplegia, and the whole of the body below the
+level of the segment affected is involved in the paralysis. Lesions
+affecting only one-half of the cord are rare and give rise to symptoms
+which are exceedingly complicated. When the lesion implicates the
+nerve-roots only, the symptoms are confined to the area supplied by
+the affected nerves.
+
+
+INJURIES OF THE SPINAL MEDULLA OR CORD
+
+As the clinical importance of a spinal injury depends almost entirely
+on the degree of damage done to the cord, we shall consider injuries
+of the cord before those of the vertebral column. They will be
+described under the headings: Concussion of the Cord; Traumatic Spinal
+Hæmorrhage; Total Transverse Lesions; Partial Lesions of the Cord and
+Nerve Roots; and "Railway Spine."
+
+#Concussion of the Spinal Cord.#--Concussion of the cord is now
+regarded as a definite entity closely resembling concussion of the
+brain. In some cases, the underlying lesion is of a temporary
+character, usually in the form of a vascular disturbance such as
+oedema or vascular engorgement, and possibly an arterial anæmia; in
+other cases there is definite evidence of injury, of the nature of
+contusion, minute hæmorrhages and blood-staining of the cerebro-spinal
+fluid. It must be clearly stated, that concussion of the cord may be
+attended with an immediate arrest of all its functions closely
+resembling the condition following upon complete crushing of the
+cord--total transverse lesion,--and it may be impossible to
+differentiate between the two conditions until two or more days have
+elapsed after the accident; it is usual, however, in concussion, as
+contrasted with crushing of the cord, that although motor conduction
+may be completely abolished, sensation is only impaired and evidence
+of sensory conduction can usually be elicited. If the lesion is merely
+a concussion, the functions of the cord will be restored within a day
+or two, first to full sensation and then to full motor power.
+
+A classical instance is that of a late Governor-General of India, who
+on being thrown in the hunting-field was found to be paralysed in all
+four extremities; Paget diagnosed a total transverse lesion of the
+cervical cord with the necessary inference that it would inevitably
+have a fatal termination. The fact that the patient recovered
+completely, and was later able to fill two Viceroyalties, proved that
+the lesion must have been of the nature of a concussion of the cord.
+
+The _treatment_ consists in adopting the same measures as in crushing
+of the cord, while careful watch is observed for the signs of recovery
+of conduction. The usual order of recovery is first the reflexes, then
+sensation, and lastly, the motor functions.
+
+#Traumatic Spinal Hæmorrhage.#--Hæmorrhage into the vertebral canal is
+a common accompaniment of all forms of injury to the spine, but the
+lower cervical region is the common seat of the severe type of
+hæmorrhage resulting from acute flexion of the spine such as occurs
+especially in a fall on the head from a horse or a vehicle in motion.
+The blood may be effused around the cord--between it and the
+dura--(extra-medullary), or into its substance (intra-medullary).
+
+_Extra-medullary Hæmorrhage--Hæmatorrachis._--The symptoms associated
+with extra-medullary hæmorrhage are at first of an irritative
+kind--muscular cramps and jerkings, radiating pains along the course
+of the nerves pressed upon, and hyperæsthesia. It is only when the
+blood accumulates in sufficient quantity to exert definite pressure on
+the cord that symptoms of paralysis ensue, and it is characteristic of
+extra-medullary hæmorrhage that the paralysis comes on gradually. When
+the effusion is in the cervical region--the commonest situation--the
+arms are more affected than the legs. The paralysis of the arms is of
+the lower neurone type, and the muscles are flaccid and undergo
+atrophy; the legs may exhibit a more complete degree of paralysis of
+the upper neurone type, with exaggeration of the knee-jerks. Blood may
+trickle down the canal and collect at a level lower than that of the
+lesion which causes the bleeding, and produce paralysis which slowly
+spreads from below upwards--_gravitation paraplegia_ (Thorburn). There
+is blood in the cerebro-spinal fluid.
+
+The _treatment_ is on the same lines as in total transverse lesions.
+When there is evidence of progressive pressure on the cord, the blood
+is removed by spinal puncture if possible, or by laminectomy performed
+at the level suggested by the symptoms; operation is, however, rarely
+called for.
+
+_Intra-medullary Hæmorrhage--Hæmatomyelia._--Traumatic hæmorrhage into
+the substance of the cord occurs almost invariably in the lower
+cervical region, and results from forcible stretching of the cord by
+acute flexion of the neck. The blood is usually effused into the
+anterior cornua of the grey matter and into the central canal, and
+there is a varying degree of laceration of the nerve tissue, in
+addition to pressure exerted by the extravasated blood.
+
+The severity of the _clinical features_ depends upon the extent of the
+lesion. In contrast with what results in extra-medullary hæmorrhage,
+the symptoms are paralytic from the outset.
+
+When the hæmorrhage is only sufficient to cause _pressure_ on the
+cord, the paralysis is usually most marked in the lower extremities
+because the conducting fibres are pressed upon. This is associated
+with evanescent anæsthesia for temperature and pain, while tactile
+sensibility is preserved. There is retention of urine and fæces, and
+in young men, priapism. As the fibres which supply the dilator pupillæ
+are involved, the pupils are contracted. The symptoms gradually
+subside as the extravasated blood is re-absorbed, sensation being
+restored before motion, and recovery may be comparatively rapid.
+
+When the blood extravasated in the cord causes disintegration of its
+substance, there is complete paralysis with atrophy, and anæsthesia in
+the area supplied by the segments of the cord directly implicated. The
+paralysis in the parts below the lesion assumes the spastic form. As
+the lesion is usually in the upper part of the cord, it is the arms
+that are most frequently affected. In less severe degrees of damage
+the paralysis of the most distant parts, _e.g._ the feet, may be
+transitory. Even in cases in which the loss of function below the
+level of the lesion has been complete, recovery may take place, but it
+is apt to be marred by a spastic condition of the muscles concerned,
+due to sclerotic changes in the cord.
+
+Except that operative treatment is contra-indicated, the _treatment_
+is the same as for extra-medullary hæmorrhage, and at a later period
+measures may be employed to relieve the spastic condition of the
+muscles.
+
+#Total Transverse Lesions.#--Total transverse lesions, that is, those
+in which the cord is completely crushed or torn across, are much more
+common than partial lesions, being an almost invariable accompaniment
+of a complete dislocation or of a fracture-dislocation of the spine.
+Even when the displacement of the vertebræ is only partial and
+temporary, the cord may be completely torn across. Similar lesions may
+result from stabs or bullet-wounds.
+
+From the records of cases in which the vertebræ were injured by modern
+rifle bullets, even although the bony walls of the spinal canal had
+not been fractured and no hæmorrhage had occurred within the spinal
+canal, the cord in the vicinity was degenerated into a "custard-like
+material" incapable of any conducting power (Makins). According to
+Stevenson, "this must have been due to the vibratory concussion
+communicated to it by the passage of the bullet at a high rate of
+velocity." The importance of this observation lies in the fact that in
+such cases no benefit can follow operative interference.
+
+The _clinical features_ vary with the level at which the cord is
+injured, and the diagnosis as to the nature and site of the lesion is
+to be made by a careful analysis of the symptoms. By gently passing
+the fingers under the patient's back as he lies recumbent, any
+irregularity in the spinous processes or laminæ may be detected, but
+movement of the patient to admit of a more direct examination of the
+spine is attended with considerable risk, and should be avoided.
+Skiagrams are indispensable, as they show the exact site and nature of
+the lesion.
+
+_Immediate Symptoms._--At whatever level the cord is damaged there is
+immediate and complete paralysis of motion and sensation (paraplegia)
+below the seat of injury, and the paralysed limbs at once become
+flaccid. On careful examination, a narrow zone of hyperæsthesia may be
+mapped out above the anæsthetic area, and the patient may complain of
+radiating pain in the lines of the nerves derived from the segments of
+the cord directly implicated. In complete transverse lesions the
+paralytic symptoms are symmetrical; any marked difference on the two
+sides indicates an incomplete lesion.
+
+Retention of urine and retention or incontinence of fæces are constant
+symptoms. In young men priapism is common--the corpus cavernosum penis
+is filled with blood without actual erection. There is other evidence
+of vaso-motor paralysis in the form of dilatation of the subcutaneous
+vessels, and local elevation of temperature in the paralysed parts.
+The deep reflexes, including the tendon reflexes, are permanently
+lost.
+
+Unless regularly emptied by the catheter, the bladder becomes
+distended, and there is dribbling of urine--the overflow from the full
+bladder. As the bladder is unable to empty itself, and its trophic
+nerve supply is interfered with, the use of the catheter involves
+considerable risk of infection, unless the most rigid precautions are
+adopted. Hypostatic pneumonia is liable to develop. Great care in
+nursing is necessary to prevent trophic sores occurring over parts
+subjected to pressure, such as the sacrum, the scapulæ, the heels, and
+the elbows.
+
+_Later symptoms_ are the result of descending degeneration taking
+place in the antero-lateral columns of the cord. There are often
+violent and painful jerkings of the muscles of the limbs; the muscles
+become rigid and the limbs flexed.
+
+_Treatment._--When the cord is completely divided, no benefit can
+follow operative interference, and treatment is directed towards the
+prevention of infective complications from cystitis and bed-sores.
+
+#Injuries of the Cord at Different Levels.#--_Cervical
+Region._--Complete lesions of the _first four cervical segments_--that
+is, above the level of the disc between the third and fourth cervical
+vertebræ--are always rapidly, if not instantaneously, fatal, as
+respiration is at once arrested by the destruction of the fibres
+which go to form the phrenic nerve. It is from this cause that death
+results in judicial hanging.
+
+In lesions between the _fifth cervical and first thoracic segments
+inclusive_, all four limbs are paralysed. Sensation is lost below the
+second intercostal space. The parts above this level retain sensation,
+as they are supplied by the supra-clavicular nerves which are derived
+from the fourth cervical segment (Fig. 205). Recession of the
+eyeballs, narrowing of the palpebral fissures, and contraction of the
+pupils result from paralysis of the cervical sympathetic. Respiration
+is almost exclusively carried on by the diaphragm, and hiccup is
+often persistent. There is at first retention of urine, followed by
+dribbling from overflow, and sugar is sometimes found in the urine.
+Priapism is common. The pulse is slow (40 to 50) and full; and the
+temperature often rises very high--a symptom which is always of grave
+omen.
+
+[Illustration: FIG. 205.--Distribution of the Segments of the Spinal
+Cord.
+
+(After Kocher.)]
+
+When the lesion is confined to the _sixth cervical segment_, the arms
+assume a characteristic attitude as a result of the contraction of the
+muscles supplied from the higher segments. The upper arm is abducted
+and rotated out, the elbow is sharply flexed, and the hand supinated
+and flexed (Fig. 206). Sensation is retained along the radial side of
+the limb.
+
+[Illustration: FIG. 206.--Attitude of Upper Extremities in Traumatic
+Lesions of the Sixth Cervical Segment. The prominence of the abdomen
+is due to gaseous distension of the bowel.]
+
+Total lesions of the lower cervical segments are usually fatal in from
+two to three days to as many weeks, from embarrassment of respiration
+and hypostatic pneumonia.
+
+When the lesion is confined to _the first thoracic segment_, the
+attitude of the arms is usually that of slight abduction at the
+shoulder and flexion at the elbow, the forearms lie semi-pronated on
+the chest or belly, and there is slight flexion of the fingers. There
+is complete anæsthesia as high as the level of the second interspace,
+and along the distribution of the ulnar nerve (Fig. 205); the
+respiration is entirely diaphragmatic; and the ocular changes
+depending on paralysis of the cervical sympathetic are present.
+
+_Thoracic Region._--In injuries of the thoracic region--second to
+eleventh thoracic segments inclusive--the anæsthesia below the level
+of the lesion is complete and its upper limit runs horizontally round
+the body, and not parallel with the intercostal nerves. Above the
+anæsthetic area there is a zone of hyperæsthesia, and the patient
+complains of a sensation as if a band were tightly tied round the
+body--"girdle-pain."
+
+The motor paralysis and the anæsthesia are co-extensive. The
+intercostal muscles below the seat of the lesion and the abdominal
+muscles are paralysed. The respiratory movements are thus impeded,
+and, as the patient is unable to cough, mucus gathers in the
+air-passages and there is a tendency to broncho-pneumonia. As the
+patient is unable to aid defecation or to expel flatus by straining,
+the bowel is liable to become distended with fæces and gas, and the
+meteorism which results adds to the embarrassment of respiration by
+pressing on the diaphragm. There is retention of urine followed by
+dribbling from overflow. As the reflex arc is intact there may be
+involuntary and unconscious micturition whenever the bladder fills.
+
+If infection of the bladder and the formation of bed-sores are
+prevented, the patient may live for months or even for years. At any
+time, however, infection of the bladder may occur and spread to the
+kidneys, setting up a pyelo-nephritis; or the patient may develop an
+ascending myelitis, and these conditions are the most common causes of
+death.
+
+_Lumbo-sacral Region._--All the spinal segments representing the
+lumbar, sacral, and coccygeal nerves lie between the level of the
+eleventh thoracic and first lumbar vertebræ. Injuries of the lower
+thoracic and upper lumbar vertebræ, therefore, may produce complete
+paralysis within the area of distribution of the lumbar and sacral
+plexuses. The anæsthesia reaches to about the level of the umbilicus.
+There is incontinence of urine and fæces from the first. Priapism is
+absent. Bed-sores and other trophic changes are common, and there is
+the usual risk of complications in relation to the urinary tract.
+
+_Conus Medullaris._--A lesion confined to the conus medullaris may
+result from a fall in the sitting position. It is attended with slight
+weakness of the legs, anæsthesia involving a saddle-shaped area over
+the buttocks and back of the thighs, the perineum, scrotum, and penis.
+The urethra and anal canal are insensitive, and there is paralysis of
+the levatores ani, the rectal and the vesical sphincters. The testes
+retain their sensation.
+
+_Cauda Equina._--As the cord terminates opposite the lower border of
+the first lumbar vertebra, injuries below this level implicate the
+cauda equina. The extent of the motor and sensory paralysis varies
+with the level of the lesion and with the particular nerves injured.
+Sometimes it is complete, sometimes, selective. As a rule all the
+muscles of the lower extremity are paralysed, except those supplied by
+the femoral (anterior crural), obturator, and superior gluteal nerves.
+The perineal and penile muscles are also implicated. There is
+anæsthesia of the penis, scrotum, perineum, lower half of the buttock,
+and the entire lower extremity, except the front and lateral aspects
+of the thigh, which are supplied by the lateral cutaneous nerve and
+the cutaneous branches of the femoral (anterior crural). There is
+incontinence of urine and fæces. The prognosis is more favourable than
+in lesions affecting the cord itself, and the only risk to life is the
+occurrence of infective complications.
+
+#Partial Lesions of the Cord and Nerve Roots.#--Partial lesions, such
+as bruises, lacerations, or incomplete ruptures, are always attended
+with hæmorrhage into the substance of the cord, and usually result
+from distortions or incomplete fractures and dislocations of the
+spine, or from bullet wounds. They are comparatively rare.
+
+When the _nerve roots_ alone are injured, sensory phenomena
+predominate. Formication, radiating pains, and neuralgia are present
+in the area of distribution of the nerves implicated. There is motor
+paresis or paralysis, which may disappear either suddenly or
+gradually, or may persist and be followed by atrophy of the muscles
+concerned. In contrast to what is observed from pressure by tumours
+and inflammatory products, twitchings and cramps are rare.
+
+In _partial lesions of the cord_ the motor phenomena predominate.
+Paresis extends to the whole of the motor area below the seat of the
+lesion, but the weakness is more marked on one side of the body. The
+distal parts--feet and legs--suffer more than the proximal--arms and
+hands, and the extensors more than the flexors. The paresis develops
+slowly, varies in extent and degree, and may soon improve. Vaso-motor
+disturbances accompany the motor symptoms. Irritative phenomena, such
+as twitchings or contractures, may come on later.
+
+The deep reflexes, particularly the knee-jerks, may be absent at
+first, but they soon return, and are usually exaggerated; a
+well-marked Babinski response may appear later. Abolition of the
+reflexes, therefore, does not necessarily indicate complete
+destruction of the cord, but their return is conclusive evidence that
+the lesion is a partial one. It is necessary, therefore, to defer
+judgment until it is determined whether the abolition of the reflexes
+is temporary or permanent.
+
+Sensory disturbances may be entirely absent. When present, they are
+incomplete, and are chiefly irritative in character. They may not
+reach the same level as the motor phenomena, and the different sensory
+functions are unequally disturbed in the areas corresponding to the
+several nerve roots. There is sometimes a combination of hyperæsthesia
+on one side and anæsthesia on the other.
+
+Retention of urine is not always present even in those cases in which
+the limbs are completely paralysed, as the fibres of one side of the
+cord are sufficient to maintain the functions of the bladder. The
+patient may be aware that the bladder is full, although he is unable
+to empty it. Similarly, sensation in the rectum and anus may be
+retained although the control of the sphincters is lost. Priapism may
+be present, but tends to disappear.
+
+In partial lesions, the difficulties of diagnosis are sometimes
+increased by the occurrence of hæmorrhage into the substance of the
+cord, so that symptoms of generalised pressure are superadded to those
+of the partial lesion. In time the symptoms due to the intra-medullary
+hæmorrhage pass off, but those due to the tearing of the cord persist.
+
+The _prognosis_ is generally favourable, but must be guarded, as
+permanent organic changes in the cord may take place, causing a
+spastic condition of the muscles. When recovery is taking place the
+first signs are the return of the knee-jerks, and a gradual change in
+the limbs from the flaccid to the spastic condition. Sensibility
+returns in the order--touch, pain, temperature, and the parts supplied
+by the lowest sacral segments usually become sentient first. Voluntary
+power returns earlier in the flexors than in the extensors, and
+flexion of the toes is almost invariably the earliest voluntary
+movement possible. Infection from bed-sores or from the urinary tract
+is the most common cause of death in cases that terminate fatally.
+
+The _treatment_ is carried out on the same lines as for total lesions.
+Laminectomy, however, is indicated when there is reason to believe
+that the pressure is due to some cause, such as a blood-clot or a
+displaced fragment of bone, which is capable of being removed.
+
+In practice when a person has lost the power of the lower extremities
+as the result of an accident, there are three conditions requiring
+ultimate differentiation--a concussion of the cord alone, a total
+transverse lesion and a partial lesion of the cord together with
+concussion. It must again be emphasised that it may not be possible to
+differentiate between these immediately after the accident. Two or
+three days may elapse before it is possible to give a definite
+opinion.
+
+"#Railway Spine.#"--This term is employed to indicate a disturbance of
+the nervous system which may develop in persons who have been in
+railway accidents, but a similar group of symptoms is met with in men
+engaged in laborious occupations such as coal-miners, who, after an
+injury to the back, develop symptoms referable to the nervous system
+on account of which they claim compensation not infrequently in the
+law-courts. It is a remarkable fact that it seldom occurs in railway
+employees, or in passengers who sustain gross injuries, such as
+fractures or lacerated wounds.
+
+_Clinical Features._--The patient usually gives a history of having
+been forcibly thrown backwards and forwards across the carriage at the
+time of the accident. He is dazed for a moment and suffers from shock
+or, it may be, is little the worse at the time, and is able to
+continue his journey. On reaching his destination, however, he feels
+weak and nervous, and complains of pain in his back and limbs. There
+is rarely any sign of local injury. For a few days he may be able to
+attend to business, but eventually feels unfit, and has to give it up.
+
+The symptoms that subsequently develop are for the most part
+subjective, and it is difficult therefore either to corroborate or to
+refute them; it will be observed that while some of them are referable
+to the cord the greater number are referable to the brain. They
+usually include a feeling of general weakness, nervousness, and
+inability to concentrate the attention on work or on business matters.
+The patient is sleepless, or his sleep is disturbed by terrifying
+dreams. His memory is defective, or rather selective, as he can
+usually recall the circumstances of the accident with clearness and
+accuracy. He becomes irritable and emotional, complains of sensations
+of weight or fullness in the head, of temporary giddiness, is
+hypersensitive to sounds, and sometimes complains of noises in the
+ears. There are weakness of vision and photophobia, but there are no
+ophthalmoscopic changes. He has pain in the back on making any
+movement, and there is a diffuse tenderness or hyperæsthesia along the
+spine. There is weakness of the limbs, sometimes attended with
+numbness, and he is easily fatigued by walking. There may be loss of
+sexual power and irritability of the bladder, but there is seldom any
+difficulty in passing urine. The patient tends to lose weight, and may
+acquire an anxious, careworn expression, and appear prematurely aged.
+Special attention should be directed to the condition of the deep
+reflexes and to the state of the muscles, as any alteration in the
+reflexes or atrophy of the muscles indicates that some definite
+organic lesion is present.
+
+As the symptoms are so entirely subjective, it is often extremely
+difficult to exclude the possibility of malingering; it is essential
+that the patient should be examined with scrupulous accuracy at
+regular intervals and careful notes made for purposes of comparison,
+and also that the doctor should retain an impartial attitude and not
+develop a bias either in favour of or against the patient's claim for
+compensation.
+
+So long as litigation is pending the patient derives little benefit
+from treatment, but after his mind is relieved by the settlement of
+his claim--whether favourable to him or not--his health is usually
+restored by the general tonic treatment employed for neurasthenia.
+
+
+INJURIES OF THE VERTEBRAL COLUMN
+
+_Partial_ lesions include twists or sprains, isolated dislocations of
+articular processes, isolated fractures of the arches and spinous
+processes, and isolated fractures of the vertebral bodies. The most
+important _complete_ lesions are total dislocations and
+fracture-dislocations.
+
+In partial lesions, the continuity of the column as a whole is not
+broken, and the cord sustains little damage, or may entirely escape;
+in complete lesions, on the other hand, the column is broken and the
+cord is always severely, and often irreparably, damaged.
+
+Twists and dislocations are most common in the cervical region, that
+is, in the part of the spine where the forward range of
+movement--flexion--is greatest. Fractures are most common in the
+lumbar region, where flexion is most restricted. Fracture-dislocations
+usually occur where the range of flexion is intermediate, that is, in
+the thoracic region.
+
+In all lesions accompanied by displacement, the upper segment of the
+spine is displaced forwards.
+
+#Twists# or #sprains# are produced by movements that suddenly put the
+ligamentous and muscular structures of the spine on the stretch--in
+other words, by lesser degrees of the same forms of violence as
+produce dislocation. When the interspinous and muscular attachments
+alone are torn, the effects are confined to the site of these
+structures, but when the ligamenta flava are involved, blood may be
+extravasated and infiltrate the space between the dura and the bone
+and give rise to symptoms of pressure on the cord. The nerve roots
+emerging in relation to the affected vertebræ may be stretched or
+lacerated, and as a result radiating pains may be felt in the area of
+their distribution.
+
+In the _cervical_ region, distortion usually results either from
+forcible extension of the neck--for example from a violent blow or
+fall on the forehead forcing the head backwards--or from forcible
+flexion of the neck. The patient complains of severe pain in the neck,
+and inability to move the head, which is often rigidly held in the
+position of wry-neck. There is marked tenderness on attempting to
+carry out passive movements, and on making pressure over the affected
+vertebræ or on the top of the head. The maximum point of tenderness
+indicates the vertebra most implicated. In diagnosis, fracture and
+dislocation are excluded by the absence of any alteration in the
+relative positions of the bony points, and by the fact that passive
+movements, although painful, are possible in all directions.
+
+In the _lumbar_ region sprains are usually due to over-exertion in
+lifting heavy weights, or to the patient having been suddenly thrown
+backwards and forwards in a railway collision. The attachments of the
+muscles of the loins are probably the parts most affected. The back is
+kept rigid, and there is pain on movement, particularly on rising from
+the stooping posture.
+
+_Treatment._--Unless carefully treated, a sprain of the spine is
+liable to cause prolonged disablement. The patient should be kept at
+rest in bed, and, when the injury is in the cervical region, extension
+should be applied to the head with the nape of the neck supported on a
+roller-pillow. Early recourse should be had to massage, but active
+movements are forbidden till all acute symptoms have disappeared. In
+patients predisposed to tuberculosis, the period of complete rest
+should be materially prolonged.
+
+#Isolated Dislocation of Articular Processes.#--This injury, which is
+most frequently met with in the cervical region and is nearly always
+unilateral, is commonly produced by the patient falling from a vehicle
+which suddenly starts, and landing on the head or shoulders in such a
+way that the neck is forcibly flexed and twisted. The articular
+process of the upper vertebra passes forward, so that it comes to lie
+in front of the one below.
+
+The pain and tenderness are much less marked than in a simple twist,
+as the ligaments are completely torn and are therefore not in a state
+of tension. The patient often thinks lightly of the condition at the
+time of the accident, and may only apply for advice some time after
+on account of the deformity. The head is flexed and the face turned
+towards the side opposite the dislocation, the attitude closely
+resembling that of ordinary wry-neck, only it is the opposite
+sterno-mastoid that is tight. The bony displacement is best recognised
+by palpating the transverse process of the dislocated vertebra. In the
+case of the upper vertebræ this is done from the pharynx, in the lower
+between the sterno-mastoid and the trachea. There is pain on
+attempting movement, and tenderness on pressure, particularly on the
+side that is not displaced, as the ligaments there are on the stretch.
+There are often radiating pains along the line of the nerves emerging
+between the affected vertebræ. As the bodies are not separated, damage
+to the cord is exceptional. The lesion can usually be recognised in a
+radiogram.
+
+_Treatment._--Reduction should be attempted at once, before the
+vertebræ become fixed in their abnormal position. Under anæsthesia
+gentle extension is made on the head by an assistant, and the abnormal
+attitude is first slightly exaggerated to relax the ligaments and to
+restore mobility to the locked articular processes. The head is then
+forcibly flexed towards the opposite side, after which it can be
+rotated into its normal attitude (Kocher). Haphazard movements to
+effect reduction are attended with risk of damaging the cord. After
+reduction has been effected, the treatment is the same as that of a
+sprain.
+
+#Isolated Fractures of the Arches, Spinous and Transverse
+Processes.#--Fractures of the arches and spinous processes usually
+result from direct violence, such as a blow or a bullet wound, and are
+accompanied by bruising of the overlying soft parts, irregularity in
+the line of the spines, and by the ordinary signs of fracture.
+Skiagrams are useful in showing the exact nature of the lesion. These
+fractures are most common in the lower cervical and in the thoracic
+regions, where the spines are most prominent and therefore most
+exposed to injury.
+
+In many cases there are no symptoms of damage to the cord or spinal
+nerves, but when both laminæ give way the posterior part of the arch
+may be driven in and cause direct pressure on the cord, or blood may
+be effused between the bone and the dura. In such cases immediate
+operation is indicated. When there are no cord symptoms, the treatment
+consists in securing rest, with the aid of extension, if necessary,
+for several weeks until the bones are reunited.
+
+The use of the X-rays has shown that one or more of the _transverse
+processes of the lumbar vertebræ_ may be chipped off by direct
+violence. The symptoms are pain and tenderness in the region of the
+fracture, and marked restriction of movement, especially in the
+direction of flexion. This lesion may explain some of the cases of
+persistent pain in the back following injuries in workmen. It is
+important to remember, however, that in a radiogram an un-united
+epiphysis may simulate a fracture.
+
+#Isolated Fracture of the Bodies--"Compression Fracture."#--The
+"compression fracture" consists in a crushing from above downwards of
+the bodies--and the bodies only--of one or more vertebræ. It is due to
+the patient falling from a height and landing on the head, buttocks,
+or feet in such a way that the force is transmitted along the bodies
+of the vertebræ while the spine is flexed.
+
+If the patient lands on his head, the compression fracture usually
+involves the lower cervical or upper thoracic vertebræ. When he lands
+on his buttocks or feet it is usually the lumbar or the lower thoracic
+vertebræ that are fractured (Fig. 207).
+
+[Illustration: FIG. 207.--Compression Fracture of Bodies of Third and
+Fourth Lumbar Vertebræ. Woman, æt. 28, who fell three storeys and
+landed on the buttocks.]
+
+As a rule, there are no external signs of injury over the spine. The
+sternum, however, is often fractured, and irregularity and
+discoloration may be detected on examining the front of the chest. The
+recognition of a fracture of the sternum should always raise the
+suspicion of a fracture of the spine. On examination of the back a
+more or less marked projection of the spinous processes of the damaged
+vertebræ may be recognised. In the cervical and lumbar regions this
+projection may merely obliterate the normal concavity. The spinous
+process which forms the apex of the projection belongs to the vertebra
+above the one that is crushed. The cord usually escapes, but the
+nerves emerging in relation to the damaged vertebræ may be bruised,
+and this gives rise to girdle-pain.
+
+Local tenderness is elicited on pressing over the affected vertebræ.
+As might be expected from the nature of the accident producing this
+lesion, it is often associated with serious injuries to the head,
+limbs, or internal organs which gravely affect the prognosis.
+
+The _treatment_ consists in taking the pressure off the injured
+vertebræ in order that the reparative material may be laid down in
+such a way as to restore the integrity of the column. In the cervical
+region, extension is applied to the head, and a roller-pillow placed
+beneath the neck. In the lumbar region, the extension is applied
+through the lower limbs, and the pillow placed under the loins. The
+patient is confined to bed for six or eight weeks, and before he gets
+up a poroplastic or plaster-of-Paris jacket is applied. This is worn
+for a month or six weeks.
+
+#Traumatic Spondylitis.#--This condition is liable to develop in
+patients who have sustained a severe injury to the back. It is
+believed to originate in a compression fracture which has not been
+recognised, and is probably due to the callus thrown out for the
+repair of the fracture being subjected to strain and pressure too
+early, or to a progressive softening of the injured vertebra and of
+the bodies of those adjacent to it. This leads to an alteration in the
+shape of the affected bones, which can be demonstrated by means of the
+X-rays. The usual history is that some considerable time after the
+patient has resumed work he suffers from pain in the back, and
+radiating pains round the body and down the legs. He becomes more and
+more unfit for work, and a marked projection appears in the back and
+may come to involve several vertebræ. While the condition is
+progressive, the prominent vertebræ are painful and tender. In course
+of time the softening process is arrested, and the affected bones
+become fused, so that the area of the spine involved becomes rigid and
+permanent deformity results. So long as the condition is progressive
+the patient should be kept in the recumbent and hyper-extended
+position over a roller-pillow and, when he gets up, the spine should
+be supported by a jacket.
+
+#Dislocation and Fracture-Dislocation.#--It is seldom possible at the
+bedside to distinguish between a complete dislocation of the spine and
+a fracture-dislocation. _Fracture-dislocation_ is by far the more
+common lesion of the two, and is the injury popularly known as a
+"broken back." It may occur in any part of the column, but is most
+frequently met with in the thoracic and thoracico-lumbar regions. It
+usually results from forcible flexion of the spine, as, for example,
+when a miner at work in the stooping posture is struck on the
+shoulders by a heavy fall of coal. The spine is acutely bent, and
+breaks at _the angle of flexion and not at the point struck_. The
+lesion consists in a complete bilateral dislocation of the articular
+processes, together with a fracture through one or more of the bodies.
+This fracture is usually oblique, running downwards and forwards. The
+upper fragment with the segment of the spine above it is displaced
+downwards and forwards, and the cord is crushed between the posterior
+edge of the broken body and the arch of the vertebra above it (Fig.
+208). In almost every case the cord is damaged beyond repair.
+
+[Illustration: FIG. 208.--Fracture--Dislocation of Ninth Thoracic
+Vertebra, showing downward and forward displacement of upper segment,
+and compression of cord by upper edge of lower segment.
+
+(Anatomical Museum, University of Edinburgh.)]
+
+_Total dislocation_, in which the articular processes on both sides
+are displaced and the contiguous intervertebral disc separated, is
+rare, and is met with chiefly in the lower cervical region.
+
+_Clinical Features._--The outstanding symptoms of total lesions are
+referable to the damage inflicted on the cord. The diagnosis should
+always be made by a consideration of the mechanism of the injury and
+the condition of the nerve functions below the lesion. On no account
+should the patient be moved to enable the back to be examined, as this
+is attended with risk of increasing the displacement and causing
+further damage to the cord. On passing the fingers under the back as
+the patient lies recumbent, it is usually found that there is some
+backward projection of the spinous processes, the most prominent
+being that of the broken vertebra. The spinous process immediately
+above it is depressed as the upper segment has slipped forward. Pain,
+tenderness, swelling and discoloration may be present over the injured
+vertebræ. It is usually possible to have skiagrams taken without risk
+of further damage to the spine. There is complete loss of motion and
+sensation below the seat of the lesion. The symptoms of total
+transverse lesions of the cord at different levels have already been
+described (p. 416).
+
+_Treatment._--An attempt may be made to reduce the displacement under
+anæsthesia, gentle traction being made in the long axis of the spine
+by assistants, while the surgeon attempts to mould the bones into
+position. No special manipulations are necessary, as the ligaments are
+extensively torn, and the bones are, as a rule, readily replaced. A
+roller-pillow is placed under the seat of fracture to allow the weight
+of the body above and below to exert gentle traction, and so to
+relieve pressure on the cord. Operative treatment is almost never of
+any avail, as the cord is not merely pressed upon, but is severely
+crushed, or even completely torn across. Even when the cord is only
+partially torn, operative treatment is not likely to yield better
+results than are obtained by reduction and extension. The usual
+precautions must be taken to prevent cystitis and bed-sores.
+
+Total fracture-dislocation between the _atlas_ and _epistropheus_
+(axis), if attended with displacement, is instantaneously fatal (Fig.
+209). This is the osseous lesion that occurs in judicial hanging.
+Fracture of the odontoid process may occur, however, without
+displacement, the transverse ligament retaining the fragment in
+position and protecting the cord from injury. The patient complains of
+stiff neck and pain, and the lesion may be recognised in a radiogram.
+A number of cases are recorded in which death took place suddenly
+weeks or months after such an injury, from softening of the transverse
+ligament and displacement of the bones.
+
+[Illustration: FIG. 209.--Fracture of Odontoid Process of Axis
+Vertebra.]
+
+#Penetrating Wounds.#--These result from stabs or gun-shot accidents,
+and are practically equivalent to compound fractures of the spine;
+their severity depends on the extent of the damage done to the cord,
+and on whether or not the wound is infected. In many cases the
+condition is complicated by injuries of the pleural or peritoneal
+cavities and their contained viscera, or by injury of the trachea,
+oesophagus, or large vessels and nerves of the neck. When the
+membranes of the cord are opened, the profuse and continued escape of
+cerebro-spinal fluid may prove a serious complication.
+
+_Treatment._--The wound of the soft parts is treated on the usual
+lines. When the spinous processes and laminæ are driven in upon the
+cord, they must be elevated at once by operation. In injuries
+involving the lumbo-sacral region it is sometimes advisable to perform
+laminectomy for the purpose of suturing divided nerve cords.
+
+When there is evidence that the spinal cord is completely divided,
+operation is contra-indicated. Attempts have been made to unite the
+two ends of the divided cord by sutures, but there is as yet no
+authentic record of restoration of function following the operation.
+
+
+
+
+CHAPTER XVII
+
+DISEASES OF THE VERTEBRAL COLUMN AND SPINAL CORD
+
+
+POTT'S DISEASE: _Pathology_; _Clinical features_--Pott's disease as it
+ affects different regions of the spine--Disease of the sacro-iliac
+ joint; Syphilitic disease of spine; Tumours of vertebræ;
+ Hysterical spine; Acute osteomyelitis; Rheumatic spondylitis;
+ Arthritis deformans; Coccydynia; Tumours of cord and
+ membranes--Spinal meningitis; Spinal myelitis--Congenital
+ deformities: _Spina bifida_; _Congenital sacro-coccygeal tumours_.
+ Congenital sacro-coccygeal sinuses and fistulæ.
+
+
+TUBERCULOUS DISEASE OF THE SPINE--POTT'S DISEASE
+
+Percival Pott, in 1779, first described a disease of the vertebral
+column which is characterised by erosion and destruction of the bodies
+of the vertebræ. It is liable to produce an angular deformity of the
+spine, and to be associated with abscess formation and with nervous
+symptoms referable to pressure on the cord. This disease is now known
+to be tuberculous. It may occur at any period of life, but in at least
+50 per cent. of cases it attacks children below the age of ten and
+rarely commences after middle life.
+
+#Morbid Anatomy.#--The tuberculous process may affect any portion of
+the spine, and as a rule is limited to one region; several vertebræ
+are usually simultaneously involved. The disease may begin either in
+the interior of the bodies of the vertebræ--tuberculous
+osteomyelitis--or in the deeper layer of the periosteum on the
+anterior surface of the bones--tuberculous periostitis.
+
+_Osteomyelitis_ is the form most frequently met with in children. The
+disease commences as a tuberculous infiltration of the marrow, which
+results in softening of the bodies of the affected vertebræ,
+particularly in their anterior parts, and, as the disease progresses,
+caseation and suppuration ensue, and the destructive process spreads
+to the adjacent intervertebral discs. In some cases a sequestrum is
+formed, either on the surface or in the interior of a vertebra. The
+pus usually works its way towards the front and sides of the bones,
+and burrows under the anterior longitudinal (common) ligament. Less
+frequently it spreads towards the vertebral canal and accumulates
+around the dura, causing pressure on the cord.
+
+The compression of the diseased vertebræ by the weight of the head and
+trunk above the seat of the lesion, and by the traction of the muscles
+passing over it, produces angling of the vertebral column. The
+anterior portions of the bodies being more extensively destroyed, sink
+in, while the less damaged posterior portions and the intact articular
+processes prevent complete dislocation. In this way the integrity of
+the canal is maintained, and the cord usually escapes being pressed
+upon. The spinous processes of the affected vertebræ project and form
+a prominence in the middle line of the back. When, as is usually the
+case, only two or three vertebræ are implicated, this prominence takes
+the form of a sharp angular projection, while if a series of vertebræ
+are involved, the deformity is of the nature of a gentle backward
+curve (Fig. 210).
+
+[Illustration: FIG. 210.--Tuberculous Osteomyelitis affecting several
+vertebræ at Thoracico-lumbar Junction.]
+
+The _periosteal form_ of vertebral tuberculosis is that most
+frequently met with in adults. The disease begins in the deeper layer
+of the periosteum on the anterior aspect of the vertebræ, and extends
+along the surface of the bones, causing widespread superficial caries.
+It may attack the discs at their margins, and spread inwards between
+the discs and the contiguous vertebræ. Owing to the comparatively
+wide area of the spine implicated, this form of the disease is not
+attended with angular deformity, but rather with a wide backward
+curvature which corresponds in extent to the number of vertebræ
+affected. The accumulation of tuberculous pus under the periosteum and
+anterior longitudinal ligament is the first stage in the formation of
+the large abscesses with which this form of spinal tuberculosis is so
+commonly associated.
+
+_Effects on the Spinal Cord and Nerve Roots._--In some cases the cord
+and nerve roots are pressed upon by an oedematous swelling of the
+membranes; in others, the tuberculous process attacks the dura mater
+and gives rise to the formation of granulation tissue on its outer
+aspect--_tuberculous pachymeningitis_. Less frequently a collection of
+pus forms between the bone and the dura, and presses the cord back
+against the laminæ. The cord is rarely subjected to pressure as a
+result of curving of the spine alone, but occasionally, especially in
+the cervical region, a sequestrum becomes displaced backward and
+exerts pressure on it, and it sometimes happens, also in the cervical
+region, that the cord is nipped by sudden displacement of diseased
+vertebræ--a condition comparable to a fracture-dislocation of the
+spine.
+
+The severity of the symptoms is aggravated by the occurrence of
+inflammation of the cord--_myelitis_--which is not due to tuberculous
+disease, but to interference with its blood-supply from the associated
+meningitis.
+
+_Repair._--When the progress of the disease is arrested, the natural
+cure of the condition is brought about by the bodies of the affected
+vertebræ becoming fused by osseous ankylosis (Fig. 211). While this
+reparative process is progressing, the cicatricial contraction renders
+the angular deformity more acute, and it may go on increasing until
+the bones are completely ankylosed; this reparative process can be
+followed in successive skiagrams. An increase in the projection in the
+back, therefore, is not necessarily an unfavourable symptom, although,
+of course, it is undesirable.
+
+[Illustration: FIG. 211.--Osseous Ankylosis of Bodies (_a_) of Dorsal
+Vertebræ, (_b_) of Lumbar Vertebræ following Pott's disease. There is
+marked kyphosis at the seat of the disease and compensatory lordosis
+above and below.
+
+(Museum of the Royal College of Surgeons, Edinburgh.)]
+
+[Illustration: FIG. 212.--Radiogram of Museum Specimen of Pott's
+disease in a Child; the disease is located at the thoracico-lumbar
+junction.
+
+(Dr. Hope Fowler.)]
+
+In rare cases the disease affects only the articular or the spinous
+processes, producing superficial caries and a localised abscess.
+
+#Clinical Features.#--The clinical features of Pott's disease vary so
+widely in different regions of the spine, that it is necessary to
+consider each region separately. To avoid repetition, however, certain
+general features may be first described.
+
+_Pain._--In the earliest stages, the patient complains of a feeling of
+tiredness, which prevents him walking far or standing for any length
+of time. Later, there is a constant, dull, gnawing pain in the back,
+increased by any form of movement, particularly such as involves
+jarring or bending of the spine. If the patient is a child, it is
+noticed that he ceases to play with his companions, and inclines to
+sit or lie about, usually assuming some attitude which tends to take
+the weight off the affected segment of the spine (Figs. 214, 217). If
+he is going about, the pain increases as the day goes on, but may pass
+off during the night. It is often referred along the course of the
+nerves emerging between the diseased vertebræ, and takes the form of
+headache, neuralgic pains in the arms or side, girdle-pain, or
+belly-ache, according to the seat of the lesion. Tenderness may be
+elicited on pressing over the spinous or transverse processes of the
+diseased vertebræ, or on making pressure in the long axis of the
+spine. These tests, however, are not of great diagnostic value, and
+they should be omitted, as they cause unnecessary suffering. It is to
+be borne in mind that in some cases the disease is not attended with
+any pain.
+
+_Rigidity._--The pain produced by movement of the diseased portion of
+the spine causes reflex contraction of the muscles passing over it,
+and the affected segment of the column is thus rendered rigid. If the
+palm of the hand is placed over the painful area while the patient
+attempts to make movements of stooping, nodding, or turning to the
+side, it is found that the vertebræ implicated move _en bloc_ instead
+of gliding on one another. This rigidity of the diseased portion of
+the column with "boarding" of the muscles of the back is one of the
+earliest and most valuable diagnostic signs of Pott's disease.
+
+_Deformity._--The most common and characteristic deformity is an
+abnormal antero-posterior curvature, with its convexity backwards. The
+situation, extent, and acuteness of the bend vary with the region of
+the spine affected, the situation of the disease in the bone, and the
+number of vertebræ implicated. When the disease has destroyed the
+bodies of one or two vertebræ, a short, sharp, angular deformity
+results; when it affects the surface of several bones, a long, wide
+curvature.
+
+Lateral deviation is occasionally met with in the early stages of the
+disease as a result of unequal muscular contraction, and in the later
+stages from excessive destruction of one side of a vertebra, or from
+partial luxation between two diseased vertebræ.
+
+_Abscess Formation._--Spinal abscesses occur with greater frequency
+and at an earlier stage in adults than in children, because in adults
+the disease usually begins on the surface of the vertebræ. Pyogenic
+infection of such abscesses after they have burst externally
+constitutes one of the chief risks to life in Pott's disease.
+
+_X-Ray Appearances._--These, when considered along with the clinical
+signs, usually afford valuable information as to the exact seat and
+nature of the lesion and the number of vertebræ involved. It is
+recommended to compare the skiagram with that of the normal spine from
+the same region and from a patient of approximately similar age. The
+outlines of the bodies are woolly or blurred; in the early stage there
+may be clear areas corresponding to cheesy foci. In progressive cases
+the bodies may be altered in shape and in size, and from destruction
+and collapse of the bones there is altered spacing, both of the bodies
+and of the ribs. In the interpretation of skiagrams, help is often
+obtained from an alteration in the axis of bodies, an angular
+deviation often drawing attention to the lesion which is located at
+the "angle." In children (Fig. 213) there is often a spindle-shaped
+shadow, outlined against the vertebral column, which is due to a cold
+abscess, and which extends above and below the bodies actually
+involved in the tuberculous process. The fusion of the bodies by new
+bone, which accompanies repair, can be followed in skiagrams taken at
+intervals.
+
+[Illustration: FIG. 213.--Radiogram of Child's Thorax, showing
+spindle-shaped shadow at site of Pott's disease of fourth, fifth, and
+sixth thoracic vertebræ.]
+
+_Cord and Nerve Symptoms._--When the spinal cord is pressed upon, the
+motor fibres are first affected as they lie superficially on the
+antero-lateral aspects of the cord, and are more sensitive to
+pressure. There is at first weakness or paresis of the muscles
+supplied from the part of the cord below the seat of pressure. The
+knee-jerks and plantar reflexes are exaggerated, and there is marked
+ankle clonus. Later, there is paralysis of the spastic type, varying
+in extent and sometimes amounting to complete paraplegia, and this may
+come on gradually or quite suddenly. There is wasting of muscles from
+disuse, and later a tendency to contracture and the development of
+deformities, as a result of sclerosis or descending degeneration of
+the cord.
+
+The sensory fibres usually escape, although in some cases there is
+partial anæsthesia and perversion of sensation. When there is also
+myelitis, loss of sensibility to pain (analgesia) below the level of
+the lesion is one of the most characteristic symptoms. In severe cases
+there is incontinence of urine and of fæces, as the patient loses
+control of the sphincters. Acute bed-sores are not uncommon.
+
+The symptoms referable to pressure on the _nerve roots_ at their
+points of emergence are pain and hyperæsthesia along the course of the
+nerves that are pressed upon, and occasionally weakness and wasting of
+the muscles supplied by them; girdle-pain is often a prominent symptom
+in adults.
+
+In the #diagnosis# of Pott's disease in young children, chief stress
+is laid on the demonstration of rigidity of the affected portion of
+spine; the child is laid prone and is lifted by the legs and feet so
+as to hyper-extend the spine; in Pott's disease the spine is held
+rigid, while in the rickety and other conditions that resemble it, the
+movements are normal.
+
+#Treatment of Pott's Disease.#--In addition to the general treatment
+of tuberculosis, the essential factor consists in _immobilising
+the spine in the recumbent posture and in the attitude of
+hyper-extension_; this must be persisted in until the diseased
+vertebræ become fused together or ankylosed by new bone, a result
+which is estimated partly by the disappearance of all symptoms and
+more accurately by observing the formation of the new bone in
+successive skiagrams.
+
+Under conservative measures it is estimated that this reparative
+process entails an immobilisation of the spine of from one to three
+years; the _operative procedures introduced by Albe and Hibbs_ bring
+about a bony ankylosis of the vertebræ in as many months, and may be
+accepted as reducing the period of spinal immobilisation in the
+recumbent posture to one year at the most.
+
+The immobilisation of the recumbent spine in the attitude of
+hyper-extension is most efficiently carried out by an apparatus on the
+lines of the _Bradford frame_; this is made of gas-piping covered by
+canvas, and is easily bent as may be required in the progress of the
+case towards convalescence. The frame does not interfere with such
+_extension_ as may be necessary, to the head, for example, in recent
+cervical caries, or to the lower extremities where flexion at the hip
+from spasmodic contraction of the psoas muscle may be efficiently
+relieved by weight-extension.
+
+_Gauvain's "wheel-barrow" splint_ and the _double Thomas' splint_
+(Fig. 215) are efficient substitutes, but _Phelps' box_ has been
+discarded because it fails to secure immobilisation of the spine.
+
+When the stage of _convalescence_ is arrived at, and recumbency is no
+longer essential, the child is allowed to sit up, stand, and go
+about, with the restraint, however, of some apparatus that will
+prevent movement of the spine, except to a limited extent. The
+_plaster-of-Paris jacket_, applied over a woollen jersey, as
+introduced by Sayre of New York, is probably the best; the jacket is
+accurately moulded to the trunk while the child is partly suspended by
+means of a tripod and the necessary strings under the chin, occiput,
+and armpits. Poroplastic felt, celluloid, papier mâché, and other
+materials, reinforced by strips of metal, may be substituted for the
+plaster of Paris. Various forms of _jury-masts_ and _collars_ have
+been employed to diminish the weight of the head in children with
+cervical caries, but have been very properly discarded as failing to
+perform the function expected of them.
+
+_Correction of the Angular Projection._--In cases in which the angular
+projection or gibbus, as it is called by continental authors, is of
+recent origin, it may be corrected by the method so successfully
+employed by Calot of Berck-sur-Mer--a plaster jacket is accurately
+moulded to the trunk, and a diamond-shaped window is cut in the jacket
+opposite the gibbus; a series of layers of cotton-wool are then
+applied, one on top of the other, so as to exert firm pressure on the
+gibbus, a plaster or elastic webbing bandage being employed to retain
+them and reinforce the pressure. The padding is renewed at intervals
+of three weeks or a month; in successful cases the projection may
+ultimately be replaced by a hollow.
+
+_Treatment of Abscess._--If a spinal abscess is causing symptoms or is
+approaching the surface, and there appears to be a risk of mixed
+infection, the abscess should be asperated and injected with iodoform
+emulsion.
+
+_Treatment of Cord-Complications._--Extension is applied, in the first
+instance, to the head or to the lower limbs, or to both, while some
+form of pillow is inserted at the seat of the disease; if the
+condition is merely one of oedema, the symptoms usually yield with
+remarkable rapidity; if they persist, in spite of extension, for three
+to six weeks, recourse should be had to _laminectomy_; it is usual to
+find evidence of mechanical pressure by granulation tissue, pus, or
+displaced bone, the relieving of which is followed by disappearance of
+the nerve symptoms. Some authors are lukewarm in their advocacy of
+this operation, but we can cite a number of cases in which, after
+laminectomy, an apparently hopeless paraplegia has been entirely got
+rid of.
+
+#Prognosis.#--As regards the _survival of persons who have suffered
+from Pott's disease_, and as having an important bearing on prognosis,
+it may be noted that surgical museums contain many specimens
+illustrating the "cured" stage of the disease, in which the bodies of
+the vertebræ, formerly the seat of tuberculous destruction or caries,
+are represented by a ridge-shaped mass of new bone, forming a solid
+union between the segments above and below (Fig. 211), or the remains
+of the original bodies may still be identifiable, although they are
+surrounded and fused together by new bone. The latter condition is the
+more liable to a recrudescence of the tuberculous infection. Further,
+it may be inferred from the number of "cured" cases of Pott's disease
+met with in everyday life, that the malady is one from which recovery
+may be expected.
+
+The cervical cases are recognised by the "telescoping" of the neck,
+the head and thorax being unduly approximated; the dorsal cases by the
+well-known _hump_ or _hunch-back_, in which the spinous processes of
+the collapsed vertebræ constitute the apex of the hump; the thorax is
+telescoped from above downwards, the ribs are crowded together, the
+lower ones, it may be, inside the iliac crests, and the sternum
+projected forwards. The hunch-back from Pott's disease is often a
+remarkably capable person, both physically and intellectually.
+
+
+POTT'S DISEASE AS IT AFFECTS DIFFERENT REGIONS OF THE SPINE
+
+#Upper Cervical Region, including Atlo-axoid Disease.#--When the
+disease affects the first and second cervical vertebræ, the atlo-axoid
+articulation becomes involved, and as a result of the destruction of
+its component bones and ligaments, the atlas tends to be dislocated
+forward. When this occurs suddenly, the odontoid process may impinge
+on the medulla and upper part of the cord and cause sudden death. When
+the displacement occurs gradually, the atlas and axis may be separated
+to a considerable extent without the cord being pressed upon, and
+recovery with ankylosis may ensue. When the third, fourth, and fifth
+vertebræ are affected, the tendency to dislocation and compression of
+the cord is not so great, but a portion of bone may be displaced
+backwards and exert pressure on the cord.
+
+The patient complains of a fixed pain in the back of the neck, and of
+radiating pains along the course of the sub-occipital and other
+cervical nerves. The neck is held rigid, and to look to the side the
+patient turns his whole body round. As the disease advances the head
+may be bent to one side as in wry-neck, or it may be retracted and the
+chin protruded. To take the weight of the head off the diseased
+vertebræ the patient often supports the chin on the hands (Fig. 214).
+
+[Illustration: FIG. 214.--Attitude of patient suffering from
+Tuberculous disease of the Cervical Spine. The swelling on the left
+side of the neck is due to a retro-pharyngeal abscess.]
+
+An abscess may form between the vertebræ and the wall of the
+pharynx--_retro-pharyngeal abscess_--the pus accumulating between the
+diseased bones and the prevertebral layer of the cervical fascia. The
+abscess may project towards the pharynx as a soft fluctuating
+swelling, and may cause difficulty in swallowing and breathing, and
+snoring during sleep; if it bursts internally it may cause
+suffocation. The abscess may bulge towards one or both sides of the
+neck, and come to the surface behind the posterior border of the
+sterno-mastoid muscle (Fig. 214). In some cases it comes to the
+surface in the sub-occipital region.
+
+If the cord is pressed upon by inflammatory products, there is
+muscular weakness, beginning in the arms and extending to the legs,
+and sometimes followed by complete paralysis. In the early stages
+there is retention of urine and constipation; later the bladder and
+rectum are paralysed, and there is incontinence.
+
+Sudden death may result when dislocation of the atlo-axoid joint takes
+place.
+
+Cervical caries has to be diagnosed from rheumatic torticollis, and
+from the effects of injuries, such as a sprain or twist of the spine.
+When a retro-pharyngeal abscess points behind the sterno-mastoid, it
+is apt to be mistaken for a cold abscess originating in tuberculous
+cervical glands. Retro-pharyngeal abscess due to other causes is
+described with diseases of the pharynx.
+
+_Treatment._--Extension is applied to the head, preferably by means of
+an elastic band fixed to the top of the bed, and the head of the bed
+is raised on blocks so that the weight of the body may furnish the
+necessary counter-extension. Lateral movements of the head are
+prevented by means of sand-bags. After the acute symptoms have
+subsided, the spine should be fixed by some rigid apparatus, such as a
+double Thomas' splint prolonged so as to support the occiput (Fig.
+215).
+
+[Illustration: FIG. 215.--Thomas' Double Splint for Tuberculous
+disease of Spine.]
+
+When it is considered advisable to open a retro-pharyngeal abscess,
+this should be done from the side of the neck by an incision along the
+posterior border of the sterno-mastoid, as first recommended by John
+Chiene. The abscess is evacuated, and the cavity filled with iodoform
+emulsion, and closed without drainage. An opening made through the
+mouth is attended with the risks of pus being inhaled into the
+air-passages and of pyogenic infection.
+
+When the patient is allowed to get up, a poroplastic collar and jacket
+of the Minerva type which supports the head and controls the movement
+of the cervical and thoracic vertebræ must be worn until the cure is
+complete.
+
+#Cervico-thoracic Region.#--When the lower cervical and upper thoracic
+vertebræ are affected, in addition to the fixed pain in the diseased
+bones, the patient complains of pain radiating along the distribution
+of the superficial cervical nerves and down the arms. There is often
+marked angular deformity. If an abscess forms, it may come to the
+surface in the lower part of the posterior triangle, or may spread
+into the posterior mediastinum or into the axilla. Sometimes the pus
+burrows behind the oesophagus and trachea, and it may find its way
+into the pleural cavity. The cord is not often pressed upon; when it
+is, the cervical sympathetic is implicated.
+
+#Thoracic or Dorsal Region.#--When the disease is confined to the
+thoracic region, stiffness of the back and boarding of the vertebral
+muscles are prominent features. On being asked to pick up an object
+from the floor, the patient reaches it by bending his knees and hips,
+while he keeps his back rigid. He refuses to make any movement that
+involves jolting of the spine, such, for example, as jumping from a
+chair to the ground. Children often attempt to take the weight off the
+diseased vertebræ by placing the palms of the hands on the edge of a
+chair so that the weight is borne by the arms.
+
+Angular deformity is often well marked, and may implicate several
+vertebræ. In order to maintain the head erect, the spine above and
+below the seat of disease becomes unduly arched forward--compensatory
+lordosis. In advanced cases the ribs become approximated, and the
+lower end of the sternum is projected forward. The antero-posterior
+diameter of the thorax is thus increased, while its vertical diameter
+is diminished. These changes, together with the telescoping of the
+vertebral bodies, lead to the deformity characteristic of the
+tuberculous hunch-back (Fig 216). The alterations in the shape of the
+chest may lead to functional disturbances of the heart and lungs.
+
+[Illustration: FIG. 216.--Hunch-back Deformity following Pott's
+disease of Thoracic Vertebræ.
+
+(Photograph lent by Sir George T. Beatson.)]
+
+_Dorsal Abscess._--As already mentioned, the earliest stage of abscess
+is well seen in skiagrams (Fig. 213), especially in children. When
+there is an extension of the suppurative process, the pus may pass
+directly backwards along the posterior branches of the intercostal
+vessels and nerves, and come to the surface behind the transverse
+processes, or it may travel forward between the pleura and the ribs,
+and, passing along the course of the lateral cutaneous branches of the
+intercostals, come to the surface opposite the middle of the rib. In
+the latter case, the abscess is liable to be mistaken for one
+associated with tuberculous disease of the rib, particularly as the
+rib is usually found to be bare. In rare cases the pus opens into the
+pleura, giving rise to empyema. When the disease is on the anterior
+surface of the bodies of the lower thoracic vertebræ, the pus may
+spread down through the pillars of the diaphragm and reach the sheath
+of the psoas muscle.
+
+_Treatment_ is on the usual lines.
+
+#Thoracico-lumbar Region.#--The symptoms are similar to those of
+disease in the thoracic region. Children while standing often assume a
+characteristic attitude--the hips and knees are slightly flexed, and
+the hands grasp the thighs just above the knees (Fig. 217). In this
+way the weight is partly taken off the affected vertebræ and borne by
+the arms. If the child is laid on its back and lifted by the heels,
+the spine remains rigid. By this test a projection due to tuberculous
+disease may be differentiated from one due to rickets, as in the
+latter case the projection disappears.
+
+[Illustration: FIG. 217.--Attitude in Pott's disease of
+Thoracico-lumbar Region of Spine.]
+
+The patient often complains of pain in the abdomen--which in children
+may be mistaken for a simple "belly-ache"--and of pain shooting down
+the buttocks and into the legs. If the cord is pressed upon at the
+level of the lumbar enlargement the anal and vesical sphincters are
+paralysed, and the reflexes are exaggerated.
+
+_Psoas Abscess._--When an abscess forms, it usually occupies the
+sheath of the psoas muscle, in which it spreads down towards the iliac
+fossa, and into the thigh, passing beneath Poupart's ligament,
+posterior and lateral to the femoral vessels. The communication
+between the pelvis and the thigh is often very narrow, so that the
+abscess cavity has to some extent the shape of an hour-glass. The pus
+may reach the surface in the region of the saphenous opening, or may
+spread farther down the thigh under cover of the deep fascia. In some
+cases it is liable to be mistaken for a femoral hernia, as the
+swelling becomes smaller when the patient lies down, and has an
+impulse on coughing.
+
+_Lumbar Abscess._--Sometimes the pus travels along the posterior
+branches of the lumbar vessels and nerves to the lateral border of the
+sacro-spinalis (erector spinæ) and comes to the surface in the space
+between the edges of the latissimus dorsi and external oblique
+muscles--the triangle of Petit.
+
+In rare cases it passes through the sacro-sciatic foramen and forms a
+swelling in the buttock (_sub-gluteal abscess_); or it may pass
+through the obturator foramen and reach the adductor region of the
+thigh or even the perineum.
+
+#Lumbo-sacral Region.#--Pott's disease in the lumbo-sacral region
+usually affects adults, and, on account of the breadth of the
+vertebral bodies and the limited range of movement in this segment of
+the spine, is seldom accompanied by marked symptoms or deformity. The
+diagnosis, therefore, is often difficult, unless good skiagrams are
+available. The disease may be associated with pain in the distribution
+of the sciatic nerve, which is liable to be mistaken for sciatica.
+Single or double _iliac abscess_ frequently forms without the patient
+showing any characteristic signs of spinal disease. When the disease
+begins in childhood it may induce a permanent deformity of the
+pelvis, the conjugate diameter at the brim being increased, while the
+transverse diameter at the outlet is diminished--kyphotic pelvis, and,
+in females, this may lead to complications in parturition.
+
+#Tuberculous Disease of the Sacro-iliac Joint.#--This condition may
+occur as a primary affection, but is much more frequently secondary to
+disease in the ilium, sacrum, or lower lumbar vertebræ, and is most
+common in adolescents and young adults of the male sex. It is attended
+with pain in the lumbar region, and sometimes in the buttock and along
+the course of the sciatic nerve. The pain is aggravated by movements,
+especially such as involve sudden and violent contraction of the
+lumbar and abdominal muscles, for example, coughing, sneezing, or
+straining during defecation. Tenderness is elicited on making pressure
+over the joint, on pressing together the iliac bones, or on attempting
+to abduct the limb while the pelvis is fixed. The muscles of the
+buttock and thigh are wasted. As any attempt to bear weight on the
+affected limb causes pain, the patient walks with a limp, and to save
+the joint he assumes an attitude which is characteristic: he throws
+his weight on the sound limb, leans forward, using a stick for
+support, tilts the affected side of the pelvis downwards, and flexes
+the hip and knee-joints of the diseased limb. The anterior superior
+spine is unduly prominent on the affected side, and the limb appears
+to be lengthened. Sooner or later, in most cases, an abscess forms,
+and the pus may reach the surface over the posterior aspect of the
+joint. When the pus forms in front of the joint, it may spread
+laterally in the iliac fossa as an _iliac abscess_ or may gravitate
+downwards in the hollow of the sacrum and emerge on the buttock
+through the sacro-sciatic foramen--_sub-gluteal abscess_. Sometimes it
+passes into the ischio-rectal fossa or into the perineum. The presence
+of an abscess in the pelvis may sometimes be recognised on rectal
+examination. The appearance of an abscess is sometimes the first thing
+to draw attention to the condition.
+
+As pain across the small of the back and along the course of the
+sciatic nerve may be among the early symptoms of sacro-iliac disease,
+the condition is liable to be mistaken for lumbago or for sciatica.
+From hip disease it is recognisable by noting that the movements of
+the hip-joint are not restricted. It is not always possible without
+the aid of skiagrams to differentiate sacro-iliac disease from disease
+of the lumbar spine, and the two conditions sometimes coexist.
+
+The _prognosis_ is unfavourable, particularly in cases complicated by
+extensive disease of the ilium with abscess formation and mixed
+infection.
+
+_Treatment._--In early cases the patient should use crutches and wear
+a patten on the foot of the sound side; in more advanced cases he must
+be confined to bed, and have absolute rest to the joint secured by
+means of extension applied to both legs, or by other apparatus. In
+children a double Thomas' splint or Stiles' abduction frame is a
+convenient appliance. Counter-irritation by blisters or the actual
+cautery may be had recourse to in dry cases in which pain is a
+prominent feature. If operative treatment becomes necessary, as it
+may, for removal of a sequestrum, access to the seat of disease is
+obtained by removing the posterior portion of the iliac bone. Cold
+abscess is treated on the usual lines.
+
+#Syphilitic Disease of the Vertebræ.#--All the clinical features of
+Pott's disease may be simulated by gummatous disease of the vertebræ.
+This is usually met with in adults who have suffered from acquired
+syphilis; it is most common in the upper cervical vertebræ, and begins
+on the anterior surface of the bodies. The onset is more sudden than
+that of tuberculous caries, and the progress more rapid. The bone is
+early and extensively destroyed, but abscess formation is rare. Severe
+nocturnal pains are complained of, and some degree of angular
+deformity may develop. In almost all cases other evidence of tertiary
+syphilis is present, and this, together with the history and the
+effects of anti-syphilitic treatment, aids in diagnosis. The local
+treatment is carried out on the same lines as for tuberculous disease.
+
+#Malignant Disease of the Vertebræ.#--_Sarcoma_ is the most important
+of the primary tumours met with in the vertebral column. It gives rise
+to symptoms which are liable to be mistaken for those of Pott's
+disease or of arthritis deformans. The pain, however, is more intense,
+and the disease progresses more continuously, and is uninfluenced by
+treatment. The changes in the vertebræ, as seen in skiagrams, are
+helpful in diagnosis. The growth may encroach upon the vertebral canal
+and cause pressure on the cord (p. 451). In the sacrum--the most
+common site--the tumour implicates the sacral nerves, and causes
+symptoms of intractable sciatica; and the real nature of the disease
+is often only detected on making a rectal examination.
+
+_Secondary cancer_ is a common disease, particularly in cases of
+advanced scirrhus of the breast. It leads to extensive softening of
+the bodies of the vertebræ, so that they yield under the weight of the
+body, as in Pott's disease. Clinically it is associated with severe
+pain in the region of the vertebræ affected, and along the course of
+the nerves emerging in the neighbourhood. If paralysis occurs from
+the cancerous bodies pressing upon the cord (_paraplegia dolorosa_),
+it is of rapid development, often becoming complete in a few hours.
+When the cervical cord is compressed all four limbs are paralysed, and
+from interference with respiration, the condition is fatal within a
+few days.
+
+#Actinomycosis#, #Blastomycosis#, and #Hydatid Cysts# also occur in
+the vertebræ, and are difficult to diagnose from tuberculous disease.
+
+#Typhoid Spine.#--An acute infective condition of the vertebræ,
+intervertebral discs, and spinal ligaments occasionally occurs during
+convalescence from typhoid fever. The lumbar region is most frequently
+affected, and the X-rays reveal inflammatory changes in the bones,
+disappearance of the discs, and, in the later stages, deposits of new
+bone leading to synostosis of adjacent vertebræ. The onset, which may
+be gradual or sudden, is attended with intense pain, and tenderness
+over the affected vertebræ. The temperature is raised, and other signs
+of an acute infective process are present. In a few cases there are
+symptoms of involvement of the membranes and cord. With prolonged rest
+and immobilisation of the spine the inflammation usually subsides, but
+sometimes it goes on to suppuration.
+
+#Hysterical Spine.#--This term is applied to a functional affection of
+the spine occasionally met with in neurotic females between the ages
+of seventeen and thirty, and liable to be mistaken for Pott's disease.
+The patient complains of pain in some part of the spine--usually the
+cervico-thoracic or thoracico-lumbar region--and there is marked
+hyperæsthesia on making even gentle pressure over the spinous
+processes. As the patients are usually thin, the pressure of the
+corset is apt to redden the skin over the more prominent vertebræ, and
+give rise to an appearance which at first sight may be mistaken for a
+projection. The general condition of the patient, the freedom of
+movement of the vertebral column, and the entire absence of rigidity,
+are sufficient to exclude tuberculosis. The condition is treated on
+the same lines as other hysterical affections.
+
+#Acute osteomyelitis# of the vertebræ is a rare affection, and is met
+with in young subjects. It attacks the more mobile portions of the
+spine--cervical and lumbar--and may begin either in the bodies or in
+the arches. It is attended with extreme sensitiveness on movement,
+severe localised pain in the region of the vertebræ attacked, and a
+marked degree of fever. Pus usually forms rapidly, but, being deeply
+placed, is not easily recognised unless it points towards the
+surface. The infection is liable to spread to the meninges of the cord
+and give rise to meningitis, particularly when the disease begins in
+the arches. A milder form occurs, in which the main incidence is on
+the periosteum; the symptoms are less severe, it does not tend to
+suppurate, and is usually recovered from. The treatment consists in
+applying extension to the spine and in opening any abscess that may be
+detected. The suppurative form usually proves fatal, and, indeed, is
+often only diagnosed on post-mortem examination.
+
+#Arthritis Deformans.#--This disease usually begins between the ages
+of thirty-five and forty, and attacks men who follow some laborious
+occupation which involves exposure to cold and wet. It is met with,
+however, in women who lead a sedentary life. There is sometimes a
+recent history of gonorrhoea, rheumatism, or other toxic disease, and
+occasionally the condition follows upon injury. The discs disappear,
+osteophytic outgrowths develop at the margins of the bodies and in
+connection with the transverse processes, and bridge across the space
+between neighbouring vertebræ (Fig. 218). The articulations between
+the ribs and the vertebræ show similar changes, and the ligaments of
+the several joints tend to undergo ossification, so that the bones are
+fused together.
+
+[Illustration: FIG. 218.--Arthritis Deformans of Spine. The vertebræ
+are fixed to one another by outgrowths of bone which bridge across the
+intervertebral spaces, and there is a slight lateral deviation to the
+left in the mid-dorsal region.
+
+(Anatomical Museum, University of Edinburgh.)]
+
+In the early stage the patient complains of pain and stiffness in the
+back; later the spine becomes rigid, and gradually develops a
+kyphotic curve, sometimes accompanied by lateral deviation. In some
+cases, the curvature of the spine assumes an extreme type, the
+shoulders are rounded, and the head depressed, the face approximating
+the sternum, so that to see an object such as a picture on a wall, the
+patient must turn his back to it. The chest is flattened and
+restricted in its movements, with the result that respiration is
+embarrassed and becomes almost entirely abdominal. The muscles of the
+back, shoulders, and hips undergo atrophy, and may exhibit tremors,
+and the deep reflexes become exaggerated. The nerves are liable to be
+pressed upon as they pass through the intervertebral foramina, and
+this gives rise to pain and other disturbances of sensation in their
+area of distribution. These pains may simulate those associated with
+renal or gastro-intestinal affections.
+
+The disease may simulate tuberculous caries or malignant disease. The
+changes in the bones are demonstrated by the use of the X-rays.
+
+The treatment is carried out on general principles (Volume I., p.
+530), but it is seldom possible to do more than arrest the progress of
+the disease.
+
+#Coccydynia# is the name applied to a condition in which the patient
+experiences severe pain in the region of the coccyx on sitting or
+walking, and during defecation. The pathology is uncertain. In some
+cases there is a definite history of injury, such as a kick or blow,
+causing fracture of the coccyx, or dislocation of the sacro-coccygeal
+joint. These lesions have also been produced during labour. In other
+cases the pain appears to be neuralgic in character, and is referable
+to the fifth sacral and the coccygeal nerves, or to the terminal
+branches of the sacral plexus distributed in this region. The
+affection is almost entirely confined to females, and the patients are
+usually of a neurotic type. On rectal examination the coccyx is
+exceedingly tender, and it is sometimes found to be less movable than
+normal, and unduly arched forward. When medicinal treatment fails to
+give relief, the coccyx may be excised.
+
+#Tumours of the Spinal Cord and Membranes.#--Tumours may develop in
+the substance of the cord (_intra-medullary_), in the membranes
+(_meningeal_), or in the tissues between the dura and the bone
+(_extra-dural_); or the cord may be pressed upon by a tumour
+originating in the vertebræ. It is seldom possible to diagnose the
+nature of a tumour before operation, and it is often difficult to
+determine in which of the above situations it has originated.
+
+Tumours growing _in the substance of the cord_ are nearly as common
+as extra-medullary growths, and as the growth is usually sarcoma,
+glioma, tuberculoma, or gumma, and infiltrates the cord, it is seldom
+capable of being removed by operation.
+
+The great majority of _meningeal_ tumours are primary sarcomas, and in
+about 25 per cent. of cases they are multiple. Hydatid cysts and
+fibromas are also met with in this situation, and they too may be
+multiple.
+
+_Extra-dural_ growths are comparatively rare. The forms usually met
+with are sarcoma and lipoma.
+
+These extra-medullary tumours seldom infiltrate the cord; they simply
+compress it, and should be subjected to operative treatment before
+secondary changes are produced in the cord.
+
+The _symptoms_ vary according as the tumour presses on the nerve
+roots, on one half, or on both halves of the cord. Pressure on nerve
+roots is a characteristic sign in extra-medullary growths. It gives
+rise to pain, which, according to the level of the tumour, passes
+round the trunk (girdle-pain), or shoots along the nerve-trunks of the
+upper or lower limbs.
+
+When the cord is pressed upon, intense neuralgic pain related to the
+segment first involved is one of the earliest symptoms, particularly
+in extra-medullary tumours. The pain is at first unilateral, but later
+becomes bilateral--a point of importance in diagnosis. The painful
+areas are anæsthetic, but the anæsthesia does not always reach to the
+level of the lesion. There may be a zone of hyperæsthesia at the upper
+limit of the anæsthesia, or in the area corresponding to the roots on
+which the tumour is situated, but there is never diffuse hyperæsthesia
+(V. Horsley). In intra-medullary tumours the pain is less severe, it
+is rarely an initial symptom, and is seldom referable to individual
+nerve roots.
+
+The next symptom to appear is motor paresis, followed by complete
+paralysis, and later by contracture of the paralysed muscles--_spastic
+paraplegia_. In intra-medullary tumours the paraplegia is usually less
+complete than in those that are extra-medullary. When only one lateral
+half of the cord is pressed upon, the motor paralysis and loss of
+ordinary sensation are on the same side as the tumour, and the loss of
+the sense of pain and of the temperature sense is on the opposite
+side. Retention of urine accompanies the onset of paralysis, and later
+gives place to incontinence. The rectum becomes paralysed, and
+cystitis and pressure sores develop.
+
+Anti-syphilitic treatment should be employed in the first instance to
+exclude the possibility of the lesion being of the nature of a gumma.
+Radical operative treatment is contra-indicated in intra-medullary
+and in metastatic growths, but decompressive measures may be employed
+for the relief of pain. In meningeal and extra-dural tumours, however,
+in view of the hopeless prognosis if the condition is allowed to take
+its course, an attempt may be made to remove the tumour by operation.
+It is to be borne in mind that the lesion may be two or three segments
+higher than the complete anæsthesia would appear to indicate; the
+vertebral canal, therefore, should be opened about four inches above
+the level of the anæsthesia.
+
+When the tumour is not removable, the patient's suffering may
+sometimes be alleviated by resecting the posterior roots of the nerves
+emerging in the vicinity of the lesion.
+
+#Chronic Spinal Meningitis.#--Victor Horsley (1909) described by this
+name a condition which gives rise to symptoms closely simulating those
+of a tumour of the cord. He believes it to consist in a
+pachymeningitis combined with a certain degree of sclero-gliosis of
+the periphery of the cord. The theca is greatly distended over a
+variable extent of the cord; the cerebro-spinal fluid is increased in
+quantity and is under considerable tension; and the cord itself
+presents a shrunken appearance. Sometimes there is thickening of the
+arachno-pia and matting of the nerve roots. The condition appears to
+begin in the lower part of the cord, and to spread up, usually as far
+as the mid-thoracic region. There is frequently a history of syphilis,
+sometimes of recent gonorrhoea, but in some cases no cause can be
+assigned for the lesion.
+
+_Clinical Features._--This affection is almost always met with in
+adults, and the earliest symptoms are pain and weakness in the legs,
+and sometimes a slight kyphotic projection of the spinous processes.
+The loss of power, which is sometimes attended with spasticity,
+usually manifests itself in one leg first, and later affects the
+other; it is progressive, and ultimately ends in complete paraplegia.
+The pain is not confined to the region supplied by any one nerve root,
+but affects a diffuse area, and the patient complains also of a
+sensation of tightness in the limbs. There is never absolute
+anæsthesia, but there is relative anæsthesia for all forms of
+sensation, which extends as a rule as far as the sixth or eighth
+thoracic root.
+
+There are no vaso-motor phenomena, and no tendency to the formation of
+pressure sores. Sometimes the patient complains of pain in the spine,
+but this is not aggravated by movement.
+
+_Treatment._--The treatment recommended by Horsley consists in
+performing laminectomy, opening the theca, and washing it out with 1
+in 1000 mercurial lotion. After the wound has healed, mercurial
+inunction over the spine is employed to hasten the absorption of
+inflammatory products. The administration of anti-syphilitic drugs has
+not proved beneficial.
+
+#Acute Spinal Meningitis.#--The spinal membranes may become implicated
+by direct spread in cases of acute intra-cranial lepto-meningitis, or
+they may be infected from without--for example, in gun-shot injuries
+or in cases of spina bifida.
+
+When the infection spreads from the cranial cavity, the cerebral
+symptoms dominate the clinical picture, but evidence of involvement of
+the membranes of the cord may be present in the form of rigidity of
+the cervical muscles with retraction of the neck; deep-seated pain in
+the back, shooting round the body (girdle-pain) and down the limbs;
+painful cramp-like spasms in the muscles of the back and limbs, with
+increased reflex excitability, sometimes so marked as to simulate the
+spasms of tetanus.
+
+When the theca of the cord is directly infected the spinal symptoms
+predominate at first, but as the condition progresses it involves the
+cerebral membranes, and symptoms of acute general lepto-meningitis
+ensue.
+
+Once the condition has started little can be done to arrest its
+progress, but the symptoms may be relieved by repeated lumbar
+puncture.
+
+#Spinal Myelitis.#--The term "myelitis" is applied to certain changes
+which occur in the spinal cord as a result, for example, of hæmorrhage
+into its substance (_hæmorrhagic myelitis_); or of pressure exerted on
+it by fragments of bone, blood-clot, tuberculous material, or new
+growths (_compression myelitis_).
+
+In another group of cases myelitis is a result of the action of
+organisms or their toxins. Syphilis is a common cause, but the
+condition may follow on infections with ordinary pyogenic cocci,
+pneumococci, the influenza bacillus or the bacillus coli.
+
+In addition to the use of anti-syphilitic remedies, or of sera
+directed to neutralise the toxins of the causative organism, attention
+must be directed to the bladder, and steps taken to prevent cystitis
+and the formation of bed-sores.
+
+
+CONGENITAL DEFORMITIES OF THE SPINE
+
+#Spina Bifida.#--Spina bifida is a congenital defect in certain of the
+vertebral arches, which permits of a protrusion of the contents of the
+vertebral canal. It is due to an arrest of development, whereby the
+closure of the primary medullary groove and the ingrowth of the
+mesoblast to form the spines and laminæ fail to take place. The cleft
+may implicate only the spinous processes, but as a rule the laminæ
+also are deficient. The defect usually extends over several vertebræ
+(Fig. 219). While the protrusion varies much in size, there is no
+constant ratio between the dimensions of the swelling and the extent
+of the defect in the neural arches.
+
+[Illustration: FIG. 219.--Meningo-myelocele of Thoracico-lumbar
+Region.]
+
+The condition is comparatively common, being met with in about one out
+of every thousand births. It is most frequent in the lumbar and sacral
+regions (Fig. 219), but occurs also in the cervical (Fig. 220) and
+thoracic regions. It is not uncommon to find spina bifida associated
+with other congenital deformities such as hydrocephalus, club-foot,
+and extroversion of the bladder.
+
+[Illustration: FIG. 220.--Meningo-myelocele of Cervical Spine.]
+
+_Varieties._--Four varieties are usually described according to the
+character of the protrusion. They are analogous, to a certain extent,
+to the varieties of cephalocele (p. 387). (1) _Spinal meningocele_, in
+which only the membranes, filled with cerebro-spinal fluid, are
+protruded. (2) _Meningo-myelocele_, the form most commonly met with
+clinically, in which the cord and some of the spinal nerves are
+protruded, and spread out over the inner aspect of the sac (Figs. 219,
+220). (3) _Syringo-myelocele_, in which there is a dilatation of the
+central canal in the protruded part of the cord. In these three forms
+the protrusion may be covered by healthy skin, or by a thin, smooth,
+translucent membrane through which the contents are visible.
+Frequently this thin covering sloughs or ulcerates, and permits the
+cerebro-spinal fluid to drain away. (4) In the _myelocele_, this skin,
+as well as the vertebral arches and membranes, is absent, and the cord
+lies exposed on the surface. This form is comparatively common, but as
+the infants are either dead born or die within a few days of birth, it
+seldom comes under the notice of the surgeon.
+
+_Clinical Features._--The presence of a swelling in the middle line of
+the back, which has existed since birth, and which contains fluid and
+increases in size and tenseness when the child cries, renders the
+diagnosis of spina bifida easy. The defect in the bone may be seen in
+skiagrams. The swelling is usually sessile, but may be pedunculated;
+it is usually possible to palpate the edges of the gap in the bones.
+It may be reduced in size by making gentle pressure over it, and in
+young children this may cause a bulging of the fontanelles. This test,
+however, must be employed with caution, as it is liable to induce
+convulsions. A meningocele, as it contains no nerve elements, may be
+translucent. In a meningo-myelocele the shadows of the cord and nerves
+stretched out in the sac may be recognised. The presence of the cord
+is sometimes indicated by a median furrow, and after withdrawal of
+some of the fluid the cord can sometimes be palpated. It is, however,
+often difficult to distinguish between a meningocele and
+meningo-myelocele.
+
+[Illustration: FIG. 221.--Meningo-myelocele in Thoracic Region.]
+
+Sometimes there are no nervous disturbances, and this is especially
+the case when the defect is in the lower lumbar and sacral regions
+below the termination of the cord. In most cases, however, there are
+paralytic symptoms referable to the lower extremities, the bladder,
+and the rectum, and there may also be trophic disturbances in the
+parts below. Paralytic symptoms may be absent during infancy, and
+develop during childhood or adolescence.
+
+_Prognosis._--Comparatively few children born with spina bifida
+survive longer than four or five years. The great majority die within
+a few weeks of birth, death being due to the escape of cerebro-spinal
+fluid, or to spinal meningitis following on infection. The condition
+in some cases remains stationary for years, but spontaneous
+disappearance is rare.
+
+_Treatment._--The more severe forms of spina bifida only call for
+palliative treatment, which consists in protecting the protrusion
+against infection and applying a sterilised dressing and a supporting
+bandage. A meningocele may be tapped with a fine needle passed through
+healthy skin, and the empty sac compressed by a pad of wool and an
+elastic bandage.
+
+Operative treatment is seldom to be recommended in a young child
+unless it is otherwise viable and the swelling is increasing rapidly
+and threatening to burst, and there is reason to believe that the
+paralysis is due to pressure. The immediate results of operation are
+usually satisfactory, but in a large proportion of cases the child
+subsequently develops hydrocephalus, from which it ultimately
+succumbs. The hope of improvement in the motor symptoms after
+operation depends on the site of the spina bifida; above the twelfth
+thoracic vertebra there is no prospect of improvement; below this
+level, inasmuch as it is the tip of the conus or the cauda equina that
+is involved, there may be regeneration of nerve fibres and return of
+power in the lower extremities, and control of the sphincters may be
+regained. Murphy has practised resection of cicatricial or atrophied
+portions of the cauda, with end-to-end suture.
+
+The term #spina bifida occulta# is applied to a condition in which
+there is no protrusion of the contents of the vertebral canal,
+although the vertebral arches are deficient. The skin over the gap is
+often puckered and adherent, and is frequently covered with a growth
+of coarse hair.
+
+A mass of fat may project towards the surface, and when situated in
+the lumbo-sacral region may suggest a caudal appendage or tail (Fig.
+222).
+
+[Illustration: FIG. 222.--Tail-like Appendage over Spina Bifida
+Occulta in a boy æt. 5, and associated with incontinence of urine.
+Operation was followed by temporary retention.]
+
+The clinical importance of spina bifida occulta lies in the fact that
+it is sometimes associated with congenital club-foot, and with nerve
+symptoms, in the form of sensory, motor, and trophic disturbances
+referable to the lower limbs, such as perforating ulcer, and to the
+sphincters. These nerve symptoms usually result from the presence of a
+tough cord composed of connective tissue, fat, and muscle, stretching
+from the skin through the vertebral canal to the lower end of the
+spinal cord. As this strand of tissue does not grow in proportion
+with the body, in the course of years it drags the cord against the
+lower border of the membrana reuniens, which closes in the vertebral
+canal posteriorly. These symptoms may be relieved by the removal of
+this strand of tissue from the gap in the vertebral arches, or by
+incising the membrana reuniens.
+
+#Congenital Sacro-coccygeal Tumours--Teratoma.#--Many varieties of
+congenital tumours are met with in the region of the sacrum and
+coccyx. The majority are developed in relation to the communication
+which exists in the embryo between the neural canal and the alimentary
+tract--the post-anal gut or neurenteric canal. Some are evidently of
+bigerminal origin, and contain parts of organs, such as limbs, partly
+or wholly formed, nerves, parts of eyes, mammary, renal, and other
+tissues.
+
+Among other tumours met with in this region may be mentioned: the
+congenital _lipoma_--a small, rounded, fatty tumour which often
+suggests a caudal appendage (Fig. 222); the _sacral hygroma_, which
+forms a sessile cystic tumour growing over the back of the sacrum, and
+is believed to be a meningocele which has become cut off _in utero_ by
+the continued growth of the vertebral arch; dermoids, sarcoma, and
+lymphangioma.
+
+[Illustration: FIG. 223.--Congenital Sacro-coccygeal Tumour.
+
+(Photograph lent by Sir George T. Beatson.)]
+
+The _treatment_ consists in removing the tumour, as from its situation
+it is exposed to injury, and this is liable to be followed by
+infection. From the position of the wound, and the fact that many of
+these tumours extend into the hollow of the sacrum and therefore
+necessitate an extensive dissection, there is considerable risk from
+infection, especially in young children. The risk is increased when
+the tumour communicates with the vertebral canal.
+
+#Congenital Sacro-coccygeal Sinuses and Fistulæ.#--The _post-anal
+dimple_, a shallow depression frequently observed over the tip of the
+coccyx, may be due to traction exerted on the skin at this spot by the
+remains of the neurenteric canal, or by the caudal ligament of
+Luschka. Sometimes the integument is retracted to such an extent that
+one or more _sinuses_ are formed, lined with skin which is furnished
+with hairs, sweat, and sebaceous glands. The bursting of a dermoid, or
+its being incised in mistake for an abscess, may result in the
+formation of such a sinus, which fails to heal and may persist for
+years.
+
+In some cases the depression communicates with the vertebral canal,
+constituting a complete _sacro-coccygeal fistula_, which may be lined
+with cylindrical or ciliated epithelium.
+
+From the accumulation of secretions and subsequent infection, these
+conditions may be associated with a persistent offensive discharge,
+and they are liable to be mistaken for ano-rectal fistulæ. They are
+best dealt with by complete excision, and as primary union cannot be
+expected, the wound should be treated by the open method.
+
+
+
+
+CHAPTER XVIII
+
+DEVIATIONS OF THE VERTEBRAL COLUMN
+
+
+LORDOSIS--KYPHOSIS--SCOLIOSIS
+
+Three main deviations of the vertebral column are described:
+_Lordosis_, in which it is unduly arched forwards; _Kyphosis_, in
+which it is unduly arched backwards; and _Scoliosis_ or lateral
+deviations, in which the spine deviates to one side of the middle
+line.
+
+#Lordosis# or _anterior curvature of the spine_ with the convexity
+forwards, is chiefly met with in the lumbar region as an exaggeration
+of the natural curvature. A minor degree of lordosis sometimes occurs
+as a peculiarity in the conformation of the individual and may be
+present in several members of the same family; also in street-hawkers
+and others who carry weights suspended in front of them; in very obese
+persons; in those who suffer from large abdominal tumours, such as
+fibroids; and in pregnant women. In its more marked and typical forms
+it is met with as a compensatory deviation when the pelvis is tilted
+forwards in association with flexion of one or of both hip-joints.
+Illustrations of this association are found in congenital dislocation
+of the hip, particularly when this is bilateral, in tuberculous
+disease of the hip when recovery has occurred with ankylosis in the
+flexed position, and in Charcot's disease of the hip. The resuming of
+the erect position with tilting of the pelvis from flexion at the hip
+is necessarily attended by an exaggeration of the forward curvature of
+the lumbar spine. Its relationship to the erect posture is readily
+demonstrated by noting its partial or complete disappearance when the
+patient is sitting and the tilting of the pelvis is thus eliminated.
+
+Lordosis elsewhere than in the lumbar segment is met with as a
+compensatory deviation to kyphotic or backward curvature of the spine:
+in Fig. 211, for example, a kyphotic projection in the mid-thoracic
+region has led to a lordosis in the cervico-thoracic segment above,
+and in the thoracico-lumbar segment below, the forward curve being
+again a necessary outcome of the resuming of the erect posture. The
+absence of a compensatory lordosis in such a condition would warrant
+the inference that the patient had been bed-ridden.
+
+#Kyphosis# or _posterior curvature of the spine_ with the convexity
+backwards, is met with at all periods of life, and results from a wide
+range of conditions.
+
+In infancy it is a common result of _general debility_. The child need
+not appear to be badly nourished, it may even be fat and look well,
+but there is a want of muscular vigour such as should enable it to
+hold itself erect in the sitting posture. It is to be noted that a
+considerable degree of kyphosis may exist without interference with
+the normal outlook in the erect posture, and, therefore, the question
+of compensatory curvature does not arise. In the adolescent a degree
+of kyphosis in the cervico-thoracic region is common, and is spoken of
+as "round shoulders"; it is largely a matter of habit that requires
+correction by the governess or nurse. Among agricultural labourers and
+gardeners after middle life, and in the aged, this type of curvature
+is of common occurrence and is evidently associated with their
+occupation. An exaggerated form of the same cervico-thoracic kyphosis
+is met with in patients suffering from progressive muscular atrophy,
+poliomyelitis, osteitis deformans of Paget, acromegaly, and many
+allied conditions in which either the muscular or the mental vigour is
+deficient, and the patient adopts the cervico-thoracic kyphosis as the
+attitude of rest.
+
+Another type of diffuse kyphosis without compensatory curvature is met
+with in _arthritis deformans_, in which the kyphosis is associated
+with the disappearance of the intervertebral discs and ankylosis of
+the vertebral bodies by bridges of new bone in the position of the
+anterior common ligament.
+
+_Partial or localised kyphosis_, on the other hand, is the result of
+organic changes in the bodies of the vertebræ of the segment of spine
+affected. It is most often met with in Pott's disease in which the
+extent of the curve depends on the number of bodies affected, and its
+degree on the amount of destruction that the bodies have undergone.
+With the resumption of the erect posture, and in order that the eyes
+should look directly forwards, a compensatory lordosis is acquired
+above and below the segment that is the seat of kyphosis (Fig. 211). A
+similar but less marked type of kyphosis may follow upon compression
+fracture of the spine--in the condition known as traumatic
+spondylitis; and as a result of other lesions, such as osteomalacia,
+or malignant disease, in which the bodies undergo softening and yield,
+so that the spinous processes project posteriorly.
+
+
+SCOLIOSIS
+
+#Scoliosis# or _lateral curvature_ is by far the commonest and most
+important deviation of the spine. The student will obtain a clearer
+conception of the nature of this deformity if we consider in the first
+place those types for which an obvious explanation is available.
+
+_Static scoliosis_, for example, when one leg is shorter than the
+other, the pelvis is tilted down on the short side, the
+thoracico-lumbar spine deviates laterally to the normal side, and to
+restore the equilibrium of the trunk the cervico-thoracic spine
+deviates again in the opposite direction. The causes of one leg being
+shorter than the other are numerous and varied; they include such
+conditions as unilateral congenital dislocation of the hip, fractures
+united with overriding of the fragments, diseases of the joints,
+_e.g._, hip disease, or of the bones, especially such as interfere
+with the function of ossifying junctions; and acquired deformities
+such as unilateral flat-foot, knock-knee, or bow-leg. Clinically,
+this type of scoliosis is identified by observing that when the
+patient sits down the deviation of the spine disappears; it is
+relieved or got rid of by raising the sole and the heel of the boot on
+the short side, and, if required, by inserting an "elevator" inside
+the boot.
+
+When there is _shortening of the muscles on one side of the trunk_
+there develops a lateral curvature of the spine with its convexity to
+the normal side; a good example of this is afforded in cases of
+infantile hemiplegia (Fig. 224) in which the deviation affects the
+entire column: a localised form is seen in congenital wry-neck, in
+which the convexity of the cervico-dorsal curve is on the side of the
+normal sterno-mastoid with a compensatory deviation to the opposite
+side in the spine below (Fig. 272). _Unilateral paralysis_ of
+_muscles_ acting on the trunk may also cause a lateral deviation of
+the spine, as is well seen in paralysis of the trapezius, which
+results in a cervical scoliosis with the convexity to the
+non-paralysed side.
+
+[Illustration: FIG. 224.--Scoliosis following upon Poliomyelitis
+affecting right arm and leg.
+
+(Mr. D. M. Greig's case.)]
+
+_Asymmetry of the thorax_, such as may follow on empyema with
+defective expansion of the lung, causes a lateral deviation of the
+dorsal spine with the convexity towards the normal side.
+
+_Attitudes_ adopted to relieve pain, such as that caused by sciatica,
+sacro-iliac or hip disease, in which the weight of the body is
+transferred to the normal side, cause a scoliosis similar to that due
+to irregularity in the length of the lower extremities, and is
+similarly made to disappear when the patient sits upon a flat surface.
+
+_Malformation_ or _disease of the vertebræ_ themselves is a well
+recognised cause of scoliosis; the best known, as it may be also the
+most severe and the most intractable, is that due to rickets, under
+which heading it has already been described (Fig. 225). In a few cases
+a rudimentary wedge-shaped vertebra has been revealed by the X-rays.
+
+[Illustration: FIG. 225.--Rickety Scoliosis in a child æt. 2.]
+
+In all of these forms or types of scoliosis the primary cause must be
+searched for and when found is made the first object of treatment; the
+treatment of the scoliosis as such is on the same lines as in the
+postural variety that now falls to be described.
+
+#Habitual or Postural Scoliosis.#--These names have been given to the
+type of scoliosis that develops in young girls and for which there is
+no mechanical explanation.
+
+It is most frequently met with in rapidly growing girls of poor
+physique who are overworked at school or lessons, or on commencing an
+apprenticeship for which they are physically unfit. In some cases
+there is nasal obstruction from adenoids, in others the development
+and free play of the chest are interfered with by tight and
+ill-fitting garments; in all of them the muscular system is weak and
+the muscles of the trunk do not take their proper share in maintaining
+the erect posture. The most important determining factor would appear
+to be the habitual or repeated assumption of faulty attitudes, partly
+from carelessness, largely from fatigue, in order to relieve the
+feeling of tiredness in the back. So far as is known, the condition
+does not occur in communities living under aboriginal conditions. In
+some cases there is a hereditary tendency to scoliosis; we have seen
+it, for example, in a father and his daughters.
+
+The excessive use of one arm in the carrying of weights, the habit of
+resting on one leg more than the other, or the assumption of a faulty
+attitude in writing or in playing the piano or violin, doubtless,
+determine the seat and direction of the curvature, and, when it has
+once commenced, tend to aggravate and to perpetuate it.
+
+It is probable that the greater frequency of the primary curvature
+towards the right is associated with the more general use of the right
+hand and arm, although primary curvatures towards the left are not
+confined to left-handed persons.
+
+_Morbid Anatomy._--The original deviation or "primary curve" is
+usually in the thoracic region, and has its convexity directed towards
+the right side. To re-establish the equilibrium of the column,
+"secondary" or "compensatory" curves, with their convexities to the
+left, develop in the regions above and below the primary curve. It has
+been proved experimentally that lateral deviation of the spine is
+inevitably accompanied by rotation of the vertebræ around a vertical
+axis, in such a way that their bodies look towards the convexity of
+the curve, while their spines, laminæ, and articular processes are
+directed towards the concavity (Fig. 226).
+
+[Illustration: FIG. 226.--Vertebræ from case of Scoliosis, showing
+alteration in shape of bones.]
+
+As the deformity increases, the individual vertebræ are distorted, the
+bodies becoming wedge-shaped from side to side, the base of the wedge
+looking towards the convexity of the curve, while the narrow end looks
+towards the concavity (Fig. 228). As the spine, laminæ, and articular
+processes also undergo alterations in shape, a line uniting the tips
+of the spinous processes does not furnish an accurate index of the
+degree of lateral deviation but minimises it considerably. The muscles
+and ligaments are altered in length in accordance with the changes in
+the shape and position of the bones.
+
+In the thoracic region, the ribs necessarily accompany the transverse
+processes, so that on the side of the convexity they form an undue
+prominence behind--the "rib-hump" (Fig. 227), while on the side of the
+concavity the chest is flattened and the ribs crowded together so that
+the intercostal spaces are diminished or even obliterated. The
+converse--flattening on the side of the concavity--is seen on the
+front of the chest.
+
+[Illustration: FIG. 227.--Adolescent Scoliosis in a girl æt. 23.]
+
+The general shape of the thorax is altered: on the side of the
+convexity it is longer and narrower than normal and its capacity
+diminished, while on the side of the concavity it is shorter and
+broader and its capacity is increased.
+
+The viscera are distorted and displaced in accordance with the altered
+shape of the thoracic and abdominal cavities. The twisting of the
+spine causes the patient to lose in stature, and the limbs appear to
+be disproportionately long. In advanced cases the pelvis becomes
+obliquely contracted--a deformity known as the _scoliotic pelvis_.
+
+[Illustration: FIG. 228.--Scoliosis with primary curve in Thoracic
+Region.]
+
+In spite of the marked deformity the spinal cord is never compressed.
+
+_Clinical features._--The development of scoliosis is always slow and
+insidious. As a rule, attention is first attracted to the deformity
+about the age of puberty, but in most cases it has existed for a
+considerable time before it is observed. The patient--usually a girl,
+although it also occurs in boys--is easily fatigued, has difficulty in
+keeping herself erect, and often complains of pain in the back and
+shoulders and along the intercostal spaces on the side of the
+convexity. To relieve the muscles of the back she is inclined to
+lounge in easy and ungainly attitudes.
+
+The most common form of scoliosis met with in adolescents is a
+_primary thoracic curvature_ with its convexity to the right (Fig.
+227), and with more or less marked compensatory curves towards the
+left in the lumbar and cervical regions. The thoracic spines lie
+towards the right of the middle line. On account of the prominence of
+the ribs, the right scapula is projected backwards, and its inferior
+angle is on a higher level and farther from the middle line than that
+of the left scapula. The right shoulder seems higher than the left,
+and is popularly said to be "growing out"--a point which is often
+first observed by the dressmaker. The right side of the back is unduly
+prominent, while the left side is flattened. A deep sulcus forms in
+the left flank below the costal margin, and the space between the arm
+and the chest wall--the "brachio-thoracic triangle"--on the left side
+is much more marked than on the right; and the left iliac crest
+usually projects upwards and backwards. As seen from the front, the
+right side of the chest is flattened, while the left side is
+abnormally prominent, the breasts are asymmetrical, and the right
+nipple is on a higher level than the left.
+
+[Illustration: FIG. 229.--Scoliosis showing rotation of bodies of
+vertebræ, and widening of intercostal spaces on side of convexity.]
+
+In aggravated cases, the patient may suffer from shortness of breath
+on exertion, and the respiratory difficulty may react on the heart,
+causing dilatation of the right side, palpitation, and precordial
+pain.
+
+Sometimes, and particularly in males, the primary curvature is in the
+lumbar region, and the convexity is to the left. The deviation of the
+lumbar vertebræ produces a prominence in the left flank which masks
+the outline of the iliac crest on that side, while the right flank
+shows a deep furrow and the right half of the pelvis is unduly
+prominent. There is a slight compensatory curve to the right in the
+thoracic region, and the right side of the chest projects backwards.
+The brachio-thoracic triangle is much more marked on the right than on
+the left side.
+
+_Diagnosis of Adolescent Scoliosis._--In many cases the patient is
+brought to the surgeon on account of pain and weakness in the back
+before any distinct deviation has developed, and, unless a careful
+examination is made, the real cause of the symptoms is liable to be
+overlooked.
+
+The patient should be stripped and examined in a good light in various
+attitudes; for example, standing in an easy position, standing as
+straight as she can, and sitting on a flat stool. She should also be
+asked to read from a book and to write, in order to exhibit her usual
+attitudes. In early cases, an inequality in the level of the angles of
+the scapulæ is often the only physical sign to be detected. It should
+also be observed whether the line of the spines is altered when the
+patient hangs from a horizontal bar or trapeze. Any backward
+projection of the ribs on one side is rendered more obvious if the
+patient folds the arms across the chest and bends well forward, while
+the surgeon looks along the back from behind.
+
+Pott's disease may be excluded by the absence of rigidity. Any
+mechanical cause of deviation of the spine, such, for example, as
+inequality in the length of the limbs or contraction of the chest
+after empyema, must be sought for. Scoliosis that depends upon
+inequality in the length of the limbs or tilting of the pelvis,
+disappears on sitting.
+
+_Treatment._--The treatment of postural scoliosis implies a
+comprehensive programme, including attention to the general health,
+habits, and exercises out of doors and in the gymnasium, clothing,
+etc., all requiring supervision over a period of months, or even of
+years. The object of the treatment is to correct the deformity before
+the position has become fixed by rotation of the vertebræ and
+alteration in their shape. The child must not be allowed to assume
+awkward attitudes while reading, writing, or playing the piano; she
+must sit on a low chair, the seat of which slopes slightly downwards
+and backwards, and the back rest of which reaches as high as the
+shoulders, and is at an angle of 100°-110° with the seat. The feet
+should rest on a sloping stool, and when the child is reading or
+writing, a desk sloping at an angle of 45° should be used. In weakly
+girls approaching the period of puberty, special care should be taken
+to avoid compression of the trunk by tight corsets. Adenoids or other
+sources of respiratory obstruction must be removed; and if the patient
+is myopic she should be provided with suitable glasses. Standing
+should be avoided, as there is a great tendency to throw the weight on
+to one leg; but walking, running, and other exercises which bring both
+sides of the body into action equally are permitted under supervision.
+Horse-riding is a suitable form of exercise, but girls must ride
+astride; cycling is not to be recommended.
+
+In mild cases--that is, those in which the curvature is obliterated
+when the patient is suspended--the prophylactic measures above
+mentioned must be rigidly enforced, and gymnastic exercises should be
+prescribed. The exercises should not be commenced, however, until,
+after a period of rest in bed, all pain and feeling of tiredness in
+the back have disappeared.
+
+In cases in which the curvature is not affected by suspension, the
+deformity is usually permanent, but by suitable exercises it may be
+prevented from becoming worse, and the patient may be educated to
+disguise it to a considerable extent. Training is also directed
+towards _regaining the muscular sense_; with the eyes shut before a
+mirror, the child should endeavour to assume the correct posture; on
+opening the eyes, the faulty attitude is seen and corrected. Forcible
+correction by means of successive plaster jackets, applied in _the
+flexed position_, somewhat on the lines employed by Calot in Pott's
+disease, has yielded results which may be described as encouraging.
+Only in very advanced cases should the patient be allowed to wear a
+supporting jacket; such appliances have no curative effect, and can
+only be expected to relieve symptoms.
+
+ * * * * *
+
+_Exercises for Lateral Curvature._--The particular exercises given
+must be carefully selected to meet the indications present in each
+case, the movements prescribed being designed to strengthen the weak
+muscles and ligaments, to increase the mobility of the spine as a
+whole, and to correct the deviation that exists. The exercises should
+be taken twice daily, preferably in the morning and afternoon, and
+after each spell the patient should rest for an hour, lying flat on
+the back. During the exercises the breathing should be carefully
+regulated, and at the end of each movement one or two deep breaths
+should be taken. Each movement should be carried out slowly, the
+number of times it is repeated varying from four to twelve or more,
+according to the nature of the exercise and the strength of the
+patient. The exercises should be stopped if the patient feels
+fatigued. Hot-air baths and massage are useful adjuvants to all forms
+of exercise.
+
+#Special Exercises for Thoracic Curvature with convexity to
+right.#--1. _Stand_ with arms by side; palms directed forward;
+shoulders braced back. This is referred to as the "_best standing
+position_" or _original position_. 2. Slowly raise arms from sides
+until level with shoulders, with palms directed forward; carry left
+arm straight upward--"_the keynote position_." Then slowly lower left
+arm to level of shoulder; lower both arms into original position. 3.
+_Assume keynote position_: slowly bend body forwards at hips until
+stooping position is reached, with legs kept quite straight, head bent
+slightly backwards, and eyes directed forward. Gradually return to
+keynote and original positions. 4. _Keynote position_: slowly bend
+whole spine to right; resume keynote and original positions. 5.
+_Keynote position_: turn body forward sideways. 6. _Keynote position_:
+rise on to balls of toes. 7. _Keynote position_: rise on to balls of
+toes; bend knees; back to original position in reverse order. 8.
+_Patient suspended from bar or rings, the left end of the bar or left
+ring being three inches higher than the right._ (_a_) Draw right knee
+upwards and forwards against resistance. (_b_) Draw legs apart against
+resistance. (_c_) Draw legs together against resistance. 9. _Patient
+lying on back._ (_a_) Bend right knee- and hip-joints against
+resistance. (_b_) Extend right knee and hip against resistance. (_c_)
+Rotate right hip against resistance. 10. _Patient lying on face with
+pillow under chest_; slowly raise arms to keynote position. While
+limbs are firmly held by a nurse, raise the body backwards and to the
+right. 11. _Same position_: make swimming movements. 12. _Patient
+astride a narrow table or chair, without a back._ (_a_) Repeat
+exercises 3, 4, 5, and 11. (_b_) Bend body forwards, backwards; and
+rotate to right and left against slight resistance made by nurse
+grasping patient's shoulders.
+
+_Klapp's "four-footed" Exercises._--Rudolf Klapp has devised a series
+of exercises designed to strengthen the muscles and ligaments of the
+spine, and to increase the mobility of the column. To take the weight
+of the body off the spine, and to render both ends of the column
+mobile, these exercises are carried out in the "all-fours" attitude,
+the patient crawling in imitation of a quadruped, that is, in such a
+way that the hand and knee of one side are approximated, while those
+of the other side are separated; in other words, the hand and knee of
+one side should not move forward simultaneously (Fig. 230). With each
+step the spine is curved laterally, the concavity of the curve being
+towards the side on which the hand and knee are approximated. The
+exercises, for a case of dorsal curvature with the convexity to the
+right, for example, are graduated as follows: (1) The child crawls in
+a straight line till he has acquired the "quadruped gait"; (2) with
+each step forward the head is inclined towards the side on which the
+hand and knee are approximated; (3) at each step the hand and knee
+which are wide apart are brought over and cross the limbs on the other
+side; (4) to open out the concave left side, he crawls in a circle
+towards the right. The exercises are practised morning and afternoon
+for from fifteen to sixty minutes at a time. If there is a marked
+_double_ curve, it is best neutralised by imitating the "pacing"
+action of a quadruped, _i.e._, the limbs of the same side moving
+forward together. The hands, knees, and toes should be protected by
+suitable gloves and leather pads. Hot-air baths and massage are useful
+adjuvants to the exercises.
+
+[Illustration: FIG. 230.--Diagram of attitudes in Klapp's four-footed
+exercises for Scoliosis.]
+
+Abbott has introduced a method of treatment applicable to cases in
+which the deformity has become permanent. Under general anæsthesia,
+the patient being slung in a bracket-frame with the spine flexed, the
+curvature is over-corrected and a plaster-case is then applied to
+maintain the attitude; the plaster-case is renewed at intervals of two
+or three months.
+
+
+
+
+CHAPTER XIX
+
+THE FACE, ORBIT, AND LIPS
+
+
+FACE--Congenital malformations: _Hare-lip and cleft palate_;
+ _Macrostoma_; _Microstoma_; _Facial cleft_; _Mandibular
+ cleft_--Injuries of soft parts: _Wounds_; _Burns_--Bacterial
+ diseases: _Boils_; _Anthrax_; _Glanders, etc._; _Lupus_;
+ _Syphilis_. Tumours: _Epithelioma_. ORBIT--Injuries: _Contusion_;
+ _Wounds_; _Fractures_--Injuries of eyeball--Orbital
+ cellulitis--Tumours. LIPS--_Cracks_; _Chronic induration_;
+ _Tuberculous ulcers_; _Syphilitic lesions_--Tumours: _Nævi_;
+ _Lymphangioma_; _Cysts_; _Epithelioma_.
+
+
+THE FACE
+
+CONGENITAL MALFORMATIONS.--The description of the various congenital
+malformations of the face will be simplified by a brief consideration
+of its development.
+
+_Development._--About the middle of the first month of intra-uterine
+life the prosencephalon bends acutely forward over the end of the
+notochord and sends out from its base a series of processes, which
+ultimately blend to form the face (Fig. 231). These processes surround
+a stellate depression, the primitive buccal cavity or stomatodæum,
+from which the mouth and nasal cavities are developed. The buccal
+cavity is bounded above by the fronto-nasal process, which is divided
+by a fissure--the nasal cleft or olfactory pit--into a lateral nasal
+process, and a mesial nasal process, at the outer angle of which a
+spheroidal elevation appears--the globular process.
+
+[Illustration: FIG. 231.--Head of human embryo about 29 days old,
+showing the division of the lower part of the mesial frontal process
+into the two globular processes, the intervention of the nasal clefts
+between the mesial and lateral nasal processes, and the approximation
+of the maxillary and lateral nasal processes, which, however, are
+separated by the nasal-orbital cleft. (After His.)]
+
+From the mesial nasal and globular processes the septum of the nose,
+the mesial segment of the premaxillary bone, and the middle portion of
+the upper lip are developed; while the lateral nasal process forms the
+roof of the nasal cavity, the ala nasi and adjacent portion of the
+cheek, and the lateral segment of the os incisivum or premaxillary
+bone. Each segment of the os incisivum carries one of the incisor
+teeth, and each of the mesial segments may contain in addition an
+accessory tooth. The nasal cleft ultimately becomes the anterior
+nares.
+
+The primitive buccal cavity is bounded below by the mandibular arch,
+which contains Meckel's cartilage, and from which are developed the
+mandible, the lower lip, and the floor of the mouth.
+
+From the lateral and back part of the mandibular arch springs the
+maxillary process, which grows upwards and blends with the lateral
+nasal process across the naso-orbital cleft--the deeper portion of
+which persists as the nasal duct. From the maxillary process are
+developed the cheeks, certain of the facial bones, the lateral
+portions of the upper lip, the soft and hard palate (with the
+exception of the os incisivum). The development of the face is
+completed about the end of the second month of intra-uterine life.
+
+
+HARE-LIP AND CLEFT PALATE
+
+Hare-lip is a congenital notch or fissure in the substance of the
+upper lip, and cleft palate a congenital defect in the roof of the
+mouth. Either of these conditions may exist alone, but they occur so
+frequently in combination that it is convenient to consider them
+together.
+
+In hare-lip the cleft may be median or lateral, and it may or may not
+be associated with a cleft in the palate. The resemblance to the
+Y-shaped cleft in the upper lip of the hare, suggested by the name, is
+in most cases only superficial.
+
+#Median hare-lip# is extremely rare. It occurs in two forms: one in
+which there is a simple cleft in the middle of the lip, the result of
+non-union of the two globular processes; another in which there is a
+wide gap due to entire absence of the parts developed from the mesial
+nasal process--the central portion of the lip, the mesial segment of
+the os incisivum, and the septum of the nose. The second form is
+usually associated with cleft palate.
+
+#Lateral hare-lip# is much more common. It is due to imperfect fusion
+of the globular process with the labial plates of the maxillary
+process. There may be a cleft only on one side of the lip, or the
+condition may be bilateral. In some cases the cleft merely extends
+into the soft parts of the lip--_simple hare-lip_ (Fig. 232) forming a
+notch with rounded margins on which the red edge of the lip shows
+almost to the apex. In other cases the cleft passes into the alveolus
+of the jaw--_alveolar hare-lip_--partly or completely separating the
+mesial and lateral segments of the premaxillary bone (Fig. 233). These
+cases are usually combined with cleft palate (Fig. 236).
+
+[Illustration: FIG. 232.--Simple Hare-lip.]
+
+[Illustration: FIG. 233.--Unilateral Hare-lip with Cleft Alveolus.]
+
+When the hare-lip is _bilateral_, the two clefts may be unequal, one
+forming a simple notch in the lip, the other passing into the nostril.
+In most cases, however, both clefts are complete, and the mesial
+portion of the lip is entirely separated from the lateral portions.
+The central portion or prolabium is usually smaller than normal, and
+is closely adherent to the os incisivum. This bone may retain its
+normal position in line with the alveolar processes of the maxilla
+(Fig. 234), or it may be tilted forward so that the incisor teeth,
+when present, project beyond the level of the prolabium (Fig. 235). In
+aggravated cases, the os incisivum and prolabium are adherent to the
+end of the nose. In these cases there is a Y-shaped cleft in the
+palate.
+
+[Illustration: FIG. 234.--Double Hare-lip in a girl æt. 17.]
+
+[Illustration: FIG. 235.--Double Hare-lip with Projection of Os
+Incisivum, in an infant before first dentition.]
+
+#Cleft Palate.#--It has already been mentioned that the palate is
+formed by the blending of the two palatal plates of the maxillary
+processes with the four segments of the os incisivum, derived from the
+nasal processes. The foramen incisivum (anterior palatine foramen)
+marks the point at which these elements of the palate unite. The
+process of fusion begins in front and spreads backwards, the two
+halves of the uvula being the last part to unite.
+
+As development may be arrested at any point, several varieties of
+cleft palate are met with. The uvula, for example, may be bifid, or
+the cleft may extend throughout the soft palate. In more severe cases,
+it extends into the hard palate as far forward as the foramen
+incisivum. In these varieties the whole cleft is mesial. In still more
+aggravated cases, the cleft passes farther forward, deviating to one
+or to both sides in the fissures between the mesial and lateral
+segments of the os incisivum or between the lateral segments and the
+maxillæ. These cases are combined with double hare-lip.
+
+The cleft varies considerably in width. It may be so wide that the
+imperfectly developed nasal septum is seen between its edges, and
+gives to the cleft the appearance of being double, or the septum is
+adherent to one edge of the palate--usually the right--and the cleft
+appears to be to the left of the middle line. In most cases the roof
+of the mouth is unduly arched, and is narrower than normal (Fig. 236).
+
+[Illustration: FIG. 236.--Asymmetrical Cleft Palate extending through
+alveolar process on left side.]
+
+_Clinical Features._--_Single hare-lip_ is about twice as common on
+the left as on the right side, and it occurs more frequently in boys
+than in girls. In a considerable proportion of cases there is a
+well-marked hereditary tendency to these deformities, and they
+frequently occur in several members of a family.
+
+The nose is characteristically broad and flattened, the ala being
+bound down to the alveolar margin of the maxilla by fibrous tissue.
+The margins of the cleft in the lip are also attached to the alveolus
+by firm reflections of the mucous membrane. The orbicularis oris and
+other muscles of expression about the mouth being defective, the
+deformity is exaggerated when the child cries or laughs. In simple
+hare-lip the child may have difficulty in sucking, but this can
+usually be overcome by some mechanical contrivance to occlude the
+cleft.
+
+When the _hare-lip is double and combined with cleft palate_, the
+child is unable to suck, and food introduced into the mouth tends to
+regurgitate through the nose. The nutrition can only be maintained by
+having recourse to spoon-feeding, and in feeding the child it is
+necessary to throw the head well back and to introduce the food
+directly into the back of the pharynx. Many of these infants are of
+such low vitality, however, that in spite of the most careful feeding
+they emaciate and die.
+
+In those who survive, the voice has a peculiar nasal twang, as in
+phonation the air is expelled through the nose instead of through the
+mouth, and the articulation, especially of certain consonants, is very
+indistinct. Taste and smell are deficient. The constant exposure of
+the nasal and pharyngeal mucous membrane renders it liable to
+catarrhal inflammation and granular pharyngitis.
+
+_Treatment._--The only means of correcting these deformities is by
+operation, and, speaking generally, it may be said that the earlier
+the operation is performed the better, provided the general condition
+of the child is equal to the strain. In simple hare-lip the best time
+is between the sixth and the twelfth weeks. When cleft palate coexists
+with hare-lip, the lip should be operated on first, as the closure of
+the lip often exerts a beneficial influence on the cleft in the
+palate, causing it to become narrower.
+
+Considerable difference of opinion exists as to when the cleft in the
+palate should be dealt with. Some surgeons, notably Arbuthnot Lane,
+recommend that it should be done in early infancy, as soon as the
+viability of the child is assured. We agree with R. W. Murray, James
+Berry, and others in preferring to wait until the child is between two
+and a half and three years old. It should not be delayed longer,
+because, even if the cleft in the palate is repaired, the nasal
+character of the voice persists, as the patient cannot overcome the
+habit of expelling the air through the nose.
+
+Before the operation is undertaken, the child must be got into the
+best possible condition; and arrangements must be made for its
+constant supervision by a competent nurse. Success depends largely on
+the avoidance of infective complications, and on absence of tension
+between the rawed surfaces that are brought into apposition. More than
+one operation is sometimes required to effect complete closure of the
+cleft.
+
+_Voice Training._--The treatment of cleft palate does not cease with a
+successful operation; the importance of voice training must be
+explained to the parents. The child must be taught, in speaking, to
+send the stream of air through the mouth, instead of through the nose.
+If the soft palate is not sufficiently large and mobile to shut off
+the mouth from the nasal cavity, little improvement in speaking can be
+looked for.
+
+In _adolescents_ and _adults_, if the cleft is wide and the soft
+tissues of the palate are thin and atrophied, better physiological
+results may be obtained by the use of an artificial obturator or
+velum. With the aid of the dentist a plate of vulcanite or gold is
+fitted to the teeth and kept in position by suction.
+
+#Other Congenital Deformities of the Face.#--_Macrostoma_ is an
+abnormal enlargement of the mouth in its transverse diameter, due to
+imperfect fusion of the maxillary and mandibular processes.
+
+_Microstoma_ is due to excessive fusion of the maxillary and
+mandibular processes. In some cases the buccal orifice is so small as
+only to admit a probe.
+
+_Facial cleft_ is due to non-closure of the fissure between the nasal
+and maxillary processes. It passes upwards through the lip and cheek
+to the lateral angular process of the frontal bone.
+
+_Mandibular cleft_ occurs in the middle line of the lower lip, and may
+extend to, or even beyond, the chin; it is due to non-union of the two
+lateral halves of the mandibular arch.
+
+These various deformities are treated by plastic operations carried
+out on the same principles as for hare-lip.
+
+_Fistulæ of the Lower Lip._--Two small openings, about the size of a
+pin's head, are occasionally met with on the free border of the lower
+lip, near the middle line. On passing a probe, each is found to lead
+into a narrow cul-de-sac, which runs for about an inch laterally and
+backwards under the mucous membrane. Watery, saliva-like fluid exudes
+through the openings. These fistulæ frequently occur in several
+members of the same family, and are usually associated with hare-lip.
+The treatment consists in dissecting them out.
+
+#Injuries of the Soft Parts of the Face.#--Owing to its free blood
+supply, the skin of the face has great vitality, and even when
+severely lacerated it not only survives, but shows such resistance to
+bacterial infection that primary union frequently takes place. In
+plastic operations, also, even extensive flaps seldom become infected,
+and they heal so rapidly that the sutures can be removed in two or
+three days.
+
+In _incised_ wounds the bleeding is usually free at first, but unless
+one of the larger arteries, such as the external maxillary (facial) or
+temporal, is injured, it soon ceases. Paralysis of the muscles of
+expression may follow if the facial nerve is injured; and loss of
+sensation may result from injury to the supra-orbital or infra-orbital
+nerves. If the parotid gland is implicated, saliva may escape from the
+wound, but it usually ceases in a few days; if the duct is involved, a
+persistent salivary fistula may form.
+
+_Punctured_ wounds may perforate the orbit, the cranial cavity, or the
+maxillary sinus, and be followed by infective complications,
+particularly if the point of the instrument breaks off and is left in
+the wound.
+
+_Contused and lacerated_ wounds result from explosions and injuries by
+firearms, and foreign bodies, such as particles of stone or coal, or
+grains of gunpowder and small shot, may lodge in the tissues. Every
+effort should be made to remove such foreign bodies, as if left
+embedded they cause unsightly pigmentation of the skin. Ligatures are
+seldom necessary for the arrest of hæmorrhage unless the larger
+branches are injured, as the bleeding from smaller twigs is arrested
+by the sutures. The edges of the wound are approximated by means of
+Michel's clips, or by a series of interrupted horse-hair stitches, and
+for this purpose a fine Hagedorn needle is to be preferred, as it
+leaves less mark than the ordinary bayonet-shaped needle. If the
+mucous membrane of the mouth or of the eyelid is implicated, its edges
+should be approximated by a separate row of catgut stitches.
+
+_Cicatricial contraction_ after severe burns may lead to marked
+deformities of the eyelids (ectropion), mouth, and nose. When the burn
+has implicated the neck, the chin may be drawn towards the chest, and
+the movements of the lower jaw and head seriously impeded.
+
+#Bacterial Disease.#--_Boils_, _carbuncles_, and _anthrax pustules_
+frequently occur on the face, and when situated near the middle line,
+and particularly on the upper lip, are liable to give rise to general
+infection and to intra-cranial complications which may prove fatal.
+The primary infection of _glanders_ and of _actinomycosis_ may also
+occur on the face.
+
+The various forms of _tuberculous lupus_ are met with more frequently
+on the face than in any other situation (Fig. 237). _Tuberculous
+disease of the facial bones_, particularly of the lateral half of the
+orbital margin at the junction of the zygomatic (malar) bone with the
+maxilla, is not uncommon in children.
+
+[Illustration: FIG. 237.--Illustrating the deformities caused by Lupus
+Vulgaris, which dated from adolescence.
+
+(Mr. D. M. Greig's case.)]
+
+The primary lesion of _syphilis_, and the various forms of secondary
+and tertiary syphilides, may simulate tuberculous lupus, cancer, and
+other ulcerative conditions.
+
+#Tumours.#--The simple tumours met with on the face include sebaceous
+and dermoid cysts, nævus, plexiform neuroma and adenoma; the malignant
+forms include the squamous epithelioma, and rodent, paraffin, and
+melanotic cancers.
+
+_Epithelioma_ occurs most frequently in men beyond the age of forty.
+The affection usually begins at the margin of the lip, the edge of the
+nostril, or the angle of the eye. There is generally a history of
+prolonged or repeated irritation, or the condition may develop in
+connection with a scar, a wart, a cutaneous horn, or an ulcerating
+sebaceous cyst. It may begin as a hard nodule, or as a papillary
+growth which breaks down on the surface, leaving a deep ulcer with a
+characteristically indurated base--the _crateriform ulcer_. The
+neighbouring lymph glands are infected early, but metastases to other
+organs are not common. The treatment consists in excising the growth
+and the associated lymph glands as early and as freely as possible.
+When excision is impracticable, benefit may be derived from the use of
+radium or of the X-rays.
+
+The face is the commonest seat of _rodent cancer_ (Volume I., p. 395).
+
+
+THE ORBIT
+
+#Injuries.#--_Wounds of the eyelids_ are liable to be complicated by
+damage to the lachrymal apparatus, leading to stenosis of the
+canaliculus and persistent watering of the eye. If the wall of the
+lachrymal sac or nasal duct is torn, the patient should be warned not
+to blow his nose for some days lest air be forced into the tissues and
+produce emphysema. In suturing wounds of the lids care must be taken
+to secure accurate apposition at the free margins, and to avoid
+constricting the canaliculi.
+
+_Contusion_ of the eyelids and circum-orbital region--the ordinary
+"black eye"--is associated with extravasation of blood into the loose
+cellular tissue of these parts, and is followed within a few hours of
+the injury by marked ecchymosis. The lids may swell to such an extent
+that the eye is completely closed. In some cases the impinging object
+lacerates the vessels of the conjunctiva and produces a
+sub-conjunctival ecchymosis, which may be situated under the palpebral
+conjunctiva of the lower lid, or close to the corneal margin on the
+front of the globe. The blood effused under the conjunctiva remains
+bright red as it is aerated from the atmospheric air. The
+characteristic play of colours which attends the disappearance of
+effused blood is observed within a week or ten days of the injury.
+
+Firm pressure applied by means of a pad of cotton wadding and an
+elastic bandage, if employed early, may limit the effusion of blood;
+and massage is useful in hastening its absorption.
+
+A black eye is to be distinguished from the effusion which sometimes
+follows such injuries as fracture of the anterior fossa of the skull,
+fracture of the orbital ridges, or a bruise of the frontal region of
+the scalp, chiefly by the facts that in the former the discoloration
+comes on within a very short time of the injury, the swelling appears
+simultaneously in both lids, and the sub-conjunctival ecchymosis, when
+present, is coeval with the ecchymosis of the lids. In fractures of
+the orbital plate and bruises of the forehead, on the other hand, the
+ecchymosis does not appear in the eyelids for several days, and that
+under the conjunctiva is usually disposed on the globe as a triangular
+patch towards the lateral canthus.
+
+_Wounds_ of the orbit result from the introduction of pointed objects,
+such as knitting pins, pencils, or fencing foils, or from chips of
+stone or metal, or small shot. They are attended with considerable
+extravasation of blood, which may be diffused throughout the cellular
+tissue of the orbit, or may form a defined hæmatoma. In either case
+the eyeball is protruded, and the cornea is exposed to irritation and
+may become inflamed and ulcerated. The optic nerve may be lacerated,
+and complete and permanent loss of vision result. Sometimes the ocular
+muscles and nerves are damaged, and deviation of the eye or loss of
+motion in one or other direction results. The globe itself may be
+injured. Foreign bodies lodged in the orbit, so long as they are
+aseptic, may give rise to little or no disturbance, and are liable to
+be overlooked. The Röntgen rays are useful in determining the presence
+and position of a foreign body.
+
+Infective complications are liable to follow injuries by bullets or
+fragments of shell, and they not only endanger the eyeball, but are
+liable to be associated with suppurative conditions in the adjacent
+air sinuses--frontal, maxillary, and ethmoidal--or in the cranial
+cavity. In purifying wounds of the orbit, and in extracting foreign
+bodies, great care is necessary to avoid injury of the eyeball or of
+its muscles or nerves.
+
+_Fracture of the margin_ of the orbit results from a direct blow, and
+is followed by circum-orbital and sub-conjunctival ecchymosis, and
+sometimes is associated with paralysis of the optic nerve, or of the
+other ocular nerves. Implication of the frontal sinus may be followed
+by emphysema of the orbit and lids, and if there is infection by
+suppurative complications.
+
+The _roof_ of the orbit is implicated in many fractures of the
+anterior fossa of the skull produced by indirect violence. It is also
+liable to be fractured by pointed instruments thrust through the
+orbit, in which case intra-cranial complications are prone to ensue,
+and these in a large proportion of cases prove fatal. When the medial
+wall is fractured and the nasal fossa opened into, epistaxis and
+emphysema of the orbit are constant symptoms. Sub-conjunctival
+ecchymosis, and some degree of exophthalmos, are almost always
+present. Treatment is directed towards the complications. When the
+nasal fossæ or the air sinuses are opened into, the patient should be
+warned against blowing his nose, as this is liable to induce or
+increase emphysema of the orbit or lids.
+
+#Injuries of the Eyeball.#--These injuries may be divided into two
+groups--(1) those in which the globe is contused without its outer
+coat being ruptured, and (2) those in which the outer coat is
+ruptured.
+
+In cases belonging to the first group, while the sclerotic coat and
+cornea remain intact, the iris may be partly torn from its ciliary
+origin, and the blood effused collects in the lower portion of the
+anterior chamber; or the pupillary margin of the iris may be ruptured
+at several points, causing apparent dilatation of the pupil. The lens
+may be partly or completely dislocated, and in the latter case it may
+pass forward into the anterior chamber or backward into the vitreous.
+Among other injuries resulting from contusion of the eye may be
+mentioned hæmorrhage into the vitreous, rupture of the choroid, and
+detachment of the retina.
+
+Injuries in which the outer coat of the eyeball is ruptured may be
+further subdivided into two groups according to whether or not a
+foreign body is lodged in the globe.
+
+Rupture of the outer coat, especially when it results from a punctured
+wound, adds greatly to the risk of the injury, by opening up a path
+through which infective material may enter the globe, and this risk is
+materially increased when a foreign body is retained in the cavity of
+the eyeball.
+
+When the globe is burst by a blow with a blunt object, the sclerotic
+usually gives way, and as the rupture takes place from within outward,
+there is less risk of infection than in punctured wounds. The lens may
+be extruded through the wound, and the iris prolapsed. If the rupture
+is large, the conjunctiva torn, and the globe collapsed from loss of
+vitreous, the eye should be removed without delay. If sight is not
+entirely lost and there is no marked collapse of the globe, an attempt
+should be made to save the eye.
+
+Wounds produced by stabs or punctures are liable to be followed by
+infective complications ending in panophthalmitis. When this is
+threatened, removal of the eye is indicated, not only because the
+affected eye is destroyed beyond hope of recovery, but to avoid the
+risk of "sympathetic ophthalmia" affecting the other eye.
+
+#Orbital Cellulitis.#--Infection of the cellular tissue of the orbit
+by pyogenic bacteria is specially liable to follow punctured wounds
+and compound fractures, if a foreign body has lodged in the orbital
+cavity. It may also result from the spread of a suppurative process
+from the globe of the eye, the conjunctiva, or the nasal fossæ or
+their accessory air sinuses. Both orbits may be affected
+simultaneously.
+
+_Clinical Features._--The disease is ushered in by rigors, high
+temperature, and severe pain, which radiates all over the affected
+side of the head. There is exophthalmos and fixation of the globe,
+with redness, swelling and tenderness of the eyelids, and congestion
+and ecchymosis of the conjunctiva. The pupil is usually dilated, the
+cornea becomes opaque and may ulcerate, and there is photophobia and
+sometimes diplopia. Suppuration usually ensues, and the pus burrows in
+every direction, and may ultimately point through the eyelids or
+conjunctiva. Sometimes the infection spreads to the meninges, and to
+the ophthalmic vein, and the phlebitis may then extend to the
+cavernous sinus. The eyeball may be infected and destructive
+panophthalmitis result. The prognosis therefore is always grave.
+
+The _treatment_ consists in making one or more incisions into the
+cellular tissue for the purpose of removing the pus and establishing
+drainage. A narrow bistoury is passed in parallel to the wall of the
+orbit, care being taken to avoid injuring the globe. When possible,
+the incision should be made through the reflection of the conjunctiva,
+but in some cases efficient drainage can only be established
+by incising through the lid. When the eye is destroyed by
+panophthalmitis, the propriety of eviscerating or enucleating it will
+have to be considered.
+
+#Tumours of the Orbit.#--Tumours may originate in the orbit or may
+invade it by spreading from adjacent cavities. Those which originate
+in the orbit may be solid or cystic. Of the solid tumours the glioma
+and the sarcoma are the most common, and when they originate in the
+pigmented structures of the globe they present the characters of
+melanotic growths. Primary carcinoma begins in the lachrymal gland.
+Osteoma--usually the ivory variety--may originate in the wall of the
+orbit, or may spread from the adjacent sinuses.
+
+_Clinical Features._--In children, the tumour is usually a glioma, and
+it is frequently bilateral. It generally occurs before the age of
+four, is associated with increased intra-ocular tension, protrusion of
+the eyeball, and dilatation of the pupil, and soon produces blindness.
+The tumour fungates and bleeds, and rapidly invades adjacent
+structures and spreads along the optic nerve to the brain. It is
+highly malignant, and recurrence usually takes place, even when the
+tumour is removed early.
+
+In adults melanotic sarcoma is most common. It occurs between the ages
+of forty and sixty, and is almost always unilateral; and while it
+shows little tendency to invade the brain, the adjacent lymph glands
+are early infected, and death usually results from dissemination.
+
+In all varieties of intra-orbital tumour exophthalmos is a prominent
+feature (Figs. 238, 239), and when the protrusion of the eyeball is
+marked the lids become swollen, oedematous, and dusky. The eye is
+seldom pushed directly forward except when the tumour is growing in
+the optic nerve or its sheath. When the tumour is solid, the eye
+cannot be pressed back into the orbit, but in cystic tumours it may to
+some extent. The movements of the eyeball are restricted in a varying
+degree, and ptosis often results from paralysis of the levator
+palpebræ superioris. In almost all cases there is also more or less
+visual disturbance. The cornea being unduly exposed is liable to
+become inflamed, or even ulcerated. Pain is a variable symptom; when
+present, it usually radiates along the branches of the first and
+second divisions of the trigeminal nerve. Tenderness on pressure is
+not always present. It is comparatively uncommon for a tumour of the
+orbit to invade the globe directly.
+
+[Illustration: FIG. 238.--Sarcoma of Orbit, causing exophthalmos and
+downward displacement of the eye, and projecting in temporal region.]
+
+[Illustration: FIG. 239.--Sarcoma of Eyelid in a child.
+
+(Mr. D. M. Greig's case.)]
+
+_Treatment._--When practicable, removal of the tumour is the only
+method of treatment, and in malignant tumours it is often necessary to
+sacrifice the eye to ensure complete removal. When the tumour has
+invaded the orbit secondarily, its removal may be impossible, but it
+may be necessary to remove the eye for the relief of pain.
+
+The _orbital dermoid_ usually occurs at the lateral end of the
+supra-orbital ridge (Fig. 240). A less common situation is the
+anterior part of the orbit, near the nasal wall, and this variety,
+from its position and from the fact that it is usually met with in
+children, is liable to be confused with orbital meningocele or
+encephalocele. Treatment consists in its removal by careful
+dissection, and this can usually be done under local anæsthesia.
+
+[Illustration: FIG. 240.--Dermoid Cyst at outer angle of orbital
+margin.]
+
+_Orbital aneurysms_ have already been described, Volume I., p. 317.
+
+
+THE LIPS
+
+_Herpes_ of the lips, due to a mild staphylococcal infection, is
+common in delicate children and in the early stages of pneumonia. A
+crop of vesicles forms and, after bursting, these leave dry scabs.
+
+A more severe staphylococcal infection may give rise to a carbuncular
+swelling with great oedema, and lead to infective phlebitis of the
+facial vein and general septicæmia. Excision of the focus is
+indicated.
+
+The lip is sometimes the seat of the malignant pustule of anthrax.
+
+Painful _cracks and fissures_ are frequently met with in the middle
+line of the lip and at the angle of the mouth in young subjects. They
+usually develop during frosty weather, and as they are constantly
+being torn open by the movements of the mouth, they are difficult to
+heal. If local applications fail, it may be necessary to cocainise the
+fissure and scrape it with a sharp spoon.
+
+_Chronic Induration of the Lips (Strumous Lip)._--A chronic oedematous
+infiltration, probably of the nature of a lymphangitis, sometimes
+affects the submucous tissue of the lips of delicate children. It is
+most common on the upper lip, and may be associated with a fissure or
+with chronic coryza. The lip is everted, and its mucous membrane
+unduly prominent. The cervical glands are frequently enlarged.
+
+The _treatment_ consists in removing the cause and in improving the
+general condition. In cases of long standing it may be necessary to
+remove from the inner aspect of the lip a horizontal strip of tissue
+having the shape of a segment of an orange.
+
+The term "_double lip_" is applied to a condition occasionally met
+with in young men, in which there is a hypertrophy of the labial
+glands in the mucous membrane of the upper lip. It is of slow growth,
+and forms an elongated swelling on each side of the frenum, covering
+the teeth, and projecting the lip. It is shotty to the feel, and the
+only complaint is of disfigurement. The treatment consists in excising
+the redundant fold of mucous membrane, including the enlarged mucous
+glands.
+
+_Tuberculous disease_ may occur in the form of lupus or of ulcers. The
+_ulcers_ generally occur in patients suffering from advanced pulmonary
+or laryngeal phthisis. They are usually superficial, may be single or
+multiple, and are exceedingly painful.
+
+_Syphilitic Lesions._--The upper lip is the most frequent seat of
+extra-genital chancre. The _chancre of the lip_ begins on the mucous
+surface as a small crack or blister, which becomes the seat of a
+rounded, indurated swelling, about a quarter of an inch in diameter.
+The surface is smooth, of a greyish colour, and exudes a small
+quantity of sero-purulent fluid. The lip is swollen and everted, and
+there is a considerable area of induration around. The submental and
+submaxillary lymph glands on one or on both sides soon become
+enlarged, and may reach the size of a pigeon's egg. At first they are
+firm, but they may subsequently soften and become painful. In some
+cases the sore is much less characteristic, resembling an ordinary
+crack or fissure, and its true nature is only revealed when the
+secondary manifestations of syphilis appear.
+
+_Mucous patches_ and _superficial ulcers_ are frequently met with on
+the mucous surface of the lips and at the angles of the mouth during
+the secondary stage of syphilis. In the inherited form of the disease
+deep cracks and fissures form, and often leave characteristic scars
+which radiate from the angles of the mouth.
+
+Gummatous lesions occur on the lips, and are liable to be mistaken for
+epithelioma.
+
+_Tumours._--_Nævi_ are not uncommon on the lips. When confined to the
+mucous surface they may be dissected out, but when they invade the
+skin they are best treated by electrolysis.
+
+_Lymphangioma._--The term _macrocheilia_ is applied to a congenital
+hypertrophy of the lip (Fig. 241), which is probably of the nature of
+a lymphangioma (Middeldorpf). One or both lips may be affected. The
+lip is protruded, the mucous membrane everted, and, when the lower lip
+is implicated, it becomes pendulous and is liable to ulcerate. The
+substance of the lip is uniformly firm and rigid, so that it moves in
+one piece, and sucking, mastication, and phonation are interfered
+with.
+
+[Illustration: FIG. 241.--Macrocheilia.
+
+(From a photograph lent by Sir H. J. Stiles.)]
+
+The _treatment_ consists in removing a wedge-shaped portion of the
+swelling on the same lines as for "strumous lip," or in employing
+electrolysis.
+
+_Mucous cysts_ occur as small rounded tumours, projecting from the
+inner surface of the lip. They are of a bluish colour, and contain a
+glairy fluid. They are treated by removal of the cyst wall, together
+with the overlying portion of mucous membrane.
+
+#Epithelioma of the lip# is of the squamous-celled variety, and is met
+with either as a fungating wart-like projection, or as an indurated
+ulcer. It almost exclusively occurs on the lower lip of men over forty
+years of age. The growth begins about midway between the middle line
+and the angle of the mouth, either as a horny epidermal thickening, or
+as a warty excrescence, which bleeds readily and soon ulcerates. The
+affection is said to be especially common in those who smoke short
+clay pipes, and it is a suggestive fact that, while epithelioma of the
+lip is rare in women, the majority of those who do suffer are
+smokers.
+
+The ulceration spreads along the lip, chiefly towards the angle of the
+mouth, and downwards towards the chin, and the substance of the lip
+becomes swollen and indurated (Figs. 242, 243). The edges are
+characteristically raised and hard, and the raw surface is extremely
+painful, especially when irritated by hot food or fluids. The growth
+is liable to spread to the mucous membrane and gum, and to invade the
+mandible. The disease spreads early to the submental and submaxillary
+glands, which are best felt with one finger inside the mouth, under
+the tongue, and another outside, behind the mandible. The infected
+glands tend to become fixed to the bone, and while at first extremely
+hard, so much so that they simulate a bony tumour of the jaw, they
+later soften, liquefy, and fungate (Fig. 244). Metastasis to internal
+organs is rare. Unless removed by operation, the disease usually
+proves fatal in from three to three and a half years.
+
+[Illustration: FIG. 242.--Squamous Epithelioma of Lower Lip in a man
+æt. 55.
+
+(Mr. D. M. Greig's case.)]
+
+[Illustration: FIG. 243.--Advanced Epithelioma of Lower Lip.]
+
+[Illustration: FIG. 244.--Recurrent Epithelioma in Glands of Neck
+adherent to mandible.]
+
+The _treatment_ consists in early and free removal of the affected
+portion of lip and of all the lymphatic connections in the
+submaxillary region and neck. Recurrence in the scar is rare; it is
+nearly always located in the glands.
+
+The operation of cleaning out the glands below the mandible on both
+sides in men who are advanced in years is not free from risk to life,
+especially from respiratory complications which may or may not be
+traceable to the anæsthetic.
+
+In inoperable cases benefit may follow the use of the X-rays, or of
+radium.
+
+_Epithelioma of the upper lip_ is less common. It occurs with equal
+frequency in the two sexes, progresses more slowly, and is, on the
+whole, less malignant. It sometimes appears to be due to contact
+infection from the lower lip. It is treated on the same lines as
+cancer of the lower lip.
+
+
+
+
+CHAPTER XX
+
+THE MOUTH, FAUCES, AND PHARYNX
+
+
+Stomatitis--Roof of mouth: _Abscess_; _Gumma_; _Tuberculous disease_;
+ _Tumours_--Elongation of uvula--Epithelioma of floor of
+ mouth--Tonsillitis: _Varieties_--Hypertrophy of
+ tonsils--Calculus--Syphilis and
+ Tuberculosis--Tumours--Retro-pharyngeal abscess.
+
+
+THE MOUTH
+
+#Stomatitis.#--The term stomatitis is applied to any inflammation of
+the buccal mucous membrane. The _catarrhal_ form is often associated
+with the presence of carious teeth or an infected wound; the mucous
+membrane is hyperæmic and swollen, and exudes an excessive amount of
+viscid mucous secretion, and the epithelium desquamates in patches,
+leaving small superficial erosions or ulcers, which are very
+sensitive. The _aphthous_ form, met with in unhealthy, underfed
+children, is characterised by the occurrence of patches of fibrinous
+exudate into the superficial layers of the mucous membrane; the
+epithelium is shed, leaving a series of whitish spots surrounded by a
+red hyperæmic zone, which may become confluent and form small ulcers.
+The condition known as _thrush_, which closely resembles aphthous
+stomatitis, is met with in infants during the period of teething, and
+is due to the _oïdium albicans_, a fungus met with in sour milk. The
+spots, which are most numerous on the lips, tongue, and throat, have
+the appearance of curdled milk.
+
+The _treatment_ of these forms consists in improving the general
+condition of the patient, and in employing a mouth-wash, such as
+peroxide of hydrogen, Condy's fluid, chlorate of potash, or
+boro-glyceride. The superficial ulcers may be touched with silver
+nitrate or with a 1 per cent. solution of chromic acid.
+
+_Ulcerative stomatitis_ is frequently met with in debilitated subjects
+with decayed teeth, and is specially liable to occur during the course
+of acute febrile diseases in which sordes accumulate about the teeth
+and gums. It also occurs in syphilitic subjects while under treatment
+by mercury--_mercurial stomatitis_. Some patients show a special
+susceptibility to mercury, and one of the first signs of intolerance
+of the drug is some degree of stomatitis, which may ensue after a
+comparatively small quantity has been administered. It begins in the
+gums, which become swollen and spongy, growing on to the teeth and
+into the interstices. The gums assume a bluish-red colour and bleed
+readily, and the teeth may become loose and fall out. The tongue may
+share in the swelling--mercurial glossitis. There is also profuse
+salivation, and the breath has a characteristically offensive odour.
+In severe cases the alveolar margin of the jaw undergoes necrosis. A
+similar condition occurs in lead and in phosphorus poisoning, and in
+patients suffering from scurvy.
+
+The _treatment_ consists in removing the cause, and in employing
+antiseptic and astringent mouth-washes. The internal administration of
+chlorate of potash is also indicated, as this drug is excreted in the
+saliva. Loose teeth should not be removed as they become fixed again
+when the stomatitis subsides.
+
+_Gangrenous stomatitis_, or cancrum oris (Fig. 245), has already been
+described (Volume I., p. 102).
+
+[Illustration: FIG. 245.--Cancrum Oris.
+
+(Mr. D. M. Greig's case.)]
+
+#Roof of the Mouth.#--_Suppuration_ in the muco-periosteum of the
+palate is usually secondary to suppuration at the root of a carious
+tooth. It may also arise in excoriations caused by an ill-fitting
+tooth-plate, or from the impaction of a foreign body, such as a fish
+or game bone, in the mucous membrane. The inflammation begins close to
+the alveolus, and may spread back along the palate. The
+muco-periosteum becomes swollen, red, and exceedingly tender, and, as
+pus forms, is raised from the bone, forming a prominent, firm,
+elongated swelling, which on bursting or being incised gives exit to
+foul-smelling pus.
+
+The _syphilitic gumma_, which begins as a rounded indolent swelling,
+is usually situated in the middle line near the posterior edge of the
+hard palate. The swelling gradually softens and ulcerates, and a
+sequestrum may separate and leave a perforation in the palate (Fig.
+246). The treatment consists in employing the usual remedies for
+tertiary syphilis. If the perforation persists and causes trouble by
+allowing food to pass into the nose, or by giving a nasal tone to the
+voice, it may be closed by an operation on the same principle as that
+performed for cleft palate, or an obturator may be fitted to occlude
+the opening.
+
+[Illustration: FIG. 246.--Perforation of Palate, the result of
+Syphilis, and Gumma of Right Frontal Bone.
+
+(From Dr. Byrom Bramwell's _Atlas of Clinical Medicine_.)]
+
+_Tuberculous_ disease is chiefly met with in the form of lupus which
+has spread from the nose or lips, and it may lead to widespread
+destruction of the soft tissues, or even to perforation of the bony
+palate.
+
+Mucous cysts, dermoids, adenomas, lipomas, and fibromas are
+occasionally met with. _Papillomatous thickening_ of the mucous
+membrane sometimes occurs in association with leucoplakia. It resists
+anti-syphilitic treatment, but yields to scraping with the sharp
+spoon. _Endotheliomas_, or _mixed tumours_, similar to those met with
+in the parotid gland, also occur in young subjects, and grow in the
+submucous tissue of the soft palate, usually to one side of the middle
+line. In their early stages they are of slow growth, and give rise to
+no inconvenience save from their size, are easily removed, and show no
+tendency to recur. Later, they grow more rapidly, tend to infiltrate
+their surroundings and to assume malignant characters, so that
+complete removal becomes difficult or impossible.
+
+_Epithelioma_ may originate in the hard palate as a result of local
+irritation, or may spread from adjacent parts. When it is confined to
+the palate it is treated by removal of the palatal and alveolar
+portions of the maxilla.
+
+#Elongation of the uvula# is usually due to a chronic inflammatory
+engorgement combined with glandular hypertrophy of the mucous
+membrane. It often occurs in children, and is associated with a
+constant hacking cough, which is usually worst when the patient is
+lying down. By tickling the back of the tongue and pharynx it may
+induce vomiting after meals. The treatment consists in snipping off
+the redundant portion with scissors.
+
+#Epithelioma of the floor of the mouth# frequently originates in the
+mucous membrane between the frenum of the tongue and the inner aspect
+of the gum. It develops insidiously, grows slowly, and gradually
+spreads to the mandible and to the substance of the tongue, tacking it
+down so that it cannot be protruded. The glands are early involved,
+and their enlargement not infrequently first draws attention to the
+condition. It is to be regarded as a particularly unfavourable site,
+as local recurrence is frequent. For the complete removal of the
+disease it is necessary to excise the tissues in the floor of the
+mouth, and a variable portion of the tongue and mandible, and to clear
+out the glands and fat from the submaxillary and submental regions.
+
+
+THE TONSILS AND PHARYNX
+
+#Infective Conditions.#--The majority of the infective conditions
+included under the popular term "sore throat" originate in the
+tonsils, and are due to the action of bacteria which under normal
+conditions are present in the crypts of the tonsils and of the mucous
+membrane of the naso-pharynx. The most important of these organisms
+are streptococci, various forms of staphylococci and of
+pneumo-bacteria, and diphtheritic and pseudo-diphtheritic bacilli. So
+long as the health is good these organisms are harmless, but when
+there is any lowering of the vitality they become virulent and give
+rise to various forms of infection.
+
+_Catarrhal tonsillitis_--usually attributed by the laity to "catching
+cold"--is characterised by hyperæmia and congestion of the tonsils and
+mucous membrane of the pharynx, soft palate, and uvula. It is often
+met with in those who are much exposed to air contaminated with
+organisms--for example, patients who have been long in hospital, or
+the resident staff of hospitals (_septic_ or _hospital throat_), and
+particularly in persons of a "rheumatic" tendency. There is slight
+pain on swallowing, and a tickling sensation passes along the
+Eustachian tube to the ear; the throat feels dry, and the patient has
+a constant desire to clear it, and there is usually a rise of
+temperature to 101°-102° F. As a rule the symptoms pass off in three
+or four days, but the condition may spread along the Eustachian tube
+to the ear, and interfere with hearing, or it may set up chronic
+suppuration of the middle ear.
+
+A similar condition of the pharynx is frequently one of the initial
+symptoms in acute febrile diseases, such as scarlet fever, measles,
+influenza, or acute rheumatism.
+
+The _treatment_ of the throat affection consists in employing
+antiseptic and soothing gargles, inhalations of chloride of ammonium,
+or a spray of peroxide of hydrogen, menthol, or eucalyptol. Lozenges
+or pastilles containing chloride of ammonium, chlorate of potash, and
+cubebs may be employed. In rheumatic cases, salicin, aspirin, and
+salicylate of soda are indicated.
+
+In _follicular tonsillitis_, the infection first implicates the
+lymphoid follicles. The crypts are distended with yellowish-white
+plugs, composed of inflammatory exudate, leucocytes, and desquamated
+epithelium, and these may project from the openings, giving the tonsil
+a spotted appearance. Sometimes the exudate accumulates on the surface
+of the tonsils and pharynx, forming a thin, greyish-white film, which
+is liable to be mistaken for the false membrane of diphtheria. It can,
+however, usually be wiped off, and when examined microscopically does
+not contain the typical Löffler's bacillus.
+
+The tonsils are enlarged, and project so that they obstruct the
+isthmus of the fauces, sometimes even meeting in the middle line.
+There is pain on swallowing, and the respiration is impeded and noisy
+during sleep. There is usually some degree of fever, and the glands
+behind the angle of the jaw are enlarged and tender and may suppurate
+and set up cellulitis. The acute symptoms usually subside in four or
+five days, but if the deeper crypts are filled with plugs of exudate
+the condition may prove obstinate. The patient is liable to periodic
+attacks, particularly if the tonsils are chronically enlarged.
+
+The _treatment_ is carried out on the same lines as for the catarrhal
+form. In recurrent cases the tonsils should be removed.
+
+#Acute Suppurative Tonsillitis and Peri-tonsillitis--Quinsy.#--This is
+an acute suppurative inflammation of the tonsils and peritonsillar
+tissue, due to infection with pyogenic bacteria. It affects the whole
+substance of the tonsils, and the cellular tissue of the pillars of
+the fauces, the soft palate, and the pharynx.
+
+_Clinical Features._--The onset is usually sudden, and the affection
+is ushered in by a rigor, high fever, and a feeling of malaise. There
+is persistent thirst and dryness of the throat, and the patient has
+the sensation of a foreign body being in the pharynx, with a constant
+desire to swallow. Swallowing is extremely painful, the pain shooting
+up to the ears, and the patient has difficulty in taking nourishment.
+The saliva accumulates in the mouth; the voice is thick and nasal; and
+the respiration impeded and noisy. If the patient can open the mouth
+sufficiently to afford a view of the back of the throat (which,
+however, is seldom the case), the inflamed parts are seen to be of a
+dull reddish-violet colour. One tonsil is often more swollen than the
+other, and the corresponding anterior pillar of the fauces more
+prominent. The uvula is swollen and oedematous, and is deviated
+towards the side on which there is least swelling. Suppuration occurs
+in from three to seven days; in adults it is usually in the
+peritonsillar tissue of the anterior pillar of the fauces, and extends
+into the soft palate. In children the pus sometimes forms in the
+substance of the tonsil. If left to burst, the abscess discharges
+itself into the mouth, and the patient experiences instant relief. The
+pus is always offensive, and if the abscess bursts during sleep, it
+may enter the air-passages and cause septic pneumonia. The lymph
+glands in the neck are usually enlarged and tender, and sometimes they
+suppurate and give rise to a diffuse cellulitis. General infection of
+the blood may follow, leading to metastatic invasion of different
+tissues and organs, particularly one or other of the large joints.
+
+_Treatment._--In the early stages soothing antiseptic gargles are
+indicated. Later, when the patient is unable to gargle, the inhalation
+of steam impregnated with the vapour of carbolic acid or friar's
+balsam, and the application of hot fomentations or a large linseed
+poultice to the neck may afford relief. When an abscess is formed, it
+should be opened by means of a fine-pointed pair of sinus forceps,
+thrust through the soft palate at a point opposite the base of the
+uvula, and in the line of the anterior pillar of the fauces. As those
+who suffer from quinsy are liable to have attacks coming on
+periodically, if the tonsils remain permanently enlarged they should
+be removed between attacks.
+
+#Hypertrophy of the tonsils# is most commonly met with in children
+between five and ten years of age, and is often associated with
+adenoid vegetations in the naso-pharynx and chronic thickening of the
+pharyngeal mucous membrane.
+
+The whole tonsil is enlarged, the mucous membrane thickened, and the
+connective tissue more or less sclerosed. The crypts appear on the
+surface as deep clefts or fissures, and the lymph follicles are
+enlarged and prominent. Secretion accumulates in the crypts, and a
+calculus may form from the deposit of lime salts. Sometimes food
+particles lodge in the crypts, and they may collect and form
+accumulations of considerable size, requiring the use of a scoop to
+dislodge them.
+
+_Clinical Features._--The hypertrophy is bilateral, but not always
+symmetrical. Sometimes the tonsils project to such an extent as almost
+to meet in the middle line; sometimes they scarcely pass beyond the
+level of the pillars of the fauces. They are usually sessile, but
+sometimes the base is so narrow as almost to form a pedicle. During
+childhood they are usually soft and spongy, but when they persist into
+adolescence or adult life they become firm and indurated. This
+sclerotic change is due to the repeated attacks of catarrhal or
+suppurative tonsillitis to which the patient is subject. The lymph
+glands behind the angle of the jaw are frequently enlarged. Swallowing
+is sometimes interfered with, and the patient is liable to attacks of
+nausea and vomiting. Respiration is always more or less impeded; the
+patient breathes through the open mouth, and snores loudly during
+sleep; and the hindrance to respiration interferes with the
+development of the chest. In some cases alarming suffocative attacks
+occasionally supervene during sleep, but the difficulty in breathing
+disappears as soon as the child is wakened. The voice is
+characteristically thick and nasal, especially when adenoids are
+present, and in many cases the patient has a vacant and stupid
+expression. Hearing is often impaired from obstruction of the
+Eustachian tube.
+
+_Treatment._--In early and mild cases, the tonsils should be painted
+with glycerine of tannic acid, or some other astringent, and an
+antiseptic mouth-wash, or spray of hydrogen peroxide, should be used
+several times a day. When the condition is interfering with the
+general health or with the development of the chest, or when there is
+deafness or disturbance of sleep, the tonsils should be removed.
+
+#Calculi# composed of phosphate or carbonate of lime are sometimes
+formed in the crypts of enlarged tonsils; as a rule they are about the
+size of a pea, but they may be much larger. They cause a sharp
+stabbing pain on swallowing, and sometimes a persistent hacking cough.
+They are easily shelled out through a small incision into the tonsil.
+
+#Syphilis.#--The fauces and tonsils are occasionally the seat of a
+hard chancre, and the condition may simulate malignant disease. The
+submaxillary glands, however, become enlarged sooner and increase more
+rapidly than in cancer, and they are tender. The secondary
+manifestations of the disease usually appear before the chancre has
+healed.
+
+Early in secondary syphilis, mucous patches and superficial ulcers are
+frequently met with. Later, severe phagedænic ulceration sometimes
+occurs, especially in alcoholic subjects, and may rapidly eat through
+the soft palate, leading to marked deformity from contraction when
+cicatrisation takes place.
+
+In the tertiary stage, a diffuse gummatous infiltration occurs, and is
+liable to be followed by ulceration, which spreads to the pharyngeal
+wall and soft palate, and, by causing cicatricial contraction and
+adhesions, may lead to narrowing or even complete occlusion of the
+communication between the pharynx and the naso-pharynx.
+
+#Tuberculous# lesions of the fauces and tonsils are almost invariably
+secondary to tubercle of the larynx or lungs, or to lupus of the face
+or naso-pharynx. They are attended with more pain than syphilitic
+lesions; are less prone to spread to the palate and cause perforation;
+but, when cicatrisation takes place, they are equally liable to
+produce contraction and deformity.
+
+#Tumours.#--_Innocent tumours_--fibroma, lipoma, myoma--are
+comparatively rare. When sessile they cause inconvenience only by
+their bulk; when pedunculated they may hang down into the pharynx and
+interfere with swallowing and breathing. They may be shelled out, or
+ligated at the base and cut off, according to circumstances.
+
+_Malignant Disease._--The _tonsil_ is frequently the primary seat of
+_lympho-sarcoma_, a very malignant form of round-celled sarcoma. The
+tumour is at first confined to the tonsil, which differs in appearance
+from simple hypertrophy only in being paler and more nodular. The
+growth rapidly infiltrates the peritonsillar connective tissue and
+adjacent palatal mucous membrane, which becomes pale and oedematous,
+and the condition at this stage may simulate a suppurative
+tonsillitis. As it increases, the tumour encroaches upon the cavity of
+the pharynx, causing interference with swallowing and breathing; the
+mucous membrane soon gives way, and widespread ulceration and
+sloughing of the tumour substance occurs, sometimes leading to serious
+and even fatal hæmorrhage. The patient emaciates rapidly. The adjacent
+lymph glands are early infected.
+
+Removal by operation is seldom practicable, but the introduction of a
+tube containing radium for several days has in some cases proved
+beneficial.
+
+_Carcinoma_ is more common than sarcoma. It may take the form of
+_squamous epithelioma_ or of _medullary cancer_, and may originate in
+the tonsil, in the groove between the tonsil and the tongue, or in the
+soft palate. By the time the patient seeks advice it has usually
+implicated the fauces, soft palate, and pharyngeal wall as well as the
+tonsil.
+
+Males suffer more frequently than females. The disease may exist for a
+considerable time before giving rise to marked symptoms, and attention
+may first be drawn to it by pain and difficulty in swallowing, or by
+pain shooting towards the ear. In some cases enlargement of the glands
+behind the angle of the jaw is the first thing to attract the
+patient's attention. The other symptoms are very like those of cancer
+of the tongue--pain during eating or drinking, salivation and foetid
+breath. Sometimes fluids regurgitate through the nose, and the voice
+may become nasal and indistinct. As the patient is usually unable to
+open the mouth widely, it is seldom possible to learn much by
+inspection, but a digital examination may reveal an irregular, hard,
+and ulcerated growth. The swelling is sometimes palpable from the
+outside, filling up the hollow behind the angle of the jaw, and in
+this situation also the enlarged lymph glands may be felt. These are
+often enlarged out of all proportion to the size of the primary
+growth. The disease tends to spread locally, causing increasing
+difficulty in swallowing and breathing. The patient gradually loses
+strength, and may die from exhaustion induced by pain and insomnia,
+from hæmorrhage, or from septic pneumonia.
+
+In early cases an attempt may be made to remove the disease by
+operation. In our experience radium has proved less efficacious in
+cancer than in sarcoma.
+
+In advanced cases, it is only possible to relieve the patient's
+suffering by palliative measures. Antiseptic mouth-washes are used to
+diminish the foetor of the breath and the risk of pneumonia, and
+heroin or morphin to relieve pain. The use of the nasal tube, or even
+a gastrostomy, may be necessary to enable the patient to take
+sufficient food, and tracheotomy may be called for to relieve
+dyspnoea.
+
+#Retro-pharyngeal Abscess.#--The _chronic_ retro-pharyngeal abscess
+associated with tuberculous disease of the cervical vertebræ, in which
+the pus accumulates behind the prevertebral fascia, has already been
+described (p. 441).
+
+The _acute_ abscess occurs in the space between the prevertebral
+fascia and the wall of the pharynx. The infection usually begins in
+one of the lymph glands that occupy this space, and rapidly ends in
+suppuration, which spreads to the surrounding cellular tissue. It is
+most common in children during the first and second years, and the
+patient may be convalescent after one of the eruptive fevers attended
+with inflammation of the bucco-pharyngeal mucous membrane--such as
+scarlet fever, measles, or chicken-pox--or may suffer from nasal
+excoriations or coryza. In some cases the irritation of dentition is
+the only discoverable cause.
+
+In infants, the condition is usually very acute, and is attended with
+fever, rigors, vomiting, and often with convulsions. The head is held
+rigid, and usually twisted to one side, and there is pain on
+attempting to move it. The child has great pain on swallowing, there
+is regurgitation of food, and the saliva dribbles from the mouth.
+There is marked dyspnoea and a short, dry cough. The back of the
+throat is red and swollen, and a localised projection, which is soft
+and fluctuating, and is usually asymmetrical, may be recognised by
+digital examination. Sometimes the voice is lost, and the patient has
+severe attacks of choking--symptoms which have led to the disease
+being mistaken for membranous laryngitis. In some cases a soft
+swelling is palpable on one or on both sides of the neck. Unless the
+abscess is promptly opened the condition usually proves fatal. The
+mouth is opened by means of a gag, the head allowed to hang over the
+end of the table, and the abscess incised, with a guarded bistoury,
+through the wall of the pharynx. The dangers associated with opening
+the abscess from the mouth appear to have been exaggerated.
+
+A _less acute_ form of retro-pharyngeal abscess sometimes develops in
+the course of chronic middle ear disease, the inflammatory process
+spreading along the Eustachian tube, in the wall of which an abscess
+forms and burrows into the retro-pharyngeal space.
+
+
+
+
+CHAPTER XXI
+
+THE JAWS, INCLUDING THE TEETH AND GUMS
+
+
+TEETH: Dental caries--Impacted wisdom tooth. GUMS: Gingivitis;
+ Pyorrhoea alveolaris; Hypertrophy; Epithelioma. JAWS: Pyogenic
+ affections: _Periostitis_; _Osteomyelitis_; Tuberculosis;
+ Syphilis; Actinomycosis--Tumours: _Of alveolar process_; _Of
+ maxilla_; _Of mandible_--Fracture of maxilla--Fracture of
+ mandible--Affections of the temporo-mandibular articulation:
+ _Dislocation of the mandible_; _Acute arthritis_; _Tuberculous
+ arthritis_; _Arthritis deformans_; _Closure of the jaws_.
+
+#Dental caries# is a process of disintegration which begins in the
+enamel of a tooth--usually in the region of its neck--and gradually
+extends through the dentine till the pulp cavity is reached.
+
+Infection of the exposed pulp cavity may set up an acute purulent
+_pulpitis_. This is associated with severe pain, which is not confined
+to the diseased tooth, but may spread to adjacent teeth, and sometimes
+to all the branches of the trigeminal nerve on the same side of the
+face.
+
+The infection may spread from the tooth to the alveolo-dental
+periosteum, and set up a _periodontitis_. In the affected tooth there
+is at first a feeling of uneasiness, which is relieved by the patient
+biting against it. Later there is severe lancinating or throbbing
+pain. The affected tooth usually projects beyond its neighbours, and
+is excessively tender when the opposing tooth comes in contact with it
+in mastication. The gum becomes red and swollen, and the cheek is
+oedematous.
+
+Periodontitis is usually followed by the formation of an _alveolar
+abscess_. The pus, which forms at the root of the tooth, in most cases
+works its way through the bone and into the gum, constituting a
+"gum-boil." The pus may then burst through the gum, or may spread
+underneath the external periosteum of the jaw and lead to necrosis.
+
+In some cases the cheek becomes adherent to the gum and to the jaw
+before the abscess bursts, and the pus escapes through the skin,
+leaving a sinus which leads down to the defaulting tooth, and which is
+slow to heal, usually because there is a small sequestrum at the
+bottom of it. The opening of the sinus is most commonly situated at
+the under margin of the mandible a little in front of the masseter
+muscle. An alveolar abscess deeply seated in the maxilla may open into
+the maxillary antrum and set up suppuration in that cavity. To avoid a
+scar on the face, the abscess should be opened from the mouth. A
+periodontal abscess of one of the upper central incisors spreads
+backwards between the muco-periosteum and the bony palate, causing an
+elongated swelling in the roof of the mouth.
+
+In all cases the extraction of the carious tooth is necessary before
+the abscess will cease discharging and the sinus heal. If a sequestrum
+is present it must be removed, and the bone scraped with a sharp
+spoon. Among the other effects of dental caries may be mentioned
+localised necrosis of the alveolar margin, cellulitis of the neck, and
+enlargement of the cervical lymph glands.
+
+A _cyst_ is frequently found attached to the root of a decayed tooth.
+It is lined with epithelium, and is probably derived from a belated
+portion of the enamel organ which has been stimulated to active growth
+by infective processes in the pulp cavity. It is seldom larger than a
+pea, and contains a pultaceous mass like inspissated pus. It gives
+rise to no symptoms, and is only recognised after extraction of the
+root.
+
+_Odontomas_ have already been described (Volume I., p. 192).
+
+A localised swelling of the mandible, associated with pain referred to
+the ear and neck, and in some cases with spasmodic contraction of the
+muscles of mastication, may be due to _impaction of the wisdom tooth_
+(lower third molar). If the tooth is merely embedded in the gum,
+incision may allow of its eruption; if the X-rays show that it is
+wedged under the second molar it must be extracted, and this may prove
+a difficult dental operation.
+
+#Affections of the Gums.#--Inflammation of the
+gums--_gingivitis_--usually occurs in association with a general
+stomatitis. The gums are swollen and spongy, and may show superficial
+ulceration, associated with bleeding and extreme foetor of the breath.
+The teeth become loose, project from the alveoli, and sometimes fall
+out. These symptoms are prominent in cases of scurvy, and of chronic
+mercurial poisoning. In chronic lead-poisoning a characteristic blue
+line is seen on the gums near the dental margin. The _treatment_
+consists in removing the cause, improving the hygienic and dietetic
+conditions of the patient, and administering lime-juice, iodide of
+potash, quinine, or cod-liver oil, according to the cause. Antiseptic
+mouth-washes and dentifrices are also indicated. Chlorate of potash,
+being excreted in the saliva, is particularly useful.
+
+_Pyorrhoea alveolaris_ is a chronic form of gingivitis, met with after
+middle life, which begins in relation to the necks of the teeth and
+the alveolo-dental periosteum. It is due to bacterial infection, and
+is associated with an accumulation of tartar between the gums and the
+teeth. A muco-purulent discharge escapes from within the free edge of
+the gum and alveolus. The alveolar borders and the gum subsequently
+undergo atrophy, so that the roots are exposed, and the teeth are
+liable to become loose and eventually to fall out. The condition may
+only affect a few teeth, or it may spread to them all, in which case
+the patient may in the course of some years become edentulous.
+Gastro-intestinal disturbances, chronic joint affections of the nature
+of arthritis deformans, a form of pernicious anæmia, and other general
+conditions have been attributed to the absorption of toxic products.
+The _treatment_ consists in removing the tartar from the teeth,
+applying strong antiseptics to the groove between the teeth and the
+gums, and employing mouth-washes and dentifrices. Massage of the gums
+night and morning, and rubbing in a paste of chlorate of potash and
+menthol, is often of great value. Good results have followed the use
+of vaccines and improvement of the general health.
+
+_Hypertrophy of the gums_ is occasionally met with in children and
+young adults who are mentally defective, and the teeth appear early
+and are abnormally large. The gum almost buries the teeth, and large
+polypoid masses form which tend to fungate. The treatment consists in
+removing not only the hypertrophied gums, but also the affected
+alveolus (Heath).
+
+A localised hypertrophy--_polypus of the gum_--sometimes results from
+the irritation of a carious tooth, or from the pressure of an
+artificial denture, and may simulate an epulis (p. 513). The swelling
+is usually pedunculated, and if cut away close to the alveolar margin
+does not tend to recur.
+
+_Epithelioma_ sometimes originates in the gum in relation to a carious
+tooth or to an artificial tooth-plate. The growth tends to invade the
+bone and to spread to the cheek or buccal mucous membrane, or to the
+maxillary antrum, and its malignant nature is suggested by its
+persisting after the removal of the irritation. The only treatment is
+early and complete removal of the growth and the adjacent segment of
+bone.
+
+Other tumours of the gums, such as angioma and papilloma, are rare.
+
+
+THE JAWS
+
+#Pyogenic Infections.#--The jaws may be infected in fractures
+communicating with the mouth or as a result of the unskilful
+extraction of teeth, but the majority of pyogenic infections originate
+in relation to carious teeth, beginning as a periodontitis which is
+followed by diffuse periostitis that may lead to necrosis of
+considerable portions of bone. In workers exposed to the fumes of
+yellow phosphorus, the bone may be so devitalised that it readily
+becomes infected with pyogenic organisms and undergoes a process of
+cario-necrosis--the _phosphorus necrosis_ of the older writers.
+
+[Illustration: FIG. 247.--Cario-necrosis of Mandible.]
+
+_Acute osteomyelitis_ occasionally attacks the mandible, less
+frequently the maxilla. Pus rapidly forms under the periosteum, and a
+considerable area of bone may undergo necrosis.
+
+In _cancrum oris_, also, the bones are frequently attacked and may
+undergo necrosis.
+
+The _treatment_ is to let out the pus, and, whenever possible, this
+should be done from the mouth to avoid a cicatrix on the face. When
+the angle or the ascending ramus of the mandible or the facial portion
+of the maxilla is involved, it is not possible to avoid making an
+external opening. Drainage is secured, and the mouth kept sweet by the
+frequent use of antiseptic washes. When the condition is due to a
+carious stump or to an unerupted tooth, this should be extracted at
+the same time as the abscess is opened.
+
+The separation of a sequestrum is usually slow, taking from two to
+four months according to the acuteness of the infection and the extent
+of the necrosis. In the mandible the sequestrum becomes surrounded by
+a sheath of new periosteal bone, so that, even if the greater part of
+the jaw undergoes necrosis, the arch is reproduced, and after removal
+of the sequestrum little or no deformity results. The sequestrum can
+usually be removed after dividing the mucous membrane and gouging away
+a portion of the outer aspect of the new sheath. The cavity is packed
+with iodoform or bismuth gauze. When the ascending ramus is involved,
+precautions must be taken to prevent fixation of the jaw taking place
+during the healing process. In the maxilla no new case is formed, and
+deformity results from sinking in of the cheek, unless this is
+prevented by wearing a plate made by the dentist.
+
+#Tuberculous disease# is comparatively rare. It is occasionally met
+with on the orbital margin of the maxilla and in the region of the
+zygomatic (malar) bone. In the mandible it usually occurs near the
+angle. Stockman isolated the tubercle bacillus from a series of cases
+of "phosphorus necrosis" investigated by him. The sinuses that form
+when a cold abscess bursts on the surface are peculiarly intractable
+and only heal after the diseased bone has been removed, leaving a
+characteristically depressed scar, which is adherent to the bone.
+
+#Syphilitic# affections are also rare. A localised gumma may develop
+in the neighbourhood of the angle of the mandible, or the whole of the
+body of that bone may be the seat of a diffuse gummatous infiltration
+(Fig. 248). In either case the clinical importance of the condition
+lies in the fact that it is liable to be mistaken for a new growth,
+such as an osteo-sarcoma, or for actinomycosis.
+
+[Illustration: FIG. 248.--Diffuse Syphilitic Disease of Mandible.]
+
+#Actinomycosis.#--This condition is met with in the jaws more
+frequently than in any other part, and the mandible is attacked
+oftener than the maxilla. The actinomyces gain access to the bone
+through a carious tooth or through the gum.
+
+At the outset the patient complains of pain and tenderness referred to
+one or more carious teeth. Within a few weeks a swelling forms--in the
+mandible near the angle as a rule, and in the maxilla in some part of
+the cheek. The swelling, which varies in consistence, implicates the
+bone and cannot be moved apart from it. The skin over it becomes red,
+suppuration occurs, and sinuses form and give exit to a sero-purulent
+fluid in which the characteristic yellow "sulphur grains" may be
+detected. The surrounding soft tissues are infiltrated, and the part
+becomes riddled with sinuses, which lead down to bare bone. The
+disease usually runs a chronic course, lasting for one or two years,
+and, unless pyogenic infection is superadded, is not attended with
+fever.
+
+In the absence of the characteristic yellow granules, actinomycosis
+may readily be mistaken for tuberculous or syphilitic disease, or for
+sarcoma.
+
+The _treatment_ consists in removing the diseased tissue with the
+knife or sharp spoon, and in the administration of large doses of
+potassium iodide. The insertion of tubes of radium has a beneficial
+effect.
+
+#Tumours of the Alveolar Process.--Epulis.#--The tumours that grow
+from the alveolar processes of the jaws appear at first sight to
+spring from the gums, hence the term _epulis_, generally applied to
+them. They really originate in the periosteum of the alveolus or in
+the periodontal membrane, and are essentially of the nature of
+fibro-sarcoma. In some, the fibrous element predominates, but the
+frequency with which they recur after removal, unless the segment of
+bone from which they spring is also excised, indicates their malignant
+tendency. In most cases the tumour is of the myeloid type--myeloma; in
+others new bone is formed in its substance--osteo-sarcoma.
+
+An epulis usually begins in the gap between two teeth, and grows
+slowly, either towards the cavity of the mouth, or more frequently
+towards the lip or cheek, where it appears as a bright red, smooth,
+firm, rounded swelling, which is adherent to the jaw, and may be
+sessile or pedunculated (Fig. 249). It causes little pain, but is
+liable to interfere with mastication. As it increases in size it
+spreads over the alveoli of several teeth, becomes softer, and assumes
+a dark violet colour, and if subjected to pressure or irritation may
+ulcerate and bleed.
+
+[Illustration: FIG. 249.--Epulis of Mandible.
+
+(Anatomical Museum, University of Edinburgh.)]
+
+The true alveolar tumour is to be diagnosed from a mass of redundant
+granulations such as may form in relation to a carious tooth, from a
+polypus or an epithelioma of the gum, a tumour of the body of the jaw,
+or an angioma.
+
+The _treatment_ consists in removing the tumour together with a
+wedge-shaped or quadrilateral portion of the alveolar process from
+which it grows. A dental plate should be fitted to fill up the gap in
+the alveolus. After such free removal these tumours show little
+tendency to recur and metastases are rare.
+
+#Malignant Tumours of the Maxilla.#--All varieties of _sarcoma_ and
+_carcinoma_ are met with; of the former, the round and spindle-celled
+are the most common. Carcinoma occurs chiefly in two forms, less
+commonly a columnar epithelioma arising from glandular epithelium,
+much more commonly a squamous epithelioma either originating within
+the antrum and causing its expansion, or spreading to the maxilla from
+the mucous membrane of the nose or mouth. Clinically it is practically
+impossible to differentiate sarcoma from carcinoma; in the later
+stages the infection of the glands below the mandible is more marked
+in carcinoma. An important point to determine is whether the growth
+arises within the maxilla or has spread to it from adjacent parts,
+such as the base of the skull, the nose, or the palate. In this the
+X-rays are helpful. Their malignancy is evidenced by the rapidity of
+their growth, the manner in which they infiltrate adjacent parts, and
+the frequency with which they recur after removal. They occur at all
+ages, and have been met with even in children.
+
+The _clinical features_ vary according to whether the tumour
+originates on the anterior aspect of the bone, in the maxillary
+antrum, or on the posterior aspect.
+
+When the tumour originates in the periosteum covering the front of the
+bone, it forms a swelling under the cheek, usually in the vicinity of
+the zygomatic (malar) bone, and grows towards the mouth as well as
+towards the surface. The cheek is gradually invaded, and in some cases
+the growth extends into the maxillary sinus.
+
+The typical malignant tumour of the upper jaw originates in the lining
+membrane of the antrum; it first fills the cavity and then bulges its
+walls in every direction, so that, on pressure being made over the
+swelling, the osseous shell of the sinus dimples and crackles under
+the finger. The sinus is dark on trans-illumination. The tumour may
+obstruct the nostril on the same side, and, by pressing on the tear
+duct, may cause the tears to flow over the cheek. It may be seen
+through the anterior nares, and may be attended with a sanious
+discharge from the nose. The eyeball is liable to be displaced
+upward, and if the ethmoid cells are invaded, it is also pushed
+outward; the palate may be depressed and the cheek projected (Figs.
+250, 251).
+
+[Illustration: FIG. 250.--Sarcoma of the Maxilla.]
+
+[Illustration: FIG. 251.--Malignant Disease of Left Maxilla, which
+displaced the eyeball and caused double vision.]
+
+When the tumour grows from the periosteum of the posterior aspect of
+the bone, and extends into the spheno-maxillary or pterygo-maxillary
+fossa, the eyeball is usually protruded by the invasion of the orbit
+from behind, and a swelling appears in the temporal region. If the
+sinus is invaded, the tumour spreads in the various directions already
+indicated. Not infrequently a tumour, which appears to have its seat
+in the maxilla, is really a downward prolongation of a growth
+originating in the base of the skull, a point on which the X-rays may
+yield valuable information.
+
+In all cases the tumour tends to infiltrate the surrounding tissues
+indiscriminately. There is severe pain referred to the distribution
+of the maxillary division of the trigeminal nerve. Hæmorrhage is
+liable to occur when exposed portions of the tumour ulcerate--for
+example in the nasal fossæ. Sarcoma is to be distinguished from the
+solid and cystic forms of odontoma, which also may distend the bone,
+bulging the hard palate and projecting on the face.
+
+_Treatment of Malignant Disease._--Without the help of radiation the
+results of operative treatment of malignant disease of the maxilla are
+far from encouraging. Probably the best line to follow is to embed
+several tubes of radium in different parts of the tumour for several
+days, and when the resulting shrinkage of the growth appears to have
+attained its limits, the maxilla should be excised. If on microscopic
+examination it is found to be a carcinoma, the glands on the same side
+of the neck should be removed at a second operation on lines similar
+to those in Butlin's operation in cancer of the tongue. The aid of the
+dentist is required to fit a denture which will at least restore the
+hard palate and alveolar margin. The operation of excising the
+upper jaw is not a dangerous one, especially if the risk of
+broncho-pneumonia is minimised by the intra-tracheal administration of
+ether. The final illness in cases of malignant disease of the upper
+jaw left to nature, or when it has recurred after operation, is a
+terrible one; the growth displaces and destroys the globe, blocks the
+nose and fungating on the face, causes hideous disfigurement.
+
+#Simple tumours# are rare. _Fibroma_ may originate in the periosteum
+or in the lining membrane of the maxillary sinus. It usually tends to
+assume the characters of sarcoma. _Chondroma_ usually begins either on
+the nasal surface of the bone or in the maxillary sinus. _Osteoma_
+occurs in two forms: the exostosis, which may be composed of
+cancellated or of compact tissue, and the diffuse osteoma or
+leontiasis ossea (Volume I., p. 485). All intermediate forms are met
+with, and when confined to the maxilla, the resulting disfigurement
+may be improved or remedied by operation; the cheek is raised or
+reflected and the bone shaved away with a strong knife or osteotome.
+
+#Tumours of the Mandible.#--The same varieties are met with as in the
+maxilla. The non-malignant forms--osteoma, chondroma, and fibroma--are
+rare.
+
+A _dentigerous cyst_ appears as a smooth, rounded, and painless
+swelling, usually in the region of the molar teeth. The bone gradually
+becomes expanded and crackles on pressure. The cyst is filled with a
+glairy mucoid fluid, and may contain one or more unerupted teeth (Fig.
+252). The X-ray appearances are characteristic. The treatment consists
+in removing the anterior wall of the cyst, scraping the interior, and
+packing the cavity with iodoform or bismuth gauze.
+
+[Illustration: FIG. 252.--Dentigerous Cyst of Mandible containing
+rudimentary tooth.
+
+(From Sir Patrick Heron Watson's collection.)]
+
+The myeloid tumour or _myeloma_ is comparatively common. It develops
+in the interior of the bone and expands the affected segment (Fig.
+253). It grows slowly, is more or less encapsulated, and therefore
+does not infiltrate the surrounding tissues. Sometimes it so weakens
+the bone that pathological fracture occurs. There is no glandular
+involvement, and the tumour shows little evidence of malignancy.
+
+[Illustration: FIG. 253.--Osseous Shell of Myeloma of Mandible.
+
+(From Professor Annandale's collection.)]
+
+The _periosteal sarcoma_ is the most malignant form. It grows rapidly,
+and infiltrates the surrounding tissues. The submaxillary salivary
+glands and the cervical lymph glands are usually implicated, and the
+disease tends to spread by metastasis to distant parts.
+
+_Epithelioma_ is the commonest new growth affecting the mandible; it
+usually involves the central portion of the bone, being a direct
+spread from the lower lip, tongue, or floor of the mouth. When it
+originates in the pillars of the fauces it implicates the ascending
+ramus. In all cases the infection of the cervical lymph glands is a
+serious factor both in prognosis and treatment.
+
+_Treatment._--_Partial removal_ of the mandible may be undertaken for
+myeloma, and in cases of sarcoma and epithelioma in which the tumour
+is limited to a small area of the bone--for example, to the alveolar
+process, the angle, the horizontal ramus, or the symphysis; in other
+cases, the whole bone must be removed.
+
+
+INJURIES OF THE JAWS
+
+#Fracture of the Maxilla.#--Fractures of the maxilla are nearly always
+due to direct violence, such as a blow on the face, a stab, or a
+gun-shot wound. They are often rendered compound by opening into the
+mouth, into the maxillary sinus, or on to the skin of the cheek. The
+alveolar process, in whole or in part, may be separated from the body
+of the bone by a severe blow, such as the kick of a horse, and when
+the whole alveolus is detached, it may carry with it the hard palate.
+Limited portions of the alveolus are frequently broken in the
+extraction of teeth. The main trouble after severe alveolar fractures
+is that the upper teeth do not accurately oppose the lower ones, and
+mastication is thereby interfered with.
+
+When the frontal (nasal) portion of the maxilla is broken, the
+lachrymal sac and nasal duct may be damaged and the flow of the tears
+obstructed. In such cases emphysema is also liable to develop.
+Fractures of the facial portion are frequently complicated by
+hæmorrhage from the infra-orbital vessels, and anæsthesia of the area
+supplied by the infra-orbital nerve. Suppuration may occur in the
+maxillary sinus. In some cases the maxilla is driven in as a whole,
+and in others the fracture radiates to the base of the skull and
+cerebral symptoms develop.
+
+The _treatment_ consists in reducing any deformity that may be
+present, ensuring efficient drainage, and keeping the mouth as aseptic
+as possible. Union takes place rapidly, and owing to the vascularity
+of the parts necrosis is rare, even when suppuration ensues. When the
+alveolar portion is comminuted, the fragments may be kept in position
+by fixing the mandible against the maxilla by means of a four-tailed
+bandage (Fig. 255), or by adjusting a moulded lead or gutta-percha
+splint to the alveolus and palate.
+
+The _zygomatic (malar) bone_ is sometimes fractured by direct
+violence, along with the adjacent portion of the maxilla. It may be
+possible to manipulate the displaced fragments into position with the
+fingers introduced between the cheek and the gum; if this fails, a
+small incision should be made in the mucous membrane anterior to the
+masseter, and the bone levered into position with an elevator.
+
+The _zygomatic arch_ is occasionally fractured by a direct blow. As
+the depressed fragments are liable to interfere with the movement of
+the mandible, they should be elevated either by manipulation or
+through an incision.
+
+#Fractures of the Mandible.#--The most common situation for fracture
+of the mandible is through the _body_ of the bone in the vicinity of
+the canine tooth (Fig. 254). The depth of the socket of this tooth,
+and the comparative narrowness of the jaw at this level, render it the
+weakest part of the arch. The fracture is usually due to direct
+violence, such as a blow with the fist, the kick of a horse, or a fall
+from a height. It is sometimes bilateral, the bone giving way at the
+canine fossa on one side and just in front of the masseter on the
+other; or both fractures may be at the canine fossæ. The fracture is
+usually oblique from above downwards and outwards, and is nearly
+always rendered compound by tearing of the mucous membrane of the
+mouth.
+
+[Illustration: FIG. 254.--Multiple Fracture of Mandible.
+
+(From Sir Patrick Heron Watson's collection.)]
+
+When only one side is broken, the smaller fragment is usually
+displaced outwards and forwards by the masseter and temporal muscles,
+so that it overlaps the larger fragment. In bilateral fractures the
+central loose segment is driven downwards and backwards towards the
+hyoid bone by the force causing the fracture, and is held in this
+position by the muscles attached to the chin, while both lateral
+fragments are tilted outwards and forwards by the masseters and
+temporals. The amount of displacement is best recognised by observing
+the degree of irregularity in the line of the teeth. Abnormal mobility
+and crepitus are readily elicited, and there is severe pain,
+particularly if the inferior dental nerve is stretched or crushed. The
+patient's attitude is characteristic; he supports the broken jaw with
+his hands, and keeps it as steady as possible when he attempts to
+speak or swallow. Saliva dribbles from the open mouth, and the speech
+is indistinct.
+
+In adults, the bone may be broken at the _symphysis_ as a result of
+lateral compression of the jaw--for example, pressing together of the
+angles. The general characters of the fracture are the same as those
+of fracture of the body, but the displacement is inconsiderable.
+
+Fractures of the _angle_ and through the _ramus_ are less common, and
+are not attended with deformity, as the fragments are retained in
+position by the masseter and internal pterygoid muscles. Fracture of
+the _coronoid process_ is rare.
+
+The _condyle_ is usually fractured just below the insertion of the
+external pterygoid muscle (Fig. 254) by a fall on the chin or by a
+severe blow on the side of the face. When the fracture is unilateral,
+the broken condyle is tilted inwards and forwards by the external
+pterygoid, and can be palpated from the mouth, while the rest of the
+jaw is displaced _towards_ the affected side, and not away from it, as
+happens in unilateral dislocation. When the fracture is bilateral, the
+mandible falls backwards, so that the lower teeth lie behind those of
+the maxilla.
+
+In a few cases the condyle has been driven through the floor of the
+glenoid cavity, causing fracture of the base of the skull. The
+diagnosis may be established by means of the X-rays.
+
+_Complications._--As the majority of these fractures are compound,
+suppuration is comparatively common during the process of repair, but
+if means are taken to keep the mouth clean it can usually be kept in
+check, and seldom leads to necrosis. The teeth adjacent to the
+fracture are liable to be loosened or displaced. If merely loosened
+they should be left in place, as they usually become firmly fixed in
+the course of a few days. Care must be taken that a displaced tooth
+does not pass between the fragments, as this has been the cause of
+difficulty in reducing a fracture and of its failure to unite.
+Irregular union, by destroying the alignment of the teeth, leads to
+interference with mastication. The bone usually unites in from four to
+six weeks. Want of union is a rare event.
+
+_Treatment._--In the majority of cases of unilateral fracture after
+reduction, the fragments can be kept in apposition by closing the
+mouth and keeping the lower jaw fixed against the upper by means of a
+four-tailed bandage (Fig. 255). Care must be taken that the posterior
+tails of the bandage do not pull the mandible backward. Additional
+security may be given by a light poroplastic or gutta-percha splint
+fitted to the chin, the vertical portion passing well up the ramus of
+the jaw. After a few days the apparatus is removed, the patient is
+encouraged to move the jaw, and massage is employed. The mouth must be
+regularly cleansed by an antiseptic mouth-wash, or by a spray of
+hydrogen peroxide.
+
+[Illustration: FIG. 255.--Four-tailed Bandage applied for Fracture of
+Mandible.]
+
+In certain fractures implicating the body of the jaw, and particularly
+when bilateral, the co-operation of the dentist is necessary to obtain
+the best results. After the fragments have been coapted, a plaster
+impression is taken of the jaw and teeth, and from this a silver frame
+is cast which surrounds but does not envelop the teeth. This frame is
+then applied to the fractured jaw, and restrains movement of the
+fragments without interfering with the action of the jaw (W. Guy).
+The use of an intra-oral frame obviates the necessity of wiring the
+fragments.
+
+Even in badly united fractures the original contour of the bone is
+eventually restored by the movements of the tongue moulding it into
+shape.
+
+
+AFFECTIONS OF THE TEMPORO-MANDIBULAR ARTICULATION
+
+#Dislocation of the Mandible.#--Dislocation of the lower jaw may be
+unilateral or bilateral. The bilateral form is the more common, and is
+met with most frequently in middle life, and in females. The liability
+to dislocation is greatest when the mouth is widely open--for example,
+in yawning, laughing, or vomiting--as under these conditions the
+condyle, accompanied by the meniscus, passes forwards out of the
+glenoid cavity and rests on the summit of the articular eminence. If,
+while the bone is in this position, the external pterygoid muscle is
+thrown into contraction, it pulls the condyle forward over the
+eminence into the hollow beneath the root of the zygoma, and the
+contraction of the masseter and temporal muscles retains it there.
+Muscular contraction is therefore an important factor in its
+production.
+
+Dislocation may be produced also by a downward blow on the chin, by
+the unskilful introduction of a mouth gag, particularly while the
+patient is anæsthetised, or even in the attempt to take a big
+bite--say, of an apple. The dislocation that results from such causes
+is usually unilateral.
+
+In some persons the ligaments of the joint are unnaturally lax, and
+dislocation is liable to occur repeatedly from comparatively slight
+causes--_recurrent dislocation_.
+
+_Clinical Features._--The appearance of a patient suffering from
+_bilateral_ dislocation is characteristic. The mouth is open, the jaw
+fixed, and the chin protruded so that the lower teeth project beyond
+the upper. The patient has difficulty in swallowing, and the saliva
+dribbles from the mouth. As the lips cannot be approximated, the
+speech is indistinct and guttural. Just in front of the auditory
+meatus a deep hollow can be felt, and in front of this the condyle
+forms an undue projection. The coronoid process is displaced below and
+behind the zygomatic (malar) bone, and may be felt through the mouth.
+The contracted temporal muscle forms a prominence above the zygoma.
+
+In _unilateral_ dislocation the deformity is the same in character,
+but is less marked, and in mild cases its cause is liable to be
+overlooked. In most cases the chin deviates towards the sound side.
+
+_Treatment._--In recent cases, reduction is usually easily effected.
+The patient should be seated on a low chair or stool, an assistant
+supporting the head from behind. The surgeon, standing in front,
+places his thumbs, well protected by a roll of lint, far back on the
+molar teeth, and with his other fingers grasps the body of the jaw.
+Pressure is now made downwards and backwards to free the condyles from
+the articular eminence, and to overcome the tension of the temporal
+and masseter muscles, and as this is effected the tip of the chin is
+carried upward, while the whole jaw is pushed directly backward. The
+condyle slips into position, sometimes with a distinct snap. When
+difficulty is experienced in levering the condyle from its abnormal
+position, a cork may be placed between the molar teeth on each side to
+act as a fulcrum. After reduction the jaw is fixed by means of a
+four-tailed bandage for a few days. The patient is warned to avoid for
+some weeks opening the mouth widely.
+
+_Old-standing Dislocation._--It sometimes happens that, from having
+been overlooked or neglected, the dislocation remains unreduced. In
+such cases the movement of the jaw is in time partly restored, and the
+patient acquires sufficient control of the lips to be able to
+articulate intelligibly and to prevent dribbling of saliva. The power
+of masticating the food, however, remains impaired. The hollow behind
+the condyle and the projection of the chin persist. Reduction by
+manipulation is seldom possible after the dislocation has existed for
+more than three months, but it has been effected as long as ten months
+after the accident. Several attempts at reduction should be made at
+intervals of two or three days, and if these fail recourse may be had
+to operation. As the masseter and internal pterygoid muscles have
+assumed a vertical position and become shortened, they form an
+obstacle to reduction, and to overcome their action it is necessary to
+separate them from their insertion to the ascending ramus of the bone
+through an incision carried round the angle. If the adhesions about
+the dislocated condyle are then separated, reduction can be effected
+(Samter). In some cases it is necessary to excise the condyle to
+restore movement.
+
+_Internal Derangements of the Temporo-mandibular Joint._--The
+intra-articular cartilage is liable to be displaced by excessive
+traction exerted on it by the external pterygoid muscle during some
+sudden movement of the joint, particularly in closing the mouth.
+There is acute pain in the region of the joint, the teeth on the
+affected side cannot be brought into apposition, so that mastication
+is interfered with, and the patient is conscious of something locking
+inside the joint. The joint is tender to the touch, but there is no
+external swelling. Replacement is effected by keeping up firm pressure
+at the back of the condyle with the mouth open, and slowly closing the
+jaw. If recurrence takes place repeatedly, the disc may be sutured to
+the periosteum (Annandale), or excised (Hogarth Pringle).
+
+#Arthritis# of the temporo-mandibular joint occurs in two forms,
+non-suppurative and suppurative.
+
+The _non-suppurative_ form is usually due to gonorrhoeal infection,
+and as a rule is bilateral. The patient complains of neuralgic pains
+shooting towards the ears and temples, and of pain in the joint on
+movement. The jaw is therefore kept fixed, usually with the mouth
+slightly open and the chin protruded. Mastication is impossible, and
+the speech is indistinct. There is effusion into the joint, and a
+swelling may be detected in front of the ear. The inflammation may
+subside and movement restored, or fibrous ankylosis may ensue.
+
+The _suppurative_ form may be due either to direct spread of infection
+from adjacent parts, as, for example, in middle ear disease,
+suppurative parotitis, or pyogenic affections of the mandible, or it
+may be part of a general pyæmic infection, as sometimes occurs after
+exanthematous fevers and in gonorrhoea. The clinical features are
+similar to those of the non-suppurative form, but the signs referable
+to the joint are often masked by those of the primary lesion. When the
+pus originates in the joint, it may point either towards the skin or
+into the external auditory meatus through the petro-tympanic
+(Glaserian) fissure. The joint is usually completely disorganised and
+ankylosis results.
+
+#Tuberculous arthritis# is rare, and is usually secondary to disease
+of the mandible, the temporal bone, or the middle ear. It leads to
+destruction of the joint and ankylosis. It is treated by incision and
+scraping, or by excision of the condyle.
+
+#Arthritis deformans# is a comparatively common affection, and is
+generally bilateral. In the earlier stages the condyle is usually
+hypertrophied and distorted, and the glenoid cavity is correspondingly
+broadened and flattened, and in time may be filled up by new bone.
+Osteophytic outgrowths form around the joint and lead to fixation or
+locking. The enlarged condyle may be felt in front of the ear, and
+there is pain and cracking on movement; the pain is worst at night and
+in wet weather. The jaw is usually depressed and the chin protruded.
+The disease runs a chronic course, with occasional acute
+exacerbations. Excision of the condyle may be advisable when
+non-operative measures have failed to give relief. In the later
+stages, the condyle, together with the meniscus, may be worn away and
+completely disappear.
+
+#Closure or Fixation of the Mandible.#--_Temporary fixation_ is due to
+spasmodic contraction of the muscles of mastication, particularly the
+masseter. This may be symptomatic of some inflammatory condition in
+the vicinity, such as a pyogenic affection of the lower jaw--for
+example, that associated with a carious root or an unerupted wisdom
+tooth, or with parotitis or tonsillitis. In such cases the spasm
+passes off on the removal of the cause. It is occasionally a
+manifestation of hysteria. The administration of a general anæsthetic
+and the introduction of a wedge or separator is usually necessary to
+confirm the diagnosis and, it may be, to permit of operative measures,
+such as the extraction of a wisdom tooth.
+
+Muscular fixation may be due to rheumatic or syphilitic myositis, and
+this is sometimes followed by fibroid degeneration of the muscles,
+rendering the fixation permanent.
+
+_Permanent fixation_ may be due to a variety of causes. Fibroid
+degeneration of muscles following myositis has already been mentioned.
+Much more frequently it results from cicatricial contraction of the
+soft parts of the face or mouth following such conditions as cancrum
+oris, ulceration, or burns. Fixation following upon prolonged
+immobilisation after fracture or dislocation, or any of the forms of
+arthritis or suppurative or tuberculous disease of the adjacent
+portions of the mandible, is also met with. The ankylosis may be
+fibrous or osseous, and may be intra- or extra-articular.
+
+The _clinical features_ vary with the degree of separation of the
+jaws. There is always some deformity, and more or less interference
+with mastication and speech. The patient usually feeds himself by
+pushing small portions of bread or meat with the fingers through some
+gap between the badly opposed and badly formed and preserved teeth. As
+the patient is unable to keep the mouth clean, particles of food lodge
+and decompose there, causing irritation of the mucous membrane, caries
+of the teeth, and foetor of the saliva and breath. When osseous
+ankylosis occurs in childhood, it leads to _arrest of development of
+the mandible_, which is small and markedly receding, so that the teeth
+do not oppose those of the maxilla (Fig. 256).
+
+[Illustration: FIG. 256.--Defective development of Mandible from
+fixation of jaw due to tuberculous osteomyelitis in infancy.]
+
+_Treatment._--When the cause of the fixation is in the joint itself,
+the best treatment is to resect one or both condyles.
+
+When the fixation is due to cicatricial contraction of the soft parts,
+mobility is best restored by forming an artificial joint well in front
+of the cicatricial tissue, as suggested by Esmarch.
+
+
+
+
+CHAPTER XXII
+
+THE TONGUE
+
+
+Surgical Anatomy--Wounds--Dental ulcer--Inflammatory affections:
+ _Acute parenchymatous glossitis and hemi-glossitis_; _Mercurial
+ glossitis_; _Chronic superficial glossitis_; _Leucoplakia_;
+ _Smoker's patch_--_Tuberculous disease_; _Syphilitic affections_;
+ _Sclerosing glossitis_; _Gummas_; _Ulcers and fissures_--Tumours:
+ _Carcinoma_; _Sarcoma_; _Innocent tumours_;
+ _Cysts_--Thyreo-glossal tumours and cysts--Malformations:
+ _Absence_; _bifid tongue_; _Tongue-tie_; _Excessive length of
+ frenum_; _Macroglossia_; _Atrophy_--Nervous affections.
+
+#Surgical Anatomy.#--The tongue is composed of interlaced, striped
+muscle fibres, partly consisting of the terminations of the extrinsic
+muscles, and partly of the intrinsic muscles. A median fibrous septum
+divides it into two lateral halves so completely that but little
+communication takes place between the blood vessels and lymphatics of
+the two sides. It is covered by stratified squamous epithelium. For
+practical purposes it is described as consisting of an _anterior_ or
+_oral_ part, and a _posterior_ or _pharyngeal_ part.
+
+The _oral part_, which includes the anterior two-thirds of the organ,
+is mobile, and the epithelium on its dorsal aspect is modified so as
+to form several varieties of papillæ. A slight median depression is
+recognisable on the dorsum as far back as the vallate (circumvallate)
+papillæ, which mark the boundary between the oral and pharyngeal
+parts. A double fold of mucous membrane--the _frenum_--connects the
+under aspect of the tip with the floor of the mouth and the mandible.
+On each side of the frenum, under the mucous membrane of the tip, are
+mucous glands--_apical glands_--in which cysts sometimes form. On the
+lateral border of the tongue, just in front of the anterior palatine
+arch, are several vertical folds of mucous membrane--the _folia
+linguæ_, or _foliate papillæ_.
+
+The _pharyngeal_ part, or base of the tongue, forms the anterior wall
+of the pharynx, and is attached to the hyoid bone. Its mucous membrane
+is devoid of papillæ, but contains numerous lymphoid follicles--the
+_lingual tonsil_. The _foramen cæcum_ lies just behind the apex of the
+vallate papillæ in the middle line.
+
+The chief artery, the _lingual_, a branch of the external carotid,
+passes forward beneath the hyoglossus muscle, and is continued to the
+apex as the ranine, lying nearer the under than the upper aspect of
+the tongue. The pharyngeal part is supplied by the dorsalis linguæ
+branch. The blood is returned to the internal jugular by the ranine
+vein, which can be seen under the mucous membrane on the inferior
+aspect near the frenum, and by the venæ comites of the lingual artery
+and its branches.
+
+The _hypoglossal_ is the motor nerve of the tongue. The _lingual_
+branch of the mandibular (inferior maxillary) supplies the anterior
+two-thirds with common sensation. It is accompanied by the _chorda
+tympani_ branch of the facial, which probably carries the taste
+fibres. The _glosso-pharyngeal_ supplies the posterior third of the
+tongue with both common and gustatory sensation.
+
+The _lymph vessels_ of the anterior two-thirds of the tongue drain
+into the submental and submaxillary glands, and these in turn into the
+deep cervical group which accompany the internal jugular vein. The
+vessels of the base converge into several large trunks which pass out
+behind the tonsils and drain directly into the deep cervical glands.
+One of these, which lies in the angle between the internal jugular and
+common facial veins, is frequently infected in cancer of the tongue.
+
+#Wounds# are commonly produced by the teeth, as, for instance, when a
+child falls on the chin with the tongue protruded, or when an
+epileptic bites his tongue during a fit. Less frequently a foreign
+body, such as a pipe-stem, a bullet, or a displaced tooth, is driven
+into the tongue. The immediate risk is hæmorrhage, particularly when
+the posterior part of the tongue is implicated and the wound
+penetrates deeply. Of the later complications, infections and
+secondary hæmorrhage are the most serious, and they are most liable to
+occur when a foreign body is embedded in the tongue.
+
+_Treatment._--In superficial wounds near the tip the oozing is
+efficiently arrested by sutures, but in deeper wounds a ligature must
+be applied to the bleeding vessel. Secondary hæmorrhage is much more
+difficult to arrest on account of the friable state of the tissues,
+and it may be necessary to ligate the lingual or even the external
+carotid in the neck.
+
+To prevent infective complications any foreign body must be removed
+and an antiseptic mouth-wash regularly employed.
+
+Cases have been recorded in which such a foreign body as a bullet, a
+needle, or a piece of a pipe-stem, has remained embedded in the
+substance of the tongue for a long period, and caused a firm, indolent
+swelling liable to be mistaken for a new growth.
+
+#Dental Ulcer.#--The continuous friction of a jagged tooth, or of an
+ill-fitting dental plate, is liable to cause swelling and excoriation
+of the side of the tongue. A painful superficial ulcer forms, and if
+the irritation continues and infection occurs, the surrounding parts
+become indurated, the ulcer assumes a crater-like appearance, not
+unlike that of a commencing epithelioma. If such an ulcer does not
+promptly heal on the removal of the irritant, a portion of the margin
+should be removed and submitted to microscopic examination to make
+sure that it is not cancerous.
+
+#Inflammatory Affections.#--_Acute Parenchymatous Glossitis_ is
+usually due to the action of streptococci. Although it affects mainly
+the mucous membrane and submucous tissue, it causes a diffuse
+oedematous swelling of the whole organ, and this may extend to the
+ary-epiglottic folds and give rise to oedema of the glottis. As a rule
+it does not go on to suppuration.
+
+The onset is sudden, and is marked by pain and stiffness of the
+tongue, particularly when the patient attempts to masticate or to
+speak. The tongue rapidly swells, and in the course of twenty-four or
+forty-eight hours may fill the mouth and protrude beyond the teeth.
+There is profuse salivation, and in addition to difficulty in
+swallowing and speaking there may be considerable interference with
+respiration. The salivary and lymph glands in the submaxillary space
+are enlarged and tender. The symptoms begin to subside in three or
+four days, unless suppuration occurs.
+
+The _treatment_ consists in administering a sharp purge and employing
+a mouth-wash; leeches may be applied to the submaxillary region with
+benefit. When the swelling is excessive, it may be necessary to make
+longitudinal incisions into the substance of the tongue, and dyspnoea
+may call for laryngotomy. If an abscess forms it must be opened.
+
+A similar condition has been met with in patients who have contracted
+the "_foot and mouth disease_" of cattle. Vesicles form on the mucous
+membrane, and after bursting, ulcerate, and a mixed infection with
+streptococci occurs, leading to diffuse oedema. Portions of the tongue
+may become gangrenous, and the infection may spread to the tissues of
+the neck and set up one form of angina Ludovici. The condition is
+usually fatal.
+
+_Acute Hemi-glossitis._--An acute transitory swelling, confined to one
+half of the tongue, in the distribution of the lingual nerve, is
+occasionally met with. It is attended with great pain and high
+temperature, and is believed to be analogous to herpes zoster
+(Güterbock).
+
+_Mercurial Glossitis_ may accompany mercurial stomatitis (p. 496).
+
+_Chronic Superficial Glossitis._--Several forms of chronic superficial
+glossitis are met with. The most important, as it is frequently
+followed by the development of epithelioma, is that known as
+_leucoplakia_ or _leucokeratosis_.
+
+The tongue is studded over with white patches, which result from
+overgrowth and cornification of the surface epithelium, whereby it
+becomes thickened and raised above the surface, and at the same time
+there is small-celled infiltration of the submucous tissue. The
+patches are irregularly lozenge-shaped, and when crowded together they
+present the appearance of a mosaic (Fig. 257). Similar patches are
+often present on the mucous membrane lining the cheek.
+
+[Illustration: FIG. 257.--Leucoplakia of the Tongue.]
+
+The disease is met with almost invariably in men between the ages of
+forty and fifty. Syphilis appears to be a predisposing factor, and any
+form of irritation--for example, the chewing or smoking of tobacco,
+the drinking of raw spirits, friction by a rough tooth or
+tooth-plate--plays an important part in inducing or in aggravating the
+condition.
+
+The milder forms give rise to no discomfort, but when the condition is
+advanced the patient complains of dryness and hardness of the tongue,
+with impairment of the sense of taste and persistent thirst. When
+cracks, fissures, or warts develop, there is pain on chewing or
+speaking, or on taking hot or irritating food. The glands below the
+jaw may be enlarged.
+
+The disease is most intractable and persistent, and even after
+disappearing for a time is liable to recur. After a variable number
+of years epithelioma is prone to develop, usually in one or other of
+the fissures which accompany the condition.
+
+The _treatment_ consists in removing all sources of irritation,
+particularly smoking, and in employing mouth-washes. Butlin recommends
+antiseptic ointments applied before going to bed. In some cases
+painting the patches with chromic acid (10 grains to the ounce) or
+lactic acid (20 per cent.) is useful in removing the excess of
+epithelium, but stronger caustics are to be avoided. Constitutional
+treatment is of little use even when the patient has suffered from
+syphilis. The best results have been attained by the use of radium.
+
+The "_smoker's patch_" consists of a small oval area on the front of
+the tongue from which the papillæ have disappeared. It is slightly
+raised, smooth and red, and may be covered with a yellowish-brown or
+yellowish-white crust. It causes no discomfort unless the crust is
+removed, when a raw, sensitive surface is exposed. The condition is
+liable to spread over the tongue if the patient persists in smoking.
+It may eventually assume the characters of leucoplakia. The
+_treatment_ consists in stopping the use of tobacco, and painting the
+patches with chromic acid, tannic acid, or alum, and employing a
+chlorate of potash mouth-wash.
+
+#Tuberculous Disease.#--The tongue is rarely the primary seat of
+tuberculosis. The majority of cases occur in adult males, who suffer
+from advanced pulmonary or laryngeal phthisis, the tongue being
+infected by bacilli from the sputum or through the blood stream. In
+other cases the infection is due to direct spread of lupus from the
+face or nose.
+
+The condition may begin as a firm, painless lump, seldom larger than a
+hazel-nut, on one side of the tongue, or near its tip. At first the
+swelling is covered by epithelium; in time caseation takes place, the
+epithelium gives way, and an open sore is formed.
+
+The _tuberculous ulcer_ is the form most frequently met with. The
+surface of the ulcer is uneven, pale and flabby, and is covered with a
+yellowish-grey discharge, with here and there feeble granulations
+showing through. The edges are shreddy, sinuous in outline, and there
+is little or no induration. The surrounding parts are slightly
+swollen, and may be studded with small tuberculous foci. The ulcer may
+be quite superficial, or it may extend into the muscular substance,
+and the tip of the tongue may be completely eaten away so that it
+looks as if it had been cut off with a knife. As the disease advances
+there is severe pain and usually profuse salivation. The submaxillary
+glands may be, but are not always, enlarged. The ulcer may heal, but
+tends to break down again.
+
+Unless there is advanced pulmonary disease or other contraindication
+to operation, the ulcer should be excised under local anæsthesia. Care
+must be taken to avoid reinfecting the raw surface. When excision is
+impracticable, it is only possible to palliate the symptoms by dusting
+with orthoform, or applying local anæsthetics, and by attending to the
+hygiene of the mouth and removing all sources of irritation.
+
+#Syphilitic Affections.#--A _primary lesion_ on the tongue is
+accompanied by marked enlargement and tenderness of the submaxillary
+lymph glands on one or on both sides. It is most common in men,
+infection usually taking place through the medium of tobacco pipes, or
+implements such as the blow-pipes of glass-blowers.
+
+During the _secondary stage_--particularly in the later
+periods--mucous patches and ulcers are common, and they may assume a
+condylomatous or warty appearance.
+
+The _tertiary_ manifestations in the tongue are sclerosing glossitis,
+gummas, and gummatous ulcers.
+
+_Sclerosing glossitis_ is the term applied by Fournier to a condition
+in which there is an abundant new formation of granulation tissue in
+the substance of the tongue, leading to the appearance of tuberous
+masses on the dorsum. These tend to be oval in outline, are elevated
+above the normal mucous membrane, and present a dull red mammilated or
+lobulated surface, comparable to the surface of a cirrhotic liver.
+They are firm, elastic, and insensitive.
+
+A _gumma_ is usually situated on the dorsum and more often towards the
+centre than at the edges. As it seldom implicates the floor of the
+mouth or the base of the tongue, the tongue can usually be protruded
+freely. It forms an indolent swelling, which tends to break down
+slowly and to ulcerate. So long as it remains unbroken it does not
+cause pain, and there is no enlargement of the adjacent lymph glands.
+Two forms are met with--the superficial, and the deep or
+parenchymatous.
+
+A _superficial_ gumma appears as a small hard nodule under the mucous
+membrane, varying in size from a pin's head to a pea. The mucous
+membrane over it is redder than normal, and in the early stages
+retains its papillæ but later becomes smooth. It tends to break down
+early, forming a superficial ulcer. Superficial gummas are often
+multiple.
+
+The _deep_ or parenchymatous form varies in size from a hazel-nut to a
+walnut, and feels like a hard body in the substance of the tongue.
+The mucous membrane over the swelling is of normal colour, but is
+usually devoid of papillæ. The gumma may remain for months unchanged,
+or may approach the surface, soften, and break down, leaving a deep,
+ragged ulcer.
+
+_Syphilitic ulcers and fissures_ are nearly always due to the
+softening and breaking down of gummas. The ulcers have seldom the
+typically rounded or serpiginous outline of gummatous ulcers on other
+parts of the body. The base is ragged and unhealthy, and on it a
+yellowish-grey slough resembling wash-leather may be seen. The edges
+are steep, ragged, and often undermined, and the surrounding parts
+thickened and indurated. The neighbouring glands are not usually
+enlarged. The ulcer is extremely painful when irritated by food, hot
+fluids, or spirits. If untreated, the sore may remain indolent and for
+months show no sign either of spreading or healing, but at any time it
+may become the seat of cancer.
+
+Syphilitic fissures are met with as long, narrow, deep clefts, or as
+stellate or sinous cracks in the substance of the tongue. After the
+healing of these ulcers and fissures permanent furrows and depressed
+scars remain.
+
+_Treatment._--The tertiary manifestations of syphilis in the tongue
+are treated on the same lines as other tertiary lesions. Locally, the
+use of mouth-washes, such as chlorate of potash or black wash diluted
+with lime-water, the insufflation of powdered iodoform and borax with
+a small quantity of morphin, or the application of mercurial ointment
+is useful. The sore must be thoroughly cleansed before these remedies
+are applied.
+
+
+NEW GROWTHS
+
+#Carcinoma# is by far the most common form of new growth met with in
+the tongue, and it is almost invariably a squamous epithelioma.
+
+Epithelioma generally occurs between the ages of forty and sixty, and
+attacks males oftener than females, in the proportion of about six to
+one. Its development is favoured by any long-continued irritation,
+such as the rubbing of the tongue against a carious tooth, an
+ill-fitting tooth-plate, or the rough end of a short clay pipe,
+particularly when such irritation leads to the formation of an ulcer.
+Chronic superficial glossitis associated with leucoplakia, and
+syphilitic fissures, ulcers, or scars, also act as predisposing
+factors. The repeated application of strong caustics to chronic
+inflammatory conditions is, according to Butlin, a determining cause
+of cancer. The degree of malignancy appears to vary in different
+cases, and is probably lowest when the disease originates in a patch
+of leucoplakia or other pre-cancerous lesion.
+
+The disease is usually situated in the anterior half of the tongue,
+and more commonly on the edge than on the dorsum. It may begin as an
+excoriation, ulcer, or fissure, or as a warty growth, particularly in
+association with a patch of leucoplakia. In all cases ulceration
+begins early, and the base of the ulcer and the surrounding parts
+become indurated. The lymph glands are, as a rule, early infected.
+
+_Clinical Features._--The clinical appearances vary widely. Sometimes
+the surface presents a warty growth; sometimes it is excavated,
+forming a deep ulcer with raised nodular edges; in other cases the
+ulcer is smooth, and its edges even and rounded. Extreme hardness of
+the edges and base of the ulcer is always a characteristic feature.
+The tongue tends to become fixed, especially when the disease spreads
+to the floor of the mouth, so that it cannot be protruded, and the
+restriction of its movement produces a characteristic interference
+with articulation, certain words being slurred, and when the fixation
+is extreme it may interfere with mastication and swallowing. The
+patient complains of a constant gnawing pain in the tongue, and of
+severe pain shooting along the branches of the trigeminal nerve, and
+especially towards the ear. In the advanced stages there is salivation
+and foetor of the breath.
+
+When the disease is situated on the edge of the tongue it tends to
+spread to the floor of the mouth and the muco-periosteum of the
+mandible. If situated far back on the dorsum, it spreads on to the
+epiglottis, the pillars of the fauces, and the tonsil.
+
+The neighbouring lymph glands--particularly those under the jaw and
+along the line of the carotid vessels--soon become infected and are
+palpable. The submaxillary and sublingual salivary glands are also
+liable to be affected. The enlarged cervical glands later undergo
+softening, or suppurate and burst on the skin surface, forming
+fungating ulcers. Metastasis to the liver, lungs, and other viscera is
+exceptional. If the disease is allowed to run its course, the patient
+usually dies in from twelve to eighteen months from repeated small
+hæmorrhages, toxin absorption, or septic broncho-pneumonia.
+
+_Differential Diagnosis._--Cancer of the tongue has to be diagnosed
+from syphilitic and tuberculous affections, from papilloma, and from
+simple ulcer and fissure. It is to be borne in mind that any of these
+conditions may take on malignant characters and develop into
+epithelioma. The microscopic examination of a portion of the growth
+removed under local anæsthesia from the base of the ulcer at some
+distance from its epithelial core is often the only certain means of
+establishing the diagnosis, and should be had recourse to as early as
+possible. When there is still doubt as to the nature of the growth, it
+should be treated as if it were cancerous.
+
+An unbroken gumma is liable to be confused only with the uncommon form
+of epithelioma which begins as a nodule under the mucous membrane.
+Gumma, however, are often multiple, and the tongue shows old scars or
+other evidence of syphilis.
+
+Gummatous ulcers are usually situated on the dorsum, are frequently
+multiple, and have sloughy, undermined edges; the surrounding parts,
+although indurated, are not so densely hard as in cancer; there is not
+necessarily any involvement of lymph glands. The cancerous ulcer is
+usually single and situated on the margin of the tongue; its edges are
+hard, raised, and nodular; and the glands are usually enlarged and
+hard. Little reliance is to be placed on the therapeutic effects of
+anti-syphilitic drugs in the differential diagnosis, as they are often
+inconclusive, and their use results in loss of time.
+
+Tuberculous ulcers usually occur in association with other and
+unmistakable evidences of tuberculosis. A papilloma, when sessile, may
+simulate cancer; these tumours show a marked tendency to become
+malignant. Simple ulcers and fissures are usually recognised by the
+history of the condition, the absence of induration and of glandular
+involvement, and by the fact that they heal quickly on removal of the
+cause.
+
+_Treatment._--The only treatment that offers any hope of cure is free
+removal of the disease, and experience has proved that unless this is
+done early the prospect of the cure being a radical one is remote. Not
+only must the segment of the tongue on which the growth is situated be
+widely excised, but all the lymphatic connections must also be removed
+whether the glands are palpably enlarged or not.
+
+The chief risk after operation is pneumonia resulting from the
+inhaling of blood and products of infection: hence the importance of
+rendering the mouth as dry and as sweet as possible before operation,
+special attention being paid to the teeth, and precautions being taken
+at the operation to prevent the passage of blood down the trachea. The
+patient is usually able to be out of bed on the second or third day,
+and is well in a fortnight or three weeks. The operation, even when
+followed by recurrence, usually prolongs life by six or eight months,
+and renders the patient more comfortable by removing the foul ulcer
+from the mouth. The speech, although impaired by the removal of
+one-half or even more of the tongue, is distinct enough for ordinary
+purposes. When recurrence takes place it is usually in the glands, and
+may be attended with great suffering.
+
+_Treatment of Inoperable Cases._--The mouth must be kept as sweet as
+possible. The pain may be relieved to some extent by cocain or
+orthoform, but as a rule the free administration of morphin is called
+for. Pain shooting up to the ear may be relieved by resection of the
+lingual nerve, or the injection of alcohol into its substance. If
+hæmorrhage takes place from the ulcerated surface and cannot be
+controlled by adrenalin, or other local styptics, it may be necessary
+to ligate the lingual, or even the external carotid artery.
+Interference with respiration may necessitate tracheotomy. When the
+patient has difficulty in taking food, recourse should be had to the
+use of the stomach-tube or to gastrostomy. The use of radium or of the
+X-rays appears to have a restraining influence on the disease in the
+glands, but has not proved curative.
+
+#Sarcoma# of the tongue is rare, and is sometimes met with in
+children. The round-cell type is the most common; it grows rapidly,
+and tends to ulcerate and fungate, pain becoming severe when the
+growth has broken down. The diagnosis is always difficult, and is
+seldom made until a portion of the growth has been removed and
+examined microscopically. The more slowly growing forms, if removed
+before ulceration has taken place, show little tendency to recur, but
+those which grow rapidly and break down, not only recur locally, but
+are liable to give rise to metastases. The treatment is the same as
+for cancer; the use of radium is more likely to be beneficial than in
+epithelioma.
+
+#Innocent Tumour and Cysts.#--_Lipoma_, _fibroma_, and various forms
+of _angioma_ (Fig. 258) are occasionally met with. They are all of
+slow growth, and give rise to inconvenience chiefly by their bulk, and
+should be removed.
+
+[Illustration: FIG. 258.--Papillomatous Angioma of left side of tongue
+in a woman aged 26.]
+
+_Papilloma_ may occur on any part of the tongue, and at any age. It
+may be single or multiple, pedunculated or sessile, and is liable to
+become malignant, especially when associated with leucoplakia. It
+should be freely removed by excising a wedge-shaped portion of the
+tongue.
+
+_Dermoid_ cyst is met with beneath the tongue, lying in the middle
+line, between the genio-glossi (genio-hyoglossi), and on the upper
+surface of the mylo-hyoid muscles. It may be noticed soon after
+birth, or may only attract attention during adult life. The cyst
+usually projects under the chin, forming a soft swelling of putty-like
+consistence, which varies in size from a pigeon's to a turkey's egg
+(Fig. 259). When it bulges towards the mouth it is liable to be
+mistaken for a retention cyst of one of the salivary glands. It is
+distinguished by its medial position, its yellow colour, and its
+opacity, the retention cyst being to one side of the middle line,
+purplish in colour, translucent and fluctuating. The cyst should be
+dissected out, either from the mouth or from under the chin, according
+to circumstances.
+
+[Illustration: FIG. 259.--Dermoid Cyst in middle line of neck.
+
+(Mr. J. W. Struthers' case.)]
+
+A _sebaceous cyst_ may reach such dimensions as to simulate a dermoid
+or thyreo-glossal cyst.
+
+_Hydatid and cysticercus cysts_ have also been met with in the tongue.
+
+#Thyreo-glossal Tumours and Cysts.#--Tumours may develop in the
+embryonic tract which passes from the isthmus of the thyreoid gland
+to the foramen cæcum at the base of the tongue--the thyreo-glossal
+tract of His. They have the same structure as the thyreoid gland, and
+occupy the dorsum of the tongue, extending from the foramen cæcum
+backwards towards the epiglottis, in some cases attaining considerable
+size. They are of a bluish-brown or dark red colour, and are liable to
+repeated attacks of hæmorrhage. These tumours sometimes become cystic,
+the cysts being lined with ciliated epithelium and containing colloid
+material. Bleeding may take place into a cyst, causing it to become
+suddenly enlarged, or the cyst may burst and the blood escape into the
+mouth. These variations in size and repeated attacks of bleeding help
+to distinguish thyreo-glossal cysts from other swellings of the
+tongue. Treatment is only called for when the swelling causes
+interference with speech or swallowing; it consists in removing the
+tumour by dissection.
+
+When the lower end of the tract becomes cystic it forms a swelling in
+the neck (p. 583).
+
+#Malformations.#--Complete or partial _absence_ of the tongue is
+exceedingly rare.
+
+Occasionally the fore part of the tongue is _bifid_. The function of
+the organ is not interfered with, and the operation of paring and
+suturing the two halves is only called for on account of the
+disfigurement.
+
+_Congenital tongue-tie_ is a condition in which the tip of the tongue
+is bound down to the floor of the mouth by an abnormally short and
+narrow frenum, or by folds of mucous membrane on each side of the
+frenum, so that the tongue cannot be protruded. Although this
+deformity is rare, it is common for parents to blame an imaginary
+tongue-tie when a child is slow in learning to speak, or when he
+speaks indistinctly or stammers, and the doctor is frequently
+requested to divide the frenum under such circumstances. In the vast
+majority of cases nothing is found to be wrong with the frenum. In the
+rare cases of true tongue-tie the edges of the shortened bands should
+be snipped with scissors close behind the incisor teeth, and then torn
+with the finger-nail.
+
+_Excessive length_ of the frenum is occasionally met with, and in
+children may allow of the tongue falling back into the throat and
+causing sudden suffocative attacks, one of which may prove fatal. In
+some cases the patient is able voluntarily to fold the tongue back
+behind the soft palate.
+
+_Macroglossia_ is the term applied to a variety of conditions in which
+the tongue becomes unduly large, so that it tends to be protruded from
+the mouth, and to become scored by the teeth. The typical
+form--lymphangiomatous macroglossia--is due to a dilatation of the
+lymph spaces of the tongue. It is often congenital, and may affect the
+whole or only a part of the tongue. The enlargement may be progressive
+from the first, or may remain stationary for years, and then begin to
+develop somewhat suddenly, sometimes after an injury or as a result of
+some infective condition. The treatment consists in removing a
+wedge-shaped portion of the tongue.
+
+In certain cases of macroglossia in children, the lesion has been
+found to be a fibromatosis of the nerves of the tongue, analogous to
+the plexiform neuroma.
+
+_Atrophy_ of the tongue is rare as a congenital condition.
+Hemi-atrophy occurs in various diseases of the central nervous system,
+as well as after injuries and diseases implicating the hypoglossal
+nerve.
+
+#Nervous Affections of the Tongue.#--_Neuralgia_ confined to the
+distribution of the lingual nerve is comparatively rare. It usually
+yields to medical treatment, but in inveterate cases it is sometimes
+necessary to resect the nerve.
+
+It is more common to meet with a condition in which the patient
+complains of severe burning or aching pain in the region of the
+foliate papilla, which is situated on the edge of the tongue just in
+front of the anterior pillar of the fauces. The patient is usually a
+middle-aged, neurotic woman, and often with a gouty or rheumatic
+tendency. The pain, for which it is seldom possible to discover any
+cause, is usually worst at night, and may last for months, or even
+years. The practical importance of the condition is that, as the
+foliate papilla is prominent and red, it is liable to be mistaken on
+superficial examination for a commencing epithelioma. An inspection of
+the opposite side of the tongue, however, will reveal an exactly
+similar condition, which is not painful. The first and most important
+step in treatment is to assure the patient that the condition is not
+cancerous. Caustics and other irritating applications are to be
+avoided.
+
+_Spasm_ of the tongue sometimes occurs after injuries of the head
+implicating either the centre or the trunk of the hypoglossal nerve.
+It may also appear as a reflex condition in infective affections of
+the teeth and gums, or as a manifestation of some general disease of
+the central nervous system.
+
+_Paralysis_ of the tongue--unilateral or bilateral--may be due to
+injury or disease of the nerve centres of the hypoglossal nerve, more
+frequently to injury of or pressure on the nerve-trunk. The nerve may
+be bruised or divided in operations for the removal of tuberculous
+glands or other tumours in the neck. When the tongue is protruded it
+deviates towards the paralysed side, being pushed over by the active
+muscles of the opposite side (Fig. 260), and speech and mastication
+may be interfered with. The paralysed half of the tongue subsequently
+undergoes atrophy, but the functional disability largely disappears.
+
+[Illustration: FIG. 260.--Temporary Unilateral Paralysis of Tongue,
+from bruising of hypoglossal nerve during operation for tuberculous
+cervical glands.]
+
+
+
+
+CHAPTER XXIII
+
+THE SALIVARY GLANDS
+
+
+Surgical Anatomy--Injuries--Salivary fistulæ--Salivary
+ calculi--Infective conditions: _Parotitis_; _Inflammation of
+ submaxillary gland_; _Angina Ludovici_; _Inflammation of
+ sublingual gland_; _Tuberculous disease_--Tumours: _Ranula_;
+ _Mixed tumours of parotid_; _Sarcoma_; _Carcinoma_; _Tumours of
+ submaxillary and sublingual glands_.
+
+#Surgical Anatomy.#--_The parotid gland_ lies on the side of the face
+below and in front of the ear, and extends deeply behind the mandible
+reaching almost to the side wall of the pharynx. Its deeper part lies
+in close relation with the internal carotid artery, the internal
+jugular vein, and the vagus, glosso-pharyngeal, accessory, and
+hypoglossal nerves. The external carotid artery passes through the
+substance of the parotid, and bifurcates opposite the neck of the
+condyle into the temporal and internal maxillary arteries. It is
+accompanied by the venous trunk formed by the junction of the temporal
+and internal maxillary veins. The facial nerve and its branches
+traverse the lower third of the gland from behind forwards. The facial
+portion of the gland lies on the surface of the masseter muscle, and
+the _parotid duct (Stenson's duct)_ emerges from its anterior border.
+After crossing the masseter, the duct pierces the buccinator muscle
+and the mucous membrane obliquely, and opens into the mouth opposite
+the second upper molar tooth. Its course is indicated by a line
+passing from the upper part of the lobule of the ear to a point midway
+between the ala of the nose and the margin of the upper lip--that
+is, at a higher level than the facial nerve. Several lymph
+glands--pre-auricular--lie inside the capsule of the parotid just in
+front of the ear.
+
+The _submaxillary gland_ lies under the integument and fascia in the
+triangle formed by the lower jaw and the two bellies of the digastric
+muscle. Its anterior part is crossed by the facial vessels, and
+several lymph glands lie inside its capsule. The _submaxillary duct
+(Wharton's duct)_ opens into the mouth by the side of the frenum of
+the tongue.
+
+The _sublingual gland_ lies in the floor of the mouth just beneath the
+mucous membrane. It has numerous ducts, some of which open directly
+into the mouth, others into the submaxillary duct.
+
+#Injuries.#--The _parotid_ is frequently injured by accidental wounds
+and in the course of operations. If the blood vessels traversing the
+gland are divided, such wounds are liable to bleed freely, and if the
+facial and auriculo-temporal nerves are damaged, motor and sensory
+paralysis of the parts supplied by them ensues. Wounds of the parotid
+heal rapidly and without complications so long as infection is
+prevented, but if suppuration takes place they are liable to be
+followed by the escape of saliva, which may go on for weeks; in some
+cases a salivary fistula is thus established.
+
+_The parotid duct_ may be divided and a salivary fistula result. If
+the external wound heals rapidly, a salivary cyst may develop in the
+substance of the cheek, forming a swelling, which fills up at meals,
+and may be emptied by external pressure, the saliva escaping into the
+mouth.
+
+In a wound implicating the whole thickness of the cheek the skin
+should be accurately sutured, care being taken that the stitches do
+not include the duct, but in order that the saliva may readily reach
+the mouth, the mucous membrane should not be stitched.
+
+#Salivary Fistulæ.#--A salivary fistula may occur in relation to the
+glandular substance of the parotid or in relation to the duct. Fistula
+in connection with the glandular substance--_parotid fistula_--seldom
+results from a wound, made, for example, in the removal of a tumour or
+in an operation on the ramus of the jaw, so long as it is aseptic; but
+as a sequel of suppuration in the gland, and particularly of an
+abscess developing around a concretion, it is not uncommon. The
+fistulous opening is usually small, and may occur at any point over
+the gland. The fistula may be dry between meals, or the saliva may
+escape in small transparent drops, but the quantity is always greatly
+increased when food is taken. A parotid fistula, although it may
+continue to discharge for weeks, or even for months, usually closes
+spontaneously.
+
+In persistent cases, the edges of the fistula may be pared and brought
+together with sutures, or the actual cautery may be applied to induce
+cicatricial contraction.
+
+_Fistula of the parotid duct_ is more serious. It is usually due to a
+wound, less frequently to abscess or impacted calculus. From the
+minute opening, which is most frequently situated over the buccinator
+muscle, there is an almost continuous flow of clear limpid saliva,
+which is greatly increased in quantity while the patient is eating.
+These fistulæ show little tendency to close spontaneously. Attempts to
+close the opening by the external application of collodion, by
+cauterising the edges, or even by paring the edges and introducing
+sutures, usually fail. It is necessary to establish an opening into
+the mouth, either by opening up the original duct or by making an
+internal fistula in place of the external one.
+
+#Salivary Calculi.#--Salivary calculi are most commonly met with _in
+the submaxillary gland or its duct_. They consist of phosphate and
+carbonate of lime with a small proportion of organic matter, and
+result from the chemical action of bacteria on the saliva. In rare
+cases a foreign body, such as a piece of straw, a fruit-seed, or a
+fish-bone, forms the nucleus of the concretion. They vary in size from
+a pea to a walnut, and are hard, of a whitish or grey colour, and
+rough on the surface. Those that form in the gland itself are usually
+irregular, while those met with in the duct are rounded or
+spindle-shaped (Fig. 261).
+
+[Illustration: FIG. 261.--Series of Salivary Calculi.]
+
+A calculus in the duct gives rise to sharp lancinating pain, which is
+aggravated when the patient takes food. The duct is seldom completely
+obstructed, but the flow of saliva is usually so much impeded that the
+gland becomes greatly swollen during meals. The swelling gradually
+subsides between meals, or can be made to disappear by external
+pressure. The calculus can usually be felt by means of a probe passed
+along the duct, or by puncturing the swelling with a needle; or, with
+one finger inside the mouth and another under the jaw, a hard lump can
+be detected under the mucous membrane of the floor of the mouth. It
+may be revealed by the X-rays. When the obstruction is complete, a
+retention cyst forms in which suppuration is liable to occur, causing
+marked aggravation of the symptoms. In some cases the wall of the duct
+and the surrounding tissues become thickened and indurated, forming a
+swelling which is liable to be mistaken for a malignant growth. The
+treatment consists in making an incision through the mucous membrane
+over the calculus and extracting it with a scoop or forceps.
+
+INFECTIVE CONDITIONS.--#Parotitis.#--Inflammation of the parotid gland
+may be non-suppurative or suppurative.
+
+Of the _non-suppurative_ varieties the most common is the epidemic
+form known as _mumps_. This is an acute infective condition, which
+usually attacks young children, and implicates both glands, either
+simultaneously or consecutively. It runs a definite course, which
+lasts for from one to two weeks, and almost invariably ends in
+resolution. The parotid gland is swollen and tender, there is pain on
+attempting to open the mouth, difficulty in swallowing, and dribbling
+of saliva. The surgical interest of this disease lies in the fact that
+it is frequently complicated by pain and swelling of the testis,
+oedema of the scrotum, and occasionally by a urethral discharge, and
+atrophy of the testis has been observed after such an attack. In
+females there is sometimes pain in the ovary, tenderness and swelling
+of the mamma, and a vaginal discharge.
+
+[Illustration: FIG. 262.--Acute Suppurative Parotitis.]
+
+The parotid on one or both sides may suddenly become swollen and
+tender in patients who are taking large doses of mercury, in gouty
+subjects, or in patients suffering from infective conditions of the
+genito-urinary organs, such as orchitis, ovaritis, urethritis, or
+cystitis. The condition is usually transient and leads to no
+complications.
+
+_Recurrent enlargement_ of the parotid and submaxillary glands, as
+well as of the lachrymal glands, is occasionally met with in adults,
+and was first described by Mikulicz. It may be associated with
+salivary lithiasis, xerostomia, or organic narrowing of the ducts, but
+in the majority of cases no such cause can be discovered (D. M.
+Greig). When the parotid is affected the condition tends to be
+bilateral and there is some constitutional disturbance. The
+submaxillary form is usually unilateral and the symptoms are entirely
+local. The affected gland rapidly becomes swollen, painful and tender
+to the touch, and the swelling increases markedly while the patient is
+eating. Each attack lasts for a few hours to one or two weeks, and
+then subsides spontaneously. The intervals between attacks vary from a
+few weeks to a year or more. In the course of a few years there is
+considerable deformity, and sometimes deficiency in the glandular
+secretion, but the disease is not attended by other inconvenience.
+Benefit has followed the administration of arsenic and iodides, and
+the use of radium and X-rays.
+
+The treatment of these non-suppurative forms of parotitis consists in
+relieving the symptoms.
+
+_Suppurative parotitis_ may be due to direct spread of infection from
+the mouth along the parotid duct, or to extension of suppurative
+processes from the temporo-mandibular joint, the jaw, or a lymph
+gland. It is liable to occur also in the course of any disease in
+which there is an infection of the blood with pyogenic bacteria, and
+has been met with in diphtheria, typhoid fever, scarlet fever,
+measles, and other eruptive fevers.
+
+The _post-operative_ form of parotitis is most frequently met with
+after laparotomy for such conditions as suppurative appendicitis,
+perforated gastric ulcer, ovarian cyst, and pyosalpinx.
+
+These secondary forms are probably due to infection from the mouth
+under conditions in which the secretion of saliva is arrested or its
+escape from the gland interfered with.
+
+The early symptoms are apt to be overshadowed by those of the general
+disease from which the patient suffers. At first the gland is swollen,
+hard, and tender, and the seat of constant, dull, boring pain; later
+there is redness, oedema, and fluctuation. The movements of the jaw
+are restricted and painful, the patient is unable to open the mouth,
+and has difficulty in swallowing. The inflammation reaches its height
+on the third or fourth day, and usually ends in suppuration. The pus
+is scattered in numerous foci throughout the gland, and sometimes
+large sloughs form. The dense capsule of the gland prevents the pus
+reaching the surface and causes it to burrow among the tissues of the
+neck, giving rise to dyspnoea and dysphagia. It may find its way
+downwards towards the mediastinum, inwards towards the pharynx--where
+it constitutes one form of retro-pharyngeal abscess--or upwards
+towards the base of the skull. Not infrequently it burrows into the
+temporo-mandibular joint, or escapes by bursting into the external
+auditory meatus. Serious hæmorrhage may result from erosion of the
+vessels traversing the gland or of the internal jugular vein, or
+venous thrombosis may ensue. Persistent paralysis may follow
+destruction of the facial nerve; and salivary fistulæ may form. Death
+may take place from toxæmia even before pus forms.
+
+_Treatment._--During the first two or three days hyperæmia is induced
+by means of poultices, hot fomentations, or Klapp's suction bells, and
+the mouth is frequently washed out with an antiseptic. As soon as
+there is reason to believe that pus has formed an incision is made
+behind the angle of the jaw, parallel to the branches of the facial
+nerve, the abscess opened by Hilton's method, a finger passed into the
+gland, and all septa broken down and drainage secured.
+
+Acute infection of the #submaxillary gland# is met with under the same
+conditions as that of the parotid. Both glands are occasionally
+attacked at the same time.
+
+The acute phlegmonous peri-adenitis of the submaxillary gland, known
+as _angina Ludovici_, is referred to at p. 597.
+
+The _treatment_ consists in making incisions through the deep fascia
+in order to relieve the tension, or to let out pus if it has formed.
+
+Acute suppurative inflammation of the #sublingual gland# may occur
+under the same conditions as in the parotid, and is associated with
+the formation of an exceedingly painful and tender swelling under the
+tongue. The tongue is gradually pushed against the roof of the mouth,
+so that swallowing is difficult and respiration may be seriously
+impeded. There is marked constitutional disturbance. An incision into
+the swelling is immediately followed by relief of the symptoms.
+
+#Tuberculous disease# of the salivary glands is rare. It usually
+begins in the lymph glands within the capsule of the parotid or
+submaxillary, and spreads thence to the salivary gland tissue.
+
+TUMOURS.--#Cystic Tumours--Ranula.#--The term ranula is applied to any
+cystic tumour formed in connection with the glands in the floor of the
+mouth. Formerly these tumours were believed to be retention cysts due
+to blocking of the salivary ducts. They are now known to be the result
+of a cystic degeneration of one or other of the secreting glands in
+the floor of the mouth. They contain a thick glairy fluid, which
+differs from saliva in containing a considerable quantity of mucin and
+albumin, while it is free from any amylolytic ferment or
+sulpho-cyanide of potassium. Numerous degenerated epithelial cells are
+found in the fluid.
+
+The _sublingual ranula_ is the most common variety. It appears as a
+painless, smooth, tense, globular swelling of a bluish colour. It
+usually lies on one side of the frenum, and over it the mucous
+membrane moves freely. As it increases in size it gradually pushes the
+tongue towards the roof of the mouth, and so causes interference with
+speech, mastication, and swallowing. It is to be differentiated from a
+retention cyst of the submaxillary gland by the fact that a probe can
+usually be passed down the submaxillary duct alongside of the
+swelling, and from sublingual dermoid (p. 539).
+
+The _treatment_ consists in making an incision through the mucous
+membrane over the swelling, dissecting away the whole of the cyst wall
+if possible, and, if any portion cannot be removed, swabbing it with a
+solution of chloride of zinc (40 grains to the ounce), after which the
+cavity is stuffed with bismuth gauze and allowed to close by
+granulation. It is sometimes found more satisfactory to dissect out
+the cyst through an incision below the jaw, and in the event of
+recurrence this should be undertaken.
+
+Cystic tumours, similar to the sublingual ranula, form in the other
+glands in the floor of the mouth--for example, the incisive gland,
+which lies just behind the symphysis menti, as well as in the apical
+gland on the under aspect of the tip of the tongue. The latter is
+distinguished by the fact that it moves with the tongue. In rare cases
+children are born with a cystic swelling in the floor of the
+mouth--the so-called _congenital ranula_. It is usually due to an
+imperfect development of the duct of the submaxillary or sublingual
+gland.
+
+#Solid Tumours--Mixed Tumours of the Parotid.#--The most important of
+the solid tumours met with in the salivary glands is the so-called
+"mixed tumour of the parotid." This was formerly believed to be an
+endothelioma derived from a proliferation of the endothelial cells
+lining the lymph spaces and blood vessels of the gland. A more
+probable view is that it develops from rests derived from the first
+branchial arch an not from the parotid. The matrix of the tumour is
+made up of cartilaginous, myxomatous, sarcomatous, or angiomatous
+tissue, the proportion of these different elements varying in
+individual specimens, and it may include some portions that are
+adenomatous. A gelatinous substance forms in the intercellular spaces
+of the tumour, and may accumulate in sufficient quantity to give rise
+to cysts of various sizes. There is reason to believe that the tumours
+of the parotid previously described as adenoma, chondroma, angioma,
+myxoma, and many of the cases of sarcoma, were really mixed tumours in
+which one or other of these tissues predominated.
+
+The tumour usually develops in the vicinity of the parotid, and
+presses on the salivary tissue, thinning it out and causing it to
+undergo atrophy.
+
+_Clinical Features._--The mixed tumour is usually first observed
+between the ages of twenty and thirty. It is of slow growth and
+painless, and forms a rounded, nodular swelling, the consistence of
+which varies with its structure. The skin over the swelling is normal
+in appearance and is not attached to the tumour (Figs. 263, 264). Only
+in rare cases does paralysis result from pressure on the facial nerve.
+
+[Illustration: FIG. 263.--Mixed Tumour of Parotid.]
+
+[Illustration: FIG. 264.--Mixed Tumour of the Parotid of over twenty
+years' duration.]
+
+Although usually benign, these tumours may, after lasting for years,
+take on malignant characters, growing rapidly, implicating adjacent
+lymph glands, and showing a marked tendency to recur after removal.
+
+The _treatment_ consists in shelling out the tumour, care being taken
+to avoid injuring the facial nerve or the parotid duct by making the
+incision and the subsequent cuts in the dissection run parallel to
+them. If the tumour is removed early and completely, recurrence is the
+exception.
+
+#Sarcoma and carcinoma# are rare. They are very malignant, grow
+rapidly, infiltrate surrounding parts, including the skin, and infect
+the adjacent lymph glands. There is severe neuralgic pain, and
+paralysis from involvement of the facial nerve is an early symptom.
+
+The _treatment_ consists in excising the whole of the parotid gland
+with the tumour, no attempt being made to conserve the facial nerve or
+other structures traversing it. Recourse should be had to the use of
+radium both before and after operation, otherwise recurrence is all
+but inevitable.
+
+The _submaxillary and sublingual glands_ may be the seat of the same
+varieties of tumour as the parotid. These glands are particularly
+liable to become invaded along with the adjacent lymph glands in
+epithelioma of the tongue and floor of the mouth.
+
+
+
+
+CHAPTER XXIV
+
+THE EAR[5]
+
+
+Surgical Anatomy--CARDINAL SYMPTOMS OF EAR DISEASE: _Impairment of
+ hearing_; _Tinnitus aurium_; _Earache_; _Giddiness_;
+ _Discharge_--Hearing tests--Inspection of ear--Inflation of middle
+ ear. AFFECTIONS OF EXTERNAL EAR: _Deformities_; _Hæmatoma auris_;
+ _Epithelioma and Rodent cancer_; _Impaction of wax_; _Eczema_;
+ _Boils_; _Foreign bodies_. AFFECTIONS OF TYMPANIC MEMBRANE AND
+ MIDDLE EAR: _Rupture of membrane_; _Acute inflammation of middle
+ ear_; _Chronic suppuration_; _Suppuration in the mastoid antrum
+ and cells_.
+
+[5] We desire here to acknowledge our indebtedness to Dr. Logan Turner
+for again revising this chapter.
+
+#Surgical Anatomy.#--The anatomical subdivision of the ear into three
+parts--the external, middle, and internal ear--forms a satisfactory
+basis for the study of ear lesions. The outer ear consists of the
+auricle and external auditory meatus, the latter being made up of an
+outer cartilaginous portion half an inch in length, and a deeper
+osseous portion three-quarters of an inch long. The canal forms a
+curved tube, which can be straightened to a considerable extent for
+purposes of examination by pulling the auricle upwards and backwards.
+It is closed internally by the tympanic membrane, which separates it
+from the tympanic cavity or middle ear. The middle ear includes the
+tympanum proper, which is crossed by the chain of ossicles--malleus,
+incus, and stapes--the Eustachian tube, which communicates with the
+naso-pharynx, and the tympanic antrum and mastoid cells. As these
+cavities lie in close relation to the middle and posterior cranial
+fossæ, infective conditions in the tympanum and mastoid cells are
+liable to spread to the interior of the skull. The internal ear or
+labyrinth lies in the petrous part of the temporal bone, its outer
+boundary being the inner wall of the middle ear.
+
+Physiologically the different parts of the auditory mechanism may be
+divided into (1) the _sound-conducting apparatus_, which includes the
+outer and middle ears; and (2) the _sound-perceiving apparatus_--the
+internal ear and central nerve tracts. Impairment of hearing may be
+due to causes existing in one or other or both of these subdivisions.
+The condition of the sound-conducting apparatus can be investigated by
+direct inspection through the speculum, and by inflation of the
+Eustachian tube and tympanum, while that of the sound-perceiving
+apparatus is ascertained partly by testing the hearing, and partly by
+excluding affections of the outer and middle ear. When the
+sound-conducting apparatus is at fault, the resulting deafness is
+spoken of as "obstructive"; when the sound-perceiving apparatus is
+affected, the term "nerve deafness" is used. The semicircular canals,
+which are peripheral organs concerned in the maintenance of
+equilibration, form part of the inner ear apparatus.
+
+CARDINAL SYMPTOMS OF EAR DISEASE.--The most important symptom of ear
+disease is _impairment of hearing_, which varies in degree, and may be
+due to lesions either in the sound-conducting or in the
+sound-perceiving apparatus. The sudden onset of deafness may be due to
+impaction of wax in the external meatus or to hæmorrhage or effusion
+into the labyrinth. A gradual onset is more common. In children there
+is a great tendency for acute inflammatory conditions of the middle
+ear to arise in connection with the exanthemata and in association
+with adenoids. In adult life chronic catarrhal processes are more
+common causes of gradually increasing deafness, while in advanced age
+there is a tendency to acoustic nerve impairment. Certain anomalous
+conditions of hearing are occasionally met with, such as the
+"paracusis of Willis"--a condition in which the patient hears better
+in a noise; "diplacusis," or double hearing; and "hyperæsthesia
+acustica," or painful impressions of sound.
+
+_Tinnitus aurium_, or subjective noises in the ear, may constitute a
+very annoying and persistent symptom. These sounds vary in their
+character, and may be described by the patient as ringing, hissing, or
+singing, or may be compared to the sound of running water or of a
+train. They are usually compared to some sound which, from his
+occupation or otherwise, the patient is accustomed to hear. They may
+be purely aural in origin, being due, for example, to increased
+pressure on the acoustic nerve endings from causes in the labyrinth
+itself or in the middle or external ear; or they may be due to certain
+reflex causes, such as naso-pharyngeal catarrh or gastric irritation.
+Vascular changes such as occur in anæmia, Bright's disease, and heart
+disease may also be concerned in their production.
+
+_Pain_, or _earache_, varies in degree from a mere sense of discomfort
+to acute agony. The pain associated with a boil in the external meatus
+is usually aggravated by movements of the jaw, by pulling the auricle,
+and by pressure upon the tragus. The pain of acute middle-ear
+inflammation is deep-seated, intermittent in character, and worse at
+night, and is aggravated by blowing the nose, coughing, and
+sneezing--acts which increase middle-ear tension by forcing air along
+the Eustachian tube. Mastoid pain and tenderness are indicative of
+inflammation in the antrum or cells, and when these symptoms supervene
+in the course of a chronic middle-ear suppuration, they should always
+be regarded as of grave import. Severe neuralgia of the ear may
+simulate the pain of acute mastoiditis, and it must not be forgotten
+that earache may be traced to a diseased tooth. A careful examination,
+not only of the ear, but also of the throat and teeth, should
+therefore be made in all cases of earache.
+
+_Vertigo_, or _giddiness_, may be produced by causes which alter the
+tension of the labyrinthine fluid, such, for example, as the pressure
+of wax upon the tympanic membrane, or exudation into the middle ear or
+into the labyrinth. Giddiness occurring in the course of chronic
+middle-ear suppuration may be significant of labyrinthine or of
+intra-cranial mischief, but is not necessarily so. Giddiness preceded
+by nausea suggests a gastric origin; if followed by nausea it points
+to an aural origin. In cases of suspected aural vertigo, the patient's
+"static sense" should be carefully tested. He should be asked (1) to
+stand with both feet together with the eyes closed, (2) to stand on
+one or other foot with eyes closed, (3) to walk in a straight line,
+(4) to hop backwards and forwards off both feet. His incapacity for
+performing such movements should be noted. As nystagmus may be
+associated with disturbance of equilibrium due to ear disease, the
+movements of the eyeballs must be carefully tested.
+
+Labyrinthine _nystagmus_ is of a rhythmic character, and consists of a
+slow and a rapid movement. Physiological nystagmus can be induced by
+stimulating the movement of the endolymph in the semicircular canals,
+by syringing the ear with hot and cold water (caloric test), by
+rotating the individual (rotation test), and by the galvanic current.
+Any departure from the normal reactions which these tests may produce,
+should raise the suspicion of a pathological condition of the
+semicircular canals.
+
+_Discharge from the ear_, or _otorrhoea_, is occasionally due to an
+eczematous condition of the skin lining the external meatus. It is
+then usually of a thin, watery character, and contains epithelial
+flakes and débris. An aural discharge is, however, most commonly of
+middle-ear origin. It may be muco-purulent and stringy, or purulent
+and of thicker consistence. A peculiar, offensive odour is
+characteristic of chronic middle-ear suppuration. The surgeon should
+smell the speculum in suspicious cases. He should never accept the
+patient's statement as regards the absence of discharge, but should
+satisfy himself by inspection and by the introduction of a cotton-wool
+wick.
+
+#The Hearing Tests.#--In testing the hearing, a definite routine
+method should be adopted, the watch, whisper, voice, and tuning-fork
+tests being systematically employed. Although the patient only
+complains of one ear, both must be examined. Each ear should be tested
+separately, and the patient should be so placed that he cannot see the
+lips of the examiner. While one ear is being tested, the other should
+be closed with the finger, and each test should be commenced outside
+the probable normal range of hearing. All the results should be
+written down at once, and the date of the test recorded, as this is
+essential for following the progress of the case.
+
+_Tuning-fork Tests._--To differentiate between deafness due to a
+lesion in the sound-conducting apparatus and that due to labyrinthine
+causes, it is necessary to enter into a little more detail. The tone
+produced by a vibrating tuning-fork is conducted to the nerve
+terminations in the labyrinth both through the air column in the
+external meatus (air-conduction), and through the cranial bones
+(bone-conduction). When, in a deaf ear, the vibrations of a
+tuning-fork placed in contact with the mastoid process are heard
+better than when the fork is held opposite the meatus, the lesion is
+in the sound-conducting apparatus. When, on the other hand, the
+vibrations are heard better by air-conduction, the lesion is in the
+sound-perceiving apparatus. In addition to these facts, we find also
+that in obstructive deafness low tones tend to be lost first, while in
+nerve deafness the higher notes are the first to go. This may be
+investigated by tuning-forks of different pitch or with the aid of a
+Galton's whistle. Again, in middle-ear deafness, hearing may be better
+in a noisy place, and be improved by inflation of the tympanum; while
+in labyrinthine deafness, hearing may be better in a quiet room, and
+be rendered worse by inflation.
+
+#Inspection of the Ear.#--This should be carried out by the aid of
+reflected light, the ear to be examined being turned away from the
+window, lamp, or other source of light that may be employed. A small
+ear reflector, either held in the hand or attached to a forehead band,
+and a set of aural specula are required. Before introducing the
+speculum, the outer ear and adjacent parts should be examined, and the
+presence of redness, swelling, sinuses or cicatrices over the mastoid,
+displacement of the auricle, or any inflammatory condition of the
+outer ear observed. To inspect the tympanic membrane, a medium-sized
+speculum held between the thumb and index finger is insinuated into
+the cartilaginous meatus, the auricle being at the same time pulled
+upwards and backwards by the middle and ring fingers, so as to
+straighten the canal. The tympanic membrane is then sought for and its
+appearance noted.
+
+The _normal membrane_ is concave as a whole on its meatal aspect; it
+occupies a doubly oblique plane, being so placed that its superior and
+posterior parts are nearer the eye of the examiner than the anterior
+and inferior parts. While varying to some extent in colour, polish,
+and transparency, it presents a bluish-grey appearance. The handle of
+the malleus traverses the membrane as a whitish-yellow ridge, which
+appears to pass from its upper and anterior parts downwards and
+backwards to a point a little below the centre. At the lower end of
+the handle of the malleus a bright triangular cone of light passes
+downwards and forwards to the periphery of the membrane. At the upper
+end of the handle is a white knob-like projection, the short process
+of the malleus. Passing forwards and backwards from this are the
+anterior and posterior folds. The portion of the membrane situated
+above the short process is known as the membrana flaccida or
+Shrapnell's membrane. Behind the malleus the long process of the incus
+may be visible through the membrane. The mobility of the membrana
+tympani should be tested by inflating the tympanum or by means of
+Siegle's pneumatic speculum.
+
+Various departures from the normal may be observed. _Atrophy_ of the
+membrane is characterised by extreme transparency of the whole disc.
+Circumscribed atrophic patches appear as dark transparent areas, which
+show considerable mobility and bulge prominently on inflation. A
+_cicatrix_ in the membrane is evidence of a healed perforation, and is
+also transparent, but differs from an atrophic patch in being more
+sharply defined from the surrounding membrane. A _thickened membrane_
+presents an opaque white appearance. _Calcareous_ or _chalky patches_
+are markedly white, and when probed are hard to the touch; they are
+often evidence of past suppuration. An _indrawn_ or retracted
+membrane, resulting from Eustachian obstruction, is characterised by
+increased concavity, undue prominence of the lateral short process of
+the malleus and of the anterior and posterior folds, and by the handle
+of the malleus assuming a more horizontal position. An _inflamed_
+membrane, showing congestion of the vessels about the malleus or a
+general diffuse redness, is evidence of middle-ear inflammation. A
+yellow appearance of the lower part of the membrane, limited above by
+a dark line stretching across the drum-head, is indicative of
+sero-purulent exudation into the tympanum. The membrane may be bulged
+outwards into the meatus by the fluid, and thus lie nearer the
+observer's eye than normally. A _perforation_ is usually single, and
+varies in size from a small pinhead to complete destruction of the
+membrane. The labyrinthine (inner) wall of the tympanum may be visible
+through the perforation, and is recognised by being on a deeper plane
+than the membrane, and by its hard bony consistence when touched with
+the probe. The diagnosis of a perforation associated with middle-ear
+discharge may be further assisted by inspection during inflation, when
+bubbles of air and secretion are visible. When the perforation is
+invisible, its existence may be inferred if a small pulsating spot of
+light can be recognised through the speculum. _Granulations_ in the
+tympanum appear as red fleshy masses of different sizes. When large
+they constitute _aural polypi_, which are recognised by their
+proximity to the outer end of the meatus, their soft consistence and
+mobility, and the fact that the probe may be passed round them.
+Granulations and polypi usually indicate the presence of middle-ear
+suppuration.
+
+#Inflation of the Middle Ear.#--Before proceeding to inflate the
+middle ear, the examiner should inspect the nose, naso-pharynx, and
+pharynx. This should be made a routine part of the examination in all
+cases of ear disease. As inflation is not only an aid in diagnosis,
+but is also of great assistance in prognosis, it is necessary that the
+hearing should be tested and noted before the ear is inflated. There
+are three methods of inflating the tympanum: Valsalva's method,
+Politzer's method, and by means of the Eustachian catheter.
+
+In _Valsalva's inflation_ the patient himself forces air into his
+Eustachian tubes, by holding his nose, closing his mouth, and forcibly
+expiring. This method of inflation has only a limited application and
+is of little therapeutic value.
+
+_Politzer's Method._--For this a Politzer's air-bag and an
+auscultating tube, one end of which is inserted into the patient's ear
+and the other into the ear of the examiner, are required. The nasal
+end of the bag should be protected with a piece of rubber tubing or be
+provided with a nozzle. The patient retains a small quantity of water
+in his mouth until directed to swallow. The nozzle of the bag is
+inserted into one nostril, and the other is occluded by the fingers of
+the surgeon. The signal to swallow is then given, and, simultaneously
+with the movement of the larynx during this act, the bag is sharply
+and forcibly compressed. Holt's modification of this method consists
+in directing the patient to puff out his cheeks while the lips are
+kept firmly closed.
+
+_Inflation through the Eustachian Catheter._--For this method, in
+addition to the Politzer's bag and the auscultating tube, a silver or
+vulcanite Eustachian catheter is required. The silver instrument has
+the advantage that it can be sterilised by boiling. The patient is
+seated facing the light, while the surgeon stands in front of him,
+and, having placed the auscultating tube in position, with his left
+thumb he tilts up the tip of the patient's nose. The beak of the
+catheter is now inserted into the inferior meatus, point downwards,
+and carried horizontally backwards along the floor of the nose until
+the convexity of the curve touches the posterior wall of the
+naso-pharynx. When the posterior pharyngeal wall is felt, the point of
+the instrument is rotated inwards through a quarter of a circle; the
+position of the point is indicated by the metal ring upon the outer
+end of the catheter. The finger and thumb of the left hand should now
+grasp the stem of the catheter just beyond the tip of the nose so as
+to steady it. It is now gently withdrawn until the concavity of the
+beak is brought against the posterior edge of the septum nasi. With
+the right hand the point of the instrument is then rotated downwards
+and outwards through a little more than half a circle, so that the
+point slips into the Eustachian orifice and the metal ring looks
+outwards and upwards towards the external canthus of the eye of the
+same side. While the instrument is maintained in this position by the
+left hand, the nozzle of the Politzer's bag is inserted into the
+funnel-shaped outer extremity of the catheter, and inflation is gently
+carried out with the least possible jerking. Before withdrawing the
+catheter its point must be disengaged from the Eustachian opening by
+turning it slightly downwards. Difficulties in introducing the
+catheter may arise from the presence of spines and ridges upon, and
+deviations of, the septum, and it may be necessary to pass the
+instrument under the guidance of the mirror and speculum.
+
+More accurate information is gained from the use of the catheter than
+from Politzer's inflation, and it is the safer method to employ when a
+cicatrix or atrophied patch exists in the tympanic membrane, as by the
+latter method rupture of these areas might occur. Further, the
+catheter has the advantage of only inflating one ear, and thus
+preventing any undue strain being put upon the other. In children the
+catheter can seldom be employed, on account of the difficulty in
+passing it.
+
+Considerable information may be derived from inflation. If the
+Eustachian tube is patent, a full clear sound is heard close to the
+examiner's ear through the auscultating tube. If the Eustachian tube
+is obstructed, the sound is fainter and more distant. If there is
+fluid in the tympanum, a fine moist sound may be detected, which must
+not be confounded with the coarser and more distant gurgling sound
+associated with moisture at the pharyngeal opening of the tube. If a
+small dry perforation exists in the tympanic membrane, the air may be
+heard whistling through it, while if the perforation is large, a
+sensation which is almost painful may be produced in the examiner's
+ear. If there is fluid associated with the perforation, these sounds
+may be accompanied by a bubbling noise. The effect of inflation upon
+the hearing must be carefully tested and recorded.
+
+
+AFFECTIONS OF THE EXTERNAL EAR
+
+#Deformities.#--The auricle, together with the external auditory
+meatus, may be _congenitally absent_ on one or on both sides. The
+condition is not amenable to surgical treatment. _Double auricles_ are
+occasionally met with; more frequently rudimentary _auricular
+appendages_ about the size of a pea, consisting of skin, subcutaneous
+connective tissue and nodules of cartilage occur in front of the
+tragus, on the lobule or in the neck. These appendages should be
+snipped off with scissors. These congenital deformities are due to
+errors in development of the mandibular arch, and are frequently
+associated with macrostoma, facial clefts, and other malformations of
+the face.
+
+_Outstanding ears_ may be treated by excising a triangular or
+elliptical portion of skin and cartilage from the posterior surface of
+the pinna and uniting the cut edges with sutures. Abnormally _large
+ears_ may be diminished in size by the removal of a V-shaped portion
+from the upper part of the auricle.
+
+The term #hæmatoma auris# is applied to a sub-perichondrial effusion
+of blood, which may occur either as the result of injury to the
+auricle, for example in football players, or as a result of trophic
+changes in the cartilage and perichondrium. The latter form is not
+uncommon among the insane. A more or less tense fluctuating swelling
+forms on the anterior surface of the auricle, presenting in some cases
+a distinctly bluish coloration. Inflammation may ensue, and in some
+cases suppuration and even necrosis of cartilage may follow.
+
+The _treatment_ in a recent case consists in applying cold or elastic
+compression with cotton-wool and a bandage, or in withdrawing the
+effused blood by means of a hollow needle. In the event of suppuration
+supervening, incision and drainage must be carried out.
+
+#Epithelioma# may attack the auricle and extend along the external
+auditory meatus. It begins as a small abrasion which refuses to heal,
+and is attended with a constant foetid discharge and intense pain. The
+disease may spread to the middle ear and invade the temporal bone, and
+facial paralysis then ensues. The adjacent lymph glands are early
+infected. The treatment consists in removing the growth freely, and
+excising the associated lymph glands at an early stage of the disease.
+In inoperable cases radium or the X-rays may be employed.
+
+#Rodent cancer# also may attack the outer ear.
+
+#Impaction of Wax or Cerumen.#--Hyper-secretion may result from
+unknown causes, or it may accompany or be induced by the discharge
+from a chronic middle-ear suppuration. The association of these two
+conditions should be borne in mind. An accumulation of wax may be
+caused by the too zealous attempts of the patient to keep the ear
+clean, the wax being forced into the narrow deeper part of the meatus.
+
+The chief _symptom_ of impacted wax is deafness, which is often of
+sudden onset. Impaction of wax causes deafness only when the lumen of
+the auditory canal becomes completely occluded by the plug. Tinnitus
+aurium and vertigo are sometimes present, and may be troublesome if
+the wax rests upon the tympanic membrane. Pain is occasionally
+complained of, and is usually due to the pressure of the plug upon an
+inflamed area of skin. Certain reflex symptoms, such as coughing and
+sneezing, have been met with.
+
+It is only by an objective examination of the ear that the diagnosis
+can be made. The plug varies in colour and consistence, and may be
+yellow, brown, or black in appearance. Sometimes from the admixture of
+a quantity of epithelium it is almost white in colour.
+
+_Treatment._--The ear should be syringed with a warm antiseptic or
+sterilised solution. The lotion is at a suitable temperature if the
+finger can be comfortably held in it. The ear should be turned to the
+light, a towel placed over the patient's dress, and a kidney basin
+held under the auricle and close to the cheek. A syringe provided with
+metal rings for the fingers and armed with a fine ear nozzle should be
+held with the point inserted just within the aperture of the external
+meatus and in contact with the roof of the canal. Care must be taken
+that all the air is first removed from the syringe. To straighten the
+canal, the pinna should be pulled upwards and backwards by the left
+hand. It may be necessary to exert some considerable degree of force
+before the plug becomes dislodged, but this must be done with caution.
+The ear should then be dried out with cotton-wool, and a small plug
+of wool inserted for a few hours. If pain is complained of, or if the
+wax is hard and cannot be readily removed, the syringing should be
+stopped, and means taken to soften it by the instillation of a few
+drops of a solution of bicarbonate of soda (10 grains to the ounce of
+water or glycerine), or of peroxide of hydrogen, several times daily.
+
+#Eczema of the external meatus# is often associated with eczema of the
+auricle and of the surrounding parts. Not infrequently there also
+exists a chronic middle-ear suppuration, which may be the cause of the
+eczema. Intense itchiness is the most characteristic symptom, and a
+watery discharge may also be complained of. Deafness and tinnitus are
+dependent upon the accumulation of epithelium and débris. After the
+ear is syringed the skin may present a dry, scaly appearance, while
+sometimes fissures and an indurated condition of the outer end of the
+meatus may be noted. Rarely is the outer surface of the tympanic
+membrane itself involved.
+
+_Treatment_ consists in keeping the ear clean by syringing and careful
+drying. Probably the best local application is nitrate of silver (10
+grains to the ounce of spiritus ætheris nitrosi). This is applied by
+means of a grooved probe dressed with a small piece of cotton-wool.
+Care should be taken that none of the fluid is allowed to escape upon
+the cheek, otherwise staining of the skin occurs. A plug of
+cotton-wool is inserted, and the solution is re-applied at the end of
+a week. Sometimes the condition is very intractable.
+
+Occasionally the vegetable parasite _aspergillus_ is present in the
+external meatus, and produces a condition that is liable to be
+mistaken for eczema. Strong antiseptic lotions are required to kill
+the fungus.
+
+#Furunculosis# or #Boils#.--Boils in the ear may arise singly or in
+crops, and may be associated with eczema of the meatus or with chronic
+suppuration of the middle ear. Pain is the chief symptom complained
+of, and it may be very acute. Deafness ensues when the meatus becomes
+completely blocked by the swelling. The boil occurs in the
+cartilaginous meatus, and it is to be borne in mind that the skin may
+present a normal appearance even when suppuration has occurred.
+Palpation of the affected area with the probe causes intense pain.
+Sometimes oedema over the mastoid with displacement forwards of the
+pinna supervenes, and simulates acute inflammation of the mastoid.
+
+_Treatment._--If seen in the earliest stages, an attempt may be made
+to relieve the pain by the application of a 20 per cent. menthol and
+parolein solution, or by the use of carbolic acid and cocain, 5 grains
+of each to a dram of glycerine. When suppuration has occurred, the
+best treatment is by early incision, transfixing the base of the
+swelling with a narrow knife and cutting into the meatus. If the
+tendency to boils persists, a staphylococcal vaccine will be found of
+value.
+
+#Foreign Bodies.#--It is unnecessary to enumerate all the varieties of
+foreign bodies that may be met with in the ear. They may be
+conveniently classified into the animate--for example maggots, larvæ,
+and insects; and the inanimate--for example beads, buttons, and peas.
+Pain, deafness, tinnitus, and giddiness may be produced, and such
+reflex symptoms as coughing and vomiting have resulted.
+
+The main practical point consists in identifying the body by
+inspection. The mere history of its introduction should not be taken
+as proof of its presence. In children it is advisable to give a
+general anæsthetic so that a thorough examination may be made with the
+aid of good illumination. If previous attempts to remove the body have
+caused oedema of the meatal walls, and if the symptoms are not urgent,
+no further attempt should be made until the swelling has been allayed
+by syringing with warm boracic lotion, and by applying one or more
+leeches to the tragus. An attempt should always be made in the first
+instance to remove the body by syringing. It is rare to find this
+method fail. Should it do so, a small hook should be used, sharp or
+blunt according to the consistence of the body. Maggots, larvæ, and
+insects should first be killed by instillations of alcohol and then
+syringed out.
+
+
+AFFECTIONS OF THE TYMPANIC MEMBRANE AND MIDDLE EAR
+
+#Traumatic Rupture of the Tympanic Membrane.#--Perforating wounds may
+result from direct violence caused by the patient--for example, in
+attempts to remove wax or foreign bodies, or by clumsiness on the part
+of the surgeon. It is also a comparatively common complication of
+fracture of the middle fossa of the base of the skull. More commonly,
+perhaps, the membrane is ruptured from indirect violence due to great
+condensation of the air in the external auditory meatus, following
+blows upon the ear, heavy artillery reports, or diving from a height.
+The injury is followed by pain in the ear, often by considerable
+deafness and tinnitus, and bleeding is frequently observed. If early
+examination of the ear is made, coagulated blood may be found in the
+meatus or upon the membrane, or ecchymosis may be visible on the
+latter. A rupture in the membrane following indirect violence is
+usually lozenge-shaped. During inflation by Valsalva's method the air
+may be heard to whistle through the perforation. In all such injuries
+the hearing should be carefully tested, and the possibility of an
+injury to the labyrinth investigated by means of the tuning-fork test.
+Prognosis as regards hearing should be guarded at first. As a rule the
+rupture heals rapidly, and no treatment is necessary save the
+introduction of a piece of cotton-wool into the meatus. Syringing
+should be avoided unless suppuration has already occurred, in which
+case treatment for this condition must be adopted. As these injuries
+frequently have a medico-legal bearing, careful notes should be made.
+
+#Acute Infection of the Middle Ear.#--This usually arises in
+connection with infective conditions of the throat and naso-pharynx.
+It varies considerably in its severity, and may run a mild or a severe
+course. It is characterised by pain in the ear, deafness, and a
+certain degree of fever. In children the symptoms may simulate those
+of meningitis. When the tympanic membrane is examined in the mild
+forms of the affection or in the early stages of the more severe type,
+the vessels about the handle of the malleus and periphery of the
+membrane are injected, and possibly a number of injected vessels may
+be seen coursing across the surface of the membrane. In the later
+stages the whole membrane presents a red surface, the anatomical
+landmarks being indistinguishable, the membrane bulges outwards into
+the meatus, and, if an abscess is pointing, a yellowish area may be
+visible upon it. The sudden cessation of pain and the appearance of a
+discharge from the meatus indicate perforation of the membrana
+tympani.
+
+The _treatment_ of acute otitis media varies with the severity of the
+attack. The patient should be confined to the house or to bed, alcohol
+and tobacco should be forbidden, and the bowels must be freely opened.
+Pain may be allayed by repeated instillations of cocain and carbolic
+acid (5 grains of each to a dram of glycerine). A few drops of
+laudanum, hot boracic instillations, or the application of a dry hot
+sponge, may prove soothing. Two or three leeches may be applied over
+the mastoid, but should the pain persist or should rupture of the
+membrane appear imminent, paracentesis must be carried out. After
+spontaneous perforation or puncture, the meatus must be kept clean. It
+is probably safer not to inflate through the Eustachian tube in the
+acute stage. Attention must be paid to any affection of the nose or
+throat that may be present.
+
+#Chronic Suppuration in the Middle Ear.#--Acute suppuration may pass
+into the chronic variety, which is characterised by a perforation of
+the tympanic membrane, a persistent purulent or muco-purulent
+discharge from the middle ear, and a certain amount of deafness.
+
+_Various complications_ may arise in the course of chronic middle-ear
+disease, and so long as a person is the subject of a chronic
+otorrhoea, he is liable to one or more of these. The complications may
+be extra-cranial or intra-cranial. Those affecting the middle ear
+itself include granulations, polypi, cholesteatoma, caries and
+necrosis of the temporal bone, destruction and loss of one or more of
+the ossicles, facial paralysis, hæmorrhage from the carotid artery or
+jugular vein, and malignant disease. As mastoid complications may be
+mentioned: suppurative mastoiditis, leading to destruction of the
+bone, mastoid fistula, and sub-periosteal mastoid abscess. The
+intra-cranial complications that may arise are: extra-dural abscess,
+sub-dural abscess, meningitis, cerebral and cerebellar abscess, and
+lateral sinus phlebitis with general septicæmia and pyæmia.
+
+The _treatment_ of chronic middle-ear suppuration consists in keeping
+the parts clean by syringing with antiseptic lotions. The installation
+of hydrogen peroxide, followed by syringing with boiled water or
+boracic lotion, and inflation through the Eustachian tube once, twice,
+or thrice daily, according to the requirements of the case, constitute
+a routine method. Packing the meatus with antiseptic gauze after
+washing out may be practised.
+
+#Suppuration in the Tympanic Antrum and Mastoid Cells#, or _Acute
+Suppurative Mastoiditis_.--Acute suppuration may occur in the mastoid
+cells in the course of an attack of acute otitis media, or as a result
+of interference with drainage in chronic suppuration of the antrum and
+middle ear. As the outer wall of the mastoid is liable to be
+perforated by cario-necrosis, the pus may find its way externally and
+form an abscess over the mastoid process behind the ear. In some cases
+the pus escapes into the external auditory meatus by perforating its
+posterior wall; in others a sinus forms on the inner side of the apex
+of the mastoid, and the pus burrows in the digastric fossa under the
+sterno-mastoid--_Bezold's mastoiditis_. If the posterior wall or roof
+of the antrum is destroyed, intra-cranial complications are liable to
+ensue.
+
+The _clinical features_ are pain behind the ear, tenderness on
+pressure or percussion over the mastoid, redness and oedematous
+swelling of the skin, and, when pus forms under the periosteum, the
+oedema may be so great as to displace the auricle downwards and
+forwards (Fig. 265). The deeper part of the posterior osseous wall of
+the meatus may be swollen so that it conceals the upper and back part
+of the membrane.
+
+[Illustration: FIG. 265.--Acute Mastoid Disease, showing oedema and
+projection of auricle.]
+
+_Treatment._--When arising in connection with acute otitis, the
+application of several leeches behind the ear, free incision of the
+membrane, and syringing with hot boracic lotion may be sufficient. As
+a rule, however, it is necessary to expose the interior of the antrum
+by opening through the mastoid cells--_Schwartze's operation_. When
+mastoid suppuration is associated with chronic middle-ear disease,
+it is usually necessary to perform the complete radical
+operation--_Stacke-Schwartze operation_. The operations are described
+in _Operative Surgery_, p. 98.
+
+
+
+
+CHAPTER XXV
+
+THE NOSE AND NASO-PHARYNX[6]
+
+
+Fracture of nasal bones--Deformities of nose: _Saddle nose_; _Partial
+ and complete destruction of nose_; _Restoration of nose_;
+ _Rhinophyma_--Intra-nasal affections--Examination of the nasal
+ cavities: _Anterior rhinoscopy_; _Posterior rhinoscopy_; _Digital
+ examination_. CARDINAL SYMPTOMS OF NASAL AFFECTIONS: Nasal
+ obstruction: _Erectile swelling of inferior turbinals_; _Nasal
+ polypi_; _Malignant tumours_; _Deviations, spines, and ridges of
+ septum_; _Hæmatoma of septum_--Nasal discharge: _Foreign bodies_;
+ _Rhinoliths_; _Ozæna_; _Epistaxis_; _Suppuration in accessory
+ sinuses_--Anomalies of smell and taste: _Anosmia_;
+ _Parosmia_--Reflex symptoms of nasal origin--Post-nasal
+ obstruction: _Adenoids_--Tumours of naso-pharynx.
+
+[6] Revised by Dr. Logan Turner.
+
+#Fracture of the Nasal Bones and Displacement of the
+Cartilages.#--These injuries are always the result of direct violence,
+such as a blow or a fall against a projecting object, and in spite of
+the fact that the fracture is usually compound through tearing of the
+mucous membrane, infective complications are rare. The fracture
+usually runs transversely across both nasal bones near their lower
+edge, but sometimes it is comminuted and involves also the frontal
+processes of the maxillæ. In nearly all cases the cartilage of the
+septum is bent or displaced so that it bulges into one or other
+nostril, and not infrequently a hæmatoma forms in the septum (p. 573).
+Sometimes the perpendicular plate of the ethmoid is implicated, and
+the fracture in this way comes to involve the base of the skull. The
+nasal ducts may be injured, obstructing the flow of the tears, and a
+lachrymal abscess and fistula may eventually form.
+
+The _clinical features_ are pain, bleeding from the nose,
+discoloration, and swelling. Crepitus can usually be elicited on
+pressing over the nasal bones. The deformity sometimes consists in a
+lateral deviation of the nose, but more frequently in flattening of
+the bridge--_traumatic saddle nose_. Within a few hours of the injury
+the swelling is often so great as to obscure the nature of the
+deformity and to render the diagnosis difficult. Subcutaneous
+emphysema is not a common symptom; when it occurs, it is usually due
+to the patient forcing air into the connective tissue while blowing
+his nose. The lateral cartilages may be separated from the nasal bones
+and give rise to clinical appearances which simulate those of
+fracture. Sometimes the septum is displaced laterally without the bone
+being broken, and this causes symptoms of nasal obstruction.
+
+_Treatment._--As the bones unite rapidly, it is of great importance
+that any displacement should be reduced without delay, and to
+facilitate this a general anæsthetic should be administered, or the
+nasal cavity sprayed with cocain. The bones can usually be levered
+into position with the aid of a pair of dressing forceps passed into
+the nostrils, the blades being protected with rubber tubing. After the
+fragments have been replaced and moulded into position, it is seldom
+necessary to employ any retaining apparatus, but the patient must be
+warned against blowing or otherwise handling the nose. When the septum
+is damaged and the bridge of the nose tends to fall in, rubber tubes
+may be placed in the nostrils to give support, or, if this is not
+sufficient, a soft lead or gutta-percha splint should be moulded over
+the nose, and the splint and the fragments transfixed with one or more
+hare-lip pins. These may be removed on the fourth or fifth day. Rigid
+appliances introduced into the nostrils are to be avoided if possible,
+as they are uncomfortable and interfere with proper cleansing and
+drainage of the nose. The inside of the nose should be smeared with
+vaseline to prevent crusting of blood, and the nasal cavities should
+be frequently irrigated.
+
+#Deformities of the Nose.#--The most common deformity is that known as
+the _sunken-bridge_ or _saddle nose_ (Volume I., p. 174). It is most
+frequently a result of inherited syphilis, the nasal bones being
+imperfectly developed, and the cartilages sinking in so that the tip
+of the nose is turned up and the nostrils look directly forward. The
+bridge of the nose may sink in also as a result of necrosis of the
+nasal bones, particularly in tertiary syphilis, and less frequently
+from tuberculous disease. A similar, but as a rule less marked
+deformity may result from fracture of the nasal bones or from
+displacement of the cartilages.
+
+When the condition is due to mal-union of a fracture, the contour of
+the nose may be restored by operation. A narrow knife is passed in at
+the nostril and the skin freely separated from the bone; the bone is
+then broken into several pieces with necrosis forceps, and the
+fragments moulded into shape. A rubber drainage tube introduced into
+each nostril maintains the contour of the nose till union has taken
+place.
+
+When it results from disease, it is much less amenable to treatment.
+The present-day tendency is to discard the use of subcutaneous
+paraffin injection and to employ grafts of cartilage or bone. An
+artificial bridge has been made by turning down from the forehead a
+flap, including the periosteum and a shaving of the outer table of the
+skull, or by implanting portions of bone or plates of gold, aluminium,
+or celluloid.
+
+Portions of the alæ nasi may be lost from injury, or from lupus,
+syphilis, or rodent cancer. After the destructive process has been
+arrested, the gap may be filled in by a flap taken from the cheek or
+adjacent part of the nose. When the tip of the nose is lost, it may be
+replaced by Syme's operation, which consists in raising flaps from the
+cheeks and bringing them together in the middle line.
+
+The whole of the nose, including the cartilages and bones, may be
+destroyed by syphilitic ulceration or by lupus. In parts of India the
+nose is sometimes cut off maliciously or as a punishment for certain
+crimes.
+
+In reconstructing the nose it is necessary to provide skin, a
+supporting structure in the form of cartilage or bone, and an
+epithelial lining. In the "Indian operation" a racket-shaped flap,
+including skin and periosteum, is turned down from the forehead and
+fixed in position, the edges of the flap being inturned to provide a
+lining for the passage. An implant of free cartilage may be necessary
+to support the skin flaps and to prevent subsequent contraction.
+Flaps of skin may be formed by Gillies' tube-pedicle method from the
+cheek, the forehead, or the neck, and utilised to form the covering of
+the nose. When the deformity cannot be corrected by operation, the
+appearance may be greatly improved by wearing an artificial nose held
+in position by spectacles.
+
+The term #Rhinophyma# has been applied by Hebra to a condition in
+which the skin of the tip and alæ of the nose becomes thick and
+coarse, and presents large, irregular, tuberous masses on which the
+orifices of the sebaceous follicles are unduly evident--_potato_ or
+_hammer nose_ (Fig. 266). The capillaries of the skin are dilated and
+tortuous, and the nose assumes a bluish-red colour, and its surface is
+soft and greasy. The condition is met with in elderly men, and the
+masses appear to be chiefly composed of sebaceous adenomas. The term
+_lipoma nasi_, formerly employed, is therefore misleading.
+
+[Illustration: FIG. 266.--Rhinophyma or Lipoma Nasi in man æt. 65.]
+
+The treatment consists in paring away the protuberant masses until the
+normal size and contour of the nose are restored, care being taken not
+to encroach on the cartilages or on the orifices of the nostrils.
+There is comparatively little bleeding, and the raw surface rapidly
+becomes covered with epidermis.
+
+#Examination of the Nasal Cavities.#--For the examination of the
+interior of the nose the following appliances are necessary: A
+reflector, such as is used in laryngoscopy, attached to a forehead
+band or spectacle frame; one of the various forms of nasal speculum; a
+long, pliable probe; a tongue depressor; and a small-sized mirror. As
+additional aids, a 10 per cent. solution of cocain, a grooved probe as
+a cotton-wool holder, and a palate retractor should be in readiness.
+Good illumination is important, and may be obtained from an electric
+light, or from a Welsbach or Argand burner. The light should be placed
+close to, and on a level with, the patient's left ear. Both the
+anterior and posterior nares should be examined.
+
+_Anterior Rhinoscopy._--Before the introduction of the speculum the
+tip of the nose should be tilted up and the interior of the vestibule
+and the anterior part of the septum examined. In this way the
+existence of eczema or small furuncules, the presence of dilated or
+bleeding vessels upon, or a perforation of, the anterior part of the
+septum may be noted, and the general appearances observed. After
+inserting the speculum into the vestibule and dilating it, the
+following parts should be sought for and examined:--Close to the
+floor, and attached to the outer wall of the nasal cavity, is the
+anterior end of the inferior concha or turbinated body (Fig. 267),
+which overhangs the inferior meatus. It presents a pink appearance,
+and its size varies in different persons. At a higher level and on a
+posterior plane is the anterior end of the middle concha or turbinated
+body, which is of a paler colour than the inferior, and is only
+visible when the head is tilted backwards. Between it and the inferior
+turbinated body is the middle meatus, with which communicate the
+openings of the maxillary sinus, the frontal sinus, and the anterior
+ethmoidal cells. A considerable area of the anterior part of the nasal
+septum is also visible by anterior rhinoscopy, and between it and the
+middle turbinal is a narrow chink--the olfactory sulcus.
+
+[Illustration: FIG. 267.--The outer wall of Left Nasal Chamber, after
+removal of the middle turbinated body. (After Logan Turner.)]
+
+_Posterior Rhinoscopy._--Examination of the posterior nares and
+naso-pharynx is frequently attended with difficulty. The patient is
+directed to breathe through the nose, the tongue is depressed with a
+spatula, and a small-sized laryngeal mirror, comfortably warmed and
+with its reflecting surface turned upwards, is introduced behind the
+soft palate. When a good examination of the naso-pharynx is obtained,
+the following parts may be seen reflected in the mirror: the posterior
+surface of the uvula and soft palate, and above them, in the mesial
+plane, the posterior free edge of the septum nasi; on each side of the
+septum the apertures of the posterior nares, in which may be seen the
+upper part of the posterior end of the inferior turbinal, the middle
+meatus, the posterior end of the middle turbinal, the superior meatus,
+and occasionally a portion of the superior turbinal. On the lateral
+wall of the naso-pharynx the Eustachian opening and cushion can be
+seen, while by tilting the mirror backwards the vault of the
+naso-pharynx can be inspected.
+
+_Digital examination_ of the naso-pharynx may be required, especially
+in children. The examiner passes his left arm and hand round the back
+of the child's head, and with one of his fingers presses the cheek
+inwards, between the jaws. His right forefinger is carried along the
+dorsum of the tongue, passed up behind the soft palate and a rapid
+examination made of the post-nasal space.
+
+CARDINAL SYMPTOMS OF NASAL AFFECTIONS.--The chief symptoms of nasal
+disease are: nasal obstruction, nasal discharge, anomalies of smell
+and taste, and certain reflex phenomena.
+
+#Nasal Obstruction.#--This may be partial or complete, intermittent or
+constant, and may be the cause of such symptoms as alteration in the
+tone of the voice, catarrh of the respiratory passages, snoring,
+cough, headache, inability to concentrate the attention, alteration in
+the physiognomy, or deformity of the chest. The half-open mouth,
+drooping jaw, lengthened appearance of the face, narrow nostrils, and
+vacant expression are characteristic signs of nasal obstruction.
+
+Nasal obstruction may be due to _intra-nasal_ or to _post-nasal_
+(naso-pharyngeal) causes. Amongst the former may be noted as the more
+common, erectile swelling and hypertrophy of the mucous membrane
+covering the inferior turbinated bones, and nasal polypi growing from
+the middle turbinal and middle meatal region. Causes originating in
+the septum include deviations, spines, and ridges, and septal hæmatoma
+and abscess. Obstruction may also be due to the presence of a foreign
+body in the nasal cavity, to a rhinolith, and to imperfect development
+of the nasal chambers. Further, tumours, both simple and malignant,
+and such conditions as tubercle, lupus, syphilis, and glanders may
+interfere more or less with nasal respiration. The most common cause
+of post-nasal obstruction is the presence of adenoids; more rarely
+fibro-mucous polypi, fibrous tumours, malignant disease, and
+cicatricial contractions and adhesions resulting from syphilis are met
+with.
+
+_Erectile swelling_ of the inferior turbinated bodies is due to
+engorgement of the venous spaces contained in the mucous membrane.
+Obstruction from this cause is usually intermittent in character, and
+may be unilateral or bilateral. It is influenced by posture, being
+worse when the patient is in the horizontal position, and also by
+changes in atmospheric conditions and temperature. It is characterised
+objectively by a swelling of the mucous membrane, which is pink or red
+in appearance and of a soft consistence, pitting when touched with the
+probe, and shrinking on the application of a 5 per cent. solution of
+cocain. Its soft consistence and the fact that it becomes smaller when
+painted with cocain differentiate it from true hypertrophy of the
+mucous membrane. Its situation and immobility, its pink colour, and
+the shrinkage under cocain, distinguish it from the mucous polypus of
+the nose. The turgescence may involve the whole extent of the mucosa
+of the inferior turbinated bodies, including their posterior ends.
+After anæsthetising with cocain, the electric cautery, or fused
+chromic acid applied on a probe, may be employed for the relief of the
+condition. If a true hypertrophy exists, it is better to remove it
+with a nasal snare.
+
+_Nasal polypi_ spring from the mucous membrane covering the middle
+turbinated bone and from the adjacent parts of the middle meatus, but
+rarely from the septum. They consist of oedematous masses of mucous
+membrane, and are as a rule multiple. They are usually pedunculated,
+and as they increase in size they become pendulous in the nasal
+cavity. They are smooth, rounded in outline, of a translucent
+bluish-grey colour, soft in consistence, and freely movable. These
+characters, and the fact that the probe can be passed round the
+greater part of the polypus, serve to differentiate this affection
+from the erectile swelling. It must not be forgotten that nasal polypi
+may be associated with suppuration in one or more of the accessory
+sinuses. They are frequently present also in malignant disease, and in
+these cases they bleed readily. They are best removed by means of the
+cold snare, with the aid of the speculum and a good light. Several
+sittings are usually necessary.
+
+_Carcinoma_ and _sarcoma_ sometimes grow from the muco-periosteum in
+the region of the ethmoid. They tend to invade adjacent parts, giving
+rise to hæmorrhage and symptoms of nasal obstruction, and as they
+increase in size they may cause considerable deformity of the face. If
+diagnosed early, an attempt should be made to remove the growth.
+
+_Deviations, spines, and ridges of the septum_ may produce partial or
+complete occlusion of the anterior nares. In deviation of the septum,
+the obstructed nostril is more or less occluded by a smooth rounded
+swelling of cartilaginous or bony hardness, which is covered with
+normal mucous membrane, while the opposite nostril shows a
+corresponding concavity or hollowing of the septum. Sometimes the
+convex side is thickened in the form of a ridge. A simple spine of the
+septum is usually situated anteriorly, and presents an acuminate
+appearance, often pressing against the inferior turbinated body; it is
+hard to the touch. Ridges and spines may be cut or sawn off, or
+removed with the chisel. Many methods of dealing with a deviated
+septum have been suggested, such as forcible fracture or excision of a
+portion of the cartilage. A submucous resection of the deflected
+portion is to be preferred.
+
+_Hæmatoma of the septum_ is usually traumatic in origin. As the result
+of a blow, an extravasation of blood takes place beneath the
+perichondrium on each side of the septum, and a bilateral, symmetrical
+swelling, smooth in outline and covered with mucous membrane, is
+visible immediately within the anterior nares. The blood is usually
+absorbed and should not be interfered with. If suppuration occurs,
+however, the swelling becomes soft, fluctuation can be detected, and
+the patient's discomfort increases. The abscess must then be incised
+and the cavity drained. It is sometimes found that a portion of the
+cartilage undergoes necrosis, leading to perforation of the septum.
+
+#Nasal discharge# may be mucous, muco-purulent, or purulent in
+character. When it is of a clear, watery nature, it is usually
+associated with erectile swelling of the inferior turbinated bodies. A
+purulent discharge may be complained of from one or both nostrils. If
+unilateral, it should suggest, in the case of children, the presence
+of a foreign body; in adults, the possibility of suppuration in one or
+more of the accessory sinuses. In infants, a purulent discharge from
+both nostrils may be due to gonorrhoeal infection or to inherited
+syphilis. Nasal discharge may be constant or intermittent. It is
+sometimes influenced by changes in posture; for example, it may be
+chiefly complained of at the back of the nose and in the throat when
+the patient occupies the horizontal position, or it may flow from the
+nostril when he bends his head forward or to one side. The discharge
+may be intra-nasal in origin, or due altogether to naso-pharyngeal
+catarrh. It varies somewhat in colour and consistence, and may be
+associated with such intra-nasal conditions as purulent rhinitis
+following scarlet fever and other exanthemata or ulceration
+accompanying malignant disease, syphilis, or tuberculosis. Sometimes
+it contains shreds of false membrane, for example in nasal diphtheria;
+or white cheesy masses as in coryza cascosa. The formation of crusts
+is significant of foetid atrophic rhinitis (ozæna) and syphilis, and
+in these conditions the discharge is associated with a most
+objectionable and distinctive foetor. Pus from the maxillary sinus is
+often foetid, and the odour is noticed by the patient; while the odour
+of ozæna is not recognised by the patient, although very obvious to
+others.
+
+#Foreign bodies# of various descriptions have been met with in the
+nasal cavities, particularly of children. They set up suppuration and
+give rise to a unilateral discharge, which is often offensive in
+character. The surgeon must not be satisfied with the history given by
+the parents, but, with the aid of good illumination, and, in young
+children, under general anæsthesia, the nose should be carefully
+inspected and probed. If there is much swelling, the introduction of a
+5 per cent. solution of cocain will facilitate the examination by
+diminishing the congestion of the mucous membrane. No attempt should
+be made to remove a foreign body from the nose by syringing. If fluid
+is injected into the obstructed nostril, it is liable to force the
+body farther back, while, if injected into the free nostril, it is apt
+to accumulate in the naso-pharnyx and to pass into the Eustachian
+tubes. A fine hook should be passed behind the body and traction made
+upon it, or sinus forceps or a snare may be employed. Care must be
+taken that the body is not pushed still deeper into the cavity. Fungi
+and parasites should first be killed with injections of chloroform
+water, or by making the patient inhale chloroform vapour.
+
+#Rhinoliths.#--Concretions having a plug of inspissated mucus or a
+small foreign body as a nucleus sometimes form in the nose. They are
+composed of phosphate and carbonate of lime, and have a covering of
+thickened nasal secretion. They are rough on the surface, dark in
+colour, and usually lie in the inferior meatus. They give rise to the
+same symptoms as a foreign body, and are treated in the same way. The
+stone, which is usually single, may be so large and so hard that it is
+necessary to crush it before it can be removed.
+
+#Ozæna#, or #foetid atrophic rhinitis#, is characterised by atrophy of
+the nasal mucous membrane, and sometimes even of the turbinated bones,
+and is accompanied by a muco-purulent discharge and the formation of
+crusts having a characteristic offensive odour, which is not
+recognised by the patient. It is usually bilateral, and the nasal
+chambers, owing to the atrophy, are very roomy. It may be
+differentiated from a tertiary syphilitic condition by the absence of
+ulceration and necrosis of bone, by the odour, and by the fact that it
+is not influenced by anti-syphilitic treatment.
+
+Various methods of treatment are in vogue, but thorough cleanliness is
+the most essential factor, and this is best secured by regular
+syringing. Plugging of the nostrils with cotton-wool for half an hour
+before washing out the nose greatly facilitates the detachment of the
+crusts. A pint of lukewarm solution containing a teaspoonful of
+bicarbonate of soda or of common salt, is then used with a Higginson's
+syringe, the patient leaning over a basin and breathing in and out
+quickly through the open mouth. The patient should then forcibly blow
+down each nostril in turn, the other being occluded with the finger,
+so that the infective material may thus be blown out without risk of
+it entering the Eustachian tubes, as may happen when the handkerchief
+is used in the ordinary way. Antiseptic sprays, such as peroxide of
+hydrogen, and ointments may be applied to the mucous membrane after
+cleansing.
+
+#Epistaxis.#--Bleeding from the nose may be due either to local or to
+general causes. Among the former may be cited injuries such as result
+from the introduction of foreign bodies, blows on the face, and
+fractures of the anterior fossa of the skull, and the ulceration of
+syphilitic, tuberculous, or malignant disease. Amongst the general
+conditions in which nasal hæmorrhage may occur are typhoid fever,
+anæmia, and purpura cardiac and renal disease, cirrhosis of the liver,
+and whooping-cough. Prolonged oozing of blood may be an evidence of
+hæmophilia. Nasal hæmorrhage usually takes place from one or more
+dilated capillaries situated at the anterior inferior part of the
+septum close to the vestibule, and in such cases the bleeding point is
+readily detected. Occasionally bleeding occurs from one of the
+anterior ethmoidal veins, and under these circumstances the blood
+flows downwards between the middle turbinal and the septum. Before
+steps are taken to arrest the bleeding, the interior of the nose
+should, if possible, be inspected and the bleeding point sought for.
+As a preliminary to the use of local applications, the nose should be
+washed out with boracic lotion or salt solution to remove all clots
+from the cavity. In many cases this is all that is necessary to stop
+the bleeding. If the bleeding is not very copious, it may be stopped
+by grasping the alæ nasi between the finger and thumb, or by spraying
+the nasal cavity with adrenalin. If the blood is evidently flowing
+from the olfactory sulcus, a strip of gauze soaked in adrenalin,
+turpentine, or other styptic should be packed between the septum and
+middle turbinated body. If recurrent hæmorrhage takes place from the
+anterior and lower part of the septum, the application of the electric
+cautery at a dull red heat, or of the chromic acid bead fused on a
+probe, is the best method of treatment. Plugging of the posterior
+nares is rarely necessary, as, in the majority of cases, an anterior
+plug suffices. In bleeders, the administration of sheep serum by the
+mouth has proved efficacious.
+
+#Suppuration in the Accessory Nasal Sinuses.#--As already stated, the
+presence of pus in the nose should always direct attention to its
+possible origin in one or more of the accessory sinuses, especially if
+the discharge is unilateral. The condition is usually a chronic one,
+and may be present for months, or even years, without the patient
+suffering much inconvenience save from the presence of the discharge.
+
+If on examination by anterior rhinoscopy, pus is seen in the middle
+meatus, suspicion should be aroused of its origin in the maxillary
+sinus, frontal sinus, or anterior ethmoidal cells, as all these
+cavities communicate with that channel. If, on the other hand, the pus
+is detected in the olfactory sulcus, attention must be directed to
+the posterior ethmoidal cells and sphenoidal sinus (Fig. 267). Further
+evidence of its source in the last-named cavities may be gained by
+finding pus in the superior meatus above the middle turbinal on
+examination by posterior rhinoscopy.
+
+As the anterior group of sinuses is most frequently affected, and of
+these most commonly the _maxillary sinus_, attention should first be
+turned to this cavity. Pain, tenderness on pressing over the canine
+fossa or on tapping the teeth of the upper jaw, and swelling of the
+cheek are rarely met with save in acute inflammation. The complaint of
+a bad odour or taste, the reappearance of pus in the middle meatus
+after mopping it away and directing the patient to bend his head well
+forwards, and opacity on trans-illumination of the suspected cavity,
+are signs which strongly suggest an affection of the maxillary sinus.
+The withdrawal of pus by a puncture through the thin outer wall of the
+inferior meatus of the nose with a fine trocar and cannula will
+establish the diagnosis.
+
+The _treatment_ consists in opening and draining the sinus. If the
+infection is due to a carious tooth, this should be extracted, the
+socket opened up and drainage established through it in recent cases.
+If the teeth are sound, and the case is of long duration, the sinus is
+opened through the canine fossa and its walls curetted. To avoid the
+risk of reinfecting the cavity from the mouth, an opening may be made
+into the nose by removing a portion of the nasal wall of the sinus and
+part of the inferior turbinated bone, after which the incision in the
+buccal mucous membrane is closed with sutures.
+
+Suppuration in the _frontal sinus_ is attended with frontal headache,
+vertigo, especially on stooping, and tenderness on pressure,
+particularly over the internal orbital angle, or on percussion over
+the frontal region. Pus escapes into the middle meatus of the nose,
+and if wiped away will reappear if the head is kept erect for a few
+minutes. After removal of the anterior end of the middle turbinated
+bone, it may be possible to catheterise the sinus and wash out pus
+from its interior. The diseased sinus may present a darker shadow than
+the healthy one on trans-illumination, or in an X-ray photograph.
+
+The _treatment_ consists in exposing the anterior wall of the sinus,
+chiselling away sufficient bone to admit of free removal of all
+infected tissue, and establishing efficient drainage through the
+infundibulum (Fig. 267) into the nose.
+
+The _anterior ethmoidal cells_ (Fig. 267) are frequently affected in
+conjunction with the frontal, and sometimes with the maxillary sinus.
+The presence of polypi and granulations, with pus oozing out from
+between them, and increasing after withdrawal of the probe, and the
+detection of carious bone are significant of ethmoidal suppuration.
+
+The _treatment_ consists in extending the operation for the frontal or
+maxillary sinus so as to ensure drainage of the ethmoidal cells.
+
+_Suppuration in the sphenoidal sinus_ (Fig. 267) is characterised in
+many cases by the presence of eye symptoms. Pus in the olfactory
+sulcus, on the upper surface of the middle turbinal posteriorly, and
+on the vault of the naso-pharynx, is suggestive of sphenoidal
+suppuration. The removal of the middle turbinated bone permits of
+inspection of the ostium sphenoidale by anterior rhinoscopy, and pus
+may be seen escaping from the orifice. A probe is then passed into the
+ostium, and the anterior wall of the sinus is removed with a curette
+or rongeur forceps.
+
+The _posterior ethmoidal cells_ (Fig. 267) are frequently affected
+along with the sphenoidal sinus. The nasal appearances just noted are
+present, and if the sphenoidal sinus can be washed out and its ostium
+temporarily plugged, and pus rapidly reappears, its origin from these
+cells is probable. The operation for draining the sphenoidal sinus is
+extended by removing the inner wall of the posterior ethmoidal cells.
+
+#Anomalies of Smell and Taste.#--_Anosmia_ or loss of smell and
+impairment or loss of the sense of recognising flavours may follow
+fracture of the anterior fossa attended with injury of the olfactory
+nerves, and is a common sequel of influenza. Any lesion that prevents
+the passage of the odoriferous particles to the olfactory region of
+the nose interferes with the sense of smell. In ozæna also the sense
+of smell is lost. _Parosmia_, or the sensation of a bad odour, may be
+of functional origin; it sometimes occurs after influenza. It may also
+be associated with maxillary suppuration.
+
+#Reflex Symptoms of Nasal Origin.#--It is only necessary here to draw
+attention to the relation that exists between affections of the nose
+and asthma. When present in asthmatic subjects, nasal polypi, erectile
+swelling of the inferior turbinated bodies, spines of the septum in
+contact with the inferior turbinal, or areas on the mucous membrane
+which, when probed, produce coughing, call for treatment with the
+object of modifying the asthma.
+
+#Post-nasal Obstruction--Adenoid Vegetations.#--The most common cause
+of post-nasal obstruction is hypertrophy of the normal lymphoid
+tissue which constitutes the naso-pharyngeal or Luschka's tonsil.
+_Adenoids_ form a soft, velvety mass, which projects from the vault of
+the naso-pharynx and extends down its posterior and lateral walls, in
+some cases filling up the fossæ of Rosenmüller behind the Eustachian
+cushions. They do not grow from the margins of the posterior nares.
+Adenoids are frequently associated with hypertrophy of the faucial
+tonsils, and the patient often suffers from granular pharyngitis and
+chronic nasal catarrh.
+
+These growths are sometimes met with in infants, but are most common
+between the ages of five and fifteen, after which they tend to undergo
+atrophy. They may, however, persist into adult life.
+
+_Clinical Features._--The most prominent symptom in most cases is
+interference with nasal respiration, so that the patient is compelled
+to breathe through the mouth. The facies of adenoids is
+characteristic: the mouth is kept partly open, the face appears
+lengthened, the nose is flattened by the falling in of the alæ nasi,
+the inner angles of the eyes are drawn down, and the eyelids droop,
+while the whole facial expression is dull and stupid. As the
+respiratory difficulty is increased during sleep, the patient snores
+loudly, and his sleep is frequently broken by sudden night terrors.
+Owing to the disturbed sleep, to imperfect oxygenation of the blood,
+and to frequent attacks of nasal and bronchial catarrh, the child's
+nutrition is interfered with, and he becomes languid and backward at
+his lessons.
+
+When the adenoids encroach upon the Eustachian cushions, the patient
+suffers from deafness, frequent attacks of earache, and sometimes from
+suppurative otitis media with a discharge from the ear.
+
+Among the rarer conditions attributed to adenoids are asthma,
+inspiratory laryngeal stridor, persistent cough, chorea, and nocturnal
+enuresis.
+
+A _diagnosis_ should never be made from the symptoms alone; an attempt
+must be made to examine the naso-pharynx by posterior rhinoscopy and
+by digital examination. The interior of the nose must always be
+examined and any further cause of obstruction excluded.
+
+_Treatment._--Thorough removal is the only satisfactory line of
+treatment, and this should be done under general anæsthesia. The
+following instruments are necessary: two Gottstein's adenoid curettes,
+one provided with a cradle and hooks, the other without, a Hartmann's
+lateral ring knife, and one pair of adenoid forceps--Kuhn's or
+Loewenberg's--a tongue depressor, a gag, and one or two throat sponges
+on holders. The patient having been anæsthetised, his head should be
+drawn over the end of the table. An assistant standing on the left
+side inserts the gag and maintains it in position. The operator, being
+on the patient's right, depresses the tongue and insinuates the
+curette provided with the hooks behind the soft palate, carrying it to
+the roof of the naso-pharynx between the growth and the posterior free
+edge of the nasal septum. Firm pressure is then made against the vault
+of the naso-pharynx, and the curette is carried backwards and
+downwards in the mesial plane and withdrawn with the main mass of the
+adenoids caught in the hooks. The unguarded curette is then introduced
+and several strokes are made with it, the instrument being carried on
+either side of the mesial plane. With Hartmann's lateral ring knife
+the posterior naso-pharyngeal wall and fossæ of Rosenmüller are
+curetted. The curette should not be used on the lateral pharyngeal
+wall in case the Eustachian orifices and cushions are damaged.
+Bleeding soon ceases when the head is again elevated, and the patient
+should be at once laid well over upon his side so that the blood may
+escape from the mouth.
+
+No local after-treatment is required, and spraying or syringing may
+prove harmful. The patient should remain in the house for five or six
+days. If nasal obstruction has been the outstanding symptom,
+respiratory exercises through the nose should be carried out for some
+considerable time; on the other hand, if Eustachian obstruction and
+deafness have been the main features of the case, a course of Politzer
+inflation should be conducted after the wound has healed.
+
+#Tumours of the Naso-Pharynx.#--Tumours are occasionally met
+with growing from the muco-periosteum of the basi-sphenoid
+and basi-occipital, and projecting from the vault of the
+naso-pharynx--_naso-pharyngeal tumour_ or retro-pharyngeal polypus.
+This usually occurs between the ages of fifteen and twenty, and while
+it may originally be a fibroma, it tends to assume the characters of a
+fibro-sarcoma and to exhibit malignant tendencies. At first the tumour
+is firm, rounded, and of slow growth, but later it becomes softer,
+more vascular, and grows more rapidly, spreading forwards towards the
+nasal cavity and downwards towards the pharynx.
+
+_Clinical Features._--In its growth the tumour blocks the nostrils,
+and so interferes with nasal respiration and causes the patient to
+snore loudly, especially during sleep. It may also bulge the soft
+palate towards the mouth and interfere with deglutition. In some cases
+the face becomes flattened and expanded and the eyes are pushed
+outwards, giving rise to the deformity known as _frog-face_. Deafness
+may result from obstruction of the Eustachian tube. The patient
+suffers from intense frontal headache, and there is a persistent and
+offensive mucous discharge from the nose. Profuse recurrent bleeding
+from the nose is a common symptom, and the patient becomes profoundly
+anæmic. The tumour can usually be seen on examination with the nasal
+speculum or by posterior rhinoscopy, and its size and limits may be
+recognised by digital examination.
+
+Unless removed by operation these tumours prove fatal from hæmorrhage,
+interference with respiration, or by perforating the base of the skull
+and giving rise to intra-cranial complications.
+
+_Treatment._--These growths are seldom recognised before they have
+attained considerable dimensions, and owing to the fact that they are
+permeated by numerous large, thin-walled venous sinuses, their removal
+is attended with formidable hæmorrhage. Attempts to remove them by the
+galvanic snare are seldom satisfactory, because the base of the tumour
+is left behind and recurrence is liable to take place. The operative
+treatment is described in _Operative Surgery_, p. 153.
+
+
+
+
+CHAPTER XXVI
+
+THE NECK
+
+
+Surgical Anatomy--Malformations: _Cervical auricles_; _Thyreo-glossal
+ cysts and fistulæ_; _Lateral fistula_--Cervical ribs--Wry-neck:
+ _Varieties_; _Cicatricial contraction_--Injuries:
+ _Contusions_--_Fractures of hyoid, larynx, etc._:
+ _Cut-throat_--Infective conditions: _Diffuse cellulitis_;
+ _Actinomycosis_; _Boils and Carbuncles_--Tumours: _Cystic_:
+ _Branchial cysts_; _Cystic lymphangioma_; _Blood cysts_; _Bursal
+ cysts_--_Solid_: _Lipoma_; _Fibroma_; _Osteoma_; _Sarcoma_;
+ _Carcinoma_--The thymus gland--The carotid gland.
+
+#Surgical Anatomy.#--In the middle line the following structures may
+be recognised on palpation: (1) the _hyoid bone_, lying below and
+behind the body of the lower jaw, on a level with the fourth cervical
+vertebra; (2) the _hyo-thyreoid membrane_, behind which lies the base
+of the epiglottis and the upper opening of the larynx; (3) the
+_thyreoid cartilage_, to the angle of which the vocal cords are
+attached about its middle; (4) the _crico-thyreoid_ membrane, across
+which run transversely the crico-thyreoid branches of the superior
+thyreoid arteries; (5) the _cricoid cartilage_, one of the most
+important landmarks in the neck. It lies opposite the disc between the
+fifth and sixth cervical vertebræ, and at this level the common
+carotid artery may be compressed against the _carotid tubercle_ on the
+transverse process of the sixth cervical vertebra. The cricoid also
+marks the junction of the larynx with the trachea, and of the pharynx
+with the oesophagus; at this point there is a constriction in the food
+passage, and foreign bodies are frequently impacted here. At the level
+of the cricoid cartilage the omo-hyoid crosses the carotid artery--a
+point of importance in connection with ligation of that vessel. The
+middle cervical ganglion of the sympathetic lies opposite the level of
+the cricoid. (6) Seven or eight rings of the _trachea_ lie above the
+level of the sternum, but they cannot be palpated individually. The
+_isthmus_ of the thyreoid gland covers the second, third, and fourth
+tracheal rings. As the trachea passes down the neck, it gradually
+recedes from the surface, till at the level of the sternum it lies
+about an inch and a half from the skin. The _thyreoidea ima_
+artery--an inconstant branch of the anonyma (innominate) or of the
+aorta--runs in front of the trachea as far up as the thyreoid isthmus.
+The inferior thyreoid plexus of veins also lies in front of the
+trachea. In the superficial fascia, cross branches between the
+anterior jugular veins cross the middle line.
+
+In children under two years of age the _thymus gland_ may extend for
+some distance into the neck in front of the trachea and carotid
+vessels, under cover of the depressors of the hyoid bone.
+
+_Cervical Fascia._--This fascia completely envelops the neck, and from
+its deep aspect two strong processes--the prevertebral and pretracheal
+layers--pass transversely across the neck, dividing it into three main
+compartments. The posterior or _vertebral compartment_ contains the
+muscles of the back of the neck, the vertebral column and its
+contents, and the prevertebral muscles. This compartment is limited
+above by the base of the skull, and below is continued into the
+posterior mediastinum. The middle or _visceral compartment_ contains
+the pharynx and oesophagus, the larynx and trachea with the thyreoid
+gland, and the carotid sheath and its contents. These different
+structures derive their special fascial coverings from the processes
+that bound this compartment. The middle compartment extends to the
+base of the skull and passes into the anterior mediastinum as far as
+the pericardium. The connective tissue space around the subclavian
+vessels is continued into the axilla. The anterior or _muscular
+compartment_ contains the sterno-mastoid muscle and the depressor
+muscles of the hyoid bone. It extends upwards as far as the hyoid bone
+and base of the mandible, and downwards as far as the sternum and
+clavicle. The arrangement and limits of the different layers of the
+cervical fascia explain the course taken by inflammatory products and
+by new growths in the neck.
+
+#Malformations of the Neck.#--Various congenital deformities result
+from interference with the developmental processes which take place in
+and around the fore-gut. These malformations are associated chiefly
+with imperfect development of the visceral or branchial arches and
+clefts, or of the hypoblastic diverticula from which the thyreoid and
+thymus glands are formed.
+
+The term _cervical auricles_ is applied to small outgrowths, composed
+of skin, connective tissue, and yellow elastic cartilage, found
+usually along the anterior border of the sterno-mastoid. These
+appendages are usually unilateral, and are derived from the second
+visceral arch. Sometimes they are situated near the orifice of a
+lateral fistula. When, on account of their size, or their situation on
+an exposed part of the neck, they give rise to disfigurement, they
+should be removed.
+
+_Thyreo-glossal Cysts and Fistulæ._--The thyreo-glossal _cyst_ is
+developed in relation to the thyreo-glossal tract of His, which in
+early embryonic life extends from the foramen cæcum at the base of the
+tongue to the isthmus of the thyreoid. Those that form in the upper
+part of the tract, in relation to the base of the tongue, have already
+been described (p. 538). Those arising from the lower part form a
+swelling in the middle line of the neck, usually above, but sometimes
+below the hyoid bone. They have to be diagnosed from other forms of
+cyst occurring in the middle line of the neck--sebaceous and dermoid
+cysts--and when giving rise to disfigurement they should be excised.
+
+Such a cyst may rupture on the surface, usually as a result of
+superadded infection, and give rise to a _thyreo-glossal_ or _median
+fistula of the neck_. As a rule the external opening of the fistula is
+above the hyoid bone, only the upper part of the duct having remained
+pervious. When the whole length of the duct has persisted, the fistula
+extends from the skin to the foramen cæcum, passing usually in front
+of, but sometimes through the substance of, the hyoid bone.
+Occasionally the fistula only extends as high as the hyoid.
+
+[Illustration: FIG. 268.--Congenital Branchial Cyst in a woman æt. 33.
+
+(Microscopically the cyst was lined with squamous epithelium and the
+wall contained rudimentary salivary-gland tissue.)]
+
+The part of the tract near the tongue is lined by squamous
+epithelium; the lower part by columnar epithelium, which, below the
+level of the hyoid, is usually ciliated. Lymphoid tissue and mucous
+glands are found in its wall.
+
+The _treatment_ consists in excising the duct and the connections, and
+it is usually necessary to resect the central portion of the hyoid
+bone to ensure complete removal.
+
+The _lateral fistula of the neck_--formerly described as a branchial
+fistula--according to Weglowski, usually takes origin from the remains
+of the hypoblastic diverticulum, which arises from the pharyngeal part
+of the third visceral cleft and extends downwards to form the thymus
+gland. The internal opening is situated in the lateral wall of the
+pharynx in the region of the posterior palatine arch close to the
+tonsil, and the fistula passes out above the hypoglossal nerve, and
+runs downwards and laterally between the carotids and along the medial
+border of the sterno-mastoid muscle. When the fistula is complete, the
+external opening is situated a short distance above the
+sterno-clavicular joint. As the lower part of the thymus canal most
+often persists, an incomplete external fistula is the form most
+frequently met with. It is lined with ciliated columnar epithelium.
+
+The fistula may be present at birth, or may result from the rupture of
+a cystic swelling, which has become infected. Clear viscous fluid
+exudes from it, and, when the fistula is complete and the lumen
+sufficiently wide, particles of food may escape. As the track is
+tortuous, it is seldom possible to pass a probe along it, but its
+extent and course may be recognised by injecting an emulsion of
+bismuth and taking an X-ray photograph.
+
+The _treatment_ consists in excising the fistula in its whole length,
+but, owing to its long and tortuous course, and its relations to
+important structures, the operation is a tedious and difficult one.
+Less radical measures, such as scraping with the sharp spoon,
+cauterising, or packing, are seldom successful.
+
+#Cervical Ribs.#--Supernumerary ribs are not infrequently met with in
+connection with the seventh cervical vertebra, and in the majority of
+cases the condition is bilateral. The extra rib may be thin and
+pointed, and project straight out from the transverse process
+terminating in a free end, in which case, as it passes above the
+subclavian artery and the brachial plexus, it gives rise to no
+trouble. In other cases it arches downwards and forwards, and is
+attached by dense fibrous tissue to the first thoracic rib about the
+level of the scalene tubercle, or to the sternum by cartilage like an
+ordinary rib. When it encroaches upon the posterior triangle the
+scalene muscles are attached to it, and the subclavian artery and the
+lower trunk and medial cord of the brachial plexus pass over it in a
+groove behind the scalenus anterior. The pleura may reach as high as
+the medial border of the rib.
+
+_Clinical Features._--The condition, which is more common in women
+than in men, is seldom recognised before the age of twenty, and is
+often discovered accidentally, for example after some emaciating
+illness, or by a tight collar causing pain. The diagnosis is
+established by the X-rays.
+
+[Illustration: FIG. 269.--Bilateral Cervical Ribs; the left one is the
+better developed.]
+
+When symptoms arise, they may be referable either to pressure on the
+artery or on the nerve roots. When the subclavian artery is displaced
+upwards it may be recognisable as a prominent pulsatile swelling, and
+as the part of the vessel distal to the rib is sometimes dilated and
+yields a systolic bruit, it may simulate an aneurysm (Sir William
+Turner). The pulse beyond is weakened while the arm hangs by the side,
+but may be restored by raising the hand above the head. Gangrene of
+the tips of the fingers has been observed in rare instances, but it is
+probably nervous rather than vascular in origin.
+
+Symptoms referable to pressure on the nerve roots usually affect the
+right arm, and may be either neuralgic or paralytic in character (Wm.
+Thorburn). In the neuralgic group there is tingling pain, a feeling of
+numbness, and sensations of cold in the limb, most marked along the
+ulnar border of the forearm; the arm is weak, and susceptible to cold.
+This condition may be mistaken for brachial neuritis; it is relieved,
+however, by holding the arm above the head, for example, during sleep.
+
+In the paralytic group, the pressure symptoms are referred to the
+first dorsal, or first dorsal and eighth cervical roots. The paralysis
+is most marked in the muscles of the thumb, and becomes less towards
+the ulnar side; the affected muscles atrophy, especially those forming
+the thenar eminence, and the finer movements of the thumb and fingers
+are impaired.
+
+When pressure symptoms are present, the extra rib should be removed
+through an incision which exposes the posterior triangle sufficiently
+to admit of the bone and its periosteum being excised, without damage
+being inflicted on the brachial plexus, the subclavian artery, or the
+pleura.
+
+Similar clinical features to those of cervical rib may be caused by a
+prominent transverse process of the first thoracic vertebra and
+similarly got rid of by its removal.
+
+_Branchial cysts and branchial tumours_ are described with tumours of
+the neck (p. 598).
+
+WRY-NECK OR TORTICOLLIS.--The term wry-neck or torticollis is applied
+to a condition in which the head assumes an abnormal attitude, which
+is usually one of combined lateral flexion and rotation.
+
+The most important form is due to faulty action of the cervical
+muscles, and three varieties of muscular wry-neck are recognised--(1)
+the acute or transient; (2) the chronic or permanent; and (3) the
+spasmodic.
+
+#Acute# or #transient wry-neck#--so-called "rheumatic
+torticollis"--comes on suddenly, usually after the patient has been
+exposed to a draught of cold air or to damp. The condition is
+popularly known as "stiff neck," and is probably associated with
+fibrositis of the affected muscles. The sterno-mastoid, and often the
+trapezius, are contracted, and pull the head to one side, twisting
+the face slightly towards the opposite side (Fig. 270). There is
+tenderness on pressing over the affected muscles, and sometimes over
+the vertebral spines, and in the lines of the cervical nerves, and
+severe pain on attempting to move the head. Usually in the course of a
+few days the condition passes off as suddenly as it came on, but in
+some cases a certain amount of wasting of the affected muscles ensues.
+
+[Illustration: FIG. 270.--Transient Wry-neck, which came on suddenly
+after sitting in a draught, and passed off completely in a few days.]
+
+In the _diagnosis_ of this form of wry-neck it is necessary to exclude
+such conditions as cellulitis, inflammation of the cervical glands,
+and disease of the cervical spine, in which the head may assume an
+abnormal attitude, the position being that which gives the patient
+greatest comfort.
+
+The _treatment_ consists in ensuring free action of the bowels and
+kidneys, in inducing hyperæmia by means of heat, and applying gentle
+massage. Salicylates and similar drugs are useful in relieving the
+pain.
+
+#Permanent# or #true wry-neck# is due to an organic shortening of the
+sterno-mastoid muscle. The trapezius, the splenius, the scaleni, and
+the levator scapulæ muscle may also undergo shortening, along with
+their investing sheaths derived from the cervical fascia.
+
+The sternal head of the sterno-mastoid is always markedly shortened,
+and stands out as a tight cord; sometimes the clavicular head is also
+prominent.
+
+There is evidence that in the majority of cases the deformity results
+from some interference with the development of the muscles during
+intra-uterine life. This is probably the effect of undue pressure on
+the foetus diminishing the arterial supply to the central part of the
+muscle, with the result that the muscle fibres undergo degeneration
+with subsequent sclerosis and contraction. It may result also from
+cicatricial contraction of the muscle following rupture of its fibres
+during delivery. In such cases there is a history that the birth was a
+difficult one, the presentation having been abnormal; and that a
+swelling was observed in the sterno-mastoid shortly after birth. This
+swelling--_a hæmatoma of the sterno-mastoid_--is at first soft, later
+becomes smaller, and eventually disappears. In course of time,
+sometimes months, sometimes years after the disappearance of the
+swelling, shortening of the muscle takes place, and the deformity is
+established.
+
+_Clinical Features._--Although the condition is usually described as
+"congenital," it is the common experience in practice that the child
+has reached the age of from seven to ten years before advice is
+sought. The appearance of the patient is characteristic (Fig. 271).
+The shortening of the sterno-mastoid pulls the head towards the
+affected side, usually the right, so that the ear is approximated to
+the shoulder. At the same time the head is rotated towards the
+opposite side and slightly tilted backwards, with the result that the
+chin is directed towards the opposite side, and is somewhat raised.
+The shortened sterno-mastoid stands out prominently, and, on any
+attempt to straighten the head, can be felt as a firm, fibrous band.
+The skin of the affected side of the neck may be thrown into
+transverse folds. The patient is unable to correct the deformity, but
+it is usually possible to diminish it by manipulation.
+
+[Illustration: FIG. 271.--Congenital Wry-neck in a boy æt. 14.]
+
+If the condition is not corrected, all the structures on the affected
+side of the neck undergo organic shortening, with the result that the
+deformity becomes accentuated. In advanced cases a lateral curvature,
+with the convexity towards the normal side, occurs in the cervical
+region, the vertebræ becoming wedge-shaped from side to side, and a
+compensatory curve may develop in the thoracic region (Fig. 272).
+
+[Illustration: FIG. 272.--Congenital Wry-neck seen from behind to show
+scoliosis.]
+
+There is also asymmetry of the head and face, the affected side being
+the smaller. The eye on this side lies on a lower level, and is more
+oblique than its neighbour, the cheek is flattened, and the mouth
+asymmetrical. Instead of the eyebrows and the lips forming parallel
+lines, their axes converge towards the side of the contracted muscles
+and fasciæ.
+
+_Treatment._--While it may be possible when the condition is
+recognised during infancy to counteract the tendency to contraction
+and deformity by manipulations, massage, and exercises alone, it is
+usually necessary to divide the shortened structures as a preliminary
+to orthopædic measures.
+
+Subcutaneous tenotomy--at one time the favourite method of
+treatment--has been entirely replaced by the _open operation_, which
+admits of all the structures at fault, including the cervical fascia,
+being thoroughly divided, without risk of injuring other structures in
+the neck. The result of division of the shortened tissues is
+seen at once in a marked increase in the interval between the
+sterno-clavicular joint and the mastoid process. As in other
+deformities, the operation is only a preliminary, although an
+essential one, to the treatment by massage, movement, and exercises
+which must be persevered with for months, and it may be for years.
+When the torticollis attitude has been corrected in childhood, the
+asymmetry of the skull disappears.
+
+#Spasmodic wry-neck# is the term applied to a condition in which
+clonic contractions of certain muscles produce jerkings of the head.
+The muscles most frequently at fault are the sterno-mastoid and
+trapezius of one side, and the posterior rotators of the opposite
+side. By these muscles the head is pulled into the wry-neck position,
+and is at the same time retracted, and there is more or less constant
+nodding or jerking of the head.
+
+The condition is usually met with in adults of a neurotic disposition
+who are in a depressed state of health, and is due to some lesion, as
+yet undiscovered, in the nerve mechanism of the affected muscles--most
+probably in their cortical centres. It would appear that in some cases
+the spasmodic jerkings are originated by certain movements habitually
+made by the patient in the course of his work. In others, as a result
+of astigmatism and other errors of refraction, the patient has
+acquired the habit of repeatedly tilting his head to enable him to see
+clearly, and these movements have become continuous and
+uncontrollable.
+
+The affection tends to become progressively worse until the patient is
+incapacitated for work or enjoyment. Sleep even may be interfered
+with.
+
+_Treatment._--In well-marked cases the use of drugs, electricity, or
+restraining apparatus is never curative, but these measures combined
+with massage have been temporarily beneficial in milder cases.
+
+Of the operative procedures, resection of portions of the accessory
+nerve on one side, and of the posterior primary divisions of the first
+five cervical nerves on the opposite side, seems to offer the best
+prospect of recovery. Simple division of these nerves or resection of
+the accessory alone has not proved permanently curative. Open division
+of the offending muscles without interfering with the nerves has given
+good results, and is a much simpler operation (Kocher).
+
+Spasmodic wry-neck must be distinguished from the #hysterical#
+variety, which after lasting for weeks, or even months, may pass off
+completely, but, like other hysterical affections, is liable to recur.
+
+Deviations of the neck simulating torticollis may occur in cervical
+caries, and in unilateral dislocation of the spine.
+
+The #cicatricial contraction# of the integument of the neck that
+results from extensive burns, abscesses, or ulcers, may cause
+unsightly deformity and fixation of the head in an abnormal attitude,
+and call for surgical treatment. The contraction which follows the
+disappearance of a gumma of the sterno-mastoid may also produce a
+deformity resembling wry-neck.
+
+
+INJURIES
+
+#Contusion# of the neck may result from a blow or crush, as, for
+example, the passage of a wheel over the neck, or from throttling,
+strangling, or hanging. In medico-legal cases the distribution of the
+discoloration should be carefully noted. When due to throttling, the
+marks of the fingers may be recognisable, and nail-prints may be
+present. In cases of strangling, the mark of the cord passes straight
+round the neck, while in suicidal hanging it is more or less oblique
+and is higher behind than in front. When due to a direct blow, for
+example by a fist, the discoloration is limited, while it is usually
+diffused over the neck when due to the passage of a wheel over the
+part.
+
+The clinical importance of these injuries depends on the complications
+that may ensue; for example, extravasation of blood under the
+cervical fascia may press upon the air-passage and oesophagus to such
+an extent as to cause interference with breathing and swallowing; the
+larynx or the trachea may be so grossly damaged that death results
+immediately from suffocation, or later from gradually increasing
+oedema causing obstruction of the glottis. If the mucous membrane of
+the air-passage or the apex of the lung and its investing pleura is
+torn, emphysema of the connective tissue may develop and spread widely
+over the body. In contusions of the lower part of the neck the cords
+of the brachial plexus may be injured.
+
+#Fractures of the Hyoid, Larynx, and Trachea.#--The _hyoid bone_, on
+account of its mobility and the protection it receives from the body
+of the mandible, is seldom fractured, except in old people in whom the
+great cornu has become ossified to the body of the bone. It is usually
+broken either by a direct blow, or by transverse pressure as in
+garrotting. The fracture is almost always at the junction of the great
+cornu with the body, and there is marked displacement of the
+fragments, which may injure the pharyngeal mucous membrane.
+
+The _thyreoid and cricoid cartilages_ are also liable to be fractured
+in run-over accidents, particularly in old people after calcification
+or ossification has taken place.
+
+The _trachea_ may be lacerated, or even completely torn from the
+larynx, by the same forms of injury as produce fracture of the
+laryngeal cartilages.
+
+The _clinical features_ common to all these injuries are swelling and
+discoloration; and if the mucous membrane is torn, air may escape into
+the tissues and produce emphysema. There is always more or less
+difficulty in breathing, which may amount to actual suffocation, and
+this may come on immediately, or in the course of a few hours from
+oedema of the glottis. Blood may pass into the lungs and be coughed
+up. Swallowing is usually difficult and painful, especially in
+fracture of the hyoid bone. There is also pain on speaking, the voice
+is husky and indistinct, and spasmodic coughing is common. When blood
+has entered the air-passages there is considerable risk of septic
+pneumonia.
+
+_Treatment._--As the immediate risk to life is from suffocation, it is
+usually necessary to perform tracheotomy at once. In fracture of the
+hyoid the fragments may be replaced by manipulation through the mouth,
+after which the head and neck are immobilised by a poroplastic collar.
+
+#Wounds--Cut-throat.#--The most important variety of wound of the neck
+met with in civil practice is that known as "cut-throat"--an injury
+usually inflicted with suicidal, less frequently with homicidal
+intent.
+
+Suicidal wounds are usually directed from left to right (if the
+patient is right-handed), and they run more or less obliquely from
+below upwards across the neck; the wound being deepest towards its
+left end, that is where the weapon enters, and gradually tailing off
+towards the right. In most cases the would-be suicide throws his head
+so far back at the moment of inflicting the wound, that the main
+vessels are carried backward under cover of the tense sterno-mastoid
+muscles, and so escape injury. The knife may even reach the vertebral
+column without damaging the contents of the carotid sheath.
+
+Homicidal wounds are usually more directly transverse, and are of
+equal depth throughout. The main vessels are generally divided, the
+oesophagus and trachea opened into, and in some cases the vertebral
+canal is opened and the cord and its membranes injured.
+
+_Clinical Features._--The clinical features vary with the level of the
+wound and with its depth. In all cases the contraction of the platysma
+causes the wound to gape widely, and its edges tend to be turned in.
+
+In a large proportion of suicidal attempts the patient only succeeds
+in inflicting one or more comparatively superficial wounds across the
+front of the neck. In many cases the hæmorrhage from these is
+trifling, but if the external jugular and other large superficial
+veins are divided, it may be fairly profuse, although it is seldom
+immediately fatal, unless the blood is sucked in to the wounded
+air-passage.
+
+Occasionally, but rarely, the wound is made _above the hyoid bone_,
+and opens directly into the mouth. There may then be sharp hæmorrhage
+from the base of the tongue or from the lingual and external maxillary
+(facial) arteries or their branches in the submaxillary region, and
+asphyxia may result from the base of the tongue and the epiglottis
+falling back and obstructing the larynx.
+
+The _hyo-thyreoid membrane_ is frequently divided, and the pharynx
+thus opened. As the depressor muscles of the hyoid are divided, there
+is interference with deglutition and phonation, but respiration is not
+affected. In such cases the upper portion of the epiglottis is often
+cut off, and the base of the tongue, the tonsil or the soft palate may
+be injured. The lingual, external maxillary and superior thyreoid
+arteries, and the hypoglossal nerve are also liable to be divided at
+this level, but the main vessels of the neck usually escape. There is
+pain and difficulty in swallowing, and food and saliva tend to escape
+through the wound. Particles of food may pass into the air-passages
+and cause violent fits of coughing.
+
+In more severe cases the knife enters the _larynx_ or the _trachea_.
+Sometimes the thyreoid cartilage is divided--as a rule only
+partly--and the vocal cords are injured; in other cases the trachea is
+opened, or it may be completely cut across. The bleeding is serious,
+as the superior thyreoid arteries are usually damaged. If the common
+carotid and the internal jugular vein also are wounded, the hæmorrhage
+usually proves fatal. The fatal issue may be contributed to by blood
+entering the air-passages and causing asphyxia, or by air being sucked
+into the open veins and causing air embolism. The laryngeal branches
+of the vagus may be divided and paralysis of the larynx ensue.
+
+In all cases there is more or less dyspnoea and persistent coughing.
+The voice is husky, and the patient can only express himself in a
+hoarse whisper. There is difficulty in swallowing, and the food may
+enter the trachea. When the external wound is small, there may be a
+considerable degree of emphysema of the cellular tissue.
+
+The _prognosis_ depends largely on the general condition of the
+patient. The majority of those who attempt to take their own lives are
+in a low state of health from alcoholic excess, mental worry,
+privation or other causes, and many succumb even when the wound in the
+neck is comparatively slight. Shock, loss of blood, asphyxia from
+blood entering the air-passages, and oedema of the glottis are the
+most frequent causes of death soon after the injury. Cellulitis,
+inhalation, pneumonia, and delirium tremens are later complications
+that may prove fatal.
+
+_Treatment._--The first indication is to arrest hæmorrhage, and this
+may be done by applying digital compression over the bleeding points.
+The bleeding vessels are then sought for and ligated, the wound being
+enlarged if necessary.
+
+If the food and air-passages are intact, any muscles that have been
+divided should be sutured.
+
+When the epiglottis is cut across in wounds opening into the pharynx,
+it should be united, preferably with fine silk sutures, as catgut is
+absorbed before healing has time to take place. The wall of the
+pharynx and the muscles should then be sutured layer by layer.
+
+When the air-passage is opened, it is usually advisable to introduce a
+tracheotomy tube (Fig. 273), and pack gauze round it to avoid the
+risk of oedema of the glottis and to prevent blood entering the lungs.
+The soft tissues may then be brought together layer by layer.
+
+[Illustration: FIG. 273.--Recovery from Suicidal Cut-throat after low
+tracheotomy and gastrostomy.
+
+(Mr. J. M. Graham's case.)]
+
+In all cases the superficial part of the wound should be drained, and
+in applying the bandage the head should be flexed on the chest to take
+all tension off the stitches. The patient must be kept under constant
+supervision lest he should interfere with the dressings, or make a
+further attempt on his life. In some cases it is necessary to feed him
+through a tube passed into the stomach either through the mouth or
+through the nose; when this is not feasible, nourishment must be given
+by the rectum, or by a gastrostomy tube (Fig. 273).
+
+_Wounds of the thoracic duct_ have been described with affections of
+the lymphatics (Volume I., p. 324), and _wounds of the brachial
+plexus_ with injuries of individual nerves (Volume I., p. 360).
+
+
+INFECTIVE CONDITIONS
+
+#Cellulitis# may occur in any of the cellular planes in the neck, the
+most important form being that which occurs under the cervical fascia,
+for example in the course of acute infective diseases, such as scarlet
+fever, measles, or pyæmia. The pus tends to spread widely throughout
+the neck, infiltrating the connective-tissue spaces around the blood
+vessels, the air-passages, and the oesophagus. The density and tension
+of the cervical fascia cause the pus to burrow downwards towards the
+mediastinal spaces of the thorax, where it may give rise to such
+complications as empyema, infective pericarditis, or gangrene of the
+lung. The pus may also reach the axilla by spread of the infection
+along the subclavian vessels.
+
+An acute phlegmonous peri-adenitis sometimes occurs in the loose
+cellular tissue around the submaxillary gland, and spreads with great
+rapidity through the cellular planes of the neck. The condition--which
+goes by the name of _angina Ludovici_--is usually met with in adults,
+and appears to originate in some infective focus in the mouth.
+
+_Clinical Features._--In all forms the process spreads rapidly, and
+the neck becomes swollen, brawny, and of a dusky red colour. The head
+is flexed towards the affected side, and there is pain on movement and
+on palpating the swelling. Pus forms early, but, as it is under great
+tension, fluctuation can seldom be detected. Respiration may be
+interfered with by pressure on the air-passages, or by the onset of
+oedema of the glottis, and tracheotomy may be urgently called for.
+Swallowing may also be affected by pressure on the pharynx and
+oesophagus. Pressure on the important nerves traversing the neck may
+give rise to irritative or paralytic symptoms. The main vessels may
+become thrombosed or eroded--particularly when the cellulitis is
+associated with scarlet fever--and in the latter case copious
+hæmorrhage may follow incision of the abscess.
+
+There is always marked constitutional disturbance, as evidenced by
+rigors, high temperature, a small, rapid pulse, and delirium; and
+death may result within a few days from toxæmia.
+
+_Treatment._--In the earliest stages hot fomentations or ichthyol and
+glycerine should be applied, but if the process does not begin to
+abate within twenty-four hours, and if the swelling becomes brawny in
+character, one or more incisions should be made through the deep
+fascia where the signs of inflammation are most intense, and the
+deeper planes of the neck opened up by dissection. Drainage is secured
+by tubes or strips of rubber tissue. If profuse hæmorrhage occurs it
+may be necessary to ligate the main artery lower in the neck.
+
+#Actinomycosis# manifests itself in the neck as a diffuse, painless
+swelling, which slowly infiltrates the superficial structures,
+becoming brawny at some places, and at others breaking down and
+forming sinuses from which the ray fungus escapes in the discharge.
+
+#Boils and carbuncles# frequently occur on the back of the neck, where
+the skin is thick and coarse and is rubbed by the collar.
+
+The affections of the _cervical lymph glands_ have already been
+described (Volume I., p. 330).
+
+
+TUMOURS
+
+#Cystic Tumours.#--A great variety of cystic tumours is met with in
+the neck.
+
+#Branchial cysts# are formed by the distension of an isolated and
+unobliterated portion of one of the branchial clefts. They usually
+form in connection with the third cleft, and are met with in the
+region of the great cornu of the hyoid bone, to which the wall of the
+cyst is almost always attached. Less frequently they take origin in
+the second cleft, and lie below the mastoid process, in which case the
+cyst is adherent either to the mastoid or to the styloid process. In
+some cases these cysts project towards the floor of the mouth. When
+near the skin they are of the nature of _dermoid cysts_, being lined
+with squamous epithelium and filled with sebaceous material. When
+deeply placed, they are lined by cylindrical or ciliated epithelium
+and contain a glairy mucoid fluid.
+
+Although of congenital origin, these cysts do not usually attract
+attention till about the age of puberty, when they are noticed as
+small, soft, fluctuating tumours over which the skin moves freely.
+They grow slowly, but may attain great dimensions. The only treatment
+that yields satisfactory results is complete excision.
+
+The _cystic lymphangioma_, _hygroma_, or _hydrocele of the neck_ (Fig.
+274), has been described with affections of lymphatics (Volume I., p.
+327); and _thyreo-glossal cysts in the neck_ at p. 583.
+
+[Illustration: FIG. 274.--Hygroma of Neck.
+
+(Photograph lent by Mr. J. W. Dowden.)]
+
+_Blood Cysts._--These may originate in a diverticulum of a vein that
+has become isolated, or in a cavernous angioma; or they may be due to
+hæmorrhage taking place into a branchial or thyreo-glossal cyst. The
+diagnosis is often only possible by exploratory puncture; and the
+treatment consists in complete excision.
+
+_Cystic Bursæ._--Cystic degeneration may occur in the supra-hyoid and
+thyreo-hyoid bursæ, and give rise to a rounded swelling which moves
+with the thyreoid on swallowing, and is only troublesome from the
+disfigurement it causes. It is treated by excision.
+
+#Solid Tumours#, apart from the common enlargements of lymph glands,
+and the various forms of goitre, are not often met with in the neck.
+
+The _circumscribed lipoma_ usually occurs over the nape of the neck or
+in the supra-clavicular region. It may attain considerable size, and
+from its weight become pedunculated and hang down over the back or
+shoulder.
+
+_Diffuse lipomatosis_ usually begins over the nape and spreads more or
+less symmetrically till it completely surrounds the neck. As the
+new-formed fat is not encapsulated, extirpation of the mass is
+difficult and is seldom called for.
+
+[Illustration: FIG. 275.--Lympho-sarcoma of Neck.
+
+(Mr. D. M. Greig's case.)]
+
+_Fibroma_ originating in the ligamentum nuchæ, or the periosteum of
+the vertebral processes, is of slow growth, but it may attain
+considerable size, and on account of its deep attachments the
+operation for its removal may be difficult.
+
+_Mixed tumours_ like that described as occurring in the vicinity of
+the parotid, and taking origin from branchial rests, are sometimes met
+with in the upper part of the anterior triangle.
+
+_Osseous_ and _cartilaginous tumours_ occasionally grow in connection
+with the transverse processes of the lower cervical vertebræ.
+
+_Sarcoma_ and _fibro-sarcoma_ of the slowly growing type may develop
+from any of the fascial structures in the neck, or from the connective
+tissue surrounding the blood vessels. In those taking origin beneath
+the sterno-mastoid, there is difficulty in removing them completely on
+account of their deep attachments, and when they are found to
+infiltrate the surrounding tissues the attempt should be abandoned.
+This rule may be relaxed in view of the aid that may be afforded by
+the insertion of a tube of radium, which is capable of rendering inert
+such portions of the growth as are not capable of being removed.
+Sacrifice of the common carotid artery is attended with the risk of
+hemiplegia and cerebral softening, especially in persons over fifty;
+resection of a portion of the vagus is less dangerous to life than
+stimulation by irritation of its fibres; resection of the internal
+jugular vein and of the cervical sympathetic cord are factors which
+add to the shock of the operation but do not carry with them any
+special risk.
+
+_Carcinoma._--The commonest form of primary cancer is the _branchial
+carcinoma_, a squamous epithelioma which originates in connection with
+the second visceral cleft (Fig. 276). It appears as a rule under the
+sterno-mastoid at the level of the hyoid bone, and extends towards the
+submaxillary region, infiltrating the muscles and the sheath of the
+vessels.
+
+[Illustration: FIG. 276.--Branchial Carcinoma--subsequently removed by
+operation.]
+
+It is more common in men than in women, and there is often a history
+of a small swelling having been present for many years, or even since
+birth. About middle life more active growth begins, the swelling
+becomes more fixed and is painful, and once it begins to grow, it
+increases rapidly and within a month or two may reach the size of a
+child's head. In spite of its size, however, it seldom causes
+interference with breathing or swallowing, and it has comparatively
+little effect on the general health. Clinically, the induration and
+fixation of the tumour suggest its epitheliomatous character, but the
+absence of a primary growth in the mouth or pharynx excludes its being
+a metastasis in the lymph glands.
+
+Unless completely removed at an early stage, recurrence inevitably
+takes place.
+
+Primary carcinoma may also occur in a supernumerary thyreoid, and in
+the para-thyreoid glands.
+
+We have met with a case of _paraffin epithelioma_ on the neck, and a
+similar type of epithelioma may be met with in a lupus or a burn of
+long standing.
+
+#The Thymus Gland.#--The thymus gland begins to diminish in size
+towards the end of the second year, and by the time puberty is reached
+it has entirely disappeared. In some cases, however, the process of
+involution fails to take place, and the gland may even undergo
+hyperplasia and exert pressure on the trachea, the great blood
+vessels, or the left vagus nerve and its recurrent branch. The
+enlargement of the thymus may be part of a general lymphatic
+hyperplasia--known as the _status lymphaticus_.
+
+The pressure effects may be entirely referable to the trachea--_thymus
+stenosis of the trachea_--giving rise to progressive dyspnoea
+accompanied by stridor, with paroxysmal exacerbations during which the
+child becomes asphyxiated. It is only expiration that is interfered
+with, as with each inspiratory effort the gland is sucked in towards
+the mediastinum and so frees the air-passages, while with expiration
+it rises again, and, becoming jammed in the upper opening of the
+thorax, exerts pressure on the trachea, and during expiration a soft
+swelling is sometimes recognisable in the episternal notch. The
+paroxysms occur at irregular intervals, and any one of them may prove
+fatal. In some cases the symptoms seem to be associated with pressure
+on the blood vessels and nerves rather than on the air-passages, and
+in these there is distension of the veins and a tendency to syncopal
+attacks.
+
+The only way to afford relief is to expose the gland and withdraw it
+from behind the sternum by making traction on its capsule. If the
+breathing is not thereby improved, the capsule should be opened and
+the gland shelled out.
+
+The term _thymic asthma_ has been applied to another form of disturbed
+respiration due to a large thymus, which comes on suddenly in infants
+otherwise apparently healthy. Without warning, the child seems to
+choke, has great difficulty in breathing, with inspiratory stridor and
+indrawing of the epigastrium; he rapidly becomes cyanosed, and in the
+majority of cases dies in a few minutes--_thymus death_. No
+satisfactory explanation of the sudden onset of the symptoms is
+forthcoming, but it appears to be associated with something which
+suddenly narrows the mediastinal space, such as backward bending of
+the head, or venous engorgement of the thymus gland. Cases are
+recorded in which an attack has come on during the administration of a
+general anæsthetic; in some instances the patient has suffered from
+the generalised status lymphaticus.
+
+#Tumours of the Carotid Gland or Glomus Carotica# (_Potato-like tumour
+of the neck_).--The carotid gland under normal conditions is about the
+size of a grain of corn, and lies to the posterior aspect of the
+bifurcation of the carotid. It is sometimes the seat of
+_endothelioma_. The tumour has a definite capsule, is moderately firm
+and elastic, increases in size slowly and gradually for a time, and
+then may grow more rapidly. Its relation to the vessels is
+characteristic: as it grows it envelops the common carotid and its
+branches, and becomes adherent to the internal jugular vein; and it
+may come to implicate the nerves in the neck, particularly the vagus
+and its recurrent branch, and the cervical sympathetic.
+
+It gives rise to few symptoms, and in the majority of cases the
+surgeon is consulted on account of the disfigurement resulting from
+the presence of the swelling in the neck. This swelling is ovoid,
+smooth or slightly lobulated; it lies at the level of the bifurcation
+of the carotid, and tends to grow upwards rather than downwards; it is
+movable from side to side, but not up and down; it lies under the
+sterno-mastoid, and the skin is not implicated. There is transmitted
+pulsation in the tumour, but no expansion.
+
+The diagnosis has to be made from lymphoma, adenoma, tuberculous
+glands, sarcoma, and carcinoma.
+
+In a large proportion of the cases operated upon it has been necessary
+to ligate the carotids and to excise portions of the internal jugular
+vein, and as severe cerebral symptoms are liable to ensue the
+mortality has hitherto been high. Operation is therefore only to be
+recommended when the growth is rapid, or the symptoms have become
+urgent.
+
+
+
+
+CHAPTER XXVII
+
+THE THYREOID GLAND
+
+
+Surgical Anatomy--Physiological hyperæmia--Acute
+ thyreoiditis--GOITRE--Varieties: _Parenchymatous_; _Adenomatous_;
+ _Cystic_; _Malignant_; _Toxic_.
+
+#Surgical Anatomy.#--The _thyreoid gland_ consists of two lateral
+lobes connected by an isthmus. The lateral lobes lie in contact with
+the side of the larynx up to the middle of the thyreoid cartilage, and
+with the sides of the first five or six rings of the trachea. The
+isthmus lies in front of the second, third and fourth rings of the
+trachea, and from it a process of gland tissue--the _pyramidal
+lobe_--passes up in the middle line towards the hyoid bone.
+
+The gland lies under cover of the superficial muscles of the neck, and
+is surrounded by a process of the cervical fascia--the external
+thyreoid capsule of Kocher--which connects it with the larynx,
+trachea, and oesophagus, so that it moves with these structures on
+swallowing. In this capsule are numerous veins; and in the groove
+between the oesophagus and trachea the recurrent (laryngeal) nerve
+runs. Enclosing the gland substance is the capsule proper, which sends
+in processes to form its fibrous stroma. The arteries of supply--the
+superior and inferior thyreoids--are very large for the size of the
+gland, and enter it at its four corners. The thyreoidea ima, when
+present, goes to the isthmus. Isolated nodules of thyreoid
+tissue--_accessory thyreoids_--are sometimes met with in different
+parts of the neck; they are liable to the same diseases as the main
+gland.
+
+The secretion of the gland is absorbed into the general circulation
+through the veins; it consists of a complex colloid substance which
+contains an iodine-albumin--iodothyrin--and plays an important part in
+maintaining the normal metabolism of the body, particularly of the
+central nervous and cutaneous tissues in adults, and of the bones in
+children. Disturbance of the function of the thyreoid gland plays a
+part in producing the symptoms characteristic of myxoedema, cretinism,
+and goitre.
+
+The _para-thyreoid glands_--usually two on each side--lie in the
+external capsule along the posterior edge of the lobes of the
+thyreoid. They are flattened, elliptical bodies, averaging a quarter
+of an inch in length and an eighth of an inch in width, of a light
+brown colour, smooth and glistening on the surface, and of a soft,
+flabby consistence (W. G. MacCallum). When tetany follows operations
+for goitre it is due to the removal of these glands.
+
+#Physiological Hyperæmia.#--The thyreoid varies greatly in size even
+within normal limits, and may become engorged and swollen from
+physiological causes, particularly in the female. Before the onset of
+menstruation at puberty, for example, the thyreoid frequently becomes
+engorged, and the enlargement may recur with each period for months or
+even years. During pregnancy also the gland may become swollen.
+
+#Acute Thyreoiditis# may occur in a healthy thyreoid or in one that is
+the seat of goitre, and may end within a few days in resolution, or go
+on to suppuration. It is due to infection with pyogenic bacteria,
+which usually gain access to the gland by the blood stream, as, for
+example, in typhoid fever, pyæmia, influenza, and other acute
+infective diseases. Direct infection sometimes occurs from an abscess,
+a cellulitis, or an infected wound in the neck; it has also occurred
+from a foreign body impacted in the oesophagus ulcerating through and
+perforating the gland.
+
+One lobe is usually more involved than the other, but the condition
+may be diffused. When pus forms it may infiltrate the stroma of the
+gland, or may be collected into several small foci.
+
+_Clinical Features._--The usual signs of inflammation are present;
+there is severe headache of a congestive nature, and sometimes
+vertigo. The swelling takes the shape of the thyreoid, and although
+the skin may not be red, the subcutaneous veins are dilated. In severe
+cases there is pain and difficulty in swallowing and dyspnoea.
+
+When suppuration ensues, all the symptoms are aggravated, and repeated
+rigors occur. The pus may burst into the cellular tissue of the neck,
+or into the air-passage or the oesophagus.
+
+_Treatment._--In the non-suppurative stage the ordinary treatment of
+acute inflammatory conditions is employed; if pus forms, the abscess
+should be opened and drained.
+
+#Tuberculous and syphilitic affections# of the thyreoid are very rare.
+
+
+PARENCHYMATOUS GOITRE OR BRONCHOCELE
+
+The term goitre is applied clinically to any non-inflammatory
+enlargement of the thyreoid gland.
+
+_Etiology._--Parenchymatous goitre, sometimes called also simple, or
+non-toxic goitre, is endemic in certain hilly districts in
+England--particularly Derbyshire and Gloucestershire--and in various
+parts of Scotland. It is exceedingly common in certain valleys in
+Switzerland. It is met with less frequently in men than in women, and
+it occurs chiefly during the child-bearing period of life. The toxic
+agent that causes goitre has been traced to certain mountain springs
+in goitrous districts; it has been observed that a patient with goitre
+may, through fæcal contamination apparently, infect the water supply,
+and that conscripts in order to avoid military service have drunk from
+goitrous springs with success. Children born in a goitrous district
+are liable to be cretins, while if goitrous parents move to a healthy
+district, the children are born healthy. If the water supply of a
+goitrous valley be changed to a healthy spring, goitre and cretinism
+disappear. Thorough boiling of the water rids it of its toxic
+properties.
+
+[Illustration: FIG. 277.--Parenchymatous Goitre in a girl æt. 15.
+
+(Mr. D. M. Greig's case.)]
+
+_Morbid Anatomy._--Both the secreting and the fibrous elements share
+in the hyperplasia, and the gland as a whole becomes enlarged and
+forms a horseshoe-shaped swelling of moderate size in the neck. This
+swelling is soft and smooth on the surface, and is seldom quite
+symmetrical. In some cases the hypertrophy involves chiefly the
+isthmus. In others an outlying accessory lobule of thyreoid tissue
+constitutes the bulk of the swelling, and this may extend a
+considerable distance from the position of the normal thyreoid,
+reaching even behind the sternum into the thorax--_infra-thoracic_ or
+_retro-sternal goitre_.
+
+[Illustration: FIG. 278.--Larynx and Trachea surrounded by Goitre.]
+
+[Illustration: FIG. 279.--Section of Goitre shown in Fig. 278, to
+illustrate compression of Trachea.]
+
+When the secreting elements increase out of proportion to the stroma,
+numerous rounded or irregular spaces filled with a thick yellow
+colloid material are formed in the substance of the goitre--_colloid
+goitre_. The majority of these spaces are not larger than a pea, but
+one or more may enlarge and form cysts of considerable size--_cystic
+goitre_. These varieties, especially the cystic form, attain greater
+dimensions than any other form of goitre.
+
+When the fibrous stroma is greatly in excess--_fibrous goitre_--the
+swelling is smaller, firmer, and shows a greater tendency to contract
+and compress the trachea. If the sclerosis is extreme and the
+secretory tissue undergoes atrophy, myxoedema may result.
+
+In some cases the hyperplasia affects chiefly the blood vessels of
+the thyreoid--_vascular goitre_. The capillaries, veins, and arteries
+are increased in size and number; the swelling pulsates and increases
+in size when the patient makes any muscular effort. Hæmorrhagic cysts
+may also develop in the substance of these goitres.
+
+ * * * * *
+
+_Effects on the Trachea._--The trachea may be _displaced laterally_
+when the enlargement of the gland affects one lobe more than the
+other; or it may be _compressed and narrowed_ from side to side--the
+_scabbard trachea_--when both lobes are about equally affected and the
+enlargement extends posteriorly so as almost to surround the
+air-passage (Figs. 278, 279). The third effect is that of _softening
+of the cartilaginous rings_ of the trachea so that the air-tube,
+instead of having a considerable degree of elastic resiliency, is soft
+and flaccid and readily yields to pressure. Under these conditions an
+alteration in the attitude of the patient, from the erect or sitting
+to the recumbent position, would appear to be sufficient to permit of
+a compression of the trachea.
+
+Further changes in the trachea consist in catarrh and engorgement of
+the blood vessels of its mucous membrane, attended with an abundant
+secretion of mucus, which, if it accumulates behind a narrowed segment
+of the trachea, may still further encroach on the lumen.
+
+_Pressure on other Structures._--The _recurrent nerve_ may be pressed
+upon intermittently causing spasms and choking, or continuously
+causing abductor paralysis and hoarseness.
+
+The gullet is rarely compressed; if marked difficulty in swallowing
+develops, some additional factor should be suspected, notably
+carcinoma at the junction of the pharynx with the oesophagus. The
+carotid arteries are displaced laterally beneath the sterno-mastoids
+without detriment; the superficial veins--anterior and external
+jugular--are greatly distended in those cases in which the goitre
+grows downwards behind the sternum.
+
+_Clinical Features._--The symptoms vary widely in different cases, and
+their severity is not proportionate to the size of the goitre. The
+disfigurement produced by the swelling is often the only cause of
+complaint. In some cases the symptoms are due to the pressure of the
+enlarged thyreoid on surrounding structures. In others toxic effects,
+in the form of cardiac, nervous, muscular, and general metabolic
+disturbances, predominate, and are due to absorption of excessive or
+abnormal thyreoid secretion. This thyreoid toxæmia varies in degree;
+in the milder cases it merely amounts to a nervousness or
+excitability that may unfit the patient for occupation; it reaches
+its maximum in the condition of hyperthyreoidism characteristic of
+exophthalmic goitre or Graves' disease (p. 614).
+
+The skin over the goitre is freely movable, and the tumour itself can
+be moved transversely, carrying the larynx and trachea with it, but it
+cannot be moved vertically. It moves up and down with the larynx on
+swallowing--a point of great diagnostic value. Of the mechanical
+symptoms dyspnoea is the most constant. It may only amount to
+shortness of breath on exertion, or the patient may suffer from sudden
+and severe dyspnoeic attacks, especially when lying on the back during
+sleep, and such an attack may prove fatal. This may be due to the
+weight of the tumour pressing on the trachea, which has been softened
+and distorted by the goitre, or to temporary congestion and
+engorgement of the mucous membrane of the air-passages. In these cases
+there is marked stridor both on inspiration and expiration, but no
+aphonia. In rare cases the goitre presses upon the recurrent nerve,
+causing spasmodic dyspnoea, hoarseness, and aphonia from impaired
+movement of the vocal cords, and these symptoms, especially if
+accompanied by pain, raise the suspicion of malignancy. Disturbance of
+the heart's action may cause palpitation and sudden attacks of
+syncope; and pressure on the blood vessels may give rise to a feeling
+of fullness in the head, and giddiness.
+
+The occurrence of hæmorrhage into the substance of the goitre or into
+a cyst, produces a sudden aggravation of the symptoms.
+
+In _intra-thoracic_ or _retro-sternal goitre_ the tumour displaces and
+compresses the trachea and causes dyspnoea, and there are occasional
+paroxysmal attacks of breathlessness, which may be mistaken for
+asthma, particularly as the patient is usually the subject also of
+bronchitis and emphysema. In some cases the patient can, by a violent
+expiratory effort, such as coughing, project the goitre upwards into
+the neck. When the goitre is fixed in the thorax, the clinical
+features are those of a mediastinal tumour with lateral displacement
+of the trachea, and engorgement of the veins of the neck.
+
+_Treatment._--The patient should change his residence to a
+non-goitrous district. The evidence regarding the benefit derived from
+the internal administration of thyreoid extract, or of preparations of
+phosphorus or of iodine, is conflicting.
+
+Operative treatment is indicated when there are symptoms referable to
+pressure on the air-passage, and in goitres which are steadily
+increasing in size. Kocher considers it advisable to operate if the
+patient becomes breathless on making pressure on the goitre from side
+to side. The suspicion of a goitre becoming malignant is also a reason
+for removing it by operation.
+
+The operation--_thyreoidectomy_--consists in excising that portion of
+the thyreoid which is causing pressure symptoms, and this usually
+involves removal of one-half of the gland. The chief danger in
+operations for goitre is cardiac insufficiency, as evidenced by
+disturbed rhythm of the heart-beats, lowering of the blood pressure,
+or dilatation of the cavities of the heart (Kocher).
+
+It is sometimes advisable to perform the operation under local
+anæsthesia. A general anæsthetic is, however, preferred in this
+country. The injection of 1/6th grain of morphin and 1/120th grain of
+atropin half an hour before the operation, and the administration of
+ether by the open method, or by intra-tracheal insufflation, is safe
+and satisfactory.
+
+There is reason to believe that the absorption of thyreoid secretion
+squeezed from the divided surfaces gives rise to a condition known as
+_acute thyreodism_ during the first few hours after operation; its
+symptoms are elevation of temperature, increase in the pulse-rate
+(150-200), rapid respiration with dyspnoea, flushing of the face,
+muscular twitchings, and mental excitement. The gentle handling of the
+tumour and the employment of a drainage tube for the first forty-eight
+hours diminishes this risk.
+
+_Tetany_, as evidenced by the occurrence of cramp-like contractions of
+the thumb and fingers, may supervene within a few days of the
+operation if one or more of the para-thyreoids have been inadvertently
+removed. It may be controlled by large doses of calcium lactate. On no
+account may the whole of the thyreoid gland be removed, as this is
+followed by the development of symptoms closely resembling those of
+myxoedema--_operative myxoedema_ or _cachexia strumipriva_.
+
+_Treatment of Sudden Dyspnoea._--When dyspnoea suddenly supervenes and
+threatens life, it is sometimes possible to relieve the pressure on
+the trachea by open division of the skin, superficial fascia, platysma
+and deep fascia in the middle line of the neck, so as to relax the
+tension on the goitre. If this is insufficient, the isthmus may be
+divided. Should relief not follow, tracheotomy must be performed, and
+a long tube or a large-sized gum-elastic catheter with a terminal
+aperture be passed along the trachea beyond the seat of obstruction.
+
+#Adenoma of the Thyreoid.#--In this condition the swelling of the
+thyreoid is due to the growth within its substance of one or more
+adenomas of variable size and surrounded by a capsule. The rest of
+the gland may be normal, or may show some degree of hyperplasia. Some
+are solid, others undergo cystic degeneration, the glandular tissue
+being replaced by a quantity of clear or yellowish fluid, sometimes
+mixed with blood. The cysts thus formed may be unilocular or
+multilocular, and intra-cystic papillary vegetations frequently grow
+from their walls. The walls of the cysts may be thin, soft, and
+flaccid, or thick and firm, or they may even be calcified.
+
+The thyreoid is enlarged, but instead of the uniform enlargement which
+characterises the parenchymatous goitre, it tends to be uneven, with
+hillocky projections corresponding to the individual cysts (Fig. 280),
+and in these fluctuation may be detected. It is to be noted that
+there are no toxic symptoms in cystic adenoma.
+
+[Illustration: FIG. 280.--Multiple Adenomata of Thyreoid in a woman
+æt. 50.
+
+(Mr. D. M. Greig's case.)]
+
+[Illustration: FIG. 281.--Cyst of Left Lobe of Thyreoid.
+
+(Mr. D. M. Greig's case.)]
+
+The treatment is necessarily operative; cystic tumours may be tapped
+and injected with iodine, but the more satisfactory procedure, both
+with the solid and cystic forms, is to incise freely the overlying
+thyreoid tissue and enucleate the tumour.
+
+#Malignant Disease of the Thyreoid.#--This, whether in the form of
+_carcinoma_ or _sarcoma_, usually develops in a gland that has been
+the seat of goitre for several years, although it may begin in a
+previously healthy gland.
+
+_Clinical Features._--Both sexes, above the age of fifty, are affected
+in about equal proportion. The characteristic features are that the
+tumour undergoes a progressive increase in size, that it becomes fixed
+to its surroundings, that its surface tends to be uneven and nodular,
+and its consistence densely hard. The voice often becomes hoarse from
+abductor paralysis due to infiltration by the growth, usually of the
+left recurrent nerve. The effects upon the trachea are more decided
+and more progressive than in parenchymatous goitre; it displaces and
+compresses the trachea and frequently overlaps it, so as to bury the
+air-passage completely. If the tumour tissue has actually penetrated
+the trachea, the expectoration is tinged with blood. Dysphagia is
+rarely a prominent symptom. The lymph glands become enlarged after the
+tumour bursts through the capsule; and metastases to the lungs and
+bones, particularly the skull, sternum, and mandible, are common. When
+the goitre extends behind the sternum--the _malignant form of
+retro-sternal goitre_--the pressure symptoms are due to the
+encroachment upon the limited accommodation of the upper opening of
+the thorax; the trachea especially suffers, and the pressure on the
+veins causes distension of the anterior and external jugulars and
+their tributaries. The patient is unable to lie down; there are
+violent paroxysms of coughing, and an abundant frothy expectoration.
+Death may take place suddenly from asphyxia, from heart failure, or
+from displacement of a thrombus from one of the veins in the neck.
+
+_Treatment._--It is only in the earliest stages that a malignant
+goitre can be successfully removed. In the later stages complete
+extirpation is not to be attempted, as it usually involves the removal
+of a portion of the trachea or oesophagus, and the operation is
+attended with grave risk to life.
+
+Operative interference is often called for, however, for the relief of
+respiratory embarrassment. _Tracheotomy_ may prove a difficult and
+dangerous procedure, owing to the trachea being buried under the
+goitre and displaced or narrowed by it, so that it is not easy to
+reach it or to introduce an efficient tube beyond the point of
+obstruction. A more certain method consists in exposing the goitre by
+an incision as for thyreoidectomy, rapidly removing sufficient of the
+growth to expose the trachea and admit of a tube being introduced. If
+there is a retro-sternal prolongation compressing the trachea within
+the thorax, a long flexible tube may have to be passed beyond the site
+of the compression before the dyspnoea is relieved. The benefit is
+immediate and decided; the accumulated secretion is coughed up, and
+after a few deep breaths the patient is able to lie down, and usually
+falls asleep. The stridor disappears. Unfortunately the relief is
+only temporary, and the patient soon succumbs to a broncho-pneumonia,
+or to secondary hæmorrhage from the trachea.
+
+#Toxic Goitre#--#Exophthalmic Goitre#--#Graves'# or #Basedow's
+Disease#.--These terms are applied to a variety of goitre
+in which the symptoms due to absorption of thyreoid
+secretion--_thyreotoxicosis_--predominate. The name "exophthalmic
+goitre" is misleading, as in some cases the enlargement of the
+thyreoid, and in others the eye symptoms, are scarcely appreciable,
+while the general symptoms are well marked. The term toxic goitre or
+_hyperthyreoidism_, suggested by C. H. Mayo, is preferable, as the
+manifestations of the disease depend upon excessive or abnormal action
+of the thyreoid tissue.
+
+[Illustration: FIG. 282.--Exophthalmic Goitre.]
+
+The condition is chiefly met with in young adult women, and may
+develop suddenly after a shock to the nervous system. The intoxication
+affects the higher cerebral functions and causes nervousness,
+irritability, and tremor; the cardiac and vaso-motor centres, causing
+tachycardia and pallor of the skin; the sympathetic fibres to the eye,
+causing protrusion of the eyeballs, staring of the eyes without
+winking, narrowing of the palpebral fissure, dilatation of the pupil,
+and lagging behind of the upper lid, and sometimes also of the lower
+lid--von Graefe's symptom. There may be diarrhoea and vomiting, loss
+of weight, and in the worst cases there is delirium at night. In
+course of time there develops cardiac insufficiency with fibroid
+degeneration of the myocardium. Coagulation of the blood is retarded,
+and there is a marked diminution in the number of leucocytes,
+especially the neutrophils, and an increase in the lymphocytes
+(Kocher).
+
+In the early stages the thyreoid is enlarged and pulsatile, and bruits
+may be heard over it; later, these vascular symptoms disappear, and
+only a firm, diffuse, uniform swelling implicating all parts of the
+gland remains.
+
+_Prognosis._--The tenure of life is uncertain as the patient offers
+little resistance to intercurrent affections such as influenza and
+pneumonia. If the average course of the disease is represented by a
+curve, the greatest height is reached during the second half of the
+first year and then descends. For the next two to four years it
+fluctuates with occasional exacerbations of symptoms due to fright or
+worry.
+
+_Treatment._--Medical measures, along with the external application of
+radium, the strict observance of rest in bed with the exclusion of all
+forms of excitement and worry, the administration of bromides, heroin
+or other sedatives, and of digitalis or other cardiac tonics, are to
+be prescribed in the first instance, and in any case, as a desirable
+preparation for operation.
+
+_Operative measures_ consist in the _ligation_ of the vessels and
+nerves at one or other pole of the gland--usually the superior on one
+side--followed by, if necessary, a partial _thyreoidectomy_.
+
+Crile of Cleveland has organised his clinic in the direction of
+arranging that the operation shall be performed without the patient
+knowing that it is to take place--what he calls "stealing the
+goitre"--the thorough preparation of the patient for the operation,
+the minimising the risk from the anæsthetic by the combination of
+novocain locally and of nitrous oxide and oxygen; and of diminishing
+the risk of absorption of thyreoid secretion by packing the (open)
+wound with gauze wrung out of a solution of flavin.
+
+Operations on the cervical sympathetic cord have been abandoned.
+
+The presence of toxic goitre may influence the question of operation
+in the treatment of other surgical conditions, and may determine the
+selection of one or other form of anæsthesia.
+
+
+
+
+CHAPTER XXVIII
+
+THE OESOPHAGUS
+
+
+Surgical Anatomy--Methods of examination--Wounds--Rupture--Swallowing
+ of caustics--Impaction of foreign bodies--Infective conditions:
+ _Oesophagitis_; _Peri-oesophagitis_; _Tuberculosis_;
+ _Syphilis_--Varix--Conditions causing difficulty in swallowing:
+ _Impaction of foreign bodies_; _Compression of the gullet from
+ without_; _Spasm of the muscular coat_; _Cardiospasm_; _Paralysis
+ of the gullet_; _Diverticula_ or _pouches of the gullet_;
+ _Innocent stricture_; _Malignant stricture, including cancer at
+ the junction of pharynx and gullet and cancer at the lower end of
+ the gullet_.
+
+#Surgical Anatomy.#--The oesophagus extends from the level of the
+cricoid cartilage to about the level of the lower end of the sternum.
+The distance from the upper incisor teeth to the commencement of the
+oesophagus is about 5 or 6 inches, and the oesophagus measures from 9
+to 10 inches. The whole distance, therefore, from the teeth to the
+stomach is from 14 to 16 inches.
+
+The cervical portion of the oesophagus, extending from the cricoid
+cartilage to the upper edge of the sternum, measures about 2 inches.
+It lies behind and to the left of the trachea, and in the groove
+between them on each side runs the recurrent nerve. The thoracic
+portion is about 7 inches long, and traverses the posterior
+mediastinum lying slightly to the left of the middle line. It is
+crossed by the left bronchus, and below this level has the pericardium
+immediately in front of it. The left pleura is closely related to the
+anterior surface of the oesophagus throughout, while the right pleura
+passes behind it in its lower part. This accounts for the frequency
+with which growths in the oesophagus invade the pleura. The oesophagus
+passes through the diaphragm about an inch above the cardiac opening
+of the stomach.
+
+There are three points at which the oesophagus shows narrowing of the
+lumen: (1) at the lower border of the cricoid--the "mouth of the
+oesophagus"; (2) where it is crossed by the left bronchus; and (3)
+where it passes through the diaphragm. It is at these points that
+foreign bodies tend to become impacted. The mucous membrane of the
+oesophagus is insensitive to tactile and painful stimuli, but is
+sensitive to heat and cold and to exaggerated peristaltic
+contractions.
+
+#Methods of Examination.#--It is sometimes possible to detect an
+impacted foreign body, a distended diverticulum, or a new growth in
+the cervical portion of the oesophagus by _palpation_.
+
+_Auscultation_ while the patient is drinking sometimes aids in the
+diagnosis of stricture; the stethoscope is placed at various points
+along the left side of the dorsal spine, and abnormal sounds may be
+heard as the fluid impinges against the stricture or trickles through
+it.
+
+_Introduction of Bougies._--Oesophageal bougies or probangs are used
+for diagnostic purposes in cases of suspected stricture, and to aid in
+the detection of foreign bodies. Various forms are employed, of which
+the most generally useful are the round-pointed gum-elastic or
+silk-web bougie, and the olive-headed metal bougie, consisting of a
+flexible whalebone stem, to which one of a graduated series of
+aluminium or steel bulbs is screwed. For some purposes, such as
+pushing onward an impacted bolus of food, the sponge probang--which
+consists of a small round sponge fixed on a whalebone stem--is to be
+preferred.
+
+Before passing bougies, it is necessary to make certain that the
+symptoms are not due to the pressure of an aneurysm on the oesophagus,
+as cases have been recorded in which a thin-walled aneurysm has been
+perforated by a bougie. The existence of ulceration or of an abscess
+pressing on the gullet also contra-indicates the use of bougies.
+
+For the passage of a bougie the patient should be seated on a chair
+with the head thrown back and supported from behind by an assistant,
+and he is directed to take full deep breaths rapidly. The bougie,
+lubricated with butter or glycerine, and held like a pen, is guided
+with the left forefinger. As soon as the instrument engages in the
+opening of the oesophagus, the chin is brought down towards the chest,
+and if the patient is now directed to swallow, the instrument may be
+carried down the oesophagus, or can be passed on by gentle pressure.
+Great gentleness must be exercised, and no attempt should be made to
+force the instrument past any obstruction. The instrument may catch
+against the hyoid bone, and this may be mistaken for an obstruction.
+
+It is to be borne in mind that in some cases the passage of a bougie
+may be attended with a considerable degree of shock, and cases are on
+record in which this has proved fatal without any gross lesion being
+found after death.
+
+_Intubation_, or the passage of a cannula through a stricture, is
+referred to later.
+
+_Oesophagoscopy._--The _oesophagoscope_--a form of speculum which
+enables the oesophagus to be illuminated by an electric lamp--is
+employed for the detection and removal of foreign bodies, for the
+examination of ulcers, diverticula, and strictures of the tube, and
+with its aid it is possible to remove a portion of a growth for
+microscopic examination. The mouth, pharynx, and entrance to the
+oesophagus having been cleansed and cocainised, the patient is placed
+in the recumbent or sitting posture, and the tube introduced. For
+prolonged examinations a general anæsthetic is preferred.
+
+The mouth of the oesophagus is closed by the sphincter-like action of
+the lower fibres of the inferior constrictor muscle, and the cervical
+part of the tube appears as a transverse slit, due to the backward
+pressure of the trachea. The thoracic portion is more open and may
+contain air, so that it is possible to see down to the lower end, the
+closed cardiac orifice appearing as an oblique cleft surrounded by a
+rosette-like cushion of mucous membrane. The pulsation of the aorta
+can be seen just above the prominence formed by the left bronchus.
+
+_Radiography._--Opaque foreign bodies can be detected by the screen or
+in a radiogram; and the position of a stricture by making the patient
+swallow capsules containing bismuth and examining with the screen. To
+determine the position and size of a diverticulum, a radiogram is
+taken after the patient has swallowed some food, such as porridge
+mixed with bismuth.
+
+#Wounds# of the oesophagus inflicted from without, for example stabs,
+cut-throat or gun-shot injuries, are rare, and are almost invariably
+accompanied by lesions of other important structures in the neck,
+which may rapidly prove fatal. It is more common to meet with wounds
+inflicted from within, for example by the swallowing of rough and
+irregularly shaped foreign bodies, or by unskilful attempts to remove
+such bodies or to pass bougies along the oesophagus. The severity of
+the lesion varies from a scratch of the mucous membrane to a
+perforation of the tube. The less severe injuries are attended with
+pain on swallowing and a sensation as if something had lodged in the
+oesophagus. In more severe cases there is bleeding, followed by
+attacks of coughing and expectoration of blood-stained mucus. When the
+oesophagus is perforated, diffuse cellulitis of the neck or of the
+posterior mediastinum may ensue. In the treatment of these injuries
+the chief point is to give the oesophagus rest by feeding the patient
+entirely by the rectum or through an opening made in the
+stomach--gastrostomy.
+
+#Rupture# of the oesophagus has occurred during violent vomiting, and
+during lavage. The tear is longitudinal and is usually near the
+cardiac orifice. It is probably due to increased pressure within the
+gullet. The accident has usually been met with in alcoholics, and has
+proved fatal by setting up left-sided empyema or cellulitis.
+
+#Swallowing of Corrosive Substances.#--The oesophagus is damaged by
+the swallowing of strong chemicals, such as sulphuric acid, nitric
+acid, carbolic acid, or caustic potash. These substances produce their
+worst effects at the two ends of the oesophagus, but in some cases the
+whole length of the tube suffers. The mucous membrane alone may be
+destroyed, or the muscular and even the fibrous coats may also be
+implicated. The damaged tissue undergoes necrosis, and when the
+sloughs separate, raw surfaces are left, and are very slow to heal.
+
+If not rapidly fatal from shock and oedema of the glottis, these
+injuries are usually attended with intense pain, severe thirst, and
+vomiting, the vomit containing shreds of mucous membrane and blood.
+Complications, such as cellulitis, perforation of the oesophagus, or
+peri-oesophageal abscess, may follow. Later, cicatricial contraction
+takes place at the injured portions, producing the most intractable
+form of fibrous stricture.
+
+The _treatment_ consists in administering solutions of carbonate of
+potash, of soda, or of magnesia when an acid has been swallowed, or
+vinegar diluted with water in the case of an alkali. When carbolic
+acid has been swallowed, a large quantity of olive oil should be
+administered. The stomach should be washed out with water, the tube
+being passed with the greatest gentleness to avoid perforating the
+softened oesophageal wall. Subsequently the patient should be fed by
+the rectum, but, in the majority of cases, gastrostomy is called for
+to enable the patient to take nourishment and put the gullet at rest.
+
+As soon as the oesophagus has healed, say in three or four weeks,
+bougies should be passed every three or four days to prevent
+cicatricial contraction. As the calibre of the tube is restored, the
+instruments may be passed less frequently, but for some years--it may
+be for the rest of the patient's life--a full-sized bougie should be
+passed at least once a month.
+
+#Impaction of Foreign Bodies in the Pharynx and Oesophagus.#--It is an
+interesting fact that foreign bodies, even as large as a dinner fork,
+when intentionally swallowed, can pass through the pharynx and
+oesophagus and enter the stomach without apparent difficulty. When the
+body is accidentally swallowed impaction is more liable to take place,
+probably on account of the spasm induced by fright and by
+inco-ordinated attempts to eject it. For obvious reasons the accident
+is most liable to occur in children, in epileptics, and in those who
+are under the influence of alcohol. It happens also during anæsthesia
+for the extraction of teeth or if the patient vomits solid substances.
+The clinical aspects vary according as the object is impacted in the
+pharynx or in the oesophagus.
+
+_In the Pharynx._--If a large bolus of unmasticated food becomes
+impacted in the pharynx, it blocks the openings of both the oesophagus
+and the larynx, and the patient may, without manifesting the usual
+signs of suffocation, suddenly fall back dead, and if he happens to be
+alone at the time of the accident, the cause of death is liable to be
+overlooked unless the pharynx is examined at the post-mortem
+examination. Most surgical museums contain specimens illustrating the
+impaction of a bolus of meat in the pharynx; this fatal accident has
+occurred especially in men in a condition of alcoholic intoxication.
+
+An object of irregular shape, for example a large denture, also, is
+most likely to lodge in the pharynx, obstructing the openings of both
+the oesophagus and the larynx, and causing suffocation. The face
+immediately becomes blue and engorged, the patient is speechless, and
+violent efforts are made to eject the object by retching and coughing.
+It may be seen from the mouth and touched with the finger.
+
+In the case of small sharp bodies, such as fish, game, and mutton
+bones, there is not the same urgency, and a methodical search for the
+foreign body is carried out. Even after the foreign body has been got
+rid of, the patient may have the sensation that it is still present.
+This may be due to a scratch of the mucous membrane, or to spasm, in
+which case the swallowing of a few drops of cocain solution will cause
+the sensation to disappear.
+
+_Treatment._--In the presence of impending suffocation, the mouth must
+be forced open by an extemporised gag, the finger passed into the back
+of the throat, and the body hooked out. If this is impossible, and if
+suitable forceps are not at hand, it may be necessary at once to
+perform laryngotomy, followed by artificial respiration, because,
+although the patient may appear lifeless, the heart continues to beat
+after breathing has ceased. The foreign body should then be removed
+with forceps. Sub-hyoid pharyngotomy, which consists in opening the
+pharynx by a mesial vertical incision carried through the hyo-thyreoid
+membrane, may be called for, as in the case of a denture, the hooks of
+which have penetrated the wall of the pharynx.
+
+_In the Oesophagus._--Smaller bodies, such as coins, bones, or pins,
+usually enter the oesophagus, and the great majority become impacted
+above the level of the manubrium sterni. Those that pass farther down
+are liable to stick where the tube is narrowed at the crossing of the
+bronchus, or at the opening through the diaphragm. In children, coins
+predominate and are nearly always arrested at the level of the upper
+end of the sternum; in adults, dentures are the commonest foreign
+bodies, and may be impacted anywhere.
+
+At the moment of impaction there is pain, which assumes the character
+of cramp due to spasm of the muscular coat, and which is increased on
+attempting to swallow, and violent retching and coughing are set up;
+in many cases, as when bodies are impacted in the pharynx, respiratory
+distress is again the predominant feature. If the passage is
+completely obstructed, food and saliva--sometimes blood-stained--are
+regurgitated with retching soon after being swallowed. When the
+obstruction is incomplete, fluids may pass into the stomach while
+solids are regurgitated.
+
+If the mucous membrane is injured, there is severe stabbing pain and
+choking attacks, both due to spasm, sometimes even after the body has
+passed on, and the pain is not always referred to the seat of the
+injury.
+
+The _diagnosis_ is made by the history, and by the use of the
+fluorescent screen, or X-ray photographs (Figs. 283, 284). The
+oesophagoscope is also of great value, both for diagnostic purposes
+and as an aid in the removal of the impacted body. Bougies are to be
+employed with great care, as there is a danger of pushing the foreign
+body farther down, or of wedging it more firmly in the oesophagus, and
+the information obtained is often misleading.
+
+[Illustration: FIG. 283.--Radiogram of Safety-pin impacted in the
+Gullet and perforating the Larynx.
+
+(Professor Annandale's case. Radiogram by Dr. Dawson Turner.)]
+
+[Illustration: FIG. 284.--Denture impacted in Oesophagus.
+
+(Professor F. M. Caird's case.)]
+
+It should be borne in mind that drunkards may suffer from a form of
+spasm of the oesophagus, which simulates the impaction of a foreign
+body; hospital records also show that the patient may only have dreamt
+that he has swallowed a foreign body, usually a denture. These
+possibilities should be always excluded before further procedures are
+undertaken.
+
+_Treatment._--There being no urgency, a careful examination is carried
+out, not only to confirm the impaction of a foreign body, but its site
+and its relation to the wall of the gullet. In skilled hands, the
+safest and most certain means of removing impacted foreign bodies is
+with the aid of the oesophagoscope. If this apparatus is not
+available, other measures must be adopted varying with the nature of
+the body, its site, and the manner of its impaction.
+
+A bolus of food, for example, or a small smooth object that is likely
+to pass safely along the alimentary canal, if it cannot be extracted
+with forceps, may be pushed on into the stomach by the aid of a
+bulbous-headed or sponge probang. This must be done gently, especially
+if the body has been impacted for any time, as the inflammatory
+softening of the oesophageal wall may predispose to rupture.
+
+Small, sharp, or irregular objects, such as fish bones, tacks, or
+pins, may be dislodged by the "umbrella probang"--an instrument which,
+after being passed beyond the foreign body, is expanded into the form
+of a circular brush which, on withdrawal, carries the foreign body out
+among its bristles.
+
+Coins usually lodge edgewise in the oesophagus, and are best removed
+by means of an instrument known as a "coin-catcher", which is passed
+beyond the coin, and on being withdrawn catches it in a hinged flange.
+In emergencies a loop of stout silver wire bent so as to form a hook
+makes an excellent substitute for a coin-catcher.
+
+In difficult cases the removal of solid objects is facilitated by
+carrying out the manipulations in the dark room with the aid of the
+X-rays and the fluorescent screen.
+
+Irregular bodies with projecting edges or hooks, such as tooth-plates,
+tend to catch in the mucous membrane, and attempts to withdraw them by
+forceps or other instruments are liable to cause laceration of the
+wall. When situated in the cervical part of the oesophagus, these
+should be removed by the operation of _oesophagostomy_ (_Operative
+Surgery_, p. 195).
+
+If the foreign body is lodged near the lower end of the gullet, it may
+be necessary to perform _gastrostomy_ (_Operative Surgery_, p. 291),
+making an opening in the anterior wall of the stomach large enough to
+admit suitable forceps, or, if necessary, the whole hand, in order
+that the body may be extracted by this route; experience shows that an
+impacted body is more easily extracted from below, that is, from the
+stomach, than from above.
+
+When the surgeon fails to remove the body by either of these routes,
+_gastrostomy_ must be performed both to feed the patient and to place
+the gullet at rest. Smooth bodies may lie latent for long periods, but
+those with points or hooks damage the mucous membrane, cause
+ulceration and perforation with the risk of erosion of vessels and
+secondary hæmorrhage or of cellulitis of the neck or mediastinum and
+empyema.
+
+Other complications include septic broncho-pneumonia from damage to
+the air-passage, and suppurative thyreoiditis.
+
+#Infective conditions# due to pyogenic infection (_oesophagitis_ and
+_peri-oesophagitis_) are rare.
+
+A _chronic form of oesophagitis_ is occasionally met with in alcoholic
+subjects, giving rise to symptoms that simulate those of impacted
+foreign body, or of stricture.
+
+In _tuberculous_ lesions the symptoms are pain, dysphagia, and
+regurgitation of food mixed with blood, and the condition is liable to
+be mistaken for gastric ulcer or for cancer of the oesophagus.
+
+_Syphilitic affections_ of the oesophagus are rare.
+
+#Varix# at the lower end of the oesophagus may give rise to
+hæmatemesis, and be mistaken for gastric ulcer. Bleeding from the
+dilated veins may follow the use of bougies or of the oesophagoscope.
+
+
+CONDITIONS CAUSING DIFFICULTY IN SWALLOWING
+
+Difficulty in swallowing may arise from a wide variety of causes which
+it is convenient to consider together.
+
+#Impaction of Foreign Bodies# has already been discussed, and
+attention has been drawn to the importance of the history given by the
+patient and to the various sources of fallacy or deception--in
+children it may be artful reticence or misrepresentation, in adults,
+the possibility of nightmare and of dreams.
+
+#Compression of the Gullet from without.#--Any one of the numerous
+structures in relation to the gullet may, when enlarged as a result of
+disease, give rise to narrowing of its lumen, for example a
+lymph-sarcoma at the root of the lung, or any enlargement of the
+thyreoid or of the mediastinal lymph glands. The possibility of
+aneurysm must always be kept in mind because of the risk attending the
+passage of instruments for diagnostic purposes.
+
+#Spasm of the Muscular Coat.#--As in other tubular structures
+containing circular muscular fibres, sudden contraction or spasm may
+occur in the oesophagus and cause narrowing of the lumen, attended
+with difficulty in swallowing. This spasmodic dysphagia includes such
+widely varying conditions as the "globus hystericus" of neurasthenic
+women, the spasm of chronic alcoholics, and the affection known as
+_cardiospasm_ or "hiatal oesophagismus."
+
+In contrast with other affections causing difficulty in swallowing,
+spasmodic dysphagia usually has a sudden and unexplained onset, the
+progress of symptoms is irregular and erratic, while the remission of
+symptoms common to all affections of the oesophagus, and the influence
+of mental impressions, such as excitement, hurry in the presence of
+strangers, are exaggerated.
+
+In testing the calibre of the gullet it is found that on one occasion
+a full-sized bougie may pass easily and be completely arrested at
+another.
+
+Apart from the treatment of the neurosis underlying the dysphagia,
+reliance is placed upon dilatation of the portion of gullet affected.
+
+#Cardiospasm# is the name given to "a recurrent interference with
+deglutition by spasmodic contraction of the lower end of the
+oesophagus." As there is no muscular or nervous mechanism at the
+cardiac end of the oesophagus forming a true sphincter, the term
+"oesophagospasm" would be more accurate (D. M. Greig).
+
+According to H. S. Plummer, who has had an experience of 130 cases,
+there are three stages in the development of this condition. In the
+initial stage, the first attack occurs suddenly and unexpectedly; a
+choking sensation is felt at some point in the gullet, usually at its
+lower end. Attacks of choking with difficulty in swallowing occur
+chiefly at meals, but they have also been known to occur apart from
+the taking of food. In this stage the peristalsis of the gullet is
+sufficient to force the food through the cardia.
+
+In the second stage, the peristalsis of the gullet above being no
+longer able to overcome the contraction, there is regurgitation of
+food, which at first is returned to the mouth immediately after being
+swallowed, but, as the gullet becomes dilated, is retained for longer
+periods.
+
+In the third stage, the gullet becomes more and more dilated, and the
+food collects in it and is regurgitated at irregular intervals. The
+patient complains of a sensation of weight and discomfort in the lower
+part of the chest, and sometimes of regurgitation of food into the
+nasal passages during sleep.
+
+Cardiospasm should be suspected as the cause of difficulty in
+swallowing if a rubber tube cannot be passed into the stomach while a
+solid one can. When it is impossible to pass a solid instrument in the
+ordinary way it can always be passed on a silk thread as a guide. The
+patient is directed to swallow 6 yards of silk thread, half in the
+afternoon and the remainder on the following morning. The first
+portion forms a snarl in the gullet or stomach which passes out into
+the intestine during the night; the proximal end is fixed to the cheek
+by a strip of plaster. The olive heads of the bougies are drilled for
+threading from the tip to one side of the base.
+
+The _treatment_ consists in dilating the contracted segments by a
+bougie. The results are immediate and are most striking, the patients
+being almost invariably able to take any kind of food at the following
+meal, and the gain in weight and strength is rapid. In a small
+proportion of cases, dilatation fails to give relief, and recourse has
+been had to anastomosing the lower end of the dilated and pouched
+oesophagus with the stomach.
+
+#Paralysis of the Gullet.#--As the passage of the food along the
+gullet is entirely dependent upon muscular peristalsis, when the
+muscular coat is paralysed, as it may be after diphtheria, for
+example, the patient is unable to swallow and the food materials are
+regurgitated, with consequent loss of flesh and strength. The
+difficulty may be tided over for a time by feeding through a rubber
+tube, but it is to be remembered that, in children, struggling in
+resisting the passage of the tube may seriously strain a heart that is
+already threatened by the toxins of diphtheria.
+
+#Diverticula or Pouches of the Gullet.#--A diverticulum consists in
+the protrusion of the mucous and submucous coats through a defect or
+weak part in the muscular tunic; it is therefore of the nature of a
+hernia and not a localised dilatation of the tube as a whole.
+Anatomically, there is such a weak spot in the posterior wall opposite
+the cricoid cartilage, known as the _pharyngeal dimple_, between the
+circular and oblique fibres of the crico-pharyngeus muscle. As the
+pouch increases in size by pressure from within, it usually extends
+downwards and to the left. This pouch is described as a _pressure or
+pulsion diverticulum_ because the hernial protrusion is ascribed to
+increased pressure within the pharynx, not only the normal increase
+caused by the act of swallowing, but an abnormal pressure from the too
+rapid swallowing or bolting of imperfectly masticated food materials.
+
+[Illustration: FIG. 285.--Radiogram, after swallowing an opaque meal,
+in a man suffering from malignant stricture of lower end of Gullet.]
+
+The _clinical features_ are not so characteristic of difficulty in
+swallowing as might be expected. The patient, usually a man over forty
+years of age, complains of dryness in the throat and of a sensation as
+of a foreign body; later there is regurgitation of saliva and of food
+with occasional choking. In about one-third of the cases, there is a
+fullness, or a palpable tumour in the neck, about three times more
+often on the left than on the right side, which may increase in size
+after a meal, and pressure on which may cause a gurgling sound and, it
+may be, regurgitation of food.
+
+It is suggestive of a pouch, if the patient regurgitates food
+materials which can be identified as having been swallowed several
+days before, currants perhaps being those most easily recognised and
+remembered.
+
+Diverticula are also met with at a lower level, springing from the
+gullet at or below the upper opening of the thorax; the distension of
+the pouch with food materials presses upon the gullet with more
+serious effect, even to the extent of complete obstruction and
+consequent rapid emaciation. In men over fifty, the resemblance to
+carcinoma may be very close.
+
+In this, as in all cases of difficulty in swallowing, chief stress
+should be laid on the X-ray appearances after the administration of an
+opaque meal; a pouch shows as a uniform, spherical shadow of from one
+to two inches in circumference.
+
+_Treatment_ is influenced by the manner in which the patient may have
+learned to overcome the difficulty of getting food into his
+stomach--Lord Jeffrey, who was the possessor of the pharyngeal pouch
+shown in Fig. 286, was in the habit of emptying it, after a meal, by
+means of a long silver spoon. Some patients learn to feed themselves
+through a soft rubber tube.
+
+[Illustration: FIG. 286.--Diverticulum of the Oesophagus at its
+junction with the Pharynx.
+
+(Anatomical Museum, University of Edinburgh.)]
+
+If an _operation_ is decided upon, and for this it is essential that
+the pouch should be accessible from the neck, the general condition is
+improved by feeding through a stomach tube and by rectal and
+subcutaneous salines. The operation consists in exposing and isolating
+the pouch by a dissection on the left side of the neck, and either
+excising it as if it were a tumour or cyst, or if the risk of
+infection of the deeper planes of cellular tissue is regarded with
+apprehension, the pouch may be _infolded_ into the lumen of the
+gullet, or the excision be carried out in two _stages_. At the first
+stage, the pouch is isolated and rotated on its pedicle, in which
+condition it is fixed by sutures; after an interval of from ten to
+fourteen days it is excised.
+
+Should the diverticulum be inaccessible from the neck, and the
+difficulty of swallowing be attended with progressive emaciation,
+_gastrostomy_ may be required to avert death by starvation.
+
+_Traction diverticula_ are due to the contraction of scar tissue
+outside the gullet, as for example that resulting from tuberculous
+glands in the posterior mediastinum; they are rarely attended with
+symptoms, and are rather of pathological than surgical interest.
+
+#Innocent Stricture or Cicatricial Stenosis of the Gullet.#--The
+innocent or fibrous stricture follows upon the swallowing of corrosive
+substances, usually by inadvertence, sometimes with suicidal intent.
+Having recovered from the initial effects of the corrosive agent, the
+patient suffers from gradually increasing difficulty in swallowing,
+first with solids and later with fluids. There is the usual variation
+or intermittence of symptoms that attend upon all conditions causing
+difficulty of swallowing, the exacerbations being due to superadded
+spasm of the muscular coat and congestion of all the coats. As the
+gullet dilates above the stricture, there is an increasing
+accumulation of what has been swallowed, and this the patient
+regurgitates at intervals; this is usually described as "vomiting,"
+but the material ejected shows no signs of gastric digestion. There is
+pain referred to the epigastrium or between the shoulder-blades, the
+patient suffers from hunger and thirst, and may present an extreme
+degree of emaciation.
+
+The _diagnosis_ is suggested by the history, and is confirmed by the
+oesophagoscope or by the X-rays after an opaque meal. The use of
+bougies has taken a secondary place since the introduction of these
+methods of examination, but, when other means are not available, the
+passage of bougies having a whalebone shaft and a series of metal
+heads shaped like an olive, may give useful information regarding the
+site, number, and size of the strictures that require to be dealt
+with.
+
+_Treatment._--If the patient is in a critical state from starvation,
+gastrostomy must be performed to enable him to be fed; otherwise he is
+prepared for treatment of the stricture by rest in bed, sedatives, and
+suitable liquid or some solid foods to improve his general condition
+and eliminate the muscular spasm and congestion already referred to.
+If the passage of bougies with the object of dilating the stricture is
+difficult or impossible, it may be made easier or possible by getting
+a silk thread through the stricture. The patient swallows several
+yards of a reliable silk thread a day or two before the proposed
+dilatation is carried out; the thread is expected to pass through the
+stricture of the stomach, and to enter for some distance into the
+small intestine; the metal head of the bougie, which is canalised in
+its long axis, is "threaded" on the silk, and the latter acting as a
+guide, the bougie is passed safely and confidently through the
+stricture. Larger olive-shaped heads are passed at intervals until the
+normal calibre of the gullet is exceeded, after which it is usually
+easy to pass an ordinary full-sized instrument at intervals of a month
+or so.
+
+In the event of failure, recourse must be had to gastrostomy, and
+through the stomach it may be possible to dilate the stricture by the
+"retrograde" route. In aggravated cases, the gastrostomy opening must
+be retained in order to prevent death from starvation.
+
+#Malignant Stricture--Carcinoma of the Gullet.#--This is met with in
+two forms which present widely different pathological and clinical
+features.
+
+Cancer of the _cervical_ portion affects the gullet at its junction
+with the pharynx, and for some unexplained reason is much more common
+in women, and at the comparatively early age of between thirty and
+fifty. Cancer of the _thoracic_ portion affects the extreme lower end
+of the gullet, and is met with almost exclusively in men over fifty.
+
+#Cancer of the Cervical Portion.#--Difficulty of swallowing may arise
+suddenly; more often it is slow and progressive over a period of
+months and, in some cases, even of years. Pain on swallowing is not a
+constant or prominent feature; it may be referred to the site of the
+lesion or to one or both ears. In a considerable number of cases, the
+complaints of the patient are referred to the larynx; coughing, with
+abundant mucous expectoration disturbing the night's rest, hoarseness,
+or even loss of voice, which symptoms are due either to direct
+invasion of the larynx or to implication of one or other recurrent
+nerve; for the same cause, difficulty of breathing may supervene,
+sometimes of such a nature as to render tracheotomy imperative. A
+gurgling noise on swallowing, and regurgitation of food are
+occasionally observed.
+
+Palpation of the neck, and particularly of the larynx and trachea,
+should be carried out in all cases presenting the symptoms described;
+and as bearing on the question of operation, enlargement of the
+cervical lymph glands and of the thyreoid should be looked for; cancer
+of the thyreoid is sometimes secondary to disease at the
+pharyngo-oesophageal junction.
+
+Direct and indirect laryngoscopic examination is then made; if the
+laryngeal mirror fails to reveal anything abnormal, suspension
+laryngoscopy, which gives a more extensive view of that part of the
+pharynx lying behind the larynx, may be employed, or the
+oesophagoscope may be preferred. A portion of the growth may be
+removed for microscopical examination.
+
+The use of the oesophageal bougie as a diagnostic agent must be
+deprecated; it gives no satisfactory explanation of the cause of the
+obstruction, and its employment when malignant ulceration is present,
+is not free from serious risk to the patient (Logan Turner).
+
+_Treatment._--The surgeon is dependent on the help of the
+laryngologist not only for the diagnosis of the disease at the
+earliest stage possible, but also for information as to its extent,
+especially with regard to involvement of the larynx.
+
+_Oesophagectomy_, or resection of the cancerous segment of the gullet,
+in suitable cases, even if it does not yield a permanent cure, not
+only prolongs life but relieves the patient of her most distressing
+symptoms. It is rarely possible to secure an end-to-end anastomosis,
+but the feeding by means of a tube introduced into the open end of the
+gullet is more satisfactory and the laryngeal symptoms are more
+efficiently relieved, than by either of the purely palliative
+operations. In the majority of cases, however, only the palliative
+measures of _oesophagostomy_ or _gastrostomy_ can be adopted.
+Oesophagostomy presents the advantage, that by exposing the cervical
+portion of the gullet, the operator is enabled to investigate the
+extent of the disease and to revise his opinion on the feasability of
+its removal if necessary. In advanced cases, when the disease has
+spread widely in the neck and involved, it may be, the thyreoid and
+the larynx, it may only be possible to relieve the urgent distress of
+the patient by gastrostomy. _Tracheotomy_ may also become necessary
+because of the spread of the cancer to the interior of the larynx.
+
+#Cancer of the Lower End of the Gullet.#--The remarkable preference of
+this location of oesophageal cancer for the male sex has already been
+referred to; it affects the same type of male patients as are subject
+to squamous epithelioma in other parts of the body. So far as we have
+observed, its association with chronic irritation of the mucous
+membrane in which it takes origin, or with any pre-cancerous
+condition, has not been demonstrated.
+
+The _clinical features_ resemble those of cicatricial stricture; the
+difficulty of swallowing is usually of gradual onset, it concerns
+solids in the first instance, then semi-solids like porridge or bread
+and milk, and finally fluids. As in other forms of oesophageal
+obstruction, the difficulty of swallowing varies quite remarkably from
+time to time, presumably from variations in the degree of congestion
+of the mucous membrane and of spasm of the muscular coat, but also
+from mere nervousness, the patient having greater difficulty when in a
+hurry, as in a railway refreshment room, or embarrassed by the
+presence of strangers.
+
+As the lumen of the gullet becomes narrower, the food materials
+accumulate above the obstruction, and the consequent dilatation of the
+gullet above the stricture accounts for the large amount that may be
+regurgitated and for the patient describing it as vomiting. Along with
+food materials there is abundant saliva, and, if the cancer has
+ulcerated, of pus and blood. Contrary to what might be expected, there
+is little or no complaint of hunger, in spite of the progressive
+starvation and emaciation which inevitably supervene.
+
+Death takes place within a year or so of the onset of symptoms,
+usually from starvation, but the fatal issue may be precipitated by
+ulceration and perforation of the gullet into a large blood vessel or
+into the left pleural sac; in the latter event, there follows a basal
+_empyema_ which may contain gas and food materials.
+
+_Diagnosis._--In the majority of cases the history is so
+characteristic that there is little doubt regarding the diagnosis; the
+most reliable corroboration, with least risk and distress to the
+patient, is obtained by radiographic examination after an opaque meal;
+the appearance of the dilated gullet is that of an elongated sausage,
+parallel with the vertebral column, and terminating abruptly at the
+site of stricture (Fig. 285). A filiform, tortuous shadow of the
+bismuth may be continued downwards and show up the lumen of the
+stricture. The use of the oesophagoscope and of bougies is to be
+deprecated as not free from risk.
+
+_Treatment._--The lower end of the gullet is one of the most
+inaccessible portions of the body, and although it has been removed by
+operation the prospects of success are so small that it is not at
+present regarded as justifiable.
+
+Among _palliative measures_, may be mentioned _intubation_ of the
+stricture with a view to increasing the amount of food that can be
+swallowed; a funnel-shaped tube like that of Symonds or of Hill is
+introduced into the lumen of the stricture by means of a bougie or
+with the help of the oesophagoscope. The tube is anchored
+to a denture, or by means of a silk thread to the cheek by
+sticking-plaster. Our experience of intubation is that it merely
+serves to tide the patient over a critical period of starvation, so
+that he may regain some strength for any other procedure that may be
+indicated.
+
+The value of making a fistula in the stomach--_gastrostomy_--in order
+to feed the patient, is a question about which widely different
+opinions are held both by patients and by surgeons. Many patients
+allege that they would prefer to die rather than prolong a precarious
+existence by being fed through a tube; some surgeons look upon the
+operation with disfavour because they doubt whether it even prolongs
+life, and it is often followed by a pneumonia which rapidly proves
+fatal. Variation in the results of gastrostomy observed by different
+surgeons is partly due to differences in the stage of the disease at
+which the operation is performed, and probably to a greater extent to
+the confusion between cases of slowly growing squamous epithelioma of
+the lower end of the gullet and cases of glandular carcinoma of the
+cardiac end of the stomach, these being grouped together under the
+clinical heading of "malignant stricture of the lower end of the
+gullet." In our experience cases of epithelioma of the gullet (in the
+strict sense of the term) benefit greatly if subjected to gastrostomy
+as soon as the condition is recognised. In a case operated upon by
+Thomas Annandale the patient survived the operation for three years
+and some months.
+
+_Radiation._--The introduction of a tube of radium into the stricture
+and its retention there, the silk thread attached to the tube being
+secured to the cheek by a strip of plaster, is described by Hill and
+Finzi as the most valuable palliative measure that has so far been
+employed in cancer of the gullet; the capacity of swallowing may be
+regained to a considerable extent. The employment of radium is
+rendered easier and more efficient if it is preceded by gastrostomy.
+
+_The Roux-operation._--This consists in making a new gullet to replace
+that which is obstructed; the abdomen is opened and a loop of jejunum
+is isolated; its lower end is anastomosed--end to side--to the
+stomach; the intestine is brought upwards through a tunnel made for it
+between the skin and the sternum, and the upper end is brought out and
+fixed to the skin, in the supra-sternal notch. It has scarcely passed
+beyond the experimental stage.
+
+
+
+
+CHAPTER XXIX
+
+THE LARYNX, TRACHEA, AND BRONCHI[7]
+
+
+Examination of the larynx--CARDINAL SYMPTOMS OF LARYNGEAL AFFECTIONS:
+ (1) Interference with the voice: _Hoarseness_; _Aphonia_--(2)
+ Dysphagia--(3) Interference with respiration: _Diphtheritic
+ laryngitis_; _Acute oedema of the larynx_; _Intubation of the
+ larynx_; _Tracheotomy_; _Bilateral abductor paralysis_;
+ _Syphilitic affections_; _Tuberculosis_--Tumours: _Papilloma_;
+ _Epithelioma_; _Sarcoma_--Foreign bodies in the air-passages: _In
+ the pharynx_, _larynx_, _trachea_, _bronchi_.
+
+[7] Revised by Dr. Logan Turner.
+
+#Examination of the Larynx.#--For this purpose the examiner requires a
+laryngeal reflector with forehead attachment, one or two sizes of
+laryngeal mirror, a tongue cloth, and the means of obtaining good
+illumination. The source of light should be by preference placed
+opposite to and on the same horizontal plane as the patient's left
+ear. The forehead reflector is placed over the observer's right eye so
+that he may look through the central aperture, while at the same time
+he throws a good circle of light into the patient's mouth. The patient
+should be seated with the head thrown slightly back; the tongue is
+protruded and covered with the cloth, and held lightly but firmly
+between the finger and thumb of the left hand. A full-sized mirror,
+warmed so as to prevent the condensation of the breath upon it, is
+inserted with the reflecting surface turned downwards, and pressed
+gently against the soft palate so as to push that structure upwards.
+The handle of the instrument is carried towards the left angle of the
+mouth, and by slightly altering the plane of the reflecting surface of
+the mirror the different parts of the larynx are in turn brought into
+view. The movements of the vocal cords should be observed during both
+respiration and phonation, and for the latter purpose the patient
+should be directed to phonate the vowel sound "eh."
+
+In the upper part of the mirror the epiglottis usually comes first
+into view: it is of a pinkish yellow colour, and presents a thin,
+sharply defined free margin. In front of the epiglottis are the median
+and lateral glosso-epiglottic folds passing forwards to the base of
+the tongue, and enclosing the two valleculæ. Extending backwards and
+downwards from the lateral margins of the epiglottis are the two
+ary-epiglottic folds which reach the arytenoid cartilages posteriorly.
+Between the two layers of mucous membrane of which the ary-epiglottic
+folds are composed are the cartilages of Wrisberg and Santorini. In
+the interval between the two arytenoid cartilages is the
+inter-arytenoid fold of mucous membrane, which forms the upper margin
+of the posterior wall of the larynx. The upper aperture of the larynx
+is bounded by the epiglottis in front, the ary-epiglottic folds
+laterally, and the inter-arytenoid fold behind. In the interior of the
+larynx the vocal folds (true vocal cords) form the most prominent
+features, being conspicuous as two flat white bands, which form the
+boundary of the rima glottidis or glottic chink. Above each true cord,
+and parallel with it, the ventricular fold or false cord is evident as
+a pink fold of mucous membrane. Between the ventricular fold and the
+vocal fold on each side is a linear interval, which indicates the
+entrance to the ventricle of the larynx.
+
+_Direct Laryngoscopy._--The larynx may also be examined by the direct
+method by means of Jackson's or Killian's spatulæ. After cocainisation
+of the base of the tongue, the soft palate, and the posterior surface
+of the epiglottis, the patient is seated upon a low stool and his head
+supported by an assistant. The light is obtained from a small lamp in
+the handle of the instrument or reflected from a forehead mirror. The
+spatula is warmed and introduced under the guidance of the eye, its
+end being passed over the epiglottis, and pressure exerted so as to
+draw the latter structure forward. In children a general anæsthetic is
+required, and the examination is made with the head hanging over the
+end of the table. Killian's "suspension laryngoscopy" affords the best
+method of examining the larynx in young children.
+
+_Tracheoscopy and Bronchoscopy._--Direct examination of the trachea
+and larger bronchi may be carried out in a similar way, by passing
+through the mouth and larynx metal tubes, after the method devised by
+Killian. This procedure is described as direct upper tracheoscopy and
+bronchoscopy. The examination may also be made through a tracheotomy
+wound--direct lower tracheoscopy. These procedures have proved of
+great service in the recognition of foreign bodies in the lower
+air-passages, and in their extraction; in the diagnosis of stenosis of
+the trachea, and of aneurysm pressing on the trachea.
+
+
+CARDINAL SYMPTOMS OF LARYNGEAL AFFECTIONS
+
+The cardinal symptoms of laryngeal affections are interference with
+the voice and with respiration, and pain on swallowing. Laryngeal
+cough of a croupy or barking character may be present, and is usually
+associated with a lesion of the posterior wall or inter-arytenoid
+fold. Hæmoptysis is seldom of laryngeal origin, and unless the
+bleeding spot is visible in the mirror, the source of the bleeding is
+much more likely to be in the bronchi or lungs.
+
+#Interference with the Voice.#--_Hoarseness_ results from some
+affection of the vocal cords: it may be simple laryngitis, some
+specific cause such as tuberculosis or syphilis, or some condition
+which prevents the proper approximation of the cords, as in tumours
+and certain forms of paralysis. Huskiness of voice occurring in a
+middle-aged person, lasting for a considerable period, and unattended
+by any other local or constitutional symptom, should always arouse
+suspicion of malignant disease, and calls for an examination of the
+larynx. Should this reveal a congested condition of one vocal cord,
+associated with some infiltration, and should the mobility of the cord
+be impaired, suspicion of the malignant character of the affection is
+still further increased. The hoarseness in these cases is sometimes
+greater than the local appearances would seem to account for.
+
+_Aphonia_, or loss of voice, sudden in origin, and sometimes
+transient, occurs more often in women, and is usually functional or
+hysterical in nature. Although the patient is unable to speak, she is
+quite able to cough. In these cases there is a bilateral paralysis of
+the adductor muscles, so that the cords do not approximate on
+attempted phonation; or the internal tensors may be paretic, leaving
+an elliptical space between the cords on attempted phonation. If the
+arytenoideus muscle alone is paralysed, a triangular interval is left
+between the cords posteriorly. There is no inflammation or other
+evidence of local disease.
+
+The _treatment_ of functional aphonia should be general and local;
+tonics such as strychnin, iron, and arsenic should be administered;
+the intra-laryngeal application of electricity usually effects a
+sudden cure. In obstinate cases the use of the shower-bath and cold
+douching, the administration of chloroform, and even hypnotism may be
+tried.
+
+An examination of the lungs should be made in all cases of adductor
+paralysis, as this functional condition may be met with in early
+pulmonary tuberculosis.
+
+#Dysphagia.#--Pain on swallowing, due to causes originating in the
+larynx, is usually associated with ulceration of the mucous membrane
+covering the epiglottis, ary-epiglottic folds, or arytenoid
+cartilages, that is, in connection with those parts with which the
+food is brought into direct contact.
+
+The most frequent causes of such ulceration are tuberculosis,
+syphilis, and malignant disease. The differential diagnosis is often
+difficult from local inspection alone. The Wasserman test, the
+previous history, the state of the lungs and sputum, and the results
+of anti-syphilitic treatment may clear it up.
+
+The _treatment_ of dysphagia, apart from that of the disease
+associated with it, resolves itself into the use of local sedative
+applications, such as a weak cocain or eucain spray before meals,
+insufflations of acetate of morphin and boracic acid, and the use of a
+menthol spray. One of the best anæsthetic applications is orthoform
+powder, introduced by means of the ordinary laryngeal insufflator. Its
+action is more prolonged than that of any of the others, often
+lasting for from twenty-four to forty-eight hours.
+
+Injection of the superior laryngeal nerve with a 60 per cent. solution
+of alcohol has been found satisfactory where other means have failed.
+
+#Interference with Respiration.#--It is only necessary here to refer
+to such causes of interference with respiration as may call for
+surgical treatment.
+
+The chief forms of _laryngitis_ to be considered in connection with
+the production of dyspnoea, are membranous or diphtheritic laryngitis
+and acute inflammatory oedema.
+
+#Diphtheria of the larynx# is described on p. 110, Volume I.
+
+#Acute Oedema of the Larynx.#--Oedema of the larynx may be
+inflammatory or non-inflammatory in origin. The former is the more
+common, and may arise in connection with disease of the larynx, such
+as tuberculosis or syphilis, or it may be secondary to acute infective
+conditions at the base of the tongue, or in the fauces or pharynx;
+more rarely it results from infective conditions of the cellular
+tissue or glands of the neck. The non-inflammatory form may be a local
+dropsy in renal or cardiac disease, may be induced by pressure on the
+large cervical veins, and in some cases it appears to follow the
+administration of potassium iodide in the treatment of laryngeal
+affections.
+
+The oedema consists of an exudation into the loose submucous areolar
+tissue, which may be of a simple serous character or may
+become sero-purulent. The situations mainly involved are the
+glosso-epiglottic fossæ between the base of the tongue and the
+epiglottis, the ary-epiglottic folds (Fig. 287), and the false cords.
+If the infective process commences in front of the epiglottis this
+structure becomes swollen and rigid, and often livid in
+colour--points which are readily discerned on examination with the
+mirror, or even without its aid in some cases. The patient complains
+of great pain on swallowing, and has the sensation of a foreign body
+in the throat. Should the oedema spread to the ary-epiglottic folds,
+either from the interior of the larynx or from the fauces and pharynx,
+dyspnoea becomes a prominent and grave symptom. The patient may
+rapidly become cyanosed, the inspirations assume a noisy, stridulous
+character, and great distress and imminent suffocation supervene. If
+laryngoscopic examination is possible, the ary-epiglottic folds may be
+found greatly swollen and the upper aperture of the larynx partly
+occluded. Digital examination may reveal the swollen condition of the
+parts. The urine should be examined for albumin and tube casts.
+
+[Illustration: FIG. 287.--Larynx from case of sudden death, due to
+oedema of ary-epiglottic folds, _a_, _a_.
+
+(From drawing lent by Dr. Logan Turner.)]
+
+_Treatment._--In the milder forms, the sucking of ice, the inhalation
+of medicated steam, or spraying with a solution of adrenalin, and the
+application of poultices to the neck, may suffice to relieve the
+condition. Scarification of the epiglottis and ary-epiglottic folds
+with a knife, followed by free bleeding, may give complete relief.
+Diaphoretic and purgative treatment should not be neglected. If
+suffocation is imminent, tracheotomy or intubation is called for.
+
+In performing #tracheotomy#, a roller pillow is placed beneath the
+neck to put the parts on the stretch, and an incision is carried from
+the lower margin of the cricoid cartilage downwards for about 2
+inches. The sterno-hyoids and sterno-thyreoids are separated; the
+cross branch between the anterior jugular veins, and any other veins
+met with, secured with forceps before being divided; and the trachea
+exposed by dividing transversely the layer of deep fascia which passes
+from the cricoid to the isthmus of the thyreoid. If the isthmus cannot
+be pulled downwards sufficiently, it may be divided in the middle
+line. All active bleeding having been arrested, the larynx is steadied
+by inserting a sharp hook into the lower edge of the cricoid
+cartilage, and the trachea is opened by thrusting a short,
+broad-bladed knife through the exposed rings. The back of the knife
+should be directed downwards, and the opening in the trachea enlarged
+upwards sufficiently to admit the tracheotomy tube. In children it is
+sometimes found necessary to divide the cricoid for this purpose
+(_laryngo-tracheotomy_). The slit in the trachea is then opened up
+with a tracheal dilator, and the outer tube inserted and fixed in
+position with tapes. The inner tube is not fixed, so that it may be
+coughed out if it becomes blocked, and that it may be frequently
+removed and cleaned by the nurse. The tube should be discarded as
+soon as the patient is able to breathe by the natural channel.
+
+_Intubation of the Larynx._--This procedure is employed as a
+substitute for tracheotomy, especially in children suffering from
+membranous and oedematous forms of laryngitis. As experience is
+required to carry out the manipulations successfully, and as its use
+is attended with certain risks which necessitate that the surgeon
+should be constantly within call, the operation is more adapted to
+hospital than to private practice. O'Dwyer's apparatus is that most
+generally employed. The operation consists in introducing through the
+glottis, by means of a specially constructed guide, a small metal or
+vulcanite tube furnished with a shoulder which rests against the false
+vocal cords. The part of the tube which passes beyond the true vocal
+cords is bulged to prevent it being coughed out.
+
+In an emergency a gum-elastic catheter with a terminal aperture may be
+passed, as recommended by Macewen and Annandale.
+
+#Bilateral Abductor Paralysis.#--Both recurrent nerves may be
+interfered with by such conditions as enlargement of the thyreoid,
+tumour of the oesophagus, or intra-thoracic tumour, or by injury in
+the course of operations for goitre. A gradually increasing
+inspiratory dyspnoea is developed, which at first is only noticed on
+exertion, when the desire for air is increased; later it becomes
+permanent, and even during sleep the stridor may be marked.
+Suffocation may become imminent. When the larynx is examined with the
+mirror, the vocal cords are seen to lie near each other, and on
+inspiration their approximation is still greater.
+
+The _treatment_ is directed to removing the cause of pressure on the
+nerves. In the majority of cases tracheotomy is called for and the
+tube must be worn permanently.
+
+#Syphilitic Affections of the Larynx.#--_Secondary syphilitic_
+manifestations in the form of congestion of the mucous membrane,
+mucous patches, or condylomata, are occasionally met with, and give
+rise to a huskiness of the voice. These conditions usually disappear
+rapidly under anti-syphilitic treatment.
+
+In _tertiary syphilis_, whether inherited or acquired, the most common
+lesion is a diffuse gummatous infiltration, which tends to go on to
+ulceration and to lead to widespread destruction of tissue. It usually
+attacks the epiglottis, the arytenoids, and the ary-epiglottic folds,
+but may spread and implicate all the structures of the larynx.
+Syphilitic ulcers are usually single, deep, and crateriform; the base
+is covered with a dirty white secretion, and the surrounding mucosa
+presents an angry red appearance. When the perichondrium becomes
+invaded, necrosis of cartilage is liable to occur.
+
+Hoarseness, dyspnoea, and, when the epiglottis is involved, dysphagia,
+are the most prominent symptoms.
+
+Cicatricial contraction leading to stenosis may ensue, and cause
+persistent dyspnoea.
+
+The usual _treatment_ for tertiary syphilis is employed, but on
+account of the tendency of potassium iodide to increase the oedema of
+the larynx, this drug must at first be used with caution. Intubation
+or tracheotomy may be called for on account of sudden urgent dyspnoea
+or of increasing stenosis. The stenosis is afterwards treated by
+gradual dilatation with bougies, which, if a tracheotomy has been
+performed, may conveniently be passed from below upwards. An annular
+stricture causing occlusion may be excised, and the ends of the
+trachea sutured.
+
+#Tuberculosis.#--The larynx is seldom the primary seat of tubercle. In
+the majority of cases the patient suffers from pulmonary phthisis, and
+the laryngeal mucous membrane is infected from the sputum. The disease
+may take the form of isolated nodules in the vicinity of the arytenoid
+cartilages, of superficial ulceration of the vocal cords and adjacent
+parts, or of a diffuse tuberculous infiltration of all the structures
+bounding the upper aperture of the larynx. The mucous membrane becomes
+oedematous and semi-translucent. The nodules coalesce and break down,
+leading to the formation of multiple superficial ulcers. The parts
+adjacent to the ulcers are pale in colour. Perichondritis may occur
+and be followed by necrosis of cartilage and the formation of
+abscesses in the submucous tissue of the larynx or in the cellular
+tissue of the neck.
+
+The voice becomes hoarse or may be lost, there is persistent and
+intractable cough, and in some cases dyspnoea supervenes. When the
+epiglottis is involved there is pain and difficulty in swallowing.
+
+In the presence of advanced pulmonary phthisis the treatment is
+chiefly palliative, but if the disease in the lungs is amenable to
+treatment, and the laryngeal lesion limited, the electric cautery may
+be used. Tracheotomy may be called for on account of urgent dyspnoea.
+
+#Tumours.#--The commonest form of simple tumour met with in the larynx
+is the _papilloma_. It may occur at any age, and is comparatively
+common in children. It most frequently springs from the vocal cords
+and adjacent parts, forming a soft, pedunculated, cauliflower-like
+mass of a pink or red colour, which may form a fringe hanging from
+the edge of the cord (Fig. 288), or may spread until it nearly fills
+the larynx. In children, the growths are frequently multiple and show
+a marked tendency to recur after removal. They sometimes disappear
+spontaneously about puberty.
+
+[Illustration: FIG. 288.--Papilloma of Larynx.
+
+(From drawing lent by Dr. Logan Turner.)]
+
+The most prominent symptoms are hoarseness, aphonia, and dyspnoea,
+which in children may be paroxysmal.
+
+The _treatment_ consists in removing the growth by means of laryngeal
+forceps or the snare, under cocain and adrenalin anæsthesia. For the
+removal of multiple papillomata, the removal of the growths through
+Killian's tubes or by suspension laryngoscopy has now taken the place
+of the external operation in children. In a certain number of cases it
+has been found that the tumour disappears after the larynx has been
+put at rest by the operation of tracheotomy.
+
+#Cancer.#--_Epithelioma_ of the larynx is almost always primary, and
+usually occurs in males between the ages of forty and seventy. It is
+important to distinguish between those cases in which the growth first
+appears in the interior of the larynx--on the vocal cords, the
+ventricular bands, or in the sub-glottic cavity (_intrinsic
+cancer_)--and those in which it attacks the epiglottis, the
+ary-epiglottic folds, or the posterior surface of the cricoid
+cartilage (_extrinsic cancer_).
+
+_Clinical Features._--In the great majority of cases of _intrinsic_
+cancer the first and for many months the only symptom is huskiness of
+the voice, which may go on to complete aphonia before any other
+symptoms manifest themselves. When the larynx is examined in an early
+stage, the presence of a small warty growth on the posterior part of
+one vocal cord, or a papillary fringe extended along the free edge of
+the cord, should raise the suspicion of malignancy, especially if the
+affected cord is congested and moves less freely than its fellow.
+Early diagnosis is essential in intrinsic cancer, and the absence of
+enlargement of lymph glands, or of foetor and cachexia, must in no way
+influence the surgeon against making a diagnosis of malignancy. The
+impaired mobility of the affected cord is an important point in
+determining the malignant nature of the growth.
+
+Intrinsic cancer may spread over the upper boundaries of the larynx
+and become _extrinsic_, or the disease may be extrinsic from the
+outset.
+
+In cases of _extrinsic_ cancer the early symptoms are much more
+marked, pain and difficulty in swallowing, and the secretion of
+frothy, blood-stained mucus being among the earliest manifestations.
+The cervical glands are infected early, sometimes even before there
+are any symptoms of laryngeal disease. Difficulty of breathing is also
+an early symptom on account of the growth obstructing the entrance of
+air. Tracheotomy may therefore be called for. In other respects the
+course and terminations are similar to those of intrinsic cancer.
+
+When the growth spreads into the tissues of the neck the patient's
+sufferings are greatly increased. The oesophagus may be invaded with
+resulting dysphagia; the nerve-trunks may be pressed upon, causing
+intense neuralgic pains; the lymph glands become infected and break
+down, and the growth fungates through the skin. The general health
+deteriorates and death results, usually from septic pneumonia set up
+by the passage of food particles into the air-passages, from
+absorption of toxins, or from hæmorrhage. The duration of this form of
+the disease varies from one to three years.
+
+The _treatment_ consists in removing the growth. In early and limited
+forms of intrinsic cancer laryngo-fissure (thyreotomy) gives good
+results; in more advanced cases the entire larynx must be
+removed--_complete laryngectomy_--and at the same time, or after an
+interval, the associated lymph glands are removed from the anterior
+triangle of the neck on both sides.
+
+In cases in which excision is impracticable, the sufferings of the
+patient may be alleviated by performing low tracheotomy, and by
+feeding with the stomach tube or by nutrient enemata. In some cases
+the difficulty of feeding the patient may make it necessary to perform
+gastrostomy.
+
+#Sarcoma# of the larynx gives rise to the same symptoms as cancer, and
+can seldom be diagnosed from it before operation.
+
+#Foreign Bodies in the Air-Passages.#--Foreign bodies impacted _in the
+pharynx_ usually consist of unmasticated pieces of meat or large
+tooth-plates, and they occlude both the food and the air-passages,
+frequently causing sudden death. They are considered with affections
+of the pharynx.
+
+The bodies most frequently impacted _in the larynx_ are small
+tooth-plates in the case of adults, and buttons, beads, sweets, coins,
+and portions of toys in children. These are drawn from the mouth into
+the air-passage during a sudden inspiratory effort, for example while
+laughing or sneezing. If the glottis is completely blocked, rapidly
+fatal asphyxia ensues. If the obstruction is incomplete, the patient
+experiences severe pain, difficulty of breathing, and a terrifying
+sensation of being choked. The irritation of the foreign body causes
+spasmodic coughing and retching, and may induce spasm of the glottis,
+with threatening suffocation.
+
+Small round bodies may lodge in the upper aperture or in one of the
+ventricles, and give rise to hoarseness and repeated attacks of
+dyspnoea and spasmodic cough. Wherever the body is situated, the
+symptoms may suddenly become urgent from its displacement into the
+glottis, or from the onset of oedema. The position of the body may
+often be ascertained by the use of the X-rays.
+
+_Treatment._--If the symptoms are urgent, laryngotomy, which consists
+in opening the larynx below the glottis by dividing the crico-thyreoid
+membrane, or tracheotomy must be performed at once, and an attempt
+made to remove the foreign body thereafter. In less severe cases in
+adults, the throat should be sprayed with cocain, and the larynx
+examined with the mirror; in children, the direct method must be
+employed. In both instances an attempt should be made to extract the
+body by the direct method. As these manipulations are liable to induce
+sudden spasm of the glottis, the means of performing tracheotomy must
+be at hand. If it is found impossible to remove the body through the
+mouth, laryngotomy or tracheotomy should be performed, and the body
+extracted through the wound, or pushed up into the pharynx and removed
+by this route. In the case of small bodies, a strand of gauze pushed
+up from the tracheotomy wound, through the larynx and out of the
+mouth, catches the foreign body and carries it out (Walker Downie).
+
+The foreign bodies that are most likely to become impacted _in the
+trachea_ are tooth-plates with projecting hooks, and small coins. The
+position of the foreign body may be ascertained by the use of
+Killian's tracheoscope, or by means of the X-rays. If the body remains
+movable in the trachea, it is apt to be displaced when the patient
+moves or coughs, and it may be driven up and become impacted in the
+glottis, setting up violent attacks of coughing and spasmodic
+dyspnoea.
+
+Tracheotomy should be performed at once, and the edges of the tracheal
+wound held widely open with retractors, the patient being inverted, or
+coughing induced by tickling the mucous membrane with a feather. The
+foreign body is usually expelled, but it may be inhaled into one of
+the bronchi. One of Killian's tracheal tubes may be introduced
+through the tracheotomy wound and the body extracted by means of
+suitable forceps.
+
+_Foreign Bodies in the Bronchi._--Rounded objects, which pass through
+the larynx, usually drop into one or other of the bronchi, usually the
+right, which is the more vertical and slightly the larger. The body
+may act as a ball-valve, permitting the escape of air with expiration,
+but preventing its entrance on inspiration, with the result that the
+portion of lung supplied by the bronchus becomes collapsed. The
+physical signs of collapse of a portion or of the whole lung may be
+recognised on examination of the chest. In some cases the body is
+dislodged and driven up into the larynx, causing severe dyspnoeic
+attacks and spasms of coughing. The irritation caused by the foreign
+body in the bronchus may set up bronchitis or pneumonia, and abscess
+of the lung may supervene. This has frequently followed the entrance
+of an extracted tooth into the air-passage, and it may be a
+considerable time before pulmonary symptoms arise. Sometimes the tooth
+is ultimately coughed up and the symptoms disappear. In some cases the
+physical signs closely simulate those of pulmonary phthisis.
+
+The _treatment_ consists in removing the body by the aid of Killian's
+or Jackson's tube passed through the mouth. If this is not successful,
+low tracheotomy is performed and the tube is passed through the
+tracheotomy opening.
+
+
+
+
+INDEX
+
+
+ Abducens nerve, 400
+
+ Abductor paralysis, 404, 639
+ splint, 221
+
+ Abscess. _See_ Individual Organs and Regions
+
+ Accessory nasal sinuses. _See_ Individual Sinuses
+ nerve, 404
+
+ Acetabulum, fracture of, 125
+ tuberculous disease of, 210
+ wandering, 210, 227
+
+ Achillo-bursitis, 294
+
+ Acoustic nerve, 579
+
+ Acromion process, fracture of, 69
+
+ Actinomycosis. _See_ Individual Organs and Regions
+
+ Adenoids, 578
+
+ Alveolar abscess, 507
+ process, fracture of, 519
+ tumours of, 513
+
+ Ambulant splint for ankle, 189
+ treatment of hip disease, 222
+
+ Amputation in compound fracture, 26
+
+ Anatomy. _See_ Surgical Anatomy
+
+ Angina Ludovici, 548, 597
+
+ Ankle, deformities of, 273
+ diseases of, 238, 240
+ dislocations of, 194
+ fractures in region of, 186, 187
+ injuries in region of, 185
+ surgical anatomy of, 185
+ tuberculous disease of, 238
+
+ Ankylosis of joints. _See_ Individual Joints
+
+ Anosmia, 399, 578
+
+ Anterior poliomyelitis, 242
+
+ Aphasia, 335
+
+ Aphonia, 636
+
+ Arm, upper, injuries of, 44
+
+ Arthritis. _See also_ Individual Joints
+
+ Arthritis, septic, 34
+
+ Arthrodesis, 246
+
+ Astragalus. _See_ Talus
+
+ Athetosis, 247
+
+ Atlo-axoid disease, 440
+ joint, fracture-dislocation of, 430
+
+ Auditory nerve, 403
+
+ Aural polypi, 558
+ vertigo, 555
+
+ Auricular appendages, 560
+
+ Avulsion of scalp, 322
+
+
+ Balkan frame splint, 150
+
+ Basedow's disease, 614
+
+ Bell's paralysis, 401
+
+ Bennett's fracture, 116
+
+ Bezold's mastoiditis, 566
+
+ Bier's constricting bandage, 12, 26
+
+ Black eye, 370, 484
+
+ Blepharospasm, 403
+
+ Bones, atrophy of, 2
+ contusion of, 1
+ fracture of, 1
+ gun-shot injuries of, 27
+ injuries of, 1
+ repair of, 8
+ wounds of, 1
+
+ Bow-knee, 271
+ -leg, 271
+
+ Box splint, 182
+
+ Brachial plexus, lesions of, 597
+
+ Brachio-thoracic triangle, 470
+
+ Bradford frame, 438
+
+ Brain, abscess of, 360, 374, 376, 378, 382
+ localisation of, 380
+ adhesions, 358
+ cerebral irritation, 342, 346
+ compression of, 347
+ differential diagnosis of, 350
+ concussion of, 341, 344
+ contusion of, 342
+ cyst of, hæmorrhagic, 344
+ decompression operations on, 396
+ diseases of, 373
+ pyogenic, 373
+ foreign bodies in, 350
+ functions of, 331
+ hæmorrhage into, 352
+ hernia of, 397
+ injuries of, 341
+ mechanism of, 343
+ repair of, 344
+ irritation of, 342, 346
+ laceration of, 342
+ lesions of, 341
+ localisation of centres in, 336
+ membranes of, 328
+ diseases of, 372
+ motor area of, 330
+ sclerosis of, 358
+ sensory mechanism of, 332
+ softening of, 342
+ surgical anatomy of, 328
+ syphilitic gumma, 395
+ traumatic oedema of, 343, 352
+ tuberculosis of, 395
+ tumours of, 393
+ localisation of, 394
+ wounds of, 357
+
+ Branchial carcinoma, 601
+ cysts, 598
+ fistulæ, 585
+
+ Broken back, 427
+
+ Bronchi, foreign bodies in, 644
+
+ Bronchocele. _See_ Goitre, 605
+
+ Bronchoscopy, 635
+
+ Bryant's triangle, 129
+
+ Bunion, 296
+
+
+ Cachexia strumipriva, 610
+
+ Calcaneus, fracture of, 193
+ separation of, tuberosity of, 193
+ spurs on, 294
+
+ Callipers, ice-tong, 165
+
+ Callus, absorption of, 10
+ excess of, 9
+ tumours of, 10
+ varieties of, 8
+
+ Cancrum oris, 497
+
+ Capitate bone, dislocation of, 114
+
+ Carcinoma. _See_ Cancer
+
+ Cardiospasm, 624
+
+ Carotid artery, internal, injuries of, 356
+ gland, tumours of, 603
+
+ Carpal bones, dislocation of, 113
+ fracture of, 110
+
+ Carpo-metacarpal dislocations, 115
+
+ Cauda equina, injuries of, 419
+
+ Caudal appendage, 458, 459
+
+ Cavernous sinus, phlebitis of, 386
+
+ Cellulitis. _See_ Individual Regions
+
+ Cephal-hydrocele, 321
+ traumatic, 390
+
+ Cephaloceles, 387
+
+ Cerebello-pontine angle, tumours of, 394
+
+ Cerebellum, abscess of, 381
+ tumours of, 394
+
+ Cerebral abscess, 360
+ apoplexy, 351
+ centres, 334
+ embolism, 351
+ hyperpyrexia, 348
+ irritation, 342, 346
+ localisation, 336
+ oedema, 352
+ palsies of childhood, 247
+ shock, 341, 344
+ softening, 358
+ tumours, 393
+ vomiting, 377
+
+ Cerebro-spinal fluid, 329, 339
+ meningitis, 378
+
+ Cerebrum. _See_ Brain
+
+ Cerumen in ear, 561
+
+ Cervical auricles, 583
+ caries, 440
+ fascia, 583
+ ribs, 585
+ sympathetic, 405, 615
+
+ Charcot's disease of hip, 228
+
+ Chauffeur's fracture, 106
+
+ Cheilotomy, 228
+
+ Chiene's test, 129
+
+ Cilio-spinal reflex, 405
+
+ Cirsoid aneurysm of scalp, 326
+
+ Clavicle, absence of, 303
+ dislocations of, 49
+ fracture of, 45
+
+ Cleft palate, 475, 477
+
+ Club-foot, 273
+
+ Club-hand, 311, 312
+
+ Coccydynia, 127, 450
+
+ Coccyx, fracture of, 127
+
+ Cock-up splint, 77
+
+ Coin-catcher, 622
+
+ Colles' fracture, 102
+ reversed, 106
+ unreduced, 106
+
+ Compound dislocation, 40
+
+ Compression of brain, 347
+
+ Compression fracture of spine, 426
+
+ Concussion of brain, 344
+ of spinal cord, 413
+
+ Congenital deformities, 241. _See_ Individual Regions
+ dislocation, 43. _See_ Individual Joints
+
+ Conus medullaris, injuries of, 419
+
+ Coracoid process, fracture of, 69
+ separation of epiphysis of, 70
+
+ Coronoid process, fracture of, 87
+
+ Coxa valga, 256, 261
+ vara, 136, 256, 257
+
+ Cranial nerves, affections of, 398. _See_ Individual Nerves
+
+ Cranium. _See_ Skull
+
+ Crepitus in fracture, 15, 30
+
+ Cricoid cartilage, fracture of, 593
+
+ Crossed-leg deformity, 224, 257
+
+ Cruciate ligaments, rupture of, 171
+
+ Cubitus valgus, 84, 308
+ varus, 84, 310
+
+ Cut-throat, 593
+
+
+ Deafness, varieties of, 553
+
+ Decompression of brain, 396
+
+ Deep sensibility, 332
+
+ Deformities of extremities, 241. _See_ Individual Regions
+
+ Dental caries, 507
+ ulcer of tongue, 529
+
+ Dentigerous cysts, 517
+
+ Diplacusis, 554
+
+ Dislocation. _See also_ Individual Joints and Bones
+ compound, 40
+ congenital, 43
+ by elongation, 96
+ with fracture, 40
+ habitual, 43, 65
+ old-standing, 40, 65
+ pathological, 43
+ recurrent, 43
+ traumatic, 36
+ varieties of, 37
+
+ Displacement of semilunar menisci, 168
+
+ Dorsal abscess, 444
+
+ Drop-finger, 318
+ wrist, 76, 311
+
+ Dugas' symptom in dislocation of shoulder, 54, 55
+
+ Dupuytren's contraction, 314
+ fracture, 187, 188, 196
+ splint, 190
+
+ Dysphagia, 623, 636
+
+
+ Ear, 553. _See also_ Tympanic membrane
+
+ Ear, aspergillus in, 562
+ boils, 562
+ cardinal symptoms of disease of, 554
+ deafness, 553, 554
+ deformities of, 560
+ discharge from, 555
+ earache, 554
+ eczema of, 562
+ foreign bodies in, 563
+ furunculosis of, 562
+ hearing tests, 555
+ inspection of, 556
+ middle, acute infection of, 564
+ chronic suppuration in, 565
+ inflation of, 558
+ noises in, 554
+ otorrhoea, 555
+ outstanding, 560
+ pain in, 554
+ physiology of, 553
+ polypi, 558
+ rupture of membrane of, 563
+ syringing of, 561
+ surgical anatomy of, 553
+ tumours of, 560
+ vertigo, 555
+ wax in, 561
+
+ Earache, 554
+
+ Ectropion, 483
+
+ Elbow, ankylosis of, 208
+ arthritis deformans of, 208
+ diseases of, 205
+ dislocations, congenital, 308
+ paralytic, 308
+ traumatic, 88, 92
+ examination of, 80
+ injuries in region of, 79
+ neuro-arthropathies of, 208
+ pyogenic diseases of, 208
+ sprain of, 96
+ surgical anatomy of, 79
+ tennis player's, 97
+ tuberculous disease of, 206
+
+ Empyema of knee, 232
+
+ Encephalitis, 376, 377
+
+ Encephalocele, 388, 389
+
+ Epicritic sensibility, 332
+
+ Epilepsy, 397
+ Jacksonian, 359
+ traumatic, 358
+
+ Epiphyses, separation of. _See_ Individual Bones
+
+ Epistaxis, 575
+
+ Epulis, 513
+
+ Ethmoidal cells, suppuration in, 577, 578
+
+ Eustachian catheter, 558
+
+ Extension by Hodgen's splint, 151, 159
+ by ice-tong callipers, 150, 158
+ by perineal band, 152
+ by Steinmann's apparatus, 150
+ vertical, 154
+ by weight and pulley, 220
+
+ Extra-dural abscess, 374
+
+ Eyeball, injuries of, 486
+
+ Eyelids, wounds of, 484
+
+
+ Face, cicatricial contraction of, 483
+ congenital malformations of, 474, 481
+ development of, 474
+ diseases of, 483
+ epithelioma of, 484
+ frog-, 581
+ injuries of, 482
+ rodent cancer of, 484
+ tumours of, 484
+
+ Facial cleft, 481
+ nerve, 400
+ paralysis, 400
+ spasm, 403
+
+ Facio-hypoglossal anastomosis, 403
+
+ False joint, 12
+
+ Fat embolism in fractures, 19
+
+ Femur, fracture of, in children, 135, 154
+ of condyles of, 162
+ of greater trochanter of, 139
+ of head of, 129
+ just below lesser trochanter of, 139
+ of lower end of, 157
+ of neck of, 130
+ of shaft of, 148
+ of upper end of, 129
+ incurvation of neck of, 257
+ separation of epiphyses of, 129, 139, 161
+
+ Fibula, absence of, 272
+ dislocation of, total, 167
+ fracture of, 165, 178, 183
+
+ Fingers, congenital contraction of, 313
+ deficiencies, 317
+ deformities of, 313
+ dislocation of, 121
+ drop-, 121, 318
+ Dupuytren's contraction of, 314
+ fractures of, 115
+ hypertrophy of, 317
+ injuries of, 115
+ mallet, 121, 318
+ supernumerary, 316
+ trigger, 318
+ webbed, 317
+
+ Flat-foot, 285
+ adolescent, 287
+ degrees of, 291
+ exercises for, 291
+ paralytic, 292
+ spasmodic, 292
+ static, 287
+ traumatic, 293
+ varieties of, 287, 294
+
+ Foerster's operation, 247
+
+ Foot, club-, 273
+ deformities of, 273
+ flat-, 285
+ hollow claw-, 284
+ injuries of, 185
+ movements of, 185
+ splay-, 285
+ surgical anatomy of, 185
+
+ Foot and mouth disease, 530
+
+ Footballer's knee, 172
+
+ Forearm, deformities of, 310
+ fracture of both bones of, 97
+ injuries of, 79
+ intra-uterine amputation of, 311
+
+ Fracture, 1. _See also_ Individual Bones
+ amputation in, 26
+ badly united, 10
+ Bennett's, 116
+ during birth, 3
+ chauffeur's, 106
+ clinical varieties of, 4
+ Colles', 102
+ comminuted, 6
+ complications of, 18
+ compound, 5, 24
+ crepitus in, 15
+ deformity in, 15
+ delayed union, 11
+ depressed, 5, 7
+ with dislocation, 40
+ displacement of fragments in, 7
+ Dupuytren's, 196
+ extension in, 26
+ fat embolism in, 19
+ fever in, 18
+ fibrous union of, 12
+ fissured, 5
+ greenstick, 5, 98
+ gun-shot, 27
+ indentation, 5
+ intra-uterine, 3
+ Jones', 194
+ longitudinal, 6
+ mal-union of, 10, 99, 183
+ massage in, 21
+ mechanism of, 14
+ multiple, 6
+ non-union, 9, 12
+ oblique, 6
+ old-standing, 87
+ open, 5
+ operation in, 24
+ pain in, 17
+ passive hyperæmia in, 12
+ pathological, 1
+ prognosis in, 19, 25
+ radiography in, 16
+ reduction of, 20
+ repair of, 8
+ retention of, 21
+ setting of, 20
+ shock in, 18
+ simple, 4, 8, 14, 19, 24
+ Smith's, 106
+ spiral, 6
+ splints in, 22
+ sprain-, 35
+ subcutaneous, 4
+ sub-periosteal, 6
+ transverse, 6
+ traumatic, 3
+ treatment of, 20, 25
+ un-united, 12, 78, 100, 101, 183
+ varieties of, 4
+ violence, forms of, causing, 3
+ X-rays in, 16
+
+ Frog-face, 581
+
+ Frontal sinus, suppuration in, 577
+
+
+ Gampsodactyly, 302
+
+ Genu recurvatum, 263
+ valgum, 264, 265
+ varum, 264, 271
+
+ Gingivitis, 508
+
+ Girdle-pain, 419
+
+ Glands, lymph. _See_ Lymph Glands
+
+ Globus hystericus, 624
+
+ Glomus carotica, tumours of, 603
+
+ Glossitis, 530, 533
+
+ Glosso-pharyngeal nerve, 403
+
+ Goitre, 605
+ adenomatous, 610
+ colloid, 607
+ cystic, 607
+ exophthalmic, 614
+ fibrous, 607
+ intra-thoracic, 607, 609, 613
+ malignant, 612
+ non-toxic, 605
+ parenchymatous, 605
+ retro-sternal, 607, 609, 613
+ sudden dyspnoea in, 608-610
+ thyreoidectomy for, 610
+ toxic, 614
+ vascular, 607
+
+ Gooch's splinting, 22
+
+ Graefe's symptom, 614
+
+ Graves' disease, 614
+
+ Gravitation paraplegia, 414
+
+ Greenstick fracture, 5
+
+ Gumboil, 507
+
+ Gums, affections of, 508
+
+ Gun-shot injuries. _See_ Individual Structures
+
+
+ Habitual dislocation, 43
+
+ Hæmarthrosis, 33
+
+ Hæmatoma auris, 560
+ of periosteum, 1
+
+ Hæmatomyelia, 414
+
+ Hæmatorrachis, 414
+
+ Hallux dolorosus, 298
+ flexus, 298
+ rigidus, 298
+ valgus, 296
+ varus, 298
+
+ Hammer nose, 570
+ toe, 300
+
+ _Hanche à ressort_, 254
+
+ Hand, club-, 311, 312
+ deformities of, 310
+ injuries of, 102
+ surgical anatomy of, 102
+
+ Hare-lip, 475
+
+ Head injuries, 340
+ after-effects of, 358
+
+ Hearing, impairment of, 554
+ tests of, 555
+
+ Heel, painful affections of, 294
+
+ Hemianopia, 335
+
+ Hemi-glossitis, 530
+
+ Hernia cerebri, 397
+
+ Hiatal oesophagismus, 624
+
+ Hip, ankylosis of, 256
+ arthritis deformans of, 226
+ Charcot's disease of, 228
+ contractures of, 256
+ contusion of, 147
+ disease, 209
+ dislocations, congenital, 248
+ old-standing, 147
+ varieties of, 126, 142
+ examination of, 128, 211
+ hysterical, 229
+ injuries in region of, 127
+ loose bodies in, 229
+ neuro-arthropathies of, 228
+ osteo-chondritis deformans juvenilis, 228
+ paralytic deformities of, 255
+ Perthes' disease of, 228
+ pyogenic diseases of, 224
+ snapping, 254
+ sprain of, 147
+ surgical anatomy of, 128
+ Thomas' splint for, 222
+ tuberculous disease of, 210
+ abscess formation in, 217
+ bilateral, 224
+ deformities following, 223
+ diagnosis of, 218
+ dislocation in, 218
+ stages of, 211
+ treatment of, 220
+
+ Histrionic spasm, 403
+
+ Hoarseness, 635
+
+ Hodgen's splint, 151
+
+ Hollow claw-foot, 284
+
+ Homonymous hemianopia, 335
+
+ Hospital throat, 500
+
+ Humerus, fracture, of anatomical neck, 74
+ of condyles, 80
+ with dislocation of shoulder, 63
+ of head, 70
+ of lower end, 84
+ of shaft, 75
+ of surgical neck, 70
+ of tuberosities, 74
+ un-united, 78
+ separation of lower epiphysis of, 82, 84
+ of upper epiphysis of, 73
+
+ Hunch-back, 440, 444
+
+ Hydrencephalocele, 388, 389
+
+ Hydrocele of neck, 599
+
+ Hydrocephalus, 391
+ acute, 386, 391
+ chronic, 391
+
+ Hygroma of neck, 599
+ sacral, 459
+
+ Hyoid bone, fracture of, 593
+
+ Hyperæsthesia acustica, 554
+
+ Hyperpituitarism, 396
+
+ Hyper-thyreoidism, 609, 614
+
+ Hypoglossal nerve, 404
+
+ Hypophysis cerebri, tumours of, 396
+
+ Hypopituitarism, 396
+
+ Hysterical aphonia, 636
+ spine, 448
+ wry-neck, 592
+
+
+ Ice-tong callipers, 150
+
+ Iliac abscess, 445, 446
+
+ Ilium, fracture of, 126
+
+ Infantile paralysis, 242
+
+ Injuries. _See_ Individual Regions
+
+ Internal derangements of knee-joint, 168
+
+ Inter-phalangeal dislocation, 200
+
+ Intra-cranial hæmorrhage, 352
+ in newly born, 356
+ syphilis, 387, 395
+ tuberculosis, 386
+ venous sinuses, injuries of, 356
+
+ Intra-uterine amputation, 311
+
+ Intubation of larynx, 639
+ of oesophagus, 632
+
+ Ischæmic contracture of muscles, 85, 98, 310
+
+ Ischium, fracture of, 127
+
+
+ Jacksonian epilepsy, 359, 394
+
+ Jaw, lower. _See_ Mandible
+ upper. _See_ Maxilla
+ _See also_ Temporo-mandibular Joint
+
+ Joints. _See also_ Individual Joints
+ Charcot's disease of, 228, 238
+ contusions of, 33
+ dislocations of, 36
+ false, 12
+ gun-shot injuries of, 34
+ injuries of, 32
+ sources of strength of, 32
+ sprains of, 35
+ wounds of, 34
+
+ Jones' fracture of fifth metatarsal, 194
+
+
+ Kernig's sign, 386
+
+ Klapp's four-footed exercises for scoliosis, 472
+
+ Knee, ankylosis of, 264
+ arthritis deformans of, 237
+ bow-, 271
+ Charcot's disease of, 238
+ cold abscess of, 234
+ contracture of, 264
+ deformities of, 236, 264
+ diseases of, 229
+ pyogenic, 237
+ tuberculous, 231
+ dislocations of, 165
+ congenital, 262
+ empyema of, 232
+ footballer's, 172
+ genu-recurvatum, 263
+ valgum, 265
+ varum, 271
+ hydrops of, 172
+ hysterical diseases of, 238
+ injuries in region of, 155
+ injuries of semilunar menisci, 167
+ internal derangement of, 168
+ knock-, 265
+ loose bodies in, 238
+ rugby, 165
+ rupture of cruciate ligaments of, 171
+ sprains of, 171
+ surgical anatomy of, 155
+ tuberculous disease of, 231
+ clinical types of, 231
+ deformities following, 236
+ extra-articular abscess in, 234
+ white swelling of, 233
+
+ Knock-knee, 265
+
+ Kocher's method of reducing dislocation of shoulder, 58
+
+ Kyphosis, 461, 462
+
+
+ Laryngitis, 637
+
+ Laryngoscopy, 635
+
+ Larynx, cancer of, 641
+ cardinal symptoms of affections of, 635
+ diphtheria of, 637
+ examination of, 634
+ foreign bodies in, 642
+ fracture of, 593
+ inflammation of, 637
+ intubation of, 639
+ oedema of, 637
+ paralysis of, 639
+ surgical anatomy of, 634
+ syphilis of, 639
+ tuberculosis of, 640
+ tumours of, 640
+ wounds of, 594
+
+ Laryngo-tracheotomy, 638
+
+ Lateral curvature of spine, 463
+ sinus. _See_ Transverse Sinus
+ ventricles, bursting of abscess into, 381
+ hæmorrhage into, 342
+
+ Leg, bow-, 271
+ fracture of bones of, 178
+ congenital deficiencies of, 272
+ injuries of, 155
+ rickety deformities of, 271
+
+ Lepto-meningitis, 376
+
+ Leucokeratosis, 530
+
+ Leucoplakia, 530
+
+ Ligaments, cruciate, rupture of, 171
+
+ Lingual dermoids, 537
+
+ Lip, chancre of, 491
+ chronic induration of, 491
+ cracks of, 491
+ cysts of, 493
+ double-lip, 491
+ epithelioma of, 493
+ fistulæ of, 482
+ hare-lip, 475
+ herpes of, 490
+ lymphangioma of, 492
+ macrocheilia, 492
+ mucous cysts of, 493
+ strumous, 491
+ syphilis of, 491
+ tuberculosis of, 491
+ tumours of, 492
+ ulcers of, 491
+
+ Lipoma nasi, 570
+
+ Liston's long splint, 152
+
+ Little's disease, 247, 357
+
+ Longitudinal sinus, phlebitis of, 385
+
+ Lordosis, 461
+
+ Ludwig's angina, 548, 597
+
+ Lumbar abscess, 445
+ puncture, 338
+
+ Lunate bone, dislocation of, 114
+ fracture of, 110
+
+ Luxation. _See_ Dislocation
+
+ Lymphangiomatous macroglossia, 540
+
+
+ Macrocheilia, 492
+
+ Macroglossia, 540
+
+ Macrostoma, 481
+
+ Madelung's deformity of wrist, 313
+
+ Malar bone. _See_ Zygomatic Bone
+
+ Malformations. _See_ Individual Regions
+
+ Mallet finger, 318
+
+ Mandible, actinomycosis of, 512
+ cleft of, 481
+ dentigerous cyst of, 517
+ dislocation of, 523
+ old-standing, 524
+ fixation of, 526
+ tumours of, 517
+
+ Manus valga, 109, 313
+ vara, 313
+
+ Massage in fractures, 21
+
+ Mastoid, suppuration in, 566
+
+ Maxilla, affections of, 510
+ fracture of, 519
+ tumours of, 514
+
+ Maxillary sinus, suppuration in, 577
+
+ Meninges, surgical anatomy of, 328
+
+ Meningitis, 360, 374
+ basal, 377
+ cerebro-spinal, 378
+ serous, 377
+ spinal, acute, 453
+ chronic, 452
+ tuberculous, 433
+ syphilitic, 387
+ tuberculous, 386
+
+ Meningocele, 388
+ spinal, 454
+
+ Meningo-encephalitis, 376
+
+ Meningo-myelocele, 454
+
+ Mercurial gingivitis, 508
+ glossitis, 530
+
+ Metacarpals, fracture of, 115, 116
+
+ Metatarsals, diseases of, 240
+ fracture of, 194
+
+ Metatarsalgia, 295
+
+ Micrencephaly, 393
+
+ Microstoma, 481
+
+ Middeldorpf's splint, 72
+
+ Middle-ear disease, cerebral abscess due to, 378
+
+ Middle meningeal hæmorrhage, 352
+
+ Mid-tarsal dislocation, 199
+
+ Miller's method of reducing dislocation of shoulder, 60
+
+ Mobile semilunar meniscus, 168
+
+ Morbus coxæ, 210
+
+ Morton's disease, 295
+
+ Motor areas, 330
+ tracts, 331
+
+ Mouth, affections of, 496
+ floor of, 499
+ roof of, 498
+
+ Mumps, 546
+
+ Musculo-spiral nerve. _See_ Radial Nerve
+
+ Myelitis, compression, 453
+ hæmorrhagic, 453
+ spinal, 453
+ syphilitic, 453
+ tuberculous, 433
+
+ Myelocele, 455
+
+ Myxoedema, post-operative, 610
+
+
+ Nasal affections. _See_ Nose
+ bones, fracture of, 567
+ ducts, injuries of, 567
+
+ Naso-pharynx, affections of, 567
+ tumours of, 580
+
+ Navicular bone, dislocation of, 115
+ fracture of, 110, 194
+
+ Neck, actinomycosis of, 598
+ boils of, 598
+ branchial carcinoma, 160
+ bursal swellings in, 599
+ carbuncles of, 598
+ cellulitis of, 597
+ cervical auricles, 583
+ fascia, 583
+ ribs, 585
+ cicatricial contraction of, 592
+ contusion of, 592
+ cystic lymphangioma of, 599
+ cysts of, 598
+ blood, 599
+ branchial, 598
+ bursal, 599
+ dermoid, 598
+ fistulæ of, 584, 585
+ hydrocele of, 599
+ hygroma of, 599
+ injuries of, 592
+ malformations of, 583
+ paraffin epithelioma of, 602
+ potato-like tumour of, 603
+ stiff, 587
+ surgical anatomy of, 582
+ thyreo-glossal cysts in, 538
+ tumours of, 598, 599
+ wounds of, 593
+ wry-, 587
+
+ Nélaton's line, 129
+
+ Nerve anastomosis, 246
+
+ Nerve roots, injuries of, 420
+
+ Neuralgia, trigeminal, 400
+
+ Neuro-arthropathies. _See_ Individual Joints
+
+ Neurone lesions, 334
+
+ Node, traumatic, 1
+
+ Nose, adenoids, 578
+ anomalies of smell, 578
+ artificial, 570
+ asthma, reflex, 578
+ bleeding from, 575
+ carcinoma of, 573
+ cardinal symptoms of nasal affections, 571
+ concretions in, 575
+ deformities of, 568
+ discharge from, 574
+ displacement of cartilages of, 567
+ emphysema of, 568
+ erectile swelling of, 572
+ examination of, 570
+ foreign bodies in, 574, 576
+ fracture of, 567
+ hammer, 570
+ lipoma nasi, 570
+ obstruction of, 572
+ ozæna, 575
+ polypi of, 573
+ potato, 570
+ reflex symptoms, 578
+ rhinitis, 575
+ rhinoliths, 575
+ rhinophyma, 570
+ saddle, 567, 568
+ sarcoma of, 580
+ septum of, deviations, 573
+ hæmatoma, 573
+ ridges, 573
+ spines, 573
+ sunken-bridge, 568
+ suppuration in accessory sinuses, 576
+ swelling of turbinated bones, 572
+ traumatic saddle, 567
+
+ Nystagmus, labyrinthine, 555
+
+
+ Oculo-motor nerve, 399
+
+ Odontoid process, fracture of, 430
+
+ Odontoma, 517
+
+ Oedema glottidis, 637
+
+ Oesophagismus, hiatal, 624
+
+ Oesophagitis, 623
+
+ Oesophagoscopy, 617
+
+ Oesophagospasm, 624
+
+ Oesophagus, carcinoma of, 629, 631
+ cicatricial contraction of, 628
+ compression of, 624
+ dilatation of, 625
+ diverticula of, 625
+ examination of, 616
+ foreign bodies in, 619, 621, 623
+ inflammation of, 623
+ intubation of, 632
+ paralysis of, 625
+ rupture of, 618
+ spasm of, 624
+ stricture of, cicatricial, 628
+ malignant, 629
+ spasmodic, 624
+ surgical anatomy of, 616
+ swallowing of corrosive substances, 618
+ syphilis of, 623
+ tuberculosis of, 623
+ tumours of, 629
+ varix of, 623
+ wounds of, 618
+ X-ray examination of, 617
+
+ Old-standing dislocations, 40. _See also_ Individual Joints
+
+ Olecranon, fracture of, 85
+ separation of epiphysis of, 87
+
+ Olfactory nerve, 399
+
+ Ophthalmia, sympathetic, 487
+
+ Ophthalmoplegia externa, 400
+
+ Optic nerve, 399
+
+ Orbit, aneurysms of, 490
+ cellulitis of, 487
+ contusions of, 484
+ emphysema of, 486
+ eyeball, injuries of, 486
+ foreign bodies in, 485
+ fractures of, 485
+ injuries of, 484
+ tumours of, 487
+ wounds of, 485
+
+ Os magnum. _See_ Capitate Bone
+
+ Osteo-chondritis deformans juvenilis, 228
+
+ Os trigonum tarsi, 193
+
+ Otitis media, 564
+
+ Otorrhoea, 555
+
+ Ozæna, 575
+
+
+ Pachymeningitis, 374, 433
+
+ Palate, affections of, 498
+ cleft, 477
+
+ Palmar fascia, Dupuytren's contraction of, 314
+
+ Panophthalmitis, 487
+
+ Paracusis of Willis, 554
+
+ Paralysis, abductor, 404, 639
+ Bell's, 401
+ conjugate, 335
+ crossed, 334
+ facial, 400
+ infantile, 242
+ spastic, 247
+ of sterno-mastoid, 404
+ of tongue, 542
+ of trapezius, 404
+
+ Paraplegia dolorosa, 448
+ gravitation, 414
+ spastic, 451
+
+ Para-thyreoid glands, 604
+
+ Parosmia, 578
+
+ Parotid, carcinoma of, 552
+ duct, affections of, 544
+ fistula, 544
+ inflammation of, 545
+ injuries of, 543
+ mixed tumours of, 549
+ recurrent enlargement of, 547
+ sarcoma of, 552
+ surgical anatomy of, 543
+ tuberculosis of, 549
+ tumours of, 549
+
+ Parotitis, 545, 547
+
+ Patella, absence of, 262
+ dislocation of, 177
+ congenital, 262
+ floating, 171, 229
+ fracture of, 173
+ injuries of, 173
+
+ Patheticus nerve, 400
+
+ Pathological dislocation, 43
+ fracture, 1
+
+ Pelvis, fractures of, 122
+ injuries of, 122
+
+ Periodontitis, 507
+
+ Peri-oesophagitis, 623
+
+ Periosteum, hæmatoma of, 1
+
+ Peri-tonsillitis, 501
+
+ Perthes' disease, 228
+
+ Pes arcuatus, 273, 284
+ calcaneo-valgus, 273, 282, 284
+ calcaneo-varus, 273, 282, 284
+ calcaneus, 273, 282
+ cavus, 273, 282, 283, 284
+ equinus, 273, 280
+ excavatus, 284
+ planus, 285, 287
+ transverso-planus, 294
+ valgus, 273, 285, 287
+ varus, 280
+
+ Phalanges of fingers, injuries of, 119, 121
+ of toes, injuries of, 194, 200
+
+ Pharyngeal dimple, 626
+
+ Pharyngitis, varieties of, 500
+
+ Pharynx, affections of, 500, 619
+ foreign bodies in, 619, 642
+ tumours of, 504
+
+ Phlebitis. _See_ Individual Vessels
+
+ Phosphorus necrosis of jaw, 510
+
+ Pigeon-toe, 298
+
+ Pituitary body, tumours of, 396
+
+ Plaster-of-Paris splints, 23
+
+ Pneumatocele capitis, 326
+
+ Pneumogastric nerve, 403
+
+ Poliomyelitis, anterior, 242
+
+ Politzer's inflation of middle ear, 558
+
+ Polydactylism, 303, 316
+
+ Polypi. _See_ Individual Organs
+
+ Poroplastic felt, 23
+
+ Post-anal dimple, 459
+
+ Posterior nerve roots, resection of, 247
+
+ Post-nasal obstruction, 578
+
+ Pott's disease of spine, 431
+ fracture, 186
+ with inversion, 191
+ puffy tumour, 375, 406
+
+ Premaxillary bone, 474
+
+ Protopathic sensibility, 332
+
+ Pseudarthrosis, 12
+
+ Psoas abscess, 445
+
+ Pubes, fracture of, 123
+
+ Pulpitis, 507
+
+ Pyorrhoea alveolaris, 509
+
+
+ Quinsy, 501
+
+
+ Radial nerve, implicated in fracture of humerus, 76
+
+ Radio-carpal joint, dislocation of, 112
+
+ Radio-ulnar joint, inferior, dislocation of, 112
+ superior, synostosis of, 310
+
+ Radius, absence of, 310
+ avulsion of tubercle of, 88
+ dislocation of, 94
+ fracture of lower end, 102
+ of shaft, 100
+ of tubercle, 88
+ of upper end, 88
+ separation of epiphyses, 88, 109, 110
+ subluxation of, 96
+
+ Railway spine, 422
+
+ Ranula, 549
+
+ Recurrent dislocation, 43
+
+ Reduction of dislocations. _See_ Individual Joints
+
+ Retro-pharyngeal abscess, 441, 442, 505
+
+ Rhinitis, 575
+
+ Rhinoliths, 575
+
+ Rhinophyma, 570
+
+ Rhinoscopy, 570, 571
+
+ Rib hump, 466
+
+ Ribs, cervical, 585
+
+ Round shoulders, 462
+
+ Rugby knee, 165
+
+
+ Sacral hygroma, 459
+
+ Sacro-coccygeal fistulæ, 459
+ sinuses, 459
+ tumours, 459
+
+ Sacro-iliac joint, tuberculosis of, 446
+
+ Sacrum, fracture of, 127
+
+ Saddle nose, 567, 568
+
+ Salivary calculi, 545
+ fistulæ, 544
+ glands. _See_ Parotid, Submaxillary, Sublingual
+ Mikulicz's disease of, 547
+ recurrent enlargement of, 547
+ surgical anatomy of, 543
+ tuberculosis of, 548
+ tumours of, 549
+
+ Scalp, abscess of, 323
+ air-containing swellings of, 326
+ aneurysms of, 326
+ avulsion of, 322
+ cellulitis of, 322, 406
+ cirsoid aneurysm of, 326
+ contusion of, 320
+ cysts of, 323
+ dangerous area of, 321
+ diseases of, 323
+ emphysema of, 326
+ erysipelas of, 323
+ hæmatoma of, 320, 366
+ infective conditions of, 323
+ injuries of, 320
+ lupus of, 323
+ pneumatocele of, 326
+ surgical anatomy of, 319
+ tumours of, 324
+ wounds of, 321
+ complications of, 322
+
+ Scaphoid. _See_ Navicular
+
+ Scapula, congenital elevation of, 303
+ displacements of, 303, 306
+ fracture of, 67
+ separation of epiphyses of, 69, 70
+ winged, 306
+
+ Schlatter's disease, 165
+
+ Scissors-leg deformity, 224, 257
+
+ Scoliosis, of adolescents, 465
+ congenital, 465
+ exercises for, 472
+ habitual, 465
+ paralytic, 464
+ postural, 465
+ rickety, 464
+ static, 463
+
+ Sculler's sprain, 97
+
+ Semilunar menisci of knee, injuries of, 167
+
+ Sensation, varieties of, 332
+
+ Separation of bony processes, 6
+ of epiphyses. _See_ Individual Bones
+
+ Shock, cerebral, 341, 344
+
+ Shoulder, ankylosis of, 204
+ arthritis deformans of, 203
+ contusion of, 66
+ diseases of, 201
+ deformities of, paralytic, 308
+ dislocation of, with fracture of humerus, 63
+ dislocation of, 52
+ congenital, 306
+ old-standing, 65
+ paralytic, 308
+ recurrent or habitual, 65
+ varieties, 53
+ examination of, 44
+ injuries of, 44
+ loose bodies in, 204
+ neuro-arthropathies of, 203
+ pyogenic diseases of, 203
+ sprain of, 66
+ Sprengel's, 303
+ surgical anatomy of, 44
+ tuberculosis of, 201
+
+ Sigmoid sinus, phlebitis of, 384
+
+ Sinus phlebitis, 383
+ thrombosis, 360
+
+ Skull, contusion of, 361
+ diseases of, 406
+ fracture of, 361
+ base, 367
+ anterior fossa, 369
+ middle fossa, 370
+ posterior fossa, 371
+ comminuted, 364
+ compound infected, 382
+ by _contre-coup_, 362
+ depressed, 364
+ fissured, 363
+ gutter, 364
+ indentation, 364
+ pond, 364
+ punctured, 364
+ vault, 361
+ injuries of, 360
+ necrosis of, 406, 407
+ osteomyelitis of, 406
+ periostitis of, 406
+ surgical anatomy of, 328
+ syphilis of, 407
+ tuberculosis of, 407
+ tumours of, 407
+
+ Smell, anomalies of, 399, 578
+
+ Smith's fracture of radius, 106
+
+ Smoker's patch on tongue, 532
+
+ Snapping hip, 254
+
+ Sore throat, varieties of, 500
+
+ Spastic paralysis, 247
+ paraplegia, 451
+
+ Speech centres, 335
+
+ Sphenoidal cells, suppuration in, 578
+
+ Spina bifida, 453
+ occulta, 457
+
+ Spinal accessory nerve, 404
+
+ Spinal cord, concussion of, 413
+ diseases of, 431
+ functions of, 331, 412
+ hæmorrhage into, 413
+ injuries of, 413
+ at different levels, 416
+ localisation of, lesions in, 410, 412
+ membranes of, 412
+ partial lesions of, 420
+ in Pott's disease, 433
+ reflex centres in, 412
+ segments of, 412
+ surgical anatomy of, 411
+ total transverse lesions of, 415
+ tuberculosis of, 433
+ tumours of, 450
+ hæmorrhage, 413
+
+ Spine, railway, 422
+
+ Splay-foot, 285
+
+ Splints, 22
+ abduction; for hip, 221
+ frame, for arm, 72
+ ambulant, for ankle, 189
+ Balkan frame, 150
+ box, 182
+ Bradford frame, 438
+ "cock-up," 77
+ for Colles' fracture, 106
+ Dupuytren's, 190
+ Hodgen's, 151
+ Liston's long, 152
+ Middeldorpf's, 72
+ Syme's stirrup, 190
+ Taylor's, for hip, 222
+ Thomas', arm, 72
+ double, 439
+ hip, 222
+ knee, 149, 159, 235
+ wheel-barrow, 439
+
+ Spondylitis, traumatic, 427
+
+ Sprains of joints, 35
+ fracture, 35, 171
+ sculler's, 97
+
+ Sprengel's shoulder, 303
+
+ Status lymphaticus, 602
+
+ Steinmann's apparatus, 150
+
+ Stenson's duct, 543
+
+ Sterno-mastoid, hæmatoma of, 588
+
+ Stomatitis, varieties of, 496
+
+ Subclavicular dislocation of shoulder, 62
+
+ Sub-conjunctival ecchymosis, 369
+
+ Sub-coracoid dislocation of shoulder, 54
+
+ Subdural abscess, 376
+
+ Sub-glenoid dislocation of shoulder, 62
+
+ Subgluteal abscess, 446
+
+ Sublingual gland, inflammation of, 548
+ ranula of, 549
+ surgical anatomy of, 543
+ tumours of, 552
+
+ Submaxillary gland, calculi of, 545
+ inflammation of, 548
+ peri-adenitis of, 548
+ recurrent enlargement of, 547
+ surgical anatomy of, 543
+ tuberculosis of, 549
+ tumours of, 552
+
+ Subspinous dislocation of shoulder, 62
+
+ Sub-taloid dislocation, 198
+
+ Superior sagittal sinus, phlebitis of, 385
+
+ Supernumerary fingers, 316
+ toes, 303
+
+ Surgical anatomy, of ankle, 185
+ of brain, 328
+ of ear, 553
+ of elbow, 79
+ of forearm, 79
+ of foot, 185
+ of hip, 128
+ of knee, 155
+ of meninges, 328
+ of neck, 582
+ of oesophagus, 616
+ of parotid gland, 543
+ of salivary glands, 543
+ of scalp, 319, 328
+ of shoulder, 44
+ of sublingual gland, 543
+ of submaxillary gland, 543
+ of thymus gland, 582
+ of thyreoid gland, 604
+ of tongue, 528
+ of tympanic membrane, 557
+ of vertebral column, 411
+ of wrist, 102
+
+ Swallowing, difficulty in, 623, 636
+ pain in, 623, 636
+
+ Syme's stirrup splint, 190
+
+ Symonds' tube, 632
+
+ Symphysis pubis, separation of, 122
+
+ Syndactylism, 303, 317
+
+ Synovitis, septic, 34
+
+ Syphilis. _See_ Individual Organs
+
+ Syringo-myelocele, 455
+
+
+ Tail-like appendage, 458, 459
+
+ Talipes equino-varus. _See also_ Pes
+ acquired, 279
+ congenital, 274
+
+ Talus, dislocation of, 196
+ fracture of, 192
+
+ Tarso-metatarsal dislocation, 200
+
+ Tarsus, diseases of, 240
+ dislocations of, 196
+ fractures of, 192
+ tuberculosis of, 240
+
+ Taste, anomalies of, 578
+
+ Taylor's splint for hip, 222
+
+ Temporal abscess, 380
+
+ Temporo-mandibular joint,
+ arthritis of, 525
+ arthritis deformans of, 525
+ dislocation of, 523
+ fixation of, 525
+ internal derangements of, 524
+ suppuration in, 525
+ tuberculosis of, 525
+
+ Tendons, lengthening of, 248
+ transplantation of, 245
+
+ Tennis elbow, 97
+
+ Tetany, 610
+
+ Thomas' flexion test for hip disease, 215
+ splints, 72, 149, 159, 222, 235, 439
+
+ Thoracic duct, 597
+
+ Throat, hospital, 500
+
+ Thrush, 496
+
+ Thumb, dislocation of, 119
+ fracture of, 116
+ stave of, 116
+
+ Thymic asthma, 603
+
+ Thymus death, 603
+ gland, affections of, 602
+ surgical anatomy of, 582
+ stenosis, 602
+
+ Thyreo-glossal cysts, 538, 583, 599
+ fistulæ, 538, 583
+ tumours, 538
+
+ Thyreoid cartilage, fracture of, 593
+ gland. _See also_ Goitre
+ accessory, 604
+ adenoma of, 610
+ carcinoma of, 281
+ goitre, 605. _See also_ Goitre
+ inflammation of, 605
+ malignant, 612
+ physiological hyperæmia of, 604
+ sarcoma of, 281
+ surgical anatomy of, 604
+ syphilis of, 605
+ tuberculosis of, 605
+
+ Thyreoidectomy, 610
+
+ Thyreoidism, acute, 610
+
+ Thyreoiditis, 605
+
+ Thyreotoxicosis, 614
+
+ Tibia, absence of, 272
+ fracture of, 183
+ upper end of, 162
+ head of, 162
+ separation of lower epiphysis of, 192
+ upper epiphysis of, 165
+ tuberosity, avulsion of, 165
+ and fibula, fracture of, 178
+
+ Tibio-fibular articulation, inferior, dislocation of, 196
+ superior, dislocation of, 167
+
+ Tinnitus aurium, 554
+
+ Toes, clawing of, 280
+ deformities of, 296
+ dislocation of, 200
+ fracture of phalanges of, 194
+ hammer-, 300
+ hypertrophy of, 302
+ pigeon-, 298
+ supernumerary, 303
+ webbing of, 303
+
+ Tongue,
+ absence of, 540
+ atrophy of, 540
+ bifid, 540
+ cancer of, 534
+ inoperable, 537
+ cysts, 537
+ dental ulcer of, 529
+ foot and mouth disease, 530
+ foreign bodies in, 529
+ glossitis, 530
+ gumma of, 533
+ hemi-glossitis, 530
+ inflammatory affections of, 530
+ leucokeratosis, 530
+ leucoplakia, 530
+ macroglossia, 540
+ malformations of, 540
+ mucous patches on, 533
+ nervous affections of, 540
+ neuralgia of, 540
+ paralysis of, 542
+ sarcoma of, 536
+ sclerosing glossitis, 533
+ smoker's parch, 532
+ spasm of, 542
+ surgical anatomy of, 528
+ syphilis of, 533
+ -tie, 540
+ tuberculosis of, 532
+ tumours of, 534, 537
+ ulcers of, 532, 536
+ wounds of, 529
+
+ Tonsil, calculi of, 503
+ hypertrophy of, 502
+ infective conditions of, 500
+ inflammation of, 500
+ Luschka's, 579
+ naso-pharyngeal, 579
+ quinsy, 501
+ syphilis of, 503
+ tuberculosis of, 503
+ tumours of, 504
+
+ Tonsillitis, varieties of, 500
+
+ Tooth, wisdom, impaction of, 508
+
+ Torn semilunar meniscus, 170
+
+ Torticollis, 587. _See_ Wry-neck
+
+ Trachea, foreign bodies in, 643
+ fracture of, 593
+ scabbard, 608
+ thymus stenosis of, 602
+ wounds of, 595
+
+ Tracheoscopy, 635
+
+ Tracheotomy, 638
+
+ Transplantation of tendons, 245
+
+ Transverse sinus, phlebitis of, 384
+ tarsal dislocation, 199
+
+ Trapezius, paralysis of, 404
+
+ Traumatic apoplexy, 355
+ cephal-hydrocele, 321, 390
+ epilepsy, 358
+ insanity, 360
+ neurasthenia, 345, 358
+ node, 1
+ oedema of brain, 352
+ spondylitis, 427
+
+ Trendelenburg's test, 252
+
+ Trigeminal nerve, 400
+ neuralgia, 400
+
+ Trigger finger, 318
+
+ Trochlear nerve, 400
+
+ Tuberculosis. _See_ Individual Organs
+
+ Tumours. _See_ Individual Organs
+
+ Tympanic antrum, suppuration in, 566
+ membrane, lesions of, 557
+ perforation of, 557
+ rupture of, 557, 563
+ surgical anatomy of, 557
+
+ Typhoid spine, 448
+
+
+ Ulna, deficiency of, 311
+ dislocation of, 94
+ fracture of upper end, 85
+ lower end, 110
+ shaft, 100
+ separation of epiphysis of, 87, 110
+
+ Uvula, bifid, 477
+ elongation of, 499
+
+
+ Vagus nerve, 403
+
+ Valsalva's method of inflating ear, 558
+
+ Venous sinuses, intra-cranial injuries of, 356
+
+ Ventricles, lateral, bursting of abscess into, 381
+ hæmorrhage into, 342
+
+ Vertebral column, actinomycosis of, 448
+ arthritis deformans of, 449
+ blastomycosis of, 448
+ compression fracture of, 426
+ congenital deformities of, 458
+ deviations of, 461
+ diseases of, 431
+ dislocations of, 424, 427, 428
+ fracture-dislocation of, 427
+ fractures of, 425, 426, 427
+ hydatid cysts of, 448
+ hysterical affections of, 448
+ injuries of, 423
+ kyphosis, 461, 462
+ lateral curvature of, 463
+ lordosis, 461
+ malignant disease of, 447
+ osteomyelitis of, 431, 448
+ Pott's disease of, 431
+ scoliosis, 463
+ sprains of, 423
+ surgical anatomy of, 411
+ syphilis of, 447
+ tuberculous disease of, 431
+ tumours of, 447
+ twists of, 423
+ typhoid, 448
+ wounds of, 430
+
+ Vertigo, 555
+
+ Visual centres, 335
+
+ Volkmann's ischæmic contracture, 85, 98, 310
+ supra-malleolar deformity, 273
+
+
+ Wandering acetabulum, 210, 227
+
+ Wax in ear, 561
+
+ Webbed fingers, 317
+ toes, 303
+
+ Wens, 324
+
+ White swelling of knee, 233
+
+ Winged scapula, 306
+
+ Wisdom tooth, impaction of, 508
+
+ Wounds. _See_ Individual Regions and Organs
+
+ Wrist, diseases of, 208
+ dislocation of, 111, 112
+ congenital, 313
+ drop-, 311
+ injuries of, 102
+ Madelung's deformity of, 313
+ sprain of, 115
+ surgical anatomy of, 102
+ tuberculous disease of, 208, 209
+
+ Wry-neck, 587
+ acute, 587
+ hysterical, 592
+ permanent, 588
+ rheumatic, 587
+ spasmodic, 591
+ transient, 587
+
+
+ Xerostomia, 547
+
+ X-rays in fracture, 16
+
+
+ Zygomatic bone, fracture of, 519
+
+
+
+
+
+End of the Project Gutenberg EBook of Manual of Surgery Volume Second:
+Extremities--Head--Neck. Sixth Edition., by Alexander Miles and Alexis Thomson
+
+*** END OF THIS PROJECT GUTENBERG EBOOK MANUAL OF SURGERY ***
+
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