294 files changed, 28887 insertions, 0 deletions
diff --git a/28428-h/28428-h.htm b/28428-h/28428-h.htm
new file mode 100644
index 0000000..61db014
--- /dev/null
+++ b/28428-h/28428-h.htm
@@ -0,0 +1,28887 @@
+<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Strict//EN"
+    "http://www.w3.org/TR/xhtml1/DTD/xhtml1-strict.dtd">
+
+<html xmlns="http://www.w3.org/1999/xhtml">
+  <head>
+    <meta http-equiv="Content-Type" content="text/html;charset=iso-8859-1" />
+    <title>
+      The Project Gutenberg eBook of Manual of Surgery Volume 2: Extremities&mdash;Head&mdash;Neck, by Alexis Thomson, F.R.C.S.Ed. and Eng.
+    </title>
+    <style type="text/css">
+
+    p {  margin-top: .75em;
+      text-align: justify;
+      margin-bottom: .75em;
+      }
+
+    .title {text-align:center;
+      font-weight:bold;
+      font-size:larger;
+      margin-top:3em;
+      }
+
+    small {font-size:70%;}
+
+    h1,h2,h3,h4 {
+      text-align: center;
+      clear: both;
+      }
+
+    h2 {padding-top:1.5em;
+        padding-bottom:0.5em;
+        width:65%;
+        margin:1.5em auto auto auto;
+        border-top:thin solid black;
+        }
+
+    h3, h4 {font-variant:small-caps;
+        margin-top:1.5em;
+        margin-bottom:.5em;}
+
+    hr { width: 33%;
+        margin-top: 1em;
+        margin-bottom: 1em;
+        margin-left: auto;
+        margin-right: auto;
+        clear: both;
+        }
+
+    ul {list-style-type:none;}
+
+    div.index > ul {margin-left:20%; }
+
+    div.index li {margin-left:0em;  }
+
+    ul.chap li {display:inline;
+        margin-left:0;
+        margin-right:0;}
+
+    table {margin-left:auto;
+        margin-right:auto;
+        }
+
+    th {font-weight:normal;}
+
+    table.az {width:70%;
+        text-align:center;
+        margin-bottom:2em;
+        border-collapse:collapse;
+        }
+
+    table.az td {text-align:center;}
+
+    table.figure td {vertical-align: top;}
+
+    table.toc {width:80%;
+        font-variant:small-caps;
+        }
+
+    table.toc .center {text-align:center;
+        padding-top:1em;
+        padding-bottom:0;
+        }
+
+    table.toc td+td, table.toc th+th {text-align:right;}
+
+    table.loi {width:80%;
+        text-align:right;
+        }
+
+    table.loi td {vertical-align:top;}
+
+    table.loi td+td {text-align:left;}
+
+    table.loi td+td+td, table.loi th+th+th {text-align:right;
+        vertical-align:bottom;}
+
+    table.eds {width:50%;}
+
+    body{margin-left: 10%;
+      margin-right: 10%;
+      }
+
+    .pagenum  {
+      position: absolute;
+      left: 92%;
+      font-size: 13px;
+      font-weight: normal;
+      font-variant:normal;
+      font-style:normal;
+      border:none;
+      text-indent: 0;
+      color: silver;
+    }
+
+    a.pagenum:after {
+      content: " [" attr(name) "] ";
+    }
+
+    .center  {text-align: center;}
+
+    .smcap  {font-variant: small-caps;}
+
+    .caption  {font-size:smaller;
+        margin-top:0;
+        margin-bottom:0.5em;
+        text-align:center;
+        }
+
+    .figcenter  {margin: auto; text-align: center;}
+
+    .figleft     {float: left;
+        clear: left;
+        margin: 0 1em 0 0;
+        padding: 0;
+        text-align: center;
+        width: auto;}
+
+    .figright    {float: right;
+        clear: right;
+        margin: 0 0 0 1em;
+        padding: 0;
+        text-align: center;
+        width: auto;}
+
+    .footnote  {font-size:smaller;}
+
+    .fnanchor  {vertical-align: super; font-size: .8em; text-decoration: none;}
+
+    .frac_top {
+      font-size: 70%;
+      vertical-align: super;
+    }
+
+    .frac_bottom {
+      font-size: 70%;
+      vertical-align: sub;
+    }
+
+    a[name] { position:absolute; }      /* Fix Opera bug                        */
+
+    #trannote {
+      border: solid 2px;
+      margin-top: 4em;
+      margin-bottom: 4em;
+      padding: 0em 1em;
+    }
+
+    </style>
+  </head>
+<body>
+
+
+<pre>
+
+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
+
+
+
+
+
+
+</pre>
+
+
+<div id="trannote">
+<p>Transcriber's note: The inverted 'Y' symbol used in this book has
+been transcribed as [inverted Y].</p>
+</div>
+
+
+
+
+<h1><small>OXFORD MEDICAL PUBLICATIONS</small></h1>
+<hr />
+<h1>MANUAL OF SURGERY</h1>
+
+<h2 style="border:none; padding:0;"><small>BY</small>
+
+<br /><br />
+ALEXIS THOMSON, <span class="smcap">F.R.C.S.Ed. AND Eng.</span>
+<br />
+<small><i>PROFESSOR OF SURGERY, UNIVERSITY OF EDINBURGH</i>
+<br />
+SURGEON EDINBURGH ROYAL INFIRMARY
+<br /><br />AND</small>
+<br /><br />
+ALEXANDER MILES, <span class="smcap">F.R.C.S.Ed.</span>
+<br />
+<small>SURGEON EDINBURGH ROYAL INFIRMARY</small></h2>
+
+<p class="title">VOLUME SECOND
+<br />EXTREMITIES&mdash;HEAD&mdash;NECK</p>
+
+<p class="title"><i>SIXTH EDITION REVISED AND ENLARGED
+<br />WITH 288 ILLUSTRATIONS</i></p>
+
+<p class="title" style="margin-bottom:3em;"><span style="letter-spacing:0.5em;">LONDON</span><br />
+<span class="smcap">HENRY FROWDE and HODDER &amp; STOUGHTON</span><br />
+THE <i>LANCET</i> BUILDING<br />
+1 &amp; 2 BEDFORD STREET, STRAND, W.C. 2</p>
+
+
+
+
+<table class="eds" summary="List of previous editions and their years">
+<tr><td><a class="pagenum" name="Pg_iv" id="Pg_iv"></a><i>First Edition      </i></td><td><i>1904</i></td></tr>
+<tr><td><i>Second Edition     </i></td><td><i>1907</i></td></tr>
+<tr><td><i>Third Edition      </i></td><td><i>1909</i></td></tr>
+
+<tr><td><i>Fourth Edition     </i></td><td><i>1912</i></td></tr>
+<tr><td><i><span style="margin-left:1em; margin-right:1em;">"</span><span style="margin-left:1em; margin-right:1em;">"</span>Second Impression               </i></td><td><i>1913</i></td></tr>
+<tr><td><i>Fifth Edition      </i></td><td><i>1915</i></td></tr>
+<tr><td><i><span style="margin-left:1em; margin-right:1em;">"</span><span style="margin-left:1em; margin-right:1em;">"</span>Second Impression               </i></td><td><i>1919</i></td></tr>
+<tr><td><i>Sixth Edition      </i></td><td><i>1921</i></td></tr>
+
+</table>
+
+<p style="margin-top:5em; text-align:center;">
+<span class="smcap">Printed in Great Britain by<br />
+Morrison and Gibb Ltd., Edinburgh</span>
+</p>
+
+
+
+
+<h2><a class="pagenum" name="Pg_v" id="Pg_v"></a><a name="CONTENTS" id="CONTENTS"></a>CONTENTS</h2>
+
+<table class="toc" summary="Table of contents">
+<tr><th>&nbsp;</th><th>page</th></tr>
+
+<tr><td class="center" colspan="2" style="padding-top:0;"><a href="#CHAPTER_I">CHAPTER I</a></td></tr>
+<tr><td>Injuries of Bones</td><td><a href="#Pg_1">1</a></td></tr>
+
+<tr><td class="center" colspan="2"><a href="#CHAPTER_II">CHAPTER II</a></td></tr>
+<tr><td>Injuries of Joints</td><td><a href="#Pg_32">32</a></td></tr>
+
+<tr><td class="center" colspan="2"><a href="#CHAPTER_III">CHAPTER III</a></td></tr>
+<tr><td>Injuries in the Region of the Shoulder and Upper Arm</td><td><a href="#Pg_44">44</a></td></tr>
+
+<tr><td class="center" colspan="2"><a href="#CHAPTER_IV">CHAPTER IV</a></td></tr>
+<tr><td>Injuries in the Region of the Elbow and Forearm</td><td><a href="#Pg_79">79</a></td></tr>
+
+<tr><td class="center" colspan="2"><a href="#CHAPTER_V">CHAPTER V</a></td></tr>
+<tr><td>Injuries in the Region of the Wrist and Hand</td><td><a href="#Pg_102">102</a></td></tr>
+
+<tr><td class="center" colspan="2"><a href="#CHAPTER_VI">CHAPTER VI</a></td></tr>
+<tr><td>Injuries in the Region of the Pelvis, Hip-Joint, and Thigh</td><td><a href="#Pg_122">122</a></td></tr>
+
+<tr><td class="center" colspan="2"><a href="#CHAPTER_VII">CHAPTER VII</a></td></tr>
+<tr><td>Injuries in the Region of the Knee and Leg</td><td><a href="#Pg_155">155</a></td></tr>
+
+<tr><td class="center" colspan="2"><a href="#CHAPTER_VIII">CHAPTER VIII</a></td></tr>
+<tr><td>Injuries in Region of Ankle and Foot</td><td><a href="#Pg_185">185</a></td></tr>
+
+<tr><td class="center" colspan="2"><a href="#CHAPTER_IX">CHAPTER IX</a></td></tr>
+<tr><td>Diseases of Individual Joints</td><td><a href="#Pg_201">201</a></td></tr>
+
+<tr><td class="center" colspan="2"><a class="pagenum" name="Pg_vi" id="Pg_vi"></a><a href="#CHAPTER_X">CHAPTER X</a></td></tr>
+<tr><td>Deformities of the Extremities</td><td><a href="#Pg_241">241</a></td></tr>
+
+<tr><td class="center" colspan="2"><a href="#CHAPTER_XI">CHAPTER XI</a></td></tr>
+<tr><td>The Scalp</td><td><a href="#Pg_319">319</a></td></tr>
+
+<tr><td class="center" colspan="2"><a href="#CHAPTER_XII">CHAPTER XII</a></td></tr>
+<tr><td>The Cranium and its Contents</td><td><a href="#Pg_328">328</a></td></tr>
+
+<tr><td class="center" colspan="2"><a href="#CHAPTER_XIII">CHAPTER XIII</a></td></tr>
+<tr><td>Injuries of the Skull</td><td><a href="#Pg_361">361</a></td></tr>
+
+<tr><td class="center" colspan="2"><a href="#CHAPTER_XIV">CHAPTER XIV</a></td></tr>
+<tr><td>Diseases of the Brain and Membranes</td><td><a href="#Pg_373">373</a></td></tr>
+
+<tr><td class="center" colspan="2"><a href="#CHAPTER_XV">CHAPTER XV</a></td></tr>
+<tr><td>Diseases of the Cranial Bones</td><td><a href="#Pg_406">406</a></td></tr>
+
+<tr><td class="center" colspan="2"><a href="#CHAPTER_XVI">CHAPTER XVI</a></td></tr>
+<tr><td>The Vertebral Column and Spinal Cord</td><td><a href="#Pg_411">411</a></td></tr>
+
+<tr><td class="center" colspan="2"><a href="#CHAPTER_XVII">CHAPTER XVII</a></td></tr>
+<tr><td>Diseases of the Vertebral Column and Spinal Cord</td><td><a href="#Pg_431">431</a></td></tr>
+
+<tr><td class="center" colspan="2"><a href="#CHAPTER_XVIII">CHAPTER XVIII</a></td></tr>
+<tr><td>Deviations of the Vertebral Column</td><td><a href="#Pg_461">461</a></td></tr>
+
+<tr><td class="center" colspan="2"><a href="#CHAPTER_XIX">CHAPTER XIX</a></td></tr>
+<tr><td>The Face, Orbit, and Lips</td><td><a href="#Pg_474">474</a></td></tr>
+
+<tr><td class="center" colspan="2"><a href="#CHAPTER_XX">CHAPTER XX</a></td></tr>
+<tr><td>The Mouth, Fauces, and Pharynx</td><td><a href="#Pg_496">496</a></td></tr>
+
+<tr><td class="center" colspan="2"><a class="pagenum" name="Pg_vii" id="Pg_vii"></a><a href="#CHAPTER_XXI">CHAPTER XXI</a></td></tr>
+<tr><td>The Jaws, including the Teeth and Gums</td><td><a href="#Pg_507">507</a></td></tr>
+
+<tr><td class="center" colspan="2"><a href="#CHAPTER_XXII">CHAPTER XXII</a></td></tr>
+<tr><td>The Tongue</td><td><a href="#Pg_528">528</a></td></tr>
+
+<tr><td class="center" colspan="2"><a href="#CHAPTER_XXIII">CHAPTER XXIII</a></td></tr>
+<tr><td>The Salivary Glands</td><td><a href="#Pg_543">543</a></td></tr>
+
+<tr><td class="center" colspan="2"><a href="#CHAPTER_XXIV">CHAPTER XXIV</a></td></tr>
+<tr><td>The Ear</td><td><a href="#Pg_553">553</a></td></tr>
+
+<tr><td class="center" colspan="2"><a href="#CHAPTER_XXV">CHAPTER XXV</a></td></tr>
+<tr><td>The Nose and Naso-Pharynx</td><td><a href="#Pg_567">567</a></td></tr>
+
+<tr><td class="center" colspan="2"><a href="#CHAPTER_XXVI">CHAPTER XXVI</a></td></tr>
+<tr><td>The Neck</td><td><a href="#Pg_582">582</a></td></tr>
+
+<tr><td class="center" colspan="2"><a href="#CHAPTER_XXVII">CHAPTER XXVII</a></td></tr>
+<tr><td>The Thyreoid Gland</td><td><a href="#Pg_604">604</a></td></tr>
+
+<tr><td class="center" colspan="2"><a href="#CHAPTER_XXVIII">CHAPTER XXVIII</a></td></tr>
+<tr><td>The &OElig;sophagus</td><td><a href="#Pg_616">616</a></td></tr>
+
+<tr><td class="center" colspan="2"><a href="#CHAPTER_XXIX">CHAPTER XXIX</a></td></tr>
+<tr><td>The Larynx, Trachea, and Bronchi</td><td><a href="#Pg_634">634</a></td></tr>
+
+<tr><td><a href="#INDEX">INDEX</a></td><td><a href="#Pg_645">645</a></td></tr>
+</table>
+
+
+<p><a class="pagenum" name="Pg_viii" id="Pg_viii"></a></p>
+
+
+
+
+<h2><a class="pagenum" name="Pg_ix" id="Pg_ix"></a><a name="LIST_OF_ILLUSTRATIONS" id="LIST_OF_ILLUSTRATIONS"></a>LIST OF ILLUSTRATIONS</h2>
+
+<table class="loi" summary="List of illustrations">
+<tr class="smcap"><th>fig.</th><th>&nbsp;</th><th>page</th></tr>
+
+<tr><td><a href="#fig_1">1.</a></td><td>Multiple Fracture of both Bones of Leg</td><td><a href="#Pg_4">4</a></td></tr>
+
+<tr><td><a href="#fig_2">2.</a></td><td>Radiogram showing Comminuted Fracture of both Bones of Forearm</td><td><a href="#Pg_5">5</a></td></tr>
+
+<tr><td><a href="#fig_3">3.</a></td><td>Oblique Fracture of Tibia; with partial Separation of Epiphysis of Upper
+End of Fibula; and Incomplete Fracture of Fibula in Upper Third</td><td><a href="#Pg_6">6</a></td></tr>
+
+<tr><td><a href="#fig_4">4.</a></td><td>Excess of Callus after Compound Fracture of Bones of Forearm</td><td><a href="#Pg_9">9</a></td></tr>
+
+<tr><td><a href="#fig_5">5.</a></td><td>Multiple Fractures of both Bones of Forearm showing Mal-union</td><td><a href="#Pg_11">11</a></td></tr>
+
+<tr><td><a href="#fig_6">6.</a></td><td>Radiogram of Un-united Fracture of Shaft of Ulna</td><td><a href="#Pg_13">13</a></td></tr>
+
+<tr><td><a href="#fig_7">7.</a></td><td>Excessive Callus Formation after Infected Compound
+Fracture of both Bones of Forearm</td><td><a href="#Pg_27">27</a></td></tr>
+
+<tr><td><a href="#fig_8">8.</a></td><td>Partial Separation of Epiphysis, with Fracture running into Diaphysis</td><td><a href="#Pg_29">29</a></td></tr>
+
+<tr><td><a href="#fig_9">9.</a></td><td>Complete Separation of Epiphysis</td><td><a href="#Pg_29">29</a></td></tr>
+
+<tr><td><a href="#fig_10">10.</a></td><td>Partial Separation with Fracture of Epiphysis</td><td><a href="#Pg_29">29</a></td></tr>
+
+<tr><td><a href="#fig_11">11.</a></td><td>Complete Separation with Fracture of Epiphysis</td><td><a href="#Pg_29">29</a></td></tr>
+
+<tr><td><a href="#fig_12">12.</a></td><td>Os Innominatum showing new Socket formed after Old-standing Dislocation</td><td><a href="#Pg_41">41</a></td></tr>
+
+<tr><td><a href="#fig_13">13.</a></td><td>Oblique Fracture of Right Clavicle in Middle Third, united</td><td><a href="#Pg_45">45</a></td></tr>
+
+<tr><td><a href="#fig_14">14.</a></td><td>Fracture of Acromial End of Clavicle</td><td><a href="#Pg_46">46</a></td></tr>
+
+<tr><td><a href="#fig_15">15.</a></td><td>Adhesive Plaster applied for Fracture of Clavicle</td><td><a href="#Pg_49">49</a></td></tr>
+
+<tr><td><a href="#fig_16">16.</a></td><td>Forward Dislocation of Sternal End of Right Clavicle</td><td><a href="#Pg_51">51</a></td></tr>
+
+<tr><td><a href="#fig_17">17.</a></td><td>Diagram of most common varieties of Dislocation of the Shoulder</td><td><a href="#Pg_53">53</a></td></tr>
+
+<tr><td><a href="#fig_18">18.</a></td><td>Sub-coracoid Dislocation of Right Shoulder</td><td><a href="#Pg_55">55</a></td></tr>
+
+<tr><td><a href="#fig_19">19.</a></td><td>Sub-coracoid Dislocation of Humerus</td><td><a href="#Pg_56">56</a></td></tr>
+
+<tr><td><a href="#fig_20">20.</a></td><td>Kocher's Method of reducing Sub-coracoid Dislocation&mdash;First Movement</td><td><a href="#Pg_57">57</a></td></tr>
+
+<tr><td><a href="#fig_21">21.</a></td><td>Kocher's Method&mdash;Second Movement</td><td><a href="#Pg_58">58</a></td></tr>
+
+<tr><td><a href="#fig_22">22.</a></td><td>Kocher's Method&mdash;Third Movement</td><td><a href="#Pg_59">59</a></td></tr>
+
+<tr><td><a href="#fig_23">23.</a></td><td>Miller's Method of reducing Sub-coracoid Dislocation&mdash;First Movement</td><td><a href="#Pg_60">60</a></td></tr>
+
+<tr><td><a href="#fig_24">24.</a></td><td>Miller's Method&mdash;Second Movement</td><td><a href="#Pg_61">61</a></td></tr>
+
+<tr><td><a href="#fig_25">25.</a></td><td>Dislocation of Shoulder with Fracture of Neck of Humerus</td><td><a href="#Pg_64">64</a></td></tr>
+
+<tr><td><a href="#fig_26">26.</a></td><td>Transverse Fracture of Scapula</td><td><a href="#Pg_68">68</a></td></tr>
+
+<tr><td><a href="#fig_27">27.</a></td><td>Fracture of Surgical Neck of Humerus, united with Angular Displacement</td><td><a href="#Pg_70">70</a></td></tr>
+
+<tr><td><a href="#fig_28">28.</a></td><td>Impacted Fracture of Neck of Humerus</td><td><a href="#Pg_71">71</a></td></tr>
+
+<tr><td><a href="#fig_29">29.</a></td><td>Ambulatory Abduction Splint for Fracture of Humerus</td><td><a href="#Pg_72">72</a></td></tr>
+
+<tr><td><a href="#fig_30">30.</a></td><td>Radiogram of Separation of Upper Epiphysis of Humerus</td><td><a href="#Pg_73">73</a></td></tr>
+
+<tr><td><a class="pagenum" name="Pg_x" id="Pg_x"></a><a href="#fig_31">31.</a></td><td>&ldquo;Cock-up&rdquo; Splint</td><td><a href="#Pg_77">77</a></td></tr>
+
+<tr><td><a href="#fig_32">32.</a></td><td>Gooch Splints for Fracture of Shaft of Humerus; and Rectangular
+Splint to secure Elbow</td><td><a href="#Pg_77">77</a></td></tr>
+
+<tr><td><a href="#fig_33">33.</a></td><td>Radiogram of Supra-condylar Fracture of Humerus in a Child</td><td><a href="#Pg_81">81</a></td></tr>
+
+<tr><td><a href="#fig_34">34.</a></td><td>Radiogram of T-shaped Fracture of Lower End of Humerus</td><td><a href="#Pg_83">83</a></td></tr>
+
+<tr><td><a href="#fig_35">35.</a></td><td>Radiogram of Fracture of Olecranon Process</td><td><a href="#Pg_86">86</a></td></tr>
+
+<tr><td><a href="#fig_36">36.</a></td><td>Backward Dislocation of Elbow in a Boy</td><td><a href="#Pg_89">89</a></td></tr>
+
+<tr><td><a href="#fig_37">37.</a></td><td>Bony Outgrowth in relation to insertion of Brachialis
+Muscle</td><td><a href="#Pg_90">90</a></td></tr>
+
+<tr><td><a href="#fig_38">38.</a></td><td>Radiogram of Incomplete Backward Dislocation of Elbow</td><td><a href="#Pg_91">91</a></td></tr>
+
+<tr><td><a href="#fig_39">39.</a></td><td>Forward Dislocation of Elbow, with Fracture of Olecranon</td><td><a href="#Pg_93">93</a></td></tr>
+
+<tr><td><a href="#fig_40">40.</a></td><td>Radiogram of Forward Dislocation of Head of Radius, with
+Fracture of Shaft of Ulna</td><td><a href="#Pg_95">95</a></td></tr>
+
+<tr><td><a href="#fig_41">41.</a></td><td>Greenstick Fracture of both Bones of the Forearm</td><td><a href="#Pg_98">98</a></td></tr>
+
+<tr><td><a href="#fig_42">42.</a></td><td>Gooch Splints for Fracture of both Bones of Forearm</td><td><a href="#Pg_99">99</a></td></tr>
+
+<tr><td><a href="#fig_43">43.</a></td><td>Colles' Fracture showing Radial Deviation of Hand</td><td><a href="#Pg_103">103</a></td></tr>
+
+<tr><td><a href="#fig_44">44.</a></td><td>Colles' Fracture showing undue prominence of Ulnar Styloid</td><td><a href="#Pg_103">103</a></td></tr>
+
+<tr><td><a href="#fig_45">45.</a></td><td>Radiogram showing the Line of Fracture and Upward Displacement
+of the Radial Styloid in Colles' Fracture</td><td><a href="#Pg_104">104</a></td></tr>
+
+<tr><td><a href="#fig_46">46.</a></td><td>Radiogram of Chauffeur's Fracture</td><td><a href="#Pg_107">107</a></td></tr>
+
+<tr><td><a href="#fig_47">47.</a></td><td>Radiogram of Smith's Fracture</td><td><a href="#Pg_108">108</a></td></tr>
+
+<tr><td><a href="#fig_48">48.</a></td><td>Manus Valga following Separation of Lower Radial Epiphysis
+in Childhood</td><td><a href="#Pg_109">109</a></td></tr>
+
+<tr><td><a href="#fig_49">49.</a></td><td>Radiogram showing Fracture of Navicular (Scaphoid) Bone</td><td><a href="#Pg_111">111</a></td></tr>
+
+<tr><td><a href="#fig_50">50.</a></td><td>Dorsal Dislocation of Wrist at Radio-carpal Articulation</td><td><a href="#Pg_113">113</a></td></tr>
+
+<tr><td><a href="#fig_51">51.</a></td><td>Radiogram showing Forward Dislocation of Navicular Bone</td><td><a href="#Pg_114">114</a></td></tr>
+
+<tr><td><a href="#fig_52">52.</a></td><td>Extension Apparatus for Oblique Fracture of Metacarpals</td><td><a href="#Pg_117">117</a></td></tr>
+
+<tr><td><a href="#fig_53">53.</a></td><td>Radiogram of Bennett's Fracture of Base of Metacarpal of
+Right Thumb</td><td><a href="#Pg_118">118</a></td></tr>
+
+<tr><td><a href="#fig_54">54.</a></td><td>Splints for Bennett's Fracture</td><td><a href="#Pg_119">119</a></td></tr>
+
+<tr><td><a href="#fig_55">55.</a></td><td>Multiple Fracture of Pelvis through Horizontal and Descending
+Rami of both Pubes, and Longitudinal Fracture of
+left side of Sacrum</td><td><a href="#Pg_123">123</a></td></tr>
+
+<tr><td><a href="#fig_56">56.</a></td><td>Fracture of Left Iliac Bone; and of both Pubic Arches</td><td><a href="#Pg_124">124</a></td></tr>
+
+<tr><td><a href="#fig_57">57.</a></td><td>Many-tailed Bandage and Binder for Fracture of Pelvic
+Girdle</td><td><a href="#Pg_125">125</a></td></tr>
+
+<tr><td><a href="#fig_58">58.</a></td><td>N&eacute;laton's Line</td><td><a href="#Pg_128">128</a></td></tr>
+
+<tr><td><a href="#fig_59">59.</a></td><td>Bryant's Line</td><td><a href="#Pg_129">129</a></td></tr>
+
+<tr><td><a href="#fig_60">60.</a></td><td>Section through Hip-Joint to show Epiphyses at Upper End
+of Femur, and their relation to the Joint</td><td><a href="#Pg_130">130</a></td></tr>
+
+<tr><td><a href="#fig_61">61.</a></td><td>Fracture through Narrow Part of Neck of Femur on Section</td><td><a href="#Pg_131">131</a></td></tr>
+
+<tr><td><a href="#fig_62">62.</a></td><td>Impacted Fracture through Narrow Part of Neck of Femur</td><td><a href="#Pg_132">132</a></td></tr>
+
+<tr><td><a href="#fig_63">63.</a></td><td>Fracture of Neck of Right Femur, showing Shortening,
+Abduction, and Eversion of Limb</td><td><a href="#Pg_133">133</a></td></tr>
+
+<tr><td><a href="#fig_64">64.</a></td><td>Fracture of Narrow Part of Neck of Femur</td><td><a href="#Pg_134">134</a></td></tr>
+
+<tr><td><a href="#fig_65">65.</a></td><td>Coxa Vara following Fracture of Neck of Femur in a Child</td><td><a href="#Pg_136">136</a></td></tr>
+
+<tr><td><a href="#fig_66">66.</a></td><td>Non-impacted Fracture through Base of Neck</td><td><a href="#Pg_137">137</a></td></tr>
+
+<tr><td><a href="#fig_67">67.</a></td><td>Fracture through Base of Neck of Femur with Impaction
+into the Trochanters</td><td><a href="#Pg_137">137</a></td></tr>
+
+<tr><td><a href="#fig_68">68.</a></td><td>Non-impacted Fracture through Base of Neck</td><td><a href="#Pg_138">138</a></td></tr>
+
+<tr><td><a href="#fig_69">69.</a></td><td>Fracture of the Femur just below the small Trochanter,
+united, showing Flexion and Lateral Rotation of Upper
+Fragment</td><td><a href="#Pg_140">140</a></td></tr>
+
+<tr><td><a href="#fig_70">70.</a></td><td>Adjustable Double-inclined Plane</td><td><a href="#Pg_141">141</a></td></tr>
+
+<tr><td><a class="pagenum" name="Pg_xi" id="Pg_xi"></a><a href="#fig_71">71.</a></td><td>Diagram of the most Common Dislocations of the Hip</td><td><a href="#Pg_142">142</a></td></tr>
+
+<tr><td><a href="#fig_72">72.</a></td><td>Dislocation of Right Femur on to Dorsum Ilii</td><td><a href="#Pg_143">143</a></td></tr>
+
+<tr><td><a href="#fig_73">73.</a></td><td>Dislocation on to Dorsum Ilii</td><td><a href="#Pg_144">144</a></td></tr>
+
+<tr><td><a href="#fig_74">74.</a></td><td>Dislocation into the Vicinity of the Ischiatic Notch</td><td><a href="#Pg_145">145</a></td></tr>
+
+<tr><td><a href="#fig_75">75.</a></td><td>Longitudinal Section of Femur showing Fracture of Shaft
+with Overriding of Fragments</td><td><a href="#Pg_148">148</a></td></tr>
+
+<tr><td><a href="#fig_76">76.</a></td><td>Radiogram of Steinmann's Apparatus applied for Direct
+Extension to the Femur</td><td><a href="#Pg_150">150</a></td></tr>
+
+<tr><td><a href="#fig_77">77.</a></td><td>Hodgen's Splint</td><td><a href="#Pg_151">151</a></td></tr>
+
+<tr><td><a href="#fig_78">78.</a></td><td>Long Splint with Perineal Band</td><td><a href="#Pg_152">152</a></td></tr>
+
+<tr><td><a href="#fig_79">79.</a></td><td>Fracture of Thigh treated by Vertical Extension</td><td><a href="#Pg_153">153</a></td></tr>
+
+<tr><td><a href="#fig_80">80.</a></td><td>Section of Knee-joint showing Extent of Synovial Cavity</td><td><a href="#Pg_156">156</a></td></tr>
+
+<tr><td><a href="#fig_81">81.</a></td><td>Extension applied by means of Ice-tong Callipers for Fracture
+of Femur</td><td><a href="#Pg_158">158</a></td></tr>
+
+<tr><td><a href="#fig_82">82.</a></td><td>Radiogram of Separation of Lower Epiphysis of Femur, with
+Backward Displacement of the Diaphysis</td><td><a href="#Pg_160">160</a></td></tr>
+
+<tr><td><a href="#fig_83">83.</a></td><td>Separation of Lower Epiphysis of Femur, with Fracture of
+Lower End of Diaphysis</td><td><a href="#Pg_161">161</a></td></tr>
+
+<tr><td><a href="#fig_84">84.</a></td><td>Radiogram of Fracture of Head of Tibia and upper Third of
+Fibula</td><td><a href="#Pg_163">163</a></td></tr>
+
+<tr><td><a href="#fig_85">85.</a></td><td>Radiogram illustrating Schlatter's Disease</td><td><a href="#Pg_164">164</a></td></tr>
+
+<tr><td><a href="#fig_86">86.</a></td><td>Diagram of Longitudinal Tear of Posterior End of Right
+Medial Semilunar Meniscus</td><td><a href="#Pg_171">171</a></td></tr>
+
+<tr><td><a href="#fig_87">87.</a></td><td>Radiogram of Fracture of Patella</td><td><a href="#Pg_173">173</a></td></tr>
+
+<tr><td><a href="#fig_88">88.</a></td><td>Fracture of Patella, showing wide Separation of Fragments</td><td><a href="#Pg_175">175</a></td></tr>
+
+<tr><td><a href="#fig_89">89.</a></td><td>Radiogram of Transverse Fracture of both Bones of Leg by
+Direct Violence</td><td><a href="#Pg_178">178</a></td></tr>
+
+<tr><td><a href="#fig_90">90.</a></td><td>Radiogram of Oblique Fracture of both Bones of Leg by
+Indirect Violence</td><td><a href="#Pg_178">178</a></td></tr>
+
+<tr><td><a href="#fig_91">91.</a></td><td>Box Splint for Fractures of Leg</td><td><a href="#Pg_180">180</a></td></tr>
+
+<tr><td><a href="#fig_92">92.</a></td><td>Box Splint applied</td><td><a href="#Pg_181">181</a></td></tr>
+
+<tr><td><a href="#fig_93">93.</a></td><td>Section through Ankle-joint showing relation of Epiphyses
+to Synovial Cavity</td><td><a href="#Pg_186">186</a></td></tr>
+
+<tr><td><a href="#fig_94">94.</a></td><td>Radiogram of Pott's Fracture, with Lateral Displacement of
+Foot</td><td><a href="#Pg_187">187</a></td></tr>
+
+<tr><td><a href="#fig_95">95.</a></td><td>Ambulant Splint of Plaster of Paris</td><td><a href="#Pg_189">189</a></td></tr>
+
+<tr><td><a href="#fig_96">96.</a></td><td>Dupuytren's Splint applied to Correct Eversion of Foot</td><td><a href="#Pg_190">190</a></td></tr>
+
+<tr><td><a href="#fig_97">97.</a></td><td>Syme's Horse-shoe Splint applied to Correct Backward Displacement
+of Foot</td><td><a href="#Pg_191">191</a></td></tr>
+
+<tr><td><a href="#fig_98">98.</a></td><td>Radiogram of Fracture of Lower End of Fibula, with Separation
+of Lower Epiphysis of Tibia</td><td><a href="#Pg_192">192</a></td></tr>
+
+<tr><td><a href="#fig_99">99.</a></td><td>Radiogram of Backward Dislocation of Ankle</td><td><a href="#Pg_195">195</a></td></tr>
+
+<tr><td><a href="#fig_100">100.</a></td><td>Compound Dislocation of Talus</td><td><a href="#Pg_197">197</a></td></tr>
+
+<tr><td><a href="#fig_101">101.</a></td><td>Radiogram of Fracture-Dislocation of Talus</td><td><a href="#Pg_198">198</a></td></tr>
+
+<tr><td><a href="#fig_102">102.</a></td><td>Radiogram of Dislocation of Toes</td><td><a href="#Pg_199">199</a></td></tr>
+
+<tr><td><a href="#fig_103">103.</a></td><td>Arthropathy of Shoulder in Syringomyelia</td><td><a href="#Pg_203">203</a></td></tr>
+
+<tr><td><a href="#fig_104">104.</a></td><td>Radiogram of Specimen of Arthropathy of Shoulder in Syringomyelia</td><td><a href="#Pg_204">204</a></td></tr>
+
+<tr><td><a href="#fig_105">105.</a></td><td>Radiogram showing Multiple partially Ossified Cartilaginous
+Loose Bodies in Shoulder-joint</td><td><a href="#Pg_205">205</a></td></tr>
+
+<tr><td><a href="#fig_106">106.</a></td><td>Diffuse Tuberculous Thickening of Synovial Membrane of Elbow</td><td><a href="#Pg_206">206</a></td></tr>
+
+<tr><td><a href="#fig_107">107.</a></td><td>Contracture of Elbow and Wrist following a Burn in Childhood</td><td><a href="#Pg_207">207</a></td></tr>
+
+<tr><td><a class="pagenum" name="Pg_xii" id="Pg_xii"></a><a href="#fig_108">108.</a></td><td>Advanced Tuberculous Disease of Acetabulum with Caries
+and Perforation into Pelvis</td><td><a href="#Pg_210">210</a></td></tr>
+
+<tr><td><a href="#fig_109">109.</a></td><td>Early Tuberculous Disease of Right Hip-joint in a Boy</td><td><a href="#Pg_212">212</a></td></tr>
+
+<tr><td><a href="#fig_110">110.</a></td><td>Disease of Left Hip; showing Moderate Flexion and Lordosis</td><td><a href="#Pg_213">213</a></td></tr>
+
+<tr><td><a href="#fig_111">111.</a></td><td>Disease of Left Hip; Disappearance of Lordosis on further
+Flexion of the Hip</td><td><a href="#Pg_213">213</a></td></tr>
+
+<tr><td><a href="#fig_112">112.</a></td><td>Disease of Left Hip; Exaggeration of Lordosis</td><td><a href="#Pg_214">214</a></td></tr>
+
+<tr><td><a href="#fig_113">113.</a></td><td>Thomas' Flexion Test, showing Angle of Flexion at Diseased
+Hip</td><td><a href="#Pg_214">214</a></td></tr>
+
+<tr><td><a href="#fig_114">114.</a></td><td>Tuberculous Disease of Left Hip: Third Stage</td><td><a href="#Pg_215">215</a></td></tr>
+
+<tr><td><a href="#fig_115">115.</a></td><td>Advanced Tuberculous Disease of Left Hip-joint in a Girl</td><td><a href="#Pg_216">216</a></td></tr>
+
+<tr><td><a href="#fig_116">116.</a></td><td>Extension by Adhesive Plaster and Weight and Pulley</td><td><a href="#Pg_220">220</a></td></tr>
+
+<tr><td><a href="#fig_117">117.</a></td><td>Stiles' Double Long Splint to admit of Abduction of Diseased Limb</td><td><a href="#Pg_221">221</a></td></tr>
+
+<tr><td><a href="#fig_118">118.</a></td><td>Thomas' Hip-splint applied for Disease of Right Hip</td><td><a href="#Pg_222">222</a></td></tr>
+
+<tr><td><a href="#fig_119">119.</a></td><td>Arthritis Deformans, showing erosion of Cartilage and
+lipping of Articular Edge of Head of Femur</td><td><a href="#Pg_225">225</a></td></tr>
+
+<tr><td><a href="#fig_120">120.</a></td><td>Upper End of Femur in advanced Arthritis Deformans of
+Hip</td><td><a href="#Pg_226">226</a></td></tr>
+
+<tr><td><a href="#fig_121">121.</a></td><td>Femur in advanced Arthritis Deformans of Hip and Knee
+Joints</td><td><a href="#Pg_227">227</a></td></tr>
+
+<tr><td><a href="#fig_122">122.</a></td><td>Tuberculous Synovial Membrane of Knee</td><td><a href="#Pg_230">230</a></td></tr>
+
+<tr><td><a href="#fig_123">123.</a></td><td>Lower End of Femur from an Advanced Case of Tuberculous
+Arthritis of the Knee</td><td><a href="#Pg_231">231</a></td></tr>
+
+<tr><td><a href="#fig_124">124.</a></td><td>Advanced Tuberculous Disease of Knee, with Backward Displacement
+of Tibia</td><td><a href="#Pg_233">233</a></td></tr>
+
+<tr><td><a href="#fig_125">125.</a></td><td>Thomas' Knee-splint applied</td><td><a href="#Pg_236">236</a></td></tr>
+
+<tr><td><a href="#fig_126">126.</a></td><td>Tuberculous Disease of Right Ankle</td><td><a href="#Pg_239">239</a></td></tr>
+
+<tr><td><a href="#fig_127">127.</a></td><td>Female Child showing the results of Poliomyelitis affecting
+the Left Lower Extremity</td><td><a href="#Pg_243">243</a></td></tr>
+
+<tr><td><a href="#fig_128">128.</a></td><td>Radiogram of Double Congenital Dislocation of Hip in
+a Girl</td><td><a href="#Pg_249">249</a></td></tr>
+
+<tr><td><a href="#fig_129">129.</a></td><td>Innominate Bone and Upper End of Femur from a case of
+Congenital Dislocation of Hip</td><td><a href="#Pg_250">250</a></td></tr>
+
+<tr><td><a href="#fig_130">130.</a></td><td>Congenital Dislocation of Left Hip in a Girl</td><td><a href="#Pg_251">251</a></td></tr>
+
+<tr><td><a href="#fig_131">131.</a></td><td>Contracture Deformities of Upper and Lower Limbs resulting
+from Spastic Cerebral Palsy in Infancy</td><td><a href="#Pg_255">255</a></td></tr>
+
+<tr><td><a href="#fig_132">132.</a></td><td>Rachitic Coxa Vara</td><td><a href="#Pg_258">258</a></td></tr>
+
+<tr><td><a href="#fig_133">133.</a></td><td>Coxa Vara, showing Adduction Curvature of Neck of Femur
+associated with Arthritis of the Hip and Knee</td><td><a href="#Pg_260">260</a></td></tr>
+
+<tr><td><a href="#fig_134">134.</a></td><td>Bilateral Coxa Vara, showing Scissors-leg Deformity</td><td><a href="#Pg_260">260</a></td></tr>
+
+<tr><td><a href="#fig_135">135.</a></td><td>Genu Valgum and Genu Varum</td><td><a href="#Pg_265">265</a></td></tr>
+
+<tr><td><a href="#fig_136">136.</a></td><td>Female Child with Right-sided Genu Valgum, the result of
+Rickets</td><td><a href="#Pg_266">266</a></td></tr>
+
+<tr><td><a href="#fig_137">137.</a></td><td>Double Genu Valgum; and Rickety Deformities of Arms</td><td><a href="#Pg_267">267</a></td></tr>
+
+<tr><td><a href="#fig_138">138.</a></td><td>Radiogram of Case of Double Genu Valgum in a Child</td><td><a href="#Pg_268">268</a></td></tr>
+
+<tr><td><a href="#fig_139">139.</a></td><td>Genu Valgum in a Child. Patient standing</td><td><a href="#Pg_269">269</a></td></tr>
+
+<tr><td><a href="#fig_140">140.</a></td><td>Genu Valgum. Same Patient as <a href="#fig_139">Fig.&nbsp;139</a>, sitting</td><td><a href="#Pg_270">270</a></td></tr>
+
+<tr><td><a href="#fig_141">141.</a></td><td>Bow-knee in Rickety Child</td><td><a href="#Pg_271">271</a></td></tr>
+
+<tr><td><a href="#fig_142">142.</a></td><td>Bilateral Congenital Club-foot in an Infant</td><td><a href="#Pg_274">274</a></td></tr>
+
+<tr><td><a href="#fig_143">143.</a></td><td>Radiogram of Bilateral Congenital Club-foot in an Infant</td><td><a href="#Pg_275">275</a></td></tr>
+
+<tr><td><a href="#fig_144">144.</a></td><td>Congenital Talipes Equino-varus in a Man</td><td><a href="#Pg_277">277</a></td></tr>
+
+<tr><td><a href="#fig_145">145.</a></td><td>Bilateral Pes Equinus in a Boy</td><td><a href="#Pg_280">280</a></td></tr>
+
+<tr><td><a href="#fig_146">146.</a></td><td>Extreme form of Pes Equinus in a Girl</td><td><a href="#Pg_281">281</a></td></tr>
+
+<tr><td><a class="pagenum" name="Pg_xiii" id="Pg_xiii"></a><a href="#fig_147">147.</a></td><td>Skeleton of Foot from case of Pes Equinus due to Poliomyelitis</td><td><a href="#Pg_282">282</a></td></tr>
+
+<tr><td><a href="#fig_148">148.</a></td><td>Pes Calcaneo-valgus with excessive arching of Foot</td><td><a href="#Pg_284">284</a></td></tr>
+
+<tr><td><a href="#fig_149">149.</a></td><td>Pes Calcaneo-valgus, the result of Poliomyelitis</td><td><a href="#Pg_285">285</a></td></tr>
+
+<tr><td><a href="#fig_150">150.</a></td><td>Pes Cavus in Association with Pes Equinus, the Result of
+Poliomyelitis</td><td><a href="#Pg_286">286</a></td></tr>
+
+<tr><td><a href="#fig_151">151.</a></td><td>Radiogram of Foot of Adult, showing Changes in the Bones
+in Pes Cavus</td><td><a href="#Pg_286">286</a></td></tr>
+
+<tr><td><a href="#fig_152">152.</a></td><td>Adolescent Flat-Foot</td><td><a href="#Pg_287">287</a></td></tr>
+
+<tr><td><a href="#fig_153">153.</a></td><td>Flat-Foot, showing Loss of Arch</td><td><a href="#Pg_288">288</a></td></tr>
+
+<tr><td><a href="#fig_154">154.</a></td><td>Imprint of Normal and of Flat Foot</td><td><a href="#Pg_290">290</a></td></tr>
+
+<tr><td><a href="#fig_155">155.</a></td><td>Bilateral Pes Valgus and Hallux Valgus in a Girl</td><td><a href="#Pg_293">293</a></td></tr>
+
+<tr><td><a href="#fig_156">156.</a></td><td>Radiogram of Spur on Under Aspect of Calcaneus</td><td><a href="#Pg_295">295</a></td></tr>
+
+<tr><td><a href="#fig_157">157.</a></td><td>Radiogram of Hallux Valgus</td><td><a href="#Pg_296">296</a></td></tr>
+
+<tr><td><a href="#fig_158">158.</a></td><td>Radiogram of Hallux Varus or Pigeon-Toe</td><td><a href="#Pg_298">298</a></td></tr>
+
+<tr><td><a href="#fig_159">159.</a></td><td>Hallux Rigidus and Flexus in a Boy</td><td><a href="#Pg_299">299</a></td></tr>
+
+<tr><td><a href="#fig_160">160.</a></td><td>Hammer-Toe</td><td><a href="#Pg_300">300</a></td></tr>
+
+<tr><td><a href="#fig_161">161.</a></td><td>Section of Hammer-Toe</td><td><a href="#Pg_301">301</a></td></tr>
+
+<tr><td><a href="#fig_162">162.</a></td><td>Congenital Hypertrophy of Left Lower Extremity in a Boy</td><td><a href="#Pg_302">302</a></td></tr>
+
+<tr><td><a href="#fig_163">163.</a></td><td>Supernumerary Great Toe</td><td><a href="#Pg_303">303</a></td></tr>
+
+<tr><td><a href="#fig_164">164.</a></td><td>Congenital Elevation of Left Scapula in a Girl: also shows
+Hairy Mole over Sacrum</td><td><a href="#Pg_304">304</a></td></tr>
+
+<tr><td><a href="#fig_165">165.</a></td><td>Winged Scapula</td><td><a href="#Pg_305">305</a></td></tr>
+
+<tr><td><a href="#fig_166">166.</a></td><td>Arrested Growth and Wasting of Tissues of Right Upper
+Extremity</td><td><a href="#Pg_307">307</a></td></tr>
+
+<tr><td><a href="#fig_167">167.</a></td><td>Lower End of Humerus from case of Cubitus Varus</td><td><a href="#Pg_309">309</a></td></tr>
+
+<tr><td><a href="#fig_168">168.</a></td><td>Intra-Uterine Amputation of Forearm</td><td><a href="#Pg_310">310</a></td></tr>
+
+<tr><td><a href="#fig_169">169.</a></td><td>Radiogram of Arm of Patient shown in <a href="#fig_168">Fig.&nbsp;168</a></td><td><a href="#Pg_310">310</a></td></tr>
+
+<tr><td><a href="#fig_170">170.</a></td><td>Congenital Absence of Left Radius and Tibia in a Child</td><td><a href="#Pg_311">311</a></td></tr>
+
+<tr><td><a href="#fig_171">171.</a></td><td>Club-Hand, the Result of Imperfect Development of
+Radius</td><td><a href="#Pg_312">312</a></td></tr>
+
+<tr><td><a href="#fig_172">172.</a></td><td>Congenital Contraction of Ring and Little Fingers</td><td><a href="#Pg_314">314</a></td></tr>
+
+<tr><td><a href="#fig_173">173.</a></td><td>Dupuytren's Contraction</td><td><a href="#Pg_315">315</a></td></tr>
+
+<tr><td><a href="#fig_174">174.</a></td><td>Splint used after Operation for Dupuytren's Contraction</td><td><a href="#Pg_316">316</a></td></tr>
+
+<tr><td><a href="#fig_175">175.</a></td><td>Supernumerary Thumb</td><td><a href="#Pg_317">317</a></td></tr>
+
+<tr><td><a href="#fig_176">176.</a></td><td>Trigger Finger</td><td><a href="#Pg_318">318</a></td></tr>
+
+<tr><td><a href="#fig_177">177.</a></td><td>Multiple Wens</td><td><a href="#Pg_324">324</a></td></tr>
+
+<tr><td><a href="#fig_178">178.</a></td><td>Adenoma of Scalp</td><td><a href="#Pg_325">325</a></td></tr>
+
+<tr><td><a href="#fig_179">179.</a></td><td>Relations of the Motor and Sensory Areas to the Convolutions
+and to Chiene's Lines</td><td><a href="#Pg_330">330</a></td></tr>
+
+<tr><td><a href="#fig_180">180.</a></td><td>Diagram of the Course of Motor and Sensory Nerve Fibres</td><td><a href="#Pg_333">333</a></td></tr>
+
+<tr><td><a href="#fig_181">181.</a></td><td>Chiene's Method of Cerebral Localisation</td><td><a href="#Pg_336">336</a></td></tr>
+
+<tr><td><a href="#fig_182">182.</a></td><td>To illustrate the Site of Various Operations on the Skull</td><td><a href="#Pg_337">337</a></td></tr>
+
+<tr><td><a href="#fig_183">183.</a></td><td>Localisation of Site for Introduction of Needle in Lumbar
+Puncture</td><td><a href="#Pg_338">338</a></td></tr>
+
+<tr><td><a href="#fig_184">184.</a></td><td>Contusion and Laceration of Brain</td><td><a href="#Pg_343">343</a></td></tr>
+
+<tr><td><a href="#fig_185">185.</a></td><td>Charts of Pyrexia in Head Injuries</td><td><a href="#Pg_348">348</a></td></tr>
+
+<tr><td><a href="#fig_186">186.</a></td><td>Relations of the Middle Meningeal Artery and Lateral Sinus
+to the Surface as indicated by Chiene's Lines</td><td><a href="#Pg_353">353</a></td></tr>
+
+<tr><td><a href="#fig_187">187.</a></td><td>Extra-Dural Clot resulting from H&aelig;morrhage from the
+Middle Meningeal Artery</td><td><a href="#Pg_354">354</a></td></tr>
+
+<tr><td><a href="#fig_188">188.</a></td><td>Depressed Fracture of Frontal Bones with Fissured Fracture</td><td><a href="#Pg_365">365</a></td></tr>
+
+<tr><td><a href="#fig_189">189.</a></td><td>Depressed and Comminuted Fracture of Right Parietal
+Bone: Pond Fracture</td><td><a href="#Pg_365">365</a></td></tr>
+
+<tr><td><a class="pagenum" name="Pg_xiv" id="Pg_xiv"></a><a href="#fig_190">190.</a></td><td>Pond Fracture of Left Frontal Bone, produced during
+Delivery</td><td><a href="#Pg_366">366</a></td></tr>
+
+<tr><td><a href="#fig_191">191.</a></td><td>Transverse Fracture through Middle Fossa of Base of
+Skull</td><td><a href="#Pg_368">368</a></td></tr>
+
+<tr><td><a href="#fig_192">192.</a></td><td>Diagram of Extra-Dural Abscess</td><td><a href="#Pg_374">374</a></td></tr>
+
+<tr><td><a href="#fig_193">193.</a></td><td>Pott's Puffy Tumour in case of Extra-Dural Abscess following
+Compound Fracture of Orbital Margin</td><td><a href="#Pg_375">375</a></td></tr>
+
+<tr><td><a href="#fig_194">194.</a></td><td>Diagram of Sub-Dural Abscess</td><td><a href="#Pg_376">376</a></td></tr>
+
+<tr><td><a href="#fig_195">195.</a></td><td>Diagram illustrating sequence of Paralysis, caused by Abscess
+in Temporal Lobe</td><td><a href="#Pg_380">380</a></td></tr>
+
+<tr><td><a href="#fig_196">196.</a></td><td>Chart of case of Sinus Phlebitis following Middle Ear Disease</td><td><a href="#Pg_384">384</a></td></tr>
+
+<tr><td><a href="#fig_197">197.</a></td><td>Occipital Meningocele</td><td><a href="#Pg_388">388</a></td></tr>
+
+<tr><td><a href="#fig_198">198.</a></td><td>Frontal Hydrencephalocele</td><td><a href="#Pg_389">389</a></td></tr>
+
+<tr><td><a href="#fig_199">199.</a></td><td>N&aelig;vus at Root of Nose, simulating Cephalocele</td><td><a href="#Pg_390">390</a></td></tr>
+
+<tr><td><a href="#fig_200">200.</a></td><td>Hydrocephalus in a Child</td><td><a href="#Pg_391">391</a></td></tr>
+
+<tr><td><a href="#fig_201">201.</a></td><td>Patient suffering from Left Facial Paralysis</td><td><a href="#Pg_402">402</a></td></tr>
+
+<tr><td><a href="#fig_202">202.</a></td><td>Skull of Woman illustrating the appearances of Tertiary
+Syphilis of Frontal Bone&mdash;Corona Veneris&mdash;in the Healed
+Condition</td><td><a href="#Pg_408">408</a></td></tr>
+
+<tr><td><a href="#fig_203">203.</a></td><td>Sarcoma of Orbital Plate of Frontal Bone in a Child at Age of
+11 months and 18 months</td><td><a href="#Pg_409">409</a></td></tr>
+
+<tr><td><a href="#fig_204">204.</a></td><td>Destruction of Bones of Left Orbit, caused by Rodent Cancer</td><td><a href="#Pg_410">410</a></td></tr>
+
+<tr><td><a href="#fig_205">205.</a></td><td>Distribution of the Segments of the Spinal Cord</td><td><a href="#Pg_417">417</a></td></tr>
+
+<tr><td><a href="#fig_206">206.</a></td><td>Attitude of Upper Extremities in Traumatic Lesions of the
+Sixth Cervical Segment</td><td><a href="#Pg_418">418</a></td></tr>
+
+<tr><td><a href="#fig_207">207.</a></td><td>Compression Fracture of Bodies of Third and Fourth
+Lumbar Vertebr&aelig;</td><td><a href="#Pg_426">426</a></td></tr>
+
+<tr><td><a href="#fig_208">208.</a></td><td>Fracture-Dislocation of Ninth Thoracic Vertebra</td><td><a href="#Pg_428">428</a></td></tr>
+
+<tr><td><a href="#fig_209">209.</a></td><td>Fracture of Odontoid Process of Axis Vertebra</td><td><a href="#Pg_429">429</a></td></tr>
+
+<tr><td><a href="#fig_210">210.</a></td><td>Tuberculous Osteomyelitis affecting several Vertebr&aelig; at
+Thoracico-Lumbar Junction</td><td><a href="#Pg_432">432</a></td></tr>
+
+<tr><td><a href="#fig_211">211.</a></td><td>Osseous Ankylosis of Bodies (<i>a</i>) of Dorsal Vertebr&aelig;, (<i>b</i>) of
+Lumbar Vertebr&aelig; following Pott's Disease</td><td><a href="#Pg_434">434</a></td></tr>
+
+<tr><td><a href="#fig_212">212.</a></td><td>Radiogram of Museum Specimen of Pott's Disease in a Child</td><td><a href="#Pg_435">435</a></td></tr>
+
+<tr><td><a href="#fig_213">213.</a></td><td>Radiogram of Child's Thorax showing Spindle-shaped
+Shadow at Site of Pott's Disease of Fourth, Fifth, and
+Sixth Thoracic Vertebr&aelig;</td><td><a href="#Pg_437">437</a></td></tr>
+
+<tr><td><a href="#fig_214">214.</a></td><td>Attitude of Patient suffering from Tuberculous Disease of
+the Cervical Spine</td><td><a href="#Pg_441">441</a></td></tr>
+
+<tr><td><a href="#fig_215">215.</a></td><td>Thomas' Double Splint for Tuberculous Disease of the
+Spine</td><td><a href="#Pg_442">442</a></td></tr>
+
+<tr><td><a href="#fig_216">216.</a></td><td>Hunch-back Deformity following Pott's Disease of Thoracic
+Vertebr&aelig;</td><td><a href="#Pg_443">443</a></td></tr>
+
+<tr><td><a href="#fig_217">217.</a></td><td>Attitude in Pott's Disease of Thoracico-Lumbar Region of
+Spine</td><td><a href="#Pg_444">444</a></td></tr>
+
+<tr><td><a href="#fig_218">218.</a></td><td>Arthritis Deformans of Spine</td><td><a href="#Pg_449">449</a></td></tr>
+
+<tr><td><a href="#fig_219">219.</a></td><td>Meningo-Myelocele of Thoracico-Lumbar Region</td><td><a href="#Pg_454">454</a></td></tr>
+
+<tr><td><a href="#fig_220">220.</a></td><td>Meningo-Myelocele of Cervical Spine</td><td><a href="#Pg_454">454</a></td></tr>
+
+<tr><td><a href="#fig_221">221.</a></td><td>Meningo-Myelocele in Thoracic Region</td><td><a href="#Pg_456">456</a></td></tr>
+
+<tr><td><a href="#fig_222">222.</a></td><td>Tail-like Appendage over Spina Bifida Occulta in a Boy</td><td><a href="#Pg_457">457</a></td></tr>
+
+<tr><td><a href="#fig_223">223.</a></td><td>Congenital Sacro-Coccygeal Tumour</td><td><a href="#Pg_458">458</a></td></tr>
+
+<tr><td><a href="#fig_224">224.</a></td><td>Scoliosis following upon Poliomyelitis affecting Right Arm
+and Leg</td><td><a href="#Pg_463">463</a></td></tr>
+
+<tr><td><a href="#fig_225">225.</a></td><td>Rickety Scoliosis in a Child</td><td><a href="#Pg_464">464</a></td></tr>
+
+<tr><td><a class="pagenum" name="Pg_xv" id="Pg_xv"></a><a href="#fig_226">226.</a></td><td>Vertebr&aelig; from case of Scoliosis showing Alteration in
+Shape of Bones</td><td><a href="#Pg_466">466</a></td></tr>
+
+<tr><td><a href="#fig_227">227.</a></td><td>Adolescent Scoliosis in a Girl</td><td><a href="#Pg_467">467</a></td></tr>
+
+<tr><td><a href="#fig_228">228.</a></td><td>Scoliosis with Primary Curve in Thoracic Region</td><td><a href="#Pg_468">468</a></td></tr>
+
+<tr><td><a href="#fig_229">229.</a></td><td>Scoliosis showing Rotation of Bodies of Vertebr&aelig;, and
+widening of Intercostal Spaces on side of Convexity</td><td><a href="#Pg_469">469</a></td></tr>
+
+<tr><td><a href="#fig_230">230.</a></td><td>Diagram of Attitudes in Klapp's Four-Footed Exercises for
+Scoliosis</td><td><a href="#Pg_473">473</a></td></tr>
+
+<tr><td><a href="#fig_231">231.</a></td><td>Head of Human Embryo about 29 days old</td><td><a href="#Pg_475">475</a></td></tr>
+
+<tr><td><a href="#fig_232">232.</a></td><td>Simple Hare-Lip</td><td><a href="#Pg_476">476</a></td></tr>
+
+<tr><td><a href="#fig_233">233.</a></td><td>Unilateral Hare-Lip with Cleft Alveolus</td><td><a href="#Pg_477">477</a></td></tr>
+
+<tr><td><a href="#fig_234">234.</a></td><td>Double Hare-Lip in a Girl</td><td><a href="#Pg_478">478</a></td></tr>
+
+<tr><td><a href="#fig_235">235.</a></td><td>Double Hare-Lip with Projection of the Os Incisivum</td><td><a href="#Pg_479">479</a></td></tr>
+
+<tr><td><a href="#fig_236">236.</a></td><td>Asymmetrical Cleft Palate extending through Alveolar
+Process on Left Side</td><td><a href="#Pg_480">480</a></td></tr>
+
+<tr><td><a href="#fig_237">237.</a></td><td>Illustrating the Deformities caused by Lupus Vulgaris</td><td><a href="#Pg_483">483</a></td></tr>
+
+<tr><td><a href="#fig_238">238.</a></td><td>Sarcoma of Orbit causing Exophthalmos and Downward
+Displacement of the Eye, and Projecting in Temporal
+Region</td><td><a href="#Pg_488">488</a></td></tr>
+
+<tr><td><a href="#fig_239">239.</a></td><td>Sarcoma of Eyelid in Child</td><td><a href="#Pg_489">489</a></td></tr>
+
+<tr><td><a href="#fig_240">240.</a></td><td>Dermoid Cyst at Outer Angle of Orbital Margin</td><td><a href="#Pg_490">490</a></td></tr>
+
+<tr><td><a href="#fig_241">241.</a></td><td>Macrocheilia</td><td><a href="#Pg_492">492</a></td></tr>
+
+<tr><td><a href="#fig_242">242.</a></td><td>Squamous Epithelioma of Lower Lip in a Man</td><td><a href="#Pg_493">493</a></td></tr>
+
+<tr><td><a href="#fig_243">243.</a></td><td>Advanced Epithelioma of Lower Lip</td><td><a href="#Pg_494">494</a></td></tr>
+
+<tr><td><a href="#fig_244">244.</a></td><td>Recurrent Epithelioma in Glands of Neck adherent to
+Mandible</td><td><a href="#Pg_495">495</a></td></tr>
+
+<tr><td><a href="#fig_245">245.</a></td><td>Cancrum Oris</td><td><a href="#Pg_497">497</a></td></tr>
+
+<tr><td><a href="#fig_246">246.</a></td><td>Perforation of Palate, the Result of Syphilis, and Gumma of
+Right Frontal Bone</td><td><a href="#Pg_498">498</a></td></tr>
+
+<tr><td><a href="#fig_247">247.</a></td><td>Cario-necrosis of Mandible</td><td><a href="#Pg_510">510</a></td></tr>
+
+<tr><td><a href="#fig_248">248.</a></td><td>Diffuse Syphilitic Disease of Mandible</td><td><a href="#Pg_512">512</a></td></tr>
+
+<tr><td><a href="#fig_249">249.</a></td><td>Epulis of Mandible</td><td><a href="#Pg_513">513</a></td></tr>
+
+<tr><td><a href="#fig_250">250.</a></td><td>Sarcoma of the Maxilla</td><td><a href="#Pg_515">515</a></td></tr>
+
+<tr><td><a href="#fig_251">251.</a></td><td>Malignant Disease of Left Maxilla</td><td><a href="#Pg_516">516</a></td></tr>
+
+<tr><td><a href="#fig_252">252.</a></td><td>Dentigerous Cyst of Mandible containing Rudimentary
+Tooth</td><td><a href="#Pg_517">517</a></td></tr>
+
+<tr><td><a href="#fig_253">253.</a></td><td>Osseous Shell of Myeloma of Mandible</td><td><a href="#Pg_518">518</a></td></tr>
+
+<tr><td><a href="#fig_254">254.</a></td><td>Multiple Fracture of Mandible</td><td><a href="#Pg_520">520</a></td></tr>
+
+<tr><td><a href="#fig_255">255.</a></td><td>Four-Tailed Bandage applied for Fracture of Mandible</td><td><a href="#Pg_522">522</a></td></tr>
+
+<tr><td><a href="#fig_256">256.</a></td><td>Defective Development of Mandible from Fixation of Jaw
+due to Tuberculous Osteomyelitis in Infancy</td><td><a href="#Pg_526">526</a></td></tr>
+
+<tr><td><a href="#fig_257">257.</a></td><td>Leucoplakia of the Tongue</td><td><a href="#Pg_531">531</a></td></tr>
+
+<tr><td><a href="#fig_258">258.</a></td><td>Papillomatous Angioma of Left Side of Tongue in a Woman</td><td><a href="#Pg_538">538</a></td></tr>
+
+<tr><td><a href="#fig_259">259.</a></td><td>Dermoid Cyst in Middle Line of Neck</td><td><a href="#Pg_539">539</a></td></tr>
+
+<tr><td><a href="#fig_260">260.</a></td><td>Temporary Unilateral Paralysis of Tongue</td><td><a href="#Pg_541">541</a></td></tr>
+
+<tr><td><a href="#fig_261">261.</a></td><td>Series of Salivary Calculi</td><td><a href="#Pg_545">545</a></td></tr>
+
+<tr><td><a href="#fig_262">262.</a></td><td>Acute Suppurative Parotitis</td><td><a href="#Pg_546">546</a></td></tr>
+
+<tr><td><a href="#fig_263">263.</a></td><td>Mixed Tumour of Parotid</td><td><a href="#Pg_550">550</a></td></tr>
+
+<tr><td><a href="#fig_264">264.</a></td><td>Mixed Tumour of the Parotid of over twenty years' duration</td><td><a href="#Pg_551">551</a></td></tr>
+
+<tr><td><a href="#fig_265">265.</a></td><td>Acute Mastoid Disease showing &OElig;dema and Projection of
+Auricle</td><td><a href="#Pg_565">565</a></td></tr>
+
+<tr><td><a href="#fig_266">266.</a></td><td>Rhinophyma or Lipoma Nasi</td><td><a href="#Pg_569">569</a></td></tr>
+
+<tr><td><a href="#fig_267">267.</a></td><td>The Outer Wall of Left Nasal Chamber after removal of
+the Middle Turbinated Body</td><td><a href="#Pg_571">571</a></td></tr>
+
+<tr><td><a class="pagenum" name="Pg_xvi" id="Pg_xvi"></a><a href="#fig_268">268.</a></td><td>Congenital Branchial Cyst in a Woman</td><td><a href="#Pg_584">584</a></td></tr>
+
+<tr><td><a href="#fig_269">269.</a></td><td>Bilateral Cervical Ribs</td><td><a href="#Pg_586">586</a></td></tr>
+
+<tr><td><a href="#fig_270">270.</a></td><td>Transient Wry-Neck</td><td><a href="#Pg_587">587</a></td></tr>
+
+<tr><td><a href="#fig_271">271.</a></td><td>Congenital Wry-Neck in a Boy</td><td><a href="#Pg_589">589</a></td></tr>
+
+<tr><td><a href="#fig_272">272.</a></td><td>Congenital Wry-Neck seen from behind to show Scoliosis</td><td><a href="#Pg_590">590</a></td></tr>
+
+<tr><td><a href="#fig_273">273.</a></td><td>Recovery from Suicidal Cut-Throat after Low Tracheotomy
+and Gastrostomy</td><td><a href="#Pg_596">596</a></td></tr>
+
+<tr><td><a href="#fig_274">274.</a></td><td>Hygroma of Neck</td><td><a href="#Pg_599">599</a></td></tr>
+
+<tr><td><a href="#fig_275">275.</a></td><td>Lympho-Sarcoma of Neck</td><td><a href="#Pg_600">600</a></td></tr>
+
+<tr><td><a href="#fig_276">276.</a></td><td>Branchial Carcinoma</td><td><a href="#Pg_601">601</a></td></tr>
+
+<tr><td><a href="#fig_277">277.</a></td><td>Parenchymatous Goitre in a Girl</td><td><a href="#Pg_606">606</a></td></tr>
+
+<tr><td><a href="#fig_278">278.</a></td><td>Larynx and Trachea surrounded by Goitre</td><td><a href="#Pg_607">607</a></td></tr>
+
+<tr><td><a href="#fig_279">279.</a></td><td>Section of Goitre shown in <a href="#fig_278">Fig.&nbsp;278</a> to illustrate Compression
+of Trachea</td><td><a href="#Pg_607">607</a></td></tr>
+
+<tr><td><a href="#fig_280">280.</a></td><td>Multiple Adenomata of Thyreoid in a Woman</td><td><a href="#Pg_611">611</a></td></tr>
+
+<tr><td><a href="#fig_281">281.</a></td><td>Cyst of Left Lobe of Thyreoid</td><td><a href="#Pg_612">612</a></td></tr>
+
+<tr><td><a href="#fig_282">282.</a></td><td>Exophthalmic Goitre</td><td><a href="#Pg_614">614</a></td></tr>
+
+<tr><td><a href="#fig_283">283.</a></td><td>Radiogram of Safety-Pin impacted in the Gullet and Perforating
+the Larynx</td><td><a href="#Pg_620">620</a></td></tr>
+
+<tr><td><a href="#fig_284">284.</a></td><td>Denture Impacted in &OElig;sophagus</td><td><a href="#Pg_621">621</a></td></tr>
+
+<tr><td><a href="#fig_285">285.</a></td><td>Radiogram, after swallowing an Opaque Meal, in a Man
+suffering from Malignant Stricture of Lower End of
+Gullet</td><td><a href="#Pg_626">626</a></td></tr>
+
+<tr><td><a href="#fig_286">286.</a></td><td>Diverticulum of the &OElig;sophagus at its Junction with the
+Pharynx</td><td><a href="#Pg_627">627</a></td></tr>
+
+<tr><td><a href="#fig_287">287.</a></td><td>Larynx from case of Sudden Death due to &OElig;dema of Ary-Epiglottic
+Folds</td><td><a href="#Pg_637">637</a></td></tr>
+
+<tr><td><a href="#fig_288">288.</a></td><td>Papilloma of Larynx</td><td><a href="#Pg_641">641</a></td></tr>
+</table>
+
+
+
+
+<h1 style="width:65%; border-top:thin solid black; padding-top:1.5em; margin:1.5em auto auto auto;"><a class="pagenum" name="Pg_1" id="Pg_1"></a><a name="MANUAL_OF_SURGERY" id="MANUAL_OF_SURGERY"></a>MANUAL OF SURGERY</h1>
+
+
+
+
+<h2><a name="CHAPTER_I" id="CHAPTER_I"></a>CHAPTER I
+<br />
+INJURIES OF BONES</h2>
+
+<ul class="chap">
+  <li><a href="#I_contusions">Contusions</a></li>
+  <li>&mdash;<a href="#I_wounds">Wounds</a></li>
+  <li>&mdash;<a href="#I_fractures"><span class="smcap">Fractures</span></a>:</li>
+  <li><a href="#I_pathological"><i>Pathological</i></a>;</li>
+  <li><a href="#I_traumatic"><i>Traumatic</i></a>;</li>
+  <li><a href="#I_varieties"><i>Varieties</i></a></li>
+  <li>&mdash;<a href="#I_simple_fracture">Simple fractures</a></li>
+  <li>&mdash;<a href="#I_compound_fracture">Compound fractures</a></li>
+  <li>&mdash;<a href="#I_fracture_repair">Repair of fractures</a></li>
+  <li>&mdash;<a href="#I_repair_interference">Interference with repair</a></li>
+  <li>&mdash;<a href="#I_gun-shot_fracture">Gun-shot fractures</a></li>
+  <li>&mdash;<a href="#I_epiphyses"><span class="smcap">Separation Of Epiphyses</span></a>.</li>
+</ul>
+
+<p>The injuries to which a bone is liable are Contusions, Open Wounds,
+and Fractures.</p>
+
+<p><a name="I_contusions" id="I_contusions"></a><b>Contusions of Bone</b> 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 <i>h&aelig;matoma of the periosteum</i>. This
+may be absorbed, or it may give place to a persistent thickening of
+the bone&mdash;<i>traumatic node</i>.</p>
+
+<p><a name="I_wounds" id="I_wounds"></a><b>Open Wounds of Bone</b> 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.</p>
+
+
+<h3><a name="I_fractures" id="I_fractures"></a>FRACTURES</h3>
+
+<p>A fracture may be defined as a sudden solution in the continuity of a
+bone.</p>
+
+
+<h4><a name="I_pathological" id="I_pathological"></a>Pathological Fractures</h4>
+
+<p>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 class="pagenum" name="Pg_2" id="Pg_2"></a> 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.</p>
+
+<p><i>Atrophy</i> 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.</p>
+
+<p>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.</p>
+
+<p>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,<a class="pagenum" name="Pg_3" id="Pg_3"></a> secondary cancer, are the commonest local
+causes of pathological fracture.</p>
+
+<p><i>Intra-uterine fractures</i> and fractures occurring <i>during birth</i> are
+usually associated with some form of violence, but in the majority of
+cases the f&oelig;tus is the subject of constitutional disease which
+renders the bones unduly fragile.</p>
+
+
+<h4><a name="I_traumatic" id="I_traumatic"></a><span class="smcap">Traumatic Fractures</span></h4>
+
+<p>Traumatic fractures are usually the result of a severe force acting
+from without, although sometimes they are produced by muscular
+contraction.</p>
+
+<div class="figleft" style="width: 144px;">
+<a name="fig_1" id="fig_1"></a>
+<img src="images/fig001.jpg" width="144" height="600" alt="Fig. 1.&mdash;Multiple Fracture of both Bones of Leg." title="" />
+<span class="caption"><span class="smcap">Fig. 1.</span>&mdash;Multiple Fracture of both Bones of Leg.</span>
+</div>
+
+<p>When the bone gives way at the point of impact of the force, the
+violence is said to be <i>direct</i>, and a &ldquo;fracture by compression&rdquo;
+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.</p>
+
+<p>When the force is transmitted to the seat of fracture from a distance,
+the violence is said to be <i>indirect</i>, and the bone is broken by
+&ldquo;torsion&rdquo; or by &ldquo;bending.&rdquo; 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.</p>
+
+<p>In fractures by <i>muscular action</i> the bone is broken by &ldquo;traction&rdquo; or
+&ldquo;tearing.&rdquo; 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<a class="pagenum" name="Pg_4" id="Pg_4"></a> 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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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&mdash;a long skirt&mdash;they
+are more exposed to unexpected or sudden falls.</p>
+
+<p><a name="I_varieties" id="I_varieties"></a><b>Clinical Varieties of Fractures.</b>&mdash;The most important subdivision of
+fractures is that into simple and compound.</p>
+
+<p><a name="I_simple_fracture" id="I_simple_fracture"></a>In a <i>simple</i> or subcutaneous fracture there is no communication,
+directly or indirectly, between the broken ends of the<a class="pagenum" name="Pg_5" id="Pg_5"></a> bone and the
+surface of the skin.<a name="I_compound_fracture" id="I_compound_fracture"></a> In a <i>compound</i> 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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>(1) <i>According to the Degree of Damage done to the Bone.</i>&mdash;A fracture
+may be incomplete, for example in <i>greenstick fractures</i>, which occur
+only in young persons&mdash;usually below the age of twelve&mdash;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 (<a href="#fig_41">Fig.&nbsp;41</a>). <i>Fissures</i> 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.
+<i>Depressions</i> or indentations are most common in the bones of the
+skull.</p>
+
+<p>The bone at the seat of fracture may be broken into several<a class="pagenum" name="Pg_6" id="Pg_6"></a> pieces,
+constituting a <i>comminuted</i> fracture. This usually results from severe
+degrees of direct violence, such as are sustained in railway or
+machinery accidents, and in gun-shot injuries (<a href="#fig_2">Fig.&nbsp;2</a>).</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_2" id="fig_2"></a>
+<img src="images/fig002.jpg" width="400" height="225" alt="Fig. 2.&mdash;Radiogram of Comminuted Fracture of both Bones
+of Forearm." title="" />
+<span class="caption"><span class="smcap">Fig. 2.</span>&mdash;Radiogram of Comminuted Fracture of both Bones
+of Forearm.</span>
+</div>
+
+<p><i>Sub-periosteal</i> 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.</p>
+
+<div class="figleft" style="width: 217px;">
+<a name="fig_3" id="fig_3"></a>
+<img src="images/fig003.jpg" width="217" height="600" alt="Fig. 3.&mdash;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 &aelig;t. 16." title="" />
+<span class="caption"><span class="smcap">Fig. 3.</span>&mdash;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 &aelig;t. 16.</span>
+</div>
+
+<p>A bone may be broken at several places, constituting a <i>multiple</i>
+fracture (<a href="#fig_1">Fig.&nbsp;1</a>).</p>
+
+<p><i>Separation of bony processes</i>, 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. <i>Separation of
+epiphyses</i> will be considered later.</p>
+
+<p>(2) <i>According to the Direction of the Break.</i>&mdash;<i>Transverse</i> 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. <i>Longitudinal</i> fractures extending the
+greater part of the length of a long bone are exceedingly rare.
+<i>Oblique</i> fractures are common, and result usually from indirect
+violence, bending, or torsion (<a href="#fig_3">Fig.&nbsp;3</a>). <i>Spiral</i> fractures result from
+forcible torsion of a long bone, and are met with most frequently in
+the tibia, femur, and humerus.</p>
+
+<p>(3) <i>According to the Relative Position of the Fragments.</i>&mdash;The bone
+may be completely broken across, yet its ends remain<a class="pagenum" name="Pg_7" id="Pg_7"></a> in apposition,
+in which case there is said to be <i>no displacement</i>. There may be an
+<i>angular</i> displacement&mdash;for example, in greenstick fracture. In
+transverse fractures of the patella or of the olecranon there is often
+<i>distraction</i> or pulling apart of the fragments (<a href="#fig_35">Fig.&nbsp;35</a>). The broken
+ends, especially in oblique fractures, may <i>override</i> one another, and
+so give rise to shortening of the limb (<a href="#fig_2">Fig.&nbsp;2</a>). Where one fragment is
+acted upon by powerful muscles, a <i>rotatory</i> 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 <i>depressed</i>, 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 <i>impacted</i> or wedged
+into the substance of the other (<a href="#fig_28">Fig.&nbsp;28</a>).</p>
+
+<p><i>Causes of Displacement.</i>&mdash;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&mdash;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.</p>
+
+<p>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.</p>
+
+
+<h4><a name="I_fracture_repair" id="I_fracture_repair"></a><a class="pagenum" name="Pg_8" id="Pg_8"></a><span class="smcap">Repair of Injuries of Bone</span></h4>
+
+<p>In a <i>simple fracture</i> 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 <i>osteoblasts</i>, 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.</p>
+
+<div class="figright" style="width: 164px;">
+<a name="fig_4" id="fig_4"></a>
+<img src="images/fig004.jpg" width="164" height="600" alt="Fig. 4.&mdash;Excess of Callus after compound fracture of
+Bones of Forearm." title="" />
+<span class="caption"><span class="smcap">Fig. 4.</span>&mdash;Excess of Callus after compound fracture of
+Bones of Forearm.</span>
+</div>
+
+<p>The reparative material, consisting of granulation tissue in the
+process of conversion into bone, is called <i>callus</i>, on account of its
+hard and unyielding character. In a fracture of a long bone, that
+which surrounds the fragments is called the <i>external</i> or <i>ensheathing
+callus</i>, 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 <i>internal</i> or <i>medullary callus</i>;
+and that which intervenes between the fragments and maintains the
+continuity of the cortical compact tissue of the shaft is called the
+<i>intermediate callus</i>. 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.</p>
+
+<p>Detached fragments or splinters of bone are usually included in the
+callus and ultimately become incorporated in the new bone that bridges
+the gap.</p>
+
+<p>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.<a class="pagenum" name="Pg_9" id="Pg_9"></a> 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.</p>
+
+<p>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.</p>
+
+<p>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
+<i>non-union</i> results.</p>
+
+<p>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.</p>
+
+<p><a name="I_repair_interference" id="I_repair_interference"></a><b>Excess of Callus.</b>&mdash;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.<a class="pagenum" name="Pg_10" id="Pg_10"></a> 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 (<a href="#fig_4">Fig.&nbsp;4</a>). 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.</p>
+
+<p><b>Absorption of Callus.</b>&mdash;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.</p>
+
+<p><b>Tumours of Callus.</b>&mdash;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.</p>
+
+<div class="figleft" style="width: 196px;">
+<a name="fig_5" id="fig_5"></a>
+<img src="images/fig005.jpg" width="196" height="600" alt="Fig. 5.&mdash;Multiple Fractures of both Bones of Forearm
+showing mal-union." title="" />
+<span class="caption"><span class="smcap">Fig. 5.</span>&mdash;Multiple Fractures of both Bones of Forearm
+showing mal-union.</span>
+</div>
+
+<p><b>Badly United Fracture&mdash;Mal-Union.</b>&mdash;Union with marked displacement of
+the fragments is most common in fractures that have not been properly
+treated&mdash;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.</p>
+
+<p>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.</p>
+
+<p>When interference is called for, if the callus is not yet firmly
+consolidated, it may be possible, under an an&aelig;sthetic, 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<a class="pagenum" name="Pg_11" id="Pg_11"></a> 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.</p>
+
+<p><b>Delayed Union.</b>&mdash;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<a class="pagenum" name="Pg_12" id="Pg_12"></a> 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.</p>
+
+<p><i>Treatment.</i>&mdash;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 hyper&aelig;mia 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 hyper&aelig;mia 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.</p>
+
+<p>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 an&aelig;sthetic 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.</p>
+
+<p><b>Non-Union.</b>&mdash;Sometimes the fragments become united by a dense band of
+fibrous tissue, and the reparative process goes no further&mdash;<i>fibrous
+union</i>. This is frequently the case in fractures of the patella, the
+olecranon, and the narrow part of the neck of the femur.</p>
+
+<p><i>False Joint&mdash;Pseudarthrosis.</i>&mdash;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.</p>
+
+<p><i>Failure of Union&mdash;&ldquo;Un-united Fracture.&rdquo;</i>&mdash;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<a class="pagenum" name="Pg_13" id="Pg_13"></a> 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 (<a href="#fig_6">Fig.&nbsp;6</a>), and the femur; in children in the bones
+of the leg and in the forearm.</p>
+
+<div class="figcenter" style="width: 297px;">
+<a name="fig_6" id="fig_6"></a>
+<img src="images/fig006.jpg" width="297" height="600" alt="Fig. 6.&mdash;Radiogram of Un-united Fracture of Shaft of
+Ulna of fifteen years&#39; duration." title="" />
+<span class="caption"><span class="smcap">Fig. 6.</span>&mdash;Radiogram of Un-united Fracture of Shaft of
+Ulna of fifteen years&#39; duration.</span>
+</div>
+
+<p><a class="pagenum" name="Pg_14" id="Pg_14"></a>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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 <i>with
+the ends reversed</i>, so that a strong bridge of bone is provided at the
+seat of non-union.</p>
+
+
+<h4>Clinical Features of Simple Fractures</h4>
+
+<p>In the first place, the <i>history of the accident</i> should be
+investigated, attention being paid to the nature of the
+violence&mdash;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<a class="pagenum" name="Pg_15" id="Pg_15"></a>
+inflicting it&mdash;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.</p>
+
+<p><i>Signs of Fracture.</i>&mdash;The most characteristic signs of fracture are
+unnatural mobility, deformity, and crepitus.</p>
+
+<p><i>Unnatural mobility</i>&mdash;that is, movement between two segments of a limb
+at a place where movement does not normally occur&mdash;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.
+<i>Deformity</i>, or the part being &ldquo;out of drawing&rdquo; 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. <i>Crepitus</i>
+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.</p>
+
+<p>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&mdash;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.</p>
+
+<p>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,<a class="pagenum" name="Pg_16" id="Pg_16"></a> causing damage to
+soft parts or producing displacement which does not already exist, or
+by converting a simple into a compound fracture.</p>
+
+<p>It is often necessary for purposes of diagnosis to administer a
+general an&aelig;sthetic, 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.</p>
+
+<p><i>Radiography in the Diagnosis of Fractures.</i>&mdash;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.</p>
+
+<p>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.</p>
+
+<p>To ensure accuracy in the diagnosis of fracture by the X-rays, it is
+necessary to take two views of the limb&mdash;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.</p>
+
+<p>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<a class="pagenum" name="Pg_17" id="Pg_17"></a> simulated. The neck of the femur may appear to be
+fractured if a foreshortened view is taken.</p>
+
+<p>It is possible, on the other hand, to overlook a fracture&mdash;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&mdash;for example, ribs, sternum, or dorsal vertebr&aelig;&mdash;it is
+sometimes difficult to obtain conclusive evidence of fracture in a
+radiogram.</p>
+
+<p>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.</p>
+
+<hr style="width: 45%;" />
+
+<p>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.</p>
+
+<p><i>Interference with Function.</i>&mdash;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.</p>
+
+<p><i>Pain.</i>&mdash;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 &ldquo;tenderness.&rdquo; 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<a class="pagenum" name="Pg_18" id="Pg_18"></a> fracture&mdash;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, &ldquo;pain on distal
+pressure,&rdquo;&mdash;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,&mdash;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.</p>
+
+<p><i>Localised swelling</i> comes on rapidly, and is due to displacement of
+the fragments and to h&aelig;morrhage from the torn vessels of the marrow
+and periosteum.</p>
+
+<p><i>Discoloration</i> 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.</p>
+
+<p>Alterations in the relative position of <i>bony landmarks</i> are valuable
+diagnostic guides. Alteration in the <i>length</i> 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.</p>
+
+<p><i>Shock</i> 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 <i>fever</i>, indicated by a
+rise of temperature to 99&deg; or 100&deg; F.</p>
+
+<p><b>Complications.</b>&mdash;<i>Injuries to large arteries</i> 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 <i>veins</i> are injured, thrombosis may occur,
+and be followed by pulmonary embolism.</p>
+
+<p><i>Injuries to nerve-trunks</i> are comparatively common, especially in
+fractures of the arm, where the radial (musculo-spiral) nerve is
+liable to suffer.</p>
+
+<p>The nerve may be implicated at the time of the injury, being<a class="pagenum" name="Pg_19" id="Pg_19"></a>
+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.</p>
+
+<p>In rare instances <i>fat embolism</i> is said to occur, and fat globules
+are alleged to have been found in the urine. In persons addicted to
+excess of alcohol, <i>delirium tremens</i> is a not infrequent
+accompaniment of a fracture which confines the patient to bed.</p>
+
+<p><b>Prognosis in Simple Fractures.</b>&mdash;<i>Danger to life</i> 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.</p>
+
+<p>The prognosis as regards the <i>function of the limb</i> 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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>Impairment of growth and eventual shortening of the limb may result
+from involvement of an epiphysial junction.</p>
+
+<p>Stiffness of joints is liable to follow fractures implicating
+articular surfaces, or it may result from arthritic changes following
+upon the injury.</p>
+
+<p>Osseous ankylosis is not a common sequel of simple fractures, but
+locking of joints from the mechanical impediment produced<a class="pagenum" name="Pg_20" id="Pg_20"></a> by the
+union of imperfectly reduced fragments, or from masses of callus, is
+not uncommon, especially in the region of the elbow.</p>
+
+<p>Wasting of the muscles and &oelig;dema 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.</p>
+
+<p><b>Treatment.</b>&mdash;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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>In many cases, particularly in muscular subjects, in restless
+alcoholic patients, and in those who do not bear pain well, a general
+an&aelig;sthetic is a valuable aid to the accurate setting of a fracture, as
+well as a means of rendering the diagnosis more certain.</p>
+
+<p>The procedure popularly known as &ldquo;setting a fracture&rdquo; consists in
+restoring the displaced parts to their normal position as nearly as
+possible, and is spoken of technically as the <i>reduction</i> of the
+fracture.</p>
+
+<p><i>The Reduction of Fractures.</i>&mdash;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
+<i>extension</i>, by making forcible but steady traction on the distal
+fragment, while <i>counter-extension</i> 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,<a class="pagenum" name="Pg_21" id="Pg_21"></a> the broken ends are
+moulded into position&mdash;a process termed <i>coaptation</i>.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><i>Practical Means of Effecting Retention&mdash;By Position.</i>&mdash;It is often
+found that only in one particular position can the fragments be made
+to meet and remain in apposition&mdash;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&mdash;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.</p>
+
+<p><i>Massage and Movement in the Treatment of
+Fractures.</i>&mdash;Lucas-Championni&egrave;re, 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-Championni&egrave;re, and have adopted his principles in fractures.</p>
+
+<p>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<a class="pagenum" name="Pg_22" id="Pg_22"></a> 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.</p>
+
+<p>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.</p>
+
+<p><i>Splints and other Appliances.</i>&mdash;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 <i>ferrule</i> 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
+<i>box</i>.</p>
+
+<p><i>Simple wooden splints</i> of plain deal board or yellow pine, sawn to
+the appropriate length and width; or <i>Gooch's splinting</i>, 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.</p>
+
+<p>When it is desirable that the splint should take the shape of the part
+accurately, a plastic material may be employed.<a class="pagenum" name="Pg_23" id="Pg_23"></a> Perhaps the most
+convenient is <i>poroplastic felt</i>, 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.</p>
+
+<p>In conditions where treatment by massage and movement is
+impracticable, and where movable splints are inconvenient, splints of
+<i>plaster of Paris</i>, <i>starch</i>, or <i>water-glass</i> 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&mdash;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.</p>
+
+<p>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 &ldquo;acetic plaster
+bandages&rdquo; 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.</p>
+
+<p>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.</p>
+
+<p><i>Padding</i> 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<a class="pagenum" name="Pg_24" id="Pg_24"></a> bandage should never be applied to the limb
+underneath the splints and pads, as congestion or even gangrene may be
+induced thereby.</p>
+
+<p><b>Operative Treatment of Simple Fractures.</b>&mdash;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 (<i>Op. Surg.</i>, 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.</p>
+
+<p>Both before and after operation, massage and movement are to be
+carried out, as in fractures treated by other methods.</p>
+
+
+<h4>Compound Fractures</h4>
+
+<p>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.</p>
+
+<p>A fracture may be rendered compound <i>from without</i>, the soft parts
+being damaged by the object which breaks the bone&mdash;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 <i>from within</i>&mdash;for example, a sharp<a class="pagenum" name="Pg_25" id="Pg_25"></a>
+fragment of bone may penetrate the skin; this is the least serious
+variety of compound fracture.</p>
+
+<p>As a rule, it is easy to recognise that the fracture is compound, as
+the bone can either be seen or felt.</p>
+
+<p>The <i>prognosis</i> 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.</p>
+
+<p>If sepsis gains the upper hand in a compound fracture there is,
+firstly, the risk of infection of the marrow&mdash;osteomyelitis&mdash;which in
+former times was liable to result in py&aelig;mia; 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&mdash;which corresponds to the involucrum
+of an osteomyelitis&mdash;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.</p>
+
+<p>It should be noted that all the above changes can be followed in
+skiagrams.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p>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-<a class="pagenum" name="Pg_26" id="Pg_26"></a>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 (<a href="#Pg_150">p.&nbsp;150</a>) 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.</p>
+
+<p>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.</p>
+
+<p><b>Question of Amputation in Compound Fractures.</b>&mdash;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.</p>
+
+<p>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.</p>
+
+<p>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<a class="pagenum" name="Pg_27" id="Pg_27"></a> 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 h&aelig;morrhage 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.</p>
+
+<p>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.</p>
+
+<p>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 h&aelig;morrhage.</p>
+
+<p><a name="I_gun-shot_fracture" id="I_gun-shot_fracture"></a><b>Gun-shot Injuries of Bone.</b>&mdash;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.</p>
+
+<div class="figcenter" style="width: 600px;">
+<a name="fig_7" id="fig_7"></a>
+<img src="images/fig007.jpg" width="600" height="150" alt="Fig. 7.&mdash;Excessive Callus Formation after infected
+Compound Fracture of both Bones of Forearm&mdash;result of gun-shot wound.
+Fusion of Bones across Interosseous Space." title="" />
+<span class="caption"><span class="smcap">Fig. 7.</span>&mdash;Excessive Callus Formation after infected
+Compound Fracture of both Bones of Forearm&mdash;result of gun-shot wound.
+Fusion of Bones across Interosseous Space.</span>
+</div>
+
+<p>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<a class="pagenum" name="Pg_28" id="Pg_28"></a> 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.</p>
+
+<p>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.</p>
+
+
+<h3><a name="I_epiphyses" id="I_epiphyses"></a>SEPARATION OF EPIPHYSES<a name="FNanchor_1_1" id="FNanchor_1_1"></a><a href="#Footnote_1_1" class="fnanchor">[1]</a></h3>
+
+<p class="footnote"><a name="Footnote_1_1" id="Footnote_1_1"></a><a href="#FNanchor_1_1"><span class="label">[1]</span></a> We do not employ the term &ldquo;diastasis,&rdquo; which has been
+used in different senses by different writers.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>An epiphysis is nourished from the articular arteries and through the
+vessels of the periosteum.</p>
+
+<p><i>Pathological Separation of Epiphyses.</i>&mdash;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.</p>
+
+<p><b>Traumatic Separations.</b><a name="FNanchor_2_2" id="FNanchor_2_2"></a><a href="#Footnote_2_2" class="fnanchor">[2]</a>&mdash;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,&mdash;for example, when the foot is caught in the
+spokes of a carriage wheel,&mdash;is the commonest cause of epiphysial
+separation. Direct<a class="pagenum" name="Pg_29" id="Pg_29"></a> violence is a much less frequent cause. Muscular
+action occasionally produces separation of the epiphyses&mdash;for example,
+the anterior superior iliac spine, the small trochanter of the femur,
+or the upper end of the fibula.</p>
+
+<p class="footnote"><a name="Footnote_2_2" id="Footnote_2_2"></a><a href="#FNanchor_2_2"><span class="label">[2]</span></a> We desire here to acknowledge our indebtedness to Mr.
+John Poland's work on <i>Traumatic Separation of the Epiphyses</i>.</p>
+
+<table class="figure" summary="Fig 8, 9, 10, 11">
+<tr>
+<td class="figcenter" style="width: 250px;">
+<a name="fig_8" id="fig_8"></a>
+<img src="images/fig008.jpg" width="250" height="338" alt="Fig. 8.&mdash;Partial Separation of Epiphysis, with Fracture
+running into Diaphysis." title="" />
+<span class="caption"><span class="smcap">Fig. 8.</span>&mdash;Partial Separation of Epiphysis, with Fracture
+running into Diaphysis.</span>
+</td>
+
+<td class="figcenter" style="width: 250px;">
+<a name="fig_9" id="fig_9"></a>
+<img src="images/fig009.jpg" width="250" height="338" alt="Fig. 9.&mdash;Complete Separation of Epiphysis." title="" />
+<span class="caption"><span class="smcap">Fig. 9.</span>&mdash;Complete Separation of Epiphysis.</span>
+</td>
+</tr>
+
+<tr>
+<td class="figcenter" style="width: 250px;">
+<a name="fig_10" id="fig_10"></a>
+<img src="images/fig010.jpg" width="250" height="342" alt="Fig. 10.&mdash;Partial Separation with Fracture of
+Epiphysis." title="" />
+<span class="caption"><span class="smcap">Fig. 10.</span>&mdash;Partial Separation with Fracture of
+Epiphysis.</span>
+</td>
+
+<td class="figcenter" style="width: 250px;">
+<a name="fig_11" id="fig_11"></a>
+<img src="images/fig011.jpg" width="250" height="342" alt="Fig. 11.&mdash;Complete Separation with Fracture of
+Epiphysis." title="" />
+<span class="caption"><span class="smcap">Fig. 11.</span>&mdash;Complete Separation with Fracture of
+Epiphysis.</span>
+</td>
+</tr>
+</table>
+
+<p><a class="pagenum" name="Pg_30" id="Pg_30"></a>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.</p>
+
+<p>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.</p>
+
+<p><i>Morbid Anatomy.</i>&mdash;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 (<a href="#fig_8">Fig.&nbsp;8</a>). It is not uncommon for more than one
+epiphysis to be separated by the same accident&mdash;for example, the lower
+end of the femur and the upper ends of the tibia and fibula.
+Epiphysial separations, like fractures, may be <i>simple</i> or <i>compound</i>.
+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&mdash;the
+<i>juxta-epiphysial strain</i> of Ollier&mdash;is a common injury in young
+children.</p>
+
+<p><i>Clinical Features.</i>&mdash;The symptoms simulate those of dislocation
+rather than of fracture. Thus, <i>unnatural mobility</i> 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 <i>deformity</i> 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 &ldquo;muffled&rdquo; nature of the
+<i>crepitus</i> 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.</p>
+
+<p>Of the subsidiary signs, <i>loss of power</i> 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. <i>Pain</i> and
+<i>tenderness</i> along the epiphysial line are valuable<a class="pagenum" name="Pg_31" id="Pg_31"></a> signs,
+particularly when the lesion is due to indirect or muscular violence
+and there is no bruising of soft parts. Localised <i>swelling</i>,
+accompanied by <i>ecchymosis</i>, is often marked; and the adjacent joint
+may be distended with fluid.</p>
+
+<p>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
+R&ouml;ntgen rays at once establishes the diagnosis.</p>
+
+<p><i>Prognosis and Results.</i>&mdash;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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><i>Treatment.</i>&mdash;The general principles which govern the treatment of
+fractures apply equally to epiphysial separations, the essential being
+the accurate replacement of the epiphysis.</p>
+
+<p>In <i>compound separations of epiphysis</i>, 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.</p>
+
+
+
+
+<h2><a class="pagenum" name="Pg_32" id="Pg_32"></a><a name="CHAPTER_II" id="CHAPTER_II"></a>CHAPTER II
+<br />
+INJURIES OF JOINTS</h2>
+
+<ul class="chap">
+  <li><a href="#II_anatomy"><span class="smcap">Surgical Anatomy</span></a></li>
+  <li>&mdash;<a href="#II_injuries"><span class="smcap">Injuries</span></a>:</li>
+  <li><a href="#II_contusions"><i>Contusions</i></a>;</li>
+  <li><a href="#II_wounds"><i>Wounds</i></a>;</li>
+  <li><a href="#II_sprains"><i>Sprains</i></a>;</li>
+  <li><a href="#II_traumatic"><i>Dislocations</i></a></li>
+  <li>&mdash;<a href="#II_traumatic"><span class="smcap">Traumatic Dislocations</span></a>:</li>
+  <li><a href="#II_causes"><i>Causes</i></a>:</li>
+  <li><a href="#II_varieties"><i>Varieties</i></a>;</li>
+  <li><a href="#II_features"><i>Clinical features</i></a>;</li>
+  <li><a href="#II_treatment"><i>Treatment</i></a></li>
+  <li>&mdash;<a href="#II_compound">Compound dislocations</a></li>
+  <li>&mdash;<a href="#II_old">Old-standing dislocations</a>.</li>
+</ul>
+
+<p><a name="II_anatomy" id="II_anatomy"></a><b>Surgical Anatomy.</b>&mdash;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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><b>Sources of Joint Strength.</b>&mdash;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<a class="pagenum" name="Pg_33" id="Pg_33"></a> are osseously strong,
+others are ligamentously strong, while a few depend chiefly upon
+adjacent muscles for their stability.</p>
+
+<p>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&mdash;especially in the elbow&mdash;portions of
+the bones are fractured before the articular surfaces are separated.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>The proximity of an easily fractured bone also contributes to prevent
+dislocation of certain joints&mdash;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.</p>
+
+<p>The mechanical axiom that &ldquo;what is gained in movement is lost in
+stability&rdquo; applies to joints, those which have the widest range of
+movement being the most frequently dislocated.</p>
+
+<hr style="width: 45%;" />
+
+<p><a name="II_injuries" id="II_injuries"></a>The injuries to which a joint is liable are Contusions, Wounds,
+Sprains, and Dislocations.</p>
+
+<p><a name="II_contusions" id="II_contusions"></a><b>Contusions of Joints.</b>&mdash;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.</p>
+
+<p>The most prominent <i>clinical features</i> 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 (<i>h&aelig;marthrosis</i>). 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 h&aelig;mophilic subjects, considerable effusion
+of blood into a joint may follow the most trivial injury.</p>
+
+<p><a class="pagenum" name="Pg_34" id="Pg_34"></a>A slight degree of serous effusion into the joint (<i>hydrarthrosis</i>)
+often persists for some time, and tuberculous affections of joints not
+infrequently date from a contusion.</p>
+
+<p>The <i>treatment</i> is the same as for sprains (<a href="#Pg_36">p.&nbsp;36</a>).</p>
+
+<p><a name="II_wounds" id="II_wounds"></a><b>Wounds of Joints.</b>&mdash;The importance of accidental wounds of
+joints&mdash;such, for example, as result from a stab with a penknife or
+the spike of a railing&mdash;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 (<i>septic synovitis</i>), or may spread to
+all the elements of the joint (<i>septic arthritis</i>). These conditions
+are described with diseases of joints.</p>
+
+<p>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.</p>
+
+<p>Penetrating wounds of joints are treated on the same lines as compound
+fractures. If the penetrating instrument is to be regarded as
+infected,&mdash;as, for example, when the spoke of a motor bicycle is
+driven through the upper pouch of the knee,&mdash;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.</p>
+
+<p><b>Gun-shot injuries</b> 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&mdash;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.</p>
+
+<p>In all degrees the great risk is from septic infection, which may be
+assumed to be present in all but the last-named variety.</p>
+
+<p>The <i>treatment</i> consists in immediately cleansing the wound by<a class="pagenum" name="Pg_35" id="Pg_35"></a>
+excising grossly damaged tissue and removing any foreign body that may
+have lodged; disinfecting the exposed part of the joint cavity with
+eusol, &ldquo;bipp,&rdquo; 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.</p>
+
+<p><a name="II_sprains" id="II_sprains"></a><b>Sprains.</b>&mdash;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.</p>
+
+<p>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 &ldquo;sprain fracture&rdquo;; or for
+intra-articular cartilages to be torn and displaced, as in the knee.</p>
+
+<p><i>Clinical Features.</i>&mdash;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.</p>
+
+<p>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 R&ouml;ntgen 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.</p>
+
+<p><i>Repair of Sprains.</i>&mdash;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.</p>
+
+<p><a class="pagenum" name="Pg_36" id="Pg_36"></a><i>Prognosis.</i>&mdash;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.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+
+<h3><a name="II_traumatic" id="II_traumatic"></a><span class="smcap">Traumatic Dislocations</span></h3>
+
+<p>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.</p>
+
+<p><a name="II_causes" id="II_causes"></a><i>Causes.</i>&mdash;The majority of dislocations are the result of <i>indirect</i>
+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.</p>
+
+<p>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<a class="pagenum" name="Pg_37" id="Pg_37"></a> 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.</p>
+
+<p>Violence applied <i>directly</i> 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&mdash;for example, by a
+kick from a horse; or the acromio-clavicular joint by a blow on the
+shoulder.</p>
+
+<p><i>Muscular contraction</i> is not often the sole cause of dislocation,
+although, as has been mentioned, it plays an important r&ocirc;le 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.</p>
+
+<p><i>Age and Sex.</i>&mdash;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.</p>
+
+<p>Muscular debility and undue laxness of ligaments resulting from
+disease or previous dislocation are also predisposing factors.</p>
+
+<p><a name="II_varieties" id="II_varieties"></a><i>Clinical Varieties.</i>&mdash;The separation between the bones may be
+<i>complete</i> or <i>partial</i>. When partial, portions of the articular
+surfaces remain in apposition, and the injury is known as a
+<i>sub-luxation</i>. Like fractures, dislocations may be <i>simple</i> or
+<i>compound</i>, 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 <i>recent</i>; but when several weeks or
+months have elapsed, it is spoken of as an <i>old-standing</i> dislocation.
+The latter will be described later.</p>
+
+<p>Dislocations, like fractures, may be <i>complicated</i> 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&mdash;a most
+important complication.</p>
+
+<p><a name="II_features" id="II_features"></a><i>Clinical Features.</i>&mdash;The most characteristic signs of dislocation are
+<i>preternatural rigidity</i>, or want of movement where movement should
+naturally take place; <i>mobility in abnormal<a class="pagenum" name="Pg_38" id="Pg_38"></a> directions</i>; and
+<i>deformity</i>, the part being &ldquo;out of drawing&rdquo; as compared with the
+uninjured side (<a href="#fig_18">Fig.&nbsp;18</a>). 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.</p>
+
+<p>Although any of the subsidiary signs may occur in lesions other than
+dislocations, due weight must be given to them in making a diagnosis.
+<i>Loss of function</i> is complete as a rule. <i>Pain</i> 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. <i>Swelling</i> 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. <i>Discoloration</i> is usually later of appearing than in
+fractures. <i>Alteration in the length</i> of the injured limb&mdash;usually in
+the direction of shortening&mdash;is a common feature; while girth
+measurements usually show an increase. A peculiar soft <i>grating</i> or
+<i>creaking sensation</i> 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 R&ouml;ntgen rays, and this should be had recourse to whenever
+possible, as a fracture may be shown that otherwise would escape
+recognition.</p>
+
+<p><i>Prognosis.</i>&mdash;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 sequel&aelig;.
+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.</p>
+
+<p><a name="II_treatment" id="II_treatment"></a><i>Treatment.</i>&mdash;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<a class="pagenum" name="Pg_39" id="Pg_39"></a> its socket by
+the same route as that by which it left it&mdash;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.</p>
+
+<p>Muscular contraction is best overcome by the administration of a
+general an&aelig;sthetic, 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.</p>
+
+<p>The appropriate man&oelig;uvres 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.</p>
+
+<p>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&mdash;and
+especially in old people&mdash;to fracture one of the bones concerned.</p>
+
+<p>After reduction, great benefit is gained by the systematic use of
+<i>massage</i> 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<a class="pagenum" name="Pg_40" id="Pg_40"></a> during which it
+should be worn will be considered with the individual dislocations.</p>
+
+<p><i>Operation in Simple Dislocations.</i>&mdash;In a limited number of cases,
+even with the aid of an an&aelig;sthetic, 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.</p>
+
+<p><a name="II_compound" id="II_compound"></a><b>Compound Dislocations.</b>&mdash;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.</p>
+
+<p><i>Treatment.</i>&mdash;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 (<a href="#Pg_26">p.&nbsp;26</a>). If an
+attempt is to be made to save the limb, the treatment is the same as
+in compound fracture (<a href="#Pg_25">p.&nbsp;25</a>).</p>
+
+<p><b>Dislocation complicated by Fracture.</b>&mdash;In certain dislocations the
+separation of small portions of bones or of epiphyses is of common
+occurrence&mdash;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.</p>
+
+<p>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&mdash;by operation if
+necessary&mdash;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.</p>
+
+<p><a name="II_old" id="II_old"></a><b>Old-standing Dislocations.</b>&mdash;When, from want of recognition&mdash;and,
+curiously enough, a dislocation is much more<a class="pagenum" name="Pg_41" id="Pg_41"></a> liable to be overlooked
+than would have been thought possible&mdash;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<a class="pagenum" name="Pg_42" id="Pg_42"></a> 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.</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_12" id="fig_12"></a>
+<img src="images/fig012.jpg" width="350" height="529" alt="Fig. 12.&mdash;Os Innominatum showing new socket formed
+after old-standing dislocation. The acetabulum is almost obliterated." title="" />
+<span class="caption"><span class="smcap">Fig. 12.</span>&mdash;Os Innominatum showing new socket formed
+after old-standing dislocation. The acetabulum is almost obliterated.</span>
+</div>
+
+<p>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.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p>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;<a class="pagenum" name="Pg_43" id="Pg_43"></a> 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
+<i>open operation</i>. 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.</p>
+
+<p><b>Habitual or recurrent dislocation</b> is almost exclusively met with in
+the shoulder, and will be described with the injuries of that joint.</p>
+
+<p><b>Pathological Dislocations.</b>&mdash;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 py&aelig;mia; (2) those due to destructive changes in the
+ligaments and bones&mdash;typically seen in tuberculous arthritis, in
+arthritis deformans, in Charcot's disease, and in nerve lesions,
+<i>e.g.</i> 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, <i>e.g.</i> the phalanges
+in arthritis deformans. These will be considered with the conditions
+which give rise to them.</p>
+
+<p><b>Congenital Dislocations.</b>&mdash;Congenital dislocations are believed to be
+the result of abnormal or arrested development <i>in utero</i>, 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.</p>
+
+
+
+
+<h2><a class="pagenum" name="Pg_44" id="Pg_44"></a><a name="CHAPTER_III" id="CHAPTER_III"></a>CHAPTER III
+<br />
+INJURIES IN THE REGION OF THE SHOULDER AND UPPER ARM</h2>
+
+<ul class="chap">
+  <li><a href="#III_anatomy">Surgical Anatomy</a></li>
+  <li>&mdash;<a href="#III_fracture_clavicle"><span class="smcap">Fractures of Clavicle</span>: <i>Varieties</i></a></li>
+  <li>&mdash;<a href="#III_dislocation_clavicle"><span class="smcap">Dislocation of Clavicle</span>: <i>Varieties</i></a></li>
+  <li>&mdash;<a href="#III_dislocation_shoulder"><span class="smcap">Dislocation of Shoulder</span>: <i>Varieties</i></a></li>
+  <li>&mdash;<a href="#III_sprain_shoulder">Sprains and contusions of shoulder</a></li>
+  <li>&mdash;<a href="#III_fracture_scapula"><span class="smcap">Fracture of Scapula</span>: Sites</a></li>
+  <li>&mdash;<a href="#III_humerus_upper"><span class="smcap">Fracture of Upper End of Humerus</span></a>:</li>
+  <li><a href="#III_neck"><i>Surgical neck</i></a>;</li>
+  <li><a href="#III_epiphysis"><i>Separation of epiphysis</i></a>;</li>
+  <li><a href="#III_head"><i>Fracture of head, anatomical neck, or tuberosities</i></a></li>
+  <li>&mdash;<a href="#III_humerus_shaft"><span class="smcap">Fractures of Shaft of Humerus</span></a>.</li>
+</ul>
+
+<p>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.</p>
+
+<p><a name="III_anatomy" id="III_anatomy"></a><b>Surgical Anatomy.</b>&mdash;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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><a class="pagenum" name="Pg_45" id="Pg_45"></a>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.</p>
+
+<p>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.</p>
+
+
+<h3><a name="III_fracture_clavicle" id="III_fracture_clavicle"></a><span class="smcap">Fracture of the Clavicle</span></h3>
+
+<p>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.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_13" id="fig_13"></a>
+<img src="images/fig013.jpg" width="400" height="136" alt="Fig. 13.&mdash;Oblique Fracture of Right Clavicle in Middle
+Third, united." title="" />
+<span class="caption"><span class="smcap">Fig. 13.</span>&mdash;Oblique Fracture of Right Clavicle in Middle
+Third, united.</span>
+</div>
+
+<p>The most common site of fracture is in the <i>middle third</i> (<a href="#fig_13">Fig.&nbsp;13</a>),
+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.</p>
+
+<p>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,<a class="pagenum" name="Pg_46" id="Pg_46"></a> 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.</p>
+
+<p>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.</p>
+
+<p><i>Clinical Features.</i>&mdash;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.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_14" id="fig_14"></a>
+<img src="images/fig014.jpg" width="400" height="137" alt="Fig. 14.&mdash;Fracture of Acromial End of Clavicle. Shows
+forward rotation of lateral fragment, and line of fracture united by
+bone." title="" />
+<span class="caption"><span class="smcap">Fig. 14.</span>&mdash;Fracture of Acromial End of Clavicle. Shows
+forward rotation of lateral fragment, and line of fracture united by
+bone.</span>
+</div>
+
+<p>Fracture of the <i>lateral</i> or <i>acromial third</i> 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.</p>
+
+<p><a class="pagenum" name="Pg_47" id="Pg_47"></a>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&mdash;the angle between the spine and the
+acromion process striking the ground. The acromial fragment rotates
+forward (<a href="#fig_14">Fig.&nbsp;14</a>), 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.</p>
+
+<p>Fractures of the <i>medial</i> or <i>sternal third</i> 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 <i>separation of the clavicular epiphysis</i>. 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.</p>
+
+<p><i>Simultaneous fracture of both clavicles</i> usually results from a
+severe transverse crush of the upper part of the thorax or from a fall
+on the outstretched hands&mdash;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.</p>
+
+<p>The <i>prognosis</i> 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.</p>
+
+<div class="figright" style="width: 300px;">
+<a name="fig_15" id="fig_15"></a>
+<img src="images/fig015.jpg" width="300" height="413" alt="Fig. 15.&mdash;Adhesive Plaster applied for Fracture of
+Clavicle." title="" />
+<span class="caption"><span class="smcap">Fig. 15.</span>&mdash;Adhesive Plaster applied for Fracture of
+Clavicle.</span>
+</div>
+
+<p><i>Treatment.</i>&mdash;The displacement in complete fractures of the clavicle
+is readily reduced by supporting the elbow, bracing back<a class="pagenum" name="Pg_48" id="Pg_48"></a> 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.</p>
+
+<p>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.</p>
+
+<p><i>Recumbent Position.</i>&mdash;There is little doubt that the most perfect
+&aelig;sthetic 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.</p>
+
+<p>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 <i>elbow</i>, 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.</p>
+
+<p>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 (<a href="#fig_15">Fig.&nbsp;15</a>). 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.</p>
+
+<p><i>The Handkerchief Method.</i>&mdash;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 <i>en
+cravate</i>, placed well over the tips of the shoulders and<a class="pagenum" name="Pg_49" id="Pg_49"></a> tied, or
+interlaced, between the scapul&aelig;. 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.</p>
+
+<p><i>Operative treatment</i> 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.</p>
+
+<p>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,&mdash;for example,
+accidents occurring on the football field,&mdash;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
+&aelig;sthetic 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.</p>
+
+<p>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.</p>
+
+
+<h3><a name="III_dislocation_clavicle" id="III_dislocation_clavicle"></a><span class="smcap">Dislocation of the Clavicle</span></h3>
+
+<p>Dislocation of the <b>acromial end</b>&mdash;sometimes, and perhaps more
+correctly, spoken of as dislocation of the scapula&mdash;is more<a class="pagenum" name="Pg_50" id="Pg_50"></a> 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 <i>upwards</i> and overrides the
+acromion process.</p>
+
+<p><i>Downward</i> 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.</p>
+
+<p>The <i>clinical features</i> 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.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p>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.</p>
+
+<p><b>The sternal end</b> may be dislocated forwards, backwards, or upwards.</p>
+
+<p><i>Forward</i> 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 (<a href="#fig_16">Fig.&nbsp;16</a>). The inter-articular cartilage sometimes remains
+attached to one bone, sometimes to the other; the rhomboid ligament is
+usually intact.</p>
+
+<p>In the <i>backward</i> dislocation the end of the clavicle lies behind the
+manubrium sterni and the muscles attached to it; there is<a class="pagenum" name="Pg_51" id="Pg_51"></a> 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 &oelig;sophagus, 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.</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_16" id="fig_16"></a>
+<img src="images/fig016.jpg" width="350" height="432" alt="Fig. 16.&mdash;Forward Dislocation of Sternal End of Right
+Clavicle. From a fall on a polished floor, in a man &aelig;t. 40." title="" />
+<span class="caption"><span class="smcap">Fig. 16.</span>&mdash;Forward Dislocation of Sternal End of Right
+Clavicle. From a fall on a polished floor, in a man &aelig;t. 40.</span>
+</div>
+
+<p>In rare cases the rhomboid ligament is torn, and the end of<a class="pagenum" name="Pg_52" id="Pg_52"></a> the
+clavicle passes <i>upwards</i>, and rests in the episternal notch behind
+the sterno-mastoid muscle.</p>
+
+<p>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 &aelig;sthetic reasons.</p>
+
+<p>Dislocation of <b>both ends</b> 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.</p>
+
+
+<h3><a name="III_dislocation_shoulder" id="III_dislocation_shoulder"></a><span class="smcap">Dislocation of the Shoulder</span></h3>
+
+<p>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&mdash;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.</p>
+
+<p>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&mdash;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.</p>
+
+<p><a class="pagenum" name="Pg_53" id="Pg_53"></a><i>Varieties.</i>&mdash;Several varieties of dislocation are recognised,
+according to the position in which the head of the humerus finally
+rests (<a href="#fig_17">Fig.&nbsp;17</a>). The simplest of these is the <i>sub-glenoid</i> 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.</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_17" id="fig_17"></a>
+<img src="images/fig017.png" width="350" height="593" alt="Fig. 17.&mdash;Diagram of most common varieties of
+Dislocation of the Shoulder." title="" />
+<span class="caption"><span class="smcap">Fig. 17.</span>&mdash;Diagram of most common varieties of
+Dislocation of the Shoulder.</span>
+</div>
+
+<p>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 <i>sub-coracoid
+dislocation</i>. Much less frequently it passes under cover of the
+pectoralis minor and against the edge of the clavicle&mdash;the
+<i>sub-clavicular</i> variety. In rare cases the head passes backward and
+lies against the spine on the dorsum of the scapula, beneath the
+infra-spinatus muscle&mdash;the <i>sub-spinous</i> variety. Other varieties are
+so rare that they do not call for mention.</p>
+
+<p><i>Clinical Features common to all Varieties.</i>&mdash;Dislocation of the
+shoulder is commonest in adult males; in advanced life the<a class="pagenum" name="Pg_54" id="Pg_54"></a> 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&mdash;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&mdash;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.</p>
+
+<p>The <b>sub-coracoid dislocation</b> (<a href="#fig_18">Fig.&nbsp;18</a>) 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.</p>
+
+<div class="figcenter" style="width: 385px;">
+<a name="fig_18" id="fig_18"></a>
+<img src="images/fig018.jpg" width="385" height="450" alt="Fig. 18.&mdash;Sub-coracoid Dislocation of Right Shoulder." title="" />
+<span class="caption"><span class="smcap">Fig. 18.</span>&mdash;Sub-coracoid Dislocation of Right Shoulder.</span>
+</div>
+
+<p>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 <i>indentation
+fracture of the head of the humerus</i> where the two bones come into
+contact (F. M. Caird).<a class="pagenum" name="Pg_55" id="Pg_55"></a> 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.</p>
+
+<p>The <i>clinical features</i> common to all dislocations are prominent,
+although Dugas' symptom is not constant.</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_19" id="fig_19"></a>
+<img src="images/fig019.jpg" width="300" height="437" alt="Fig. 19.&mdash;Sub-coracoid Dislocation of Humerus." title="" />
+<span class="caption"><span class="smcap">Fig. 19.</span>&mdash;Sub-coracoid Dislocation of Humerus.<br /><br />
+(Sir H. J. Stiles&#39; case. Radiogram by Dr. Edmund Price.)</span>
+</div>
+
+<p><i>Treatment.</i>&mdash;The guiding principle in the reduction of these<a class="pagenum" name="Pg_56" id="Pg_56"></a>
+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<a class="pagenum" name="Pg_57" id="Pg_57"></a> with tendons,
+ligaments, or bony points, appropriate means must be taken to
+counteract each of these factors.</p>
+
+<p>A general an&aelig;sthetic 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.</p>
+
+<p>When an an&aelig;sthetic 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.</p>
+
+<p><a class="pagenum" name="Pg_58" id="Pg_58"></a><i>Kocher's method</i> 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 <i>rotates the humerus away from the middle
+line</i> (<a href="#fig_20">Fig.&nbsp;20</a>) 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<a class="pagenum" name="Pg_59" id="Pg_59"></a> 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) <i>The elbow is next carried forward, upward, and
+towards the middle line</i> (<a href="#fig_21">Fig.&nbsp;21</a>); 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 <i>rotated towards
+the middle line</i> by carrying the hand across the chest towards the
+opposite<a class="pagenum" name="Pg_60" id="Pg_60"></a> shoulder (<a href="#fig_22">Fig.&nbsp;22</a>). 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.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_20" id="fig_20"></a>
+<img src="images/fig020.jpg" width="400" height="387" alt="Fig. 20.&mdash;Kocher&#39;s Method of reducing Sub-coracoid
+Dislocation&mdash;First Movement; Rotation of Arm away from Middle Line." title="" />
+<span class="caption"><span class="smcap">Fig. 20.</span>&mdash;Kocher&#39;s Method of reducing Sub-coracoid
+Dislocation&mdash;First Movement; Rotation of Arm away from Middle Line.</span>
+</div>
+
+<p>&nbsp;</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_21" id="fig_21"></a>
+<img src="images/fig021.jpg" width="400" height="460" alt="Fig. 21.&mdash;Kocher&#39;s Method&mdash;Second Movement; Elbow
+carried forward, upward, and towards the Middle Line." title="" />
+<span class="caption"><span class="smcap">Fig. 21.</span>&mdash;Kocher&#39;s Method&mdash;Second Movement; Elbow
+carried forward, upward, and towards the Middle Line.</span>
+</div>
+
+<p>&nbsp;</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_22" id="fig_22"></a>
+<img src="images/fig022.jpg" width="400" height="534" alt="Fig. 22.&mdash;Kocher&#39;s Method&mdash;Third Movement; Rotation of
+Arm towards Middle Line." title="" />
+<span class="caption"><span class="smcap">Fig. 22.</span>&mdash;Kocher&#39;s Method&mdash;Third Movement; Rotation of
+Arm towards Middle Line.</span>
+</div>
+
+<p>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 (<a href="#fig_23">Fig.&nbsp;23</a>). 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 (<a href="#fig_24">Fig.&nbsp;24</a>), and the bone gradually glides
+into the socket.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_23" id="fig_23"></a>
+<img src="images/fig023.jpg" width="400" height="319" alt="Fig. 23.&mdash;Miller&#39;s Method of reducing Sub-coracoid
+Dislocation&mdash;First Movement." title="" />
+<span class="caption"><span class="smcap">Fig. 23.</span>&mdash;Miller&#39;s Method of reducing Sub-coracoid
+Dislocation&mdash;First Movement.</span>
+</div>
+
+<p>&nbsp;</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_24" id="fig_24"></a>
+<img src="images/fig024.jpg" width="400" height="362" alt="Fig. 24.&mdash;Miller&#39;s Method of reducing Sub-coracoid
+Dislocation&mdash;Second Movement." title="" />
+<span class="caption"><span class="smcap">Fig. 24.</span>&mdash;Miller&#39;s Method of reducing Sub-coracoid
+Dislocation&mdash;Second Movement.</span>
+</div>
+
+<p>In a certain number of cases reduction can be effected by
+<i>hyper-abduction</i> 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<a class="pagenum" name="Pg_61" id="Pg_61"></a> 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.</p>
+
+<p>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.</p>
+
+<p><i>After-Treatment.</i>&mdash;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<a class="pagenum" name="Pg_62" id="Pg_62"></a> end of a month the patient should be advised to
+use the arm freely.</p>
+
+<p>The <b>sub-clavicular dislocation</b> (<a href="#fig_17">Fig.&nbsp;17</a>) 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.</p>
+
+<p><b>Sub-glenoid dislocation</b> (<a href="#fig_17">Fig.&nbsp;17</a>) 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.</p>
+
+<p>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 (<a href="#Pg_60">p.&nbsp;60</a>).</p>
+
+<p><b>Sub-spinous Dislocation.</b>&mdash;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
+(<i>sub-acromial</i>) (<a href="#fig_17">Fig.&nbsp;17</a>). 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.</p>
+
+<p>In the milder cases the <i>clinical features</i> are not always well<a class="pagenum" name="Pg_63" id="Pg_63"></a>
+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.</p>
+
+<p>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.</p>
+
+<p><i>Prognosis.</i>&mdash;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.</p>
+
+<p><b>Dislocation of the Shoulder complicated with Fracture of the Upper End
+of the Humerus.</b>&mdash;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.</p>
+
+<p>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 an&aelig;sthetic, 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<a class="pagenum" name="Pg_64" id="Pg_64"></a> when the
+support is withdrawn. In many cases it is only by the aid of a
+radiogram that an accurate diagnosis can be made (<a href="#fig_25">Fig.&nbsp;25</a>).</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_25" id="fig_25"></a>
+<img src="images/fig025.jpg" width="400" height="338" alt="Fig. 25.&mdash;Dislocation of Shoulder with Fracture of Neck
+of Humerus." title="" />
+<span class="caption"><span class="smcap">Fig. 25.</span>&mdash;Dislocation of Shoulder with Fracture of Neck
+of Humerus.<br /><br />
+(Sir Robert Jones&#39; case. Radiogram by Dr. D. Morgan.)</span>
+</div>
+
+<p><i>Treatment.</i>&mdash;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 an&aelig;sthesia, 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.</p>
+
+<p>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.</p>
+
+<p><a class="pagenum" name="Pg_65" id="Pg_65"></a>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.</p>
+
+<p>When it is found impossible to reduce the dislocation, it is usually
+advisable to remove the upper fragment.</p>
+
+<p>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.</p>
+
+<p><b>Old-standing Dislocation of the Shoulder.</b>&mdash;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.</p>
+
+<p>The patient is an&aelig;sthetised, 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.</p>
+
+<p>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.</p>
+
+<p><b>Habitual or Recurrent Dislocation.</b>&mdash;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<a class="pagenum" name="Pg_66" id="Pg_66"></a> 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 &ldquo;doing&rdquo;
+the hair.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+<p>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.</p>
+
+<p><a name="III_sprain_shoulder" id="III_sprain_shoulder"></a><b>Sprain</b> 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.</p>
+
+<p><b>Contusion</b> 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
+h&aelig;matoma 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-<a class="pagenum" name="Pg_67" id="Pg_67"></a>joint. Under treatment by massage and
+movement, the symptoms usually pass off completely in two or three
+weeks. The affections of the <i>bursa</i> are described elsewhere.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+
+<h3><a name="III_fracture_scapula" id="III_fracture_scapula"></a><span class="smcap">Fracture of the Scapula</span></h3>
+
+<p>Fractures of the scapula may implicate the body, the surgical neck,
+the acromion, or the coracoid process. They are rarely compound.</p>
+
+<div class="figleft" style="width: 300px;">
+<a name="fig_26" id="fig_26"></a>
+<img src="images/fig026.jpg" width="300" height="483" alt="Fig. 26.&mdash;Transverse Fracture of Scapula, with fissures
+radiating into spinous process and dorsum." title="" />
+<span class="caption"><span class="smcap">Fig. 26.</span>&mdash;Transverse Fracture of Scapula, with fissures
+radiating into spinous process and dorsum.</span>
+</div>
+
+<p><b>Fracture of the Body.</b>&mdash;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&mdash;one longitudinal, the other
+transverse&mdash;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 (<a href="#fig_26">Fig.&nbsp;26</a>). In other cases the line of the primary
+fracture is longitudinal, passing through the spine and involving both
+foss&aelig;.</p>
+
+<p>The <i>clinical features</i> 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&mdash;although sometimes they are drawn
+apart&mdash;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.</p>
+
+<p><a class="pagenum" name="Pg_68" id="Pg_68"></a><i>Treatment.</i>&mdash;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.</p>
+
+<p><b>Fracture of the surgical neck of the scapula</b>, 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.</p>
+
+<p>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<a class="pagenum" name="Pg_69" id="Pg_69"></a> 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.</p>
+
+<p>A partial fracture carrying away the lower part of the <i>glenoid
+cavity</i> simulates a sub-glenoid dislocation. This is, however, a rare
+injury.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+<p><b>Fracture of the acromion process</b> 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.</p>
+
+<p>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&mdash;<i>separate acromion</i>. 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).</p>
+
+<p>Between the fourteenth and twenty-second years a true <i>separation of
+the epiphysis</i> 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.</p>
+
+<p>The <i>treatment</i> is the same as for fracture of the lateral end of the
+clavicle.</p>
+
+<p><b>Fracture of the coracoid process</b> 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<a class="pagenum" name="Pg_70" id="Pg_70"></a> laterally by the combined action of the
+pectoralis minor, biceps, and coraco-brachialis muscles. Crepitus may
+be elicited on moving the fragment. <i>Separation of the epiphysial
+portion</i> of the coracoid may occur up to the seventeenth year.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+
+<h3><a name="III_humerus_upper" id="III_humerus_upper"></a><span class="smcap">Fracture of the Upper End of the Humerus</span></h3>
+
+<p>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.</p>
+
+<div class="figleft" style="width: 136px;">
+<a name="fig_27" id="fig_27"></a>
+<img src="images/fig027.jpg" width="136" height="550" alt="Fig. 27.&mdash;Fracture of Surgical Neck of Humerus, united
+with Angular Displacement." title="" />
+<span class="caption"><span class="smcap">Fig. 27.</span>&mdash;Fracture of Surgical Neck of Humerus, united
+with Angular Displacement.</span>
+</div>
+
+<div class="figright" style="width: 350px;">
+<a name="fig_28" id="fig_28"></a>
+<img src="images/fig028.jpg" width="350" height="354" alt="Fig. 28.&mdash;Impacted Fracture of Neck of Humerus, in man
+&aelig;t. 75." title="" />
+<span class="caption"><span class="smcap">Fig. 28.</span>&mdash;Impacted Fracture of Neck of Humerus, in man
+&aelig;t. 75.<br /><br />
+(Sir H. J. Stiles&#39; case. Radiogram by Dr. Edmund Price.)</span>
+</div>
+
+<p><a name="III_neck" id="III_neck"></a><b>Fracture of the Surgical Neck.</b>&mdash;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<a class="pagenum" name="Pg_71" id="Pg_71"></a> 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.</p>
+
+<p>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.</p>
+
+<p><a class="pagenum" name="Pg_72" id="Pg_72"></a><i>Treatment.</i>&mdash;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.</p>
+
+<p>In comminuted fractures and those with marked displacement, a general
+an&aelig;sthetic 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 (<a href="#fig_29">Fig.&nbsp;29</a>), or a splint, such as Middeldorpf's,
+which consists of a<a class="pagenum" name="Pg_73" id="Pg_73"></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.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_29" id="fig_29"></a>
+<img src="images/fig029.jpg" width="400" height="402" alt="Fig. 29.&mdash;Ambulatory Abduction Splint for Fracture of
+Humerus." title="" />
+<span class="caption"><span class="smcap">Fig. 29.</span>&mdash;Ambulatory Abduction Splint for Fracture of
+Humerus.</span>
+</div>
+
+<p>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.</p>
+
+<p><a name="III_epiphysis" id="III_epiphysis"></a><b>Separation of Epiphysis.</b>&mdash;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.</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_30" id="fig_30"></a>
+<img src="images/fig030.jpg" width="350" height="289" alt="Fig. 30.&mdash;Radiogram of Separation of Upper Epiphysis of
+Humerus." title="" />
+<span class="caption"><span class="smcap">Fig. 30.</span>&mdash;Radiogram of Separation of Upper Epiphysis of
+Humerus.</span>
+</div>
+
+<p>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<a class="pagenum" name="Pg_74" id="Pg_74"></a> direct violence, but may be
+caused by a fall on the lateral side of the elbow.</p>
+
+<p>The epiphysis, especially in young children, may be separated without
+being displaced, or the displacement may be incomplete.</p>
+
+<p>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 (<a href="#fig_30">Fig.&nbsp;30</a>).
+Dislocation is rare at the age when separation of the epiphysis
+occurs.</p>
+
+<p>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.</p>
+
+<p><i>Treatment.</i>&mdash;This injury is treated on the same general lines as
+fracture of the surgical neck. General an&aelig;sthesia 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.</p>
+
+<p><a name="III_head" id="III_head"></a><b>Fractures of the Head, Anatomical Neck, and Tuberosities of
+Humerus.</b>&mdash;These fractures are met with as accompaniments of
+dislocation of the shoulder, and as results of gun-shot injuries,
+blows, or falls.</p>
+
+<p>In sub-coracoid dislocation the <i>head</i> of the humerus may be indented
+by coming in contact with the anterior edge of the glenoid cavity (F.
+M. Caird).</p>
+
+<p>The <i>anatomical neck</i> 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.</p>
+
+<p>The <i>tuberosities</i> may be implicated in other fractures in this region
+and in dislocation of the shoulder; and either of them<a class="pagenum" name="Pg_75" id="Pg_75"></a> may be
+separated by muscular contraction or by direct violence.</p>
+
+<p><i>Clinically</i> 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.</p>
+
+<p>When the <i>great tuberosity</i> 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.</p>
+
+<p><i>Treatment.</i>&mdash;These fractures are treated on the same lines as
+fracture of the surgical neck of the humerus.</p>
+
+<p>The combination of fracture of the upper end of the humerus with
+dislocation of the shoulder has already been referred to.</p>
+
+
+<h3><a name="III_humerus_shaft" id="III_humerus_shaft"></a><span class="smcap">Fracture of the Shaft of the Humerus</span></h3>
+
+<p>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&mdash;the majority being in the latter situation.</p>
+
+<p>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&mdash;as in throwing a cricket-ball. Twisting forms of violence may
+produce spiral fractures.</p>
+
+<p>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<a class="pagenum" name="Pg_76" id="Pg_76"></a> 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&mdash;undue mobility, deformity, shortening, and crepitus&mdash;are at
+once evident, and the patient himself usually recognises that the bone
+is broken.</p>
+
+<p>The nerve-trunks in the arm&mdash;the median, ulnar, and radial
+(musculo-spiral)&mdash;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 &ldquo;wrist-drop.&rdquo; 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.</p>
+
+<p>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&mdash;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.</p>
+
+<p><i>Treatment.</i>&mdash;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 an&aelig;sthetic, 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.</p>
+
+<p>In <i>transverse</i> 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<a class="pagenum" name="Pg_77" id="Pg_77"></a> days the limb may be bound to the
+chest by a broad roller bandage.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_31" id="fig_31"></a>
+<img src="images/fig031.jpg" width="400" height="222" alt="Fig. 31.&mdash;&ldquo;Cock-up&rdquo; Splint, for maintaining
+Dorsiflexion at Wrist." title="" />
+<span class="caption"><span class="smcap">Fig. 31.</span>&mdash;&ldquo;Cock-up&rdquo; Splint, for maintaining
+Dorsiflexion at Wrist.</span>
+</div>
+
+<p>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.</p>
+
+<div class="figright" style="width: 350px;">
+<a name="fig_32" id="fig_32"></a>
+<img src="images/fig032.jpg" width="350" height="296" alt="Fig. 32.&mdash;Gooch Splints for Fracture of Shaft of
+Humerus; and Rectangular Splint to secure Elbow." title="" />
+<span class="caption"><span class="smcap">Fig. 32.</span>&mdash;Gooch Splints for Fracture of Shaft of
+Humerus; and Rectangular Splint to secure Elbow.</span>
+</div>
+
+<p>In <i>oblique and spiral</i> 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.</p>
+
+<p>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<a class="pagenum" name="Pg_78" id="Pg_78"></a>
+the fragments and leave a gap between them. The elbow should not be
+retained in the extended position for more than three weeks.</p>
+
+<p>In rare cases it is necessary to have recourse to operative treatment.</p>
+
+<p>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
+&ldquo;cock-up&rdquo; splint, with the hand in the attitude of marked dorsiflexion
+(<a href="#fig_31">Fig.&nbsp;31</a>).</p>
+
+<p>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).</p>
+
+<p>In cases of <i>un-united fracture</i>, 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.</p>
+
+
+
+
+<h2><a class="pagenum" name="Pg_79" id="Pg_79"></a><a name="CHAPTER_IV" id="CHAPTER_IV"></a>CHAPTER IV
+<br />
+INJURIES IN THE REGION OF THE ELBOW AND FOREARM</h2>
+
+<ul class="chap">
+  <li><a href="#IV_anatomy">Surgical Anatomy</a></li>
+  <li>&mdash;<a href="#IV_elbow">Examination of injured elbow</a></li>
+  <li>&mdash;<a href="#IV_fracture_humerus_lower"><span class="smcap">Fracture of Lower End of Humerus</span></a>:</li>
+  <li><a href="#IV_supra_condylar"><i>Supra-condylar</i></a>;</li>
+  <li><a href="#IV_inter_condylar"><i>Inter-condylar</i></a>;</li>
+  <li><a href="#IV_humerus_epiphysis"><i>Separation of epiphysis</i></a>;</li>
+  <li><a href="#IV_condyle"><i>Fracture of either condyle alone</i></a>;</li>
+  <li><a href="#IV_epicondyle"><i>Fracture of either epicondyle alone</i></a></li>
+  <li>&mdash;<a href="#IV_ulna"><span class="smcap">Fracture of Upper End of Ulna</span></a>:</li>
+  <li><a href="#IV_olecranon"><i>Olecranon</i></a>;</li>
+  <li><a href="#IV_coronoid"><i>Coronoid</i></a></li>
+  <li>&mdash;<a href="#IV_radius"><span class="smcap">Fracture of Upper End of Radius</span></a>:</li>
+  <li><a href="#IV_head"><i>Head</i></a>;</li>
+  <li><a href="#IV_neck"><i>Neck</i></a>;</li>
+  <li><a href="#IV_head"><i>Separation of epiphysis</i></a></li>
+  <li>&mdash;<a href="#IV_dislocated_elbow"><span class="smcap">Dislocation of Elbow</span></a>:</li>
+  <li><a href="#IV_elbow_bones"><i>Both bones</i></a>;</li>
+  <li><a href="#IV_elbow_ulna"><i>Ulna alone</i></a>;</li>
+  <li><a href="#IV_elbow_radius"><i>Radius alone</i></a></li>
+  <li>&mdash;<a href="#IV_forearm"><span class="smcap">Fracture of Forearm</span></a>:</li>
+  <li><a href="#IV_forearm_bones"><i>Both bones</i></a>;</li>
+  <li><a href="#IV_forearm_radius"><i>Radius alone</i></a>;</li>
+  <li><a href="#IV_forearm_ulna"><i>Ulna alone</i></a>.</li>
+</ul>
+
+<p>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 <i>at</i> the joint or <i>near</i> it.</p>
+
+<p><a name="IV_anatomy" id="IV_anatomy"></a><b>Surgical Anatomy.</b>&mdash;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&mdash;the &ldquo;carrying angle.&rdquo; 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.</p>
+
+<p><a name="IV_elbow" id="IV_elbow"></a><a class="pagenum" name="Pg_80" id="Pg_80"></a>In <i>examining an injured elbow</i>, 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.</p>
+
+<p>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.</p>
+
+
+<h3><a name="IV_fracture_humerus_lower" id="IV_fracture_humerus_lower"></a><span class="smcap">Fractures of the Lower End of the Humerus</span></h3>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><a name="IV_supra_condylar" id="IV_supra_condylar"></a>The <b>supra-condylar</b> 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 (<a href="#fig_33">Fig.&nbsp;33</a>).</p>
+
+<div class="figcenter" style="width: 400px;"><a class="pagenum" name="Pg_81" id="Pg_81"></a>
+<a name="fig_33" id="fig_33"></a>
+<img src="images/fig033.jpg" width="400" height="227" alt="Fig. 33.&mdash;Radiogram of Supra-condylar Fracture of
+Humerus, in a child &aelig;t. 7." title="" />
+<span class="caption"><span class="smcap">Fig. 33.</span>&mdash;Radiogram of Supra-condylar Fracture of
+Humerus, in a child &aelig;t. 7.</span>
+</div>
+
+<p><a class="pagenum" name="Pg_82" id="Pg_82"></a><i>Clinical Features.</i>&mdash;The elbow is flexed at an angle of 120&deg; or 130&deg;,
+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.</p>
+
+<p>In rare cases the obliquity of the fracture is downward and backward,
+and the lower fragment is displaced forward.</p>
+
+<p><a name="IV_inter_condylar" id="IV_inter_condylar"></a>The <b>inter-condylar</b> 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.</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_34" id="fig_34"></a>
+<img src="images/fig034.jpg" width="350" height="362" alt="Fig. 34.&mdash;Radiogram of T-shaped Fracture of Lower End
+of Humerus." title="" />
+<span class="caption"><span class="smcap">Fig. 34.</span>&mdash;Radiogram of T-shaped Fracture of Lower End
+of Humerus.</span>
+</div>
+
+<p><a name="IV_humerus_epiphysis" id="IV_humerus_epiphysis"></a><b>Separation of the lower epiphysis</b> 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&mdash;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<a class="pagenum" name="Pg_83" id="Pg_83"></a> separation is <i>compound</i>, the diaphysis
+protruding through the skin.</p>
+
+<p>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.</p>
+
+<p><a name="IV_condyle" id="IV_condyle"></a><b>Fracture of either Condyle alone.</b>&mdash;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.<a class="pagenum" name="Pg_84" id="Pg_84"></a> 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 &ldquo;carrying angle&rdquo; of
+the limb&mdash;<i>cubitus varus</i> or <i>cubitus valgus</i>.</p>
+
+<p><a name="IV_epicondyle" id="IV_epicondyle"></a><b>Fracture of Epicondyles.</b>&mdash;Fracture of the <i>lateral epicondyle</i> alone
+is so rare that it need only be mentioned.</p>
+
+<p>The <i>medial epicondyle</i> 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.</p>
+
+<p>Up to the age of seventeen or eighteen the epiphysis of the epicondyle
+may be separated.</p>
+
+<p><b>Treatment of Fractures in Region of Elbow.</b>&mdash;The administration of a
+general an&aelig;sthetic 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.</p>
+
+<p>The <i>supra-condylar fracture</i> 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<a class="pagenum" name="Pg_85" id="Pg_85"></a>
+attempted is that of complete extension. Operative treatment is rarely
+called for.</p>
+
+<p><i>Separation of the epiphysis</i> and <i>fracture of the medial epicondyle</i>
+are treated on the same lines as supra-condylar fracture.</p>
+
+<p><i>T- or Y-shaped fractures</i> and <i>fractures of the condyles</i>, 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.</p>
+
+<p>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. <i>Volkmann's isch&aelig;mic contracture</i>
+is liable to occur after fractures in the region of the elbow from
+impairment of the blood supply as a result of tight bandaging.</p>
+
+
+<h3><a name="IV_ulna" id="IV_ulna"></a><span class="smcap">Fracture of the Upper End of the Ulna</span></h3>
+
+<p><a name="IV_olecranon" id="IV_olecranon"></a><b>Fracture of the olecranon</b> 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.</p>
+
+<p><i>Clinical Features.</i>&mdash;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<a class="pagenum" name="Pg_86" id="Pg_86"></a> 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 (<a href="#fig_35">Fig.&nbsp;35</a>), 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.</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_35" id="fig_35"></a>
+<img src="images/fig035.jpg" width="350" height="323" alt="Fig. 35.&mdash;Radiogram of Fracture of Olecranon Process,
+showing marked degree of displacement." title="" />
+<span class="caption"><span class="smcap">Fig. 35.</span>&mdash;Radiogram of Fracture of Olecranon Process,
+showing marked degree of displacement.<br /><br />
+(Sir Robert Jones&#39; case. Radiogram by Dr. D. Morgan.)</span>
+</div>
+
+<p>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.</p>
+
+<p><a class="pagenum" name="Pg_87" id="Pg_87"></a>Separation of the olecranon <i>epiphysis</i> 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.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><i>Operative Treatment.</i>&mdash;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.</p>
+
+<p><i>Old-standing Fracture.</i>&mdash;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.</p>
+
+<p><a name="IV_coronoid" id="IV_coronoid"></a><b>Fracture of the coronoid process</b> 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.<a class="pagenum" name="Pg_88" id="Pg_88"></a> 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).</p>
+
+
+<h3><a name="IV_radius" id="IV_radius"></a><span class="smcap">Fracture of the Upper End of the Radius</span></h3>
+
+<p><a name="IV_head" id="IV_head"></a>Intra-capsular fracture of the <b>head of the radius</b> may result from
+direct violence, from a fall on the pronated hand, or from forcible
+pronation or abduction&mdash;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
+<i>epiphysis</i>, which is entirely intra-articular, may be separated.</p>
+
+<p>The <i>clinical features</i> 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.</p>
+
+<p>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.</p>
+
+<p><a name="IV_neck" id="IV_neck"></a>Fracture of the <b>neck of the radius</b> between the capsule and the
+tubercle is rare.</p>
+
+<p><b>Avulsion of the tubercle</b> may occur from forcible contraction of the
+biceps, or, in children, from traction made on the forearm (A. L.
+Hall).</p>
+
+<p>These injuries are treated with the elbow in the flexed position, and
+massage and movement are carried out as already described.</p>
+
+
+<h3><a name="IV_dislocated_elbow" id="IV_dislocated_elbow"></a><span class="smcap">Dislocation of the Elbow</span></h3>
+
+<p>Dislocations of the elbow-joint may involve one or both bones of the
+forearm, and may be complete or incomplete.</p>
+
+<p><a name="IV_elbow_bones" id="IV_elbow_bones"></a><b>Dislocation of both bones backward</b> 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<a class="pagenum" name="Pg_89" id="Pg_89"></a> of the joint with
+abduction&mdash;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.</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_36" id="fig_36"></a>
+<img src="images/fig036.jpg" width="300" height="558" alt="Fig. 36.&mdash;Backward Dislocation of Elbow, in a boy &aelig;t.
+10, caused by a fall off a wall, landing on the elbow." title="" />
+<span class="caption"><span class="smcap">Fig. 36.</span>&mdash;Backward Dislocation of Elbow, in a boy &aelig;t.
+10, caused by a fall off a wall, landing on the elbow.</span>
+</div>
+
+<p><i>Morbid Anatomy.</i>&mdash;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.</p>
+
+<p>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<a class="pagenum" name="Pg_90" id="Pg_90"></a> 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 (<a href="#fig_37">Fig.&nbsp;37</a>). 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.</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_37" id="fig_37"></a>
+<img src="images/fig037.jpg" width="350" height="381" alt="Fig. 37.&mdash;Bony Outgrowth in relation to insertion of
+Brachialis Muscle, following Backward Dislocation of Elbow." title="" />
+<span class="caption"><span class="smcap">Fig. 37.</span>&mdash;Bony Outgrowth in relation to insertion of
+Brachialis Muscle, following Backward Dislocation of Elbow.<br /><br />
+(Sir Robert Jones&#39; case. Radiogram by Dr. D. Morgan.)</span>
+</div>
+
+<p>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.</p>
+
+<p><a class="pagenum" name="Pg_91" id="Pg_91"></a>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.</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_38" id="fig_38"></a>
+<img src="images/fig038.jpg" width="350" height="290" alt="Fig. 38.&mdash;Radiogram of Incomplete Backward Dislocation
+of Elbow." title="" />
+<span class="caption"><span class="smcap">Fig. 38.</span>&mdash;Radiogram of Incomplete Backward Dislocation
+of Elbow.</span>
+</div>
+
+<p><i>Clinical features.</i>&mdash;The elbow is held fixed at an angle of about
+120&deg;, 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.</p>
+
+<p>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 an&aelig;sthetic is often necessary to
+enable an accurate diagnosis to be<a class="pagenum" name="Pg_92" id="Pg_92"></a> 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&mdash;according to E. H. Bennett, in the majority&mdash;this dislocation
+is <i>incomplete</i>, 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.</p>
+
+<p><b>Dislocation forward</b> 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 (<a href="#fig_39">Fig.&nbsp;39</a>). 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.</p>
+
+<p><b>Medial and Lateral Dislocations.</b>&mdash;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.</p>
+
+<p>The dislocation to the radial side is also incomplete as a rule,
+although cases have been recorded in which complete separation had
+taken place.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>In a few cases <i>diverging dislocations</i> 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.</p>
+
+<p><b>Treatment of Dislocations of Elbow.</b>&mdash;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<a class="pagenum" name="Pg_93" id="Pg_93"></a> 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
+an&aelig;sthetised, these manipulations must be adapted to the recumbent
+position.</p>
+
+<p>When some days have elapsed before reduction is attempted,<a class="pagenum" name="Pg_94" id="Pg_94"></a> 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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>If there is a fracture of the olecranon, the treatment must be
+modified accordingly (<a href="#Pg_87">p.&nbsp;87</a>).</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_39" id="fig_39"></a>
+<img src="images/fig039.jpg" width="350" height="296" alt="Fig. 39.&mdash;Forward Dislocation of Elbow, with Fracture
+of Olecranon." title="" />
+<span class="caption"><span class="smcap">Fig. 39.</span>&mdash;Forward Dislocation of Elbow, with Fracture
+of Olecranon.<br /><br />
+(Sir Robert Jones&#39; case. Radiogram by Dr. D. Morgan.)</span>
+</div>
+
+<p>Comminuted and compound injuries usually call for operative treatment,
+the fractured bones being wired after reduction of the dislocation, or
+the loose fragments removed.</p>
+
+<p>The <i>forward dislocation</i> is reduced by fully flexing the elbow, and
+then pushing the bones of the forearm backward, while the humerus is
+pulled forward.</p>
+
+<p><i>Old-standing Dislocations.</i>&mdash;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.</p>
+
+<p><a name="IV_elbow_ulna" id="IV_elbow_ulna"></a><b>Dislocation of the ulna alone</b> is a rare injury, and is usually
+associated with fracture of one or other of its processes or of the
+inner condyle.</p>
+
+<p><a name="IV_elbow_radius" id="IV_elbow_radius"></a><b>Dislocation of the radius alone</b>, on the other hand, is comparatively
+common, especially as a concomitant of fracture of the upper third of
+the shaft of the ulna (<a href="#fig_40">Fig.&nbsp;40</a>).</p>
+
+<p>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 <i>forward</i>, and rests on the anterior
+edge of the capitellum, thus preventing complete flexion and
+supination of the limb.</p>
+
+<p><a class="pagenum" name="Pg_95" id="Pg_95"></a>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.</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_40" id="fig_40"></a>
+<img src="images/fig040.jpg" width="350" height="320" alt="Fig. 40.&mdash;Radiogram of Forward Dislocation of Head of
+Radius, with Fracture of Shaft of Ulna." title="" />
+<span class="caption"><span class="smcap">Fig. 40.</span>&mdash;Radiogram of Forward Dislocation of Head of
+Radius, with Fracture of Shaft of Ulna.</span>
+</div>
+
+<p>In a few cases the displacement of the head has been <i>backwards</i> or
+<i>laterally</i>.</p>
+
+<p><i>Treatment.</i>&mdash;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 pre<a class="pagenum" name="Pg_96" id="Pg_96"></a>vented 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.</p>
+
+<p>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.</p>
+
+<p><b>Sub-luxation of the head of the radius</b>, or &ldquo;dislocation by
+elongation,&rdquo; 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.</p>
+
+<p>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.</p>
+
+<p><i>Treatment.</i>&mdash;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 an&aelig;sthesia, 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.</p>
+
+<p><b>Sprain</b> 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&mdash;a feature which aids
+in determining the diagnosis between a sprain and a dislocation or
+fracture. In children it is often difficult to distinguish<a class="pagenum" name="Pg_97" id="Pg_97"></a> between a
+sprain and the partial separation of an epiphysis. Sprains of the
+elbow are treated on the same lines as similar lesions elsewhere&mdash;by
+massage and movement.</p>
+
+<p>The condition known as <i>tennis elbow</i> 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&mdash;<i>sculler's sprain</i>&mdash;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.</p>
+
+
+<h3><a name="IV_forearm" id="IV_forearm"></a><span class="smcap">Fracture of the Forearm</span></h3>
+
+<p>The <i>shafts</i> of the bones of the forearm may be broken separately, but
+it is much more common to find both broken together.</p>
+
+<p><a name="IV_forearm_bones" id="IV_forearm_bones"></a><b>Fracture of both bones</b> 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&mdash;this indeed being one of the commonest examples of
+greenstick fracture met with (<a href="#fig_41">Fig.&nbsp;41</a>).</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_41" id="fig_41"></a>
+<img src="images/fig041.jpg" width="400" height="274" alt="Fig. 41.&mdash;Greenstick Fracture of both Bones of the
+Forearm, in a boy." title="" />
+<span class="caption"><span class="smcap">Fig. 41.</span>&mdash;Greenstick Fracture of both Bones of the
+Forearm, in a boy.</span>
+</div>
+
+<p>The <i>displacement</i> 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.</p>
+
+<p>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.</p>
+
+<p>The usual <i>symptoms</i> of fracture are present, and there is seldom any
+difficulty in diagnosis.</p>
+
+<p>The <i>prognosis</i> must be guarded, especially with regard to the
+preservation of pronation and supination. These movements<a class="pagenum" name="Pg_98" id="Pg_98"></a> 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.</p>
+
+<p>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.</p>
+
+<p>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 isch&aelig;mic contracture occasionally develops after
+fractures of the forearm.</p>
+
+<p>In uncomplicated cases, union takes place in from three to four
+weeks.</p>
+
+<div class="figright" style="width: 350px;">
+<a name="fig_42" id="fig_42"></a>
+<img src="images/fig042.jpg" width="350" height="163" alt="Fig. 42.&mdash;Gooch Splints for Fracture of both Bones of
+Forearm. (These are applied with the wooden side towards the skin.)" title="" />
+<span class="caption"><span class="smcap">Fig. 42.</span>&mdash;Gooch Splints for Fracture of both Bones of
+Forearm. (These are applied with the wooden side towards the skin.)</span>
+</div>
+
+<p><a class="pagenum" name="Pg_99" id="Pg_99"></a><i>Treatment.</i>&mdash;To ensure accurate reduction and coaptation, a general
+an&aelig;sthetic is usually necessary. In the greenstick variety the bones
+must be straightened, the fracture being rendered complete, if
+necessary, for this purpose.</p>
+
+<p>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 (<a href="#fig_42">Fig.&nbsp;42</a>). 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.</p>
+
+<p>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.</p>
+
+<p>Massage and movement should be carried out from the first. It is
+usually necessary to continue wearing the splints for about three
+weeks.</p>
+
+<p>In cases of <i>mal-union</i>, 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<a class="pagenum" name="Pg_100" id="Pg_100"></a> good position. In comparatively recent cases it
+is sometimes possible, without operation, to re-fracture the bones and
+to set them anew.</p>
+
+<p><i>Un-united fracture</i> 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.</p>
+
+<p><a name="IV_forearm_radius" id="IV_forearm_radius"></a><b>Fracture of the shaft of the radius alone</b> 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.</p>
+
+<p>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 <i>Chauffeur's fracture</i>; 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.</p>
+
+<p>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.</p>
+
+<p><a name="IV_forearm_ulna" id="IV_forearm_ulna"></a><b>Fracture of the shaft of the ulna alone</b> 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.</p>
+
+<p>The upper third is most frequently broken, and this injury is often
+associated with dislocation of the head of the radius (<a href="#fig_40">Fig.&nbsp;40</a>), or
+some other injury implicating the elbow-joint. On account of the
+superficial position of the bone, this fracture is frequently
+compound.</p>
+
+<p>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<a class="pagenum" name="Pg_101" id="Pg_101"></a> is dislocated at the
+same time. The diagnosis is, as a rule, easy.</p>
+
+<p>The <i>treatment</i> is the same as for fracture of both bones, but the
+splints may be discarded at the end of a fortnight.</p>
+
+<p>For some unexplained reason, a fracture of the upper third of the
+shaft of the ulna frequently fails to unite.</p>
+
+
+
+
+<h2><a class="pagenum" name="Pg_102" id="Pg_102"></a><a name="CHAPTER_V" id="CHAPTER_V"></a>CHAPTER V
+<br />
+INJURIES IN THE REGION OF THE WRIST AND HAND</h2>
+
+<ul class="chap">
+  <li><a href="#V_anatomy">Surgical Anatomy</a></li>
+  <li>&mdash;<a href="#V_fracture_radius"><span class="smcap">Fracture of Lower End of Radius</span></a>:</li>
+  <li><a href="#V_colles"><i>Colles' fracture</i></a>;</li>
+  <li><a href="#V_chauffeurs"><i>Chauffeur's fracture</i></a>;</li>
+  <li><a href="#V_smiths"><i>Smith's fracture</i></a>;</li>
+  <li><a href="#V_longitudinal"><i>Longitudinal fracture</i></a>;</li>
+  <li><a href="#V_radius_epiphysis"><i>Separation of epiphysis</i></a></li>
+  <li>&mdash;<a href="#V_fracture_ulna"><span class="smcap">Fracture of Lower End of Ulna</span></a>:</li>
+  <li><a href="#V_fracture_ulna"><i>Shaft</i></a>;</li>
+  <li><a href="#V_fracture_ulna"><i>Styloid process</i></a>;</li>
+  <li><a href="#V_ulna_epiphysis"><i>Separation of epiphysis</i></a></li>
+  <li>&mdash;<a href="#V_carpal"><span class="smcap">Fracture of Carpal Bones</span></a></li>
+  <li>&mdash;<a href="#V_dislocation_wrist"><span class="smcap">Dislocation</span></a>:</li>
+  <li><a href="#V_radio_ulnar"><i>Inferior radio-ulnar joint</i></a>;</li>
+  <li><a href="#V_radio_carpal"><i>Radio-carpal joint</i></a>;</li>
+  <li><a href="#V_dislocation_carpal"><i>Carpal bones</i></a>;</li>
+  <li><a href="#V_carpo_metacarpal"><i>Carpo-metacarpal joint</i></a></li>
+  <li>&mdash;<a href="#V_sprain"><span class="smcap">Sprains</span></a></li>
+  <li>&mdash;<a href="#V_fingers"><span class="smcap">Injuries of Fingers</span></a>:</li>
+  <li><a href="#V_fracture_finger"><i>Fractures</i></a>;</li>
+  <li><a href="#V_dislocation_finger"><i>Dislocations</i></a>;</li>
+  <li><a href="#V_mallet_finger"><i>Mallet finger</i></a>.</li>
+</ul>
+
+<h3><span class="smcap">Injuries in the Region of the Wrist</span></h3>
+
+<p>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.</p>
+
+<p><a name="V_anatomy" id="V_anatomy"></a><b>Surgical Anatomy.</b>&mdash;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 &ldquo;anatomical snuff-box&rdquo; 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.</p>
+
+<p>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.</p>
+
+<p>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&mdash;active and passive&mdash;at the various joints should also be
+tested.</p>
+
+
+<h3><a name="V_fracture_radius" id="V_fracture_radius"></a><span class="smcap">Fracture of the Lower End of the Radius</span></h3>
+
+<p><a name="V_colles" id="V_colles"></a><b>Colles' Fracture.</b>&mdash;This injury, which was described by Colles of
+Dublin in 1814, is one of the commonest fractures in the<a class="pagenum" name="Pg_103" id="Pg_103"></a> 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.</p>
+
+<p>The fracture takes place through the cancellated extremity of the
+bone, within a half to three-quarters of an inch of its articular
+surface (<a href="#fig_45">Fig.&nbsp;45</a>). 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.</p>
+
+<table class="figure" summary="Fig 43, 44">
+<tr>
+<td class="figcenter" style="width: 225px;">
+<a name="fig_43" id="fig_43"></a>
+<img src="images/fig043.jpg" width="225" height="353" alt="Fig. 43.&mdash;Colles&#39; Fracture showing radial deviation of
+hand." title="" />
+<span class="caption"><span class="smcap">Fig. 43.</span>&mdash;Colles&#39; Fracture showing radial deviation of
+hand.</span>
+</td>
+
+<td style="width: 50px;">&nbsp;</td>
+
+<td class="figcenter" style="width: 225px;">
+<a name="fig_44" id="fig_44"></a>
+<img src="images/fig044.jpg" width="225" height="353" alt="Fig. 44.&mdash;Colles&#39; Fracture showing undue prominence of
+ulnar styloid." title="" />
+<span class="caption"><span class="smcap">Fig. 44.</span>&mdash;Colles&#39; Fracture showing undue prominence of
+ulnar styloid.</span>
+</td>
+</tr>
+</table>
+
+<p>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.</p>
+
+<p>In the majority of cases the styloid process of the ulna is torn off
+by traction exerted through the medial ulno-carpal<a class="pagenum" name="Pg_104" id="Pg_104"></a> (internal lateral)
+ligament, and in a considerable proportion there is also a fracture of
+one of the carpal bones.</p>
+
+<p>The resulting <i>displacement</i> 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.</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_45" id="fig_45"></a>
+<img src="images/fig045.jpg" width="350" height="359" alt="Fig. 45.&mdash;Radiogram showing the line of fracture and
+upward displacement of the radial styloid in Colles&#39; Fracture." title="" />
+<span class="caption"><span class="smcap">Fig. 45.</span>&mdash;Radiogram showing the line of fracture and
+upward displacement of the radial styloid in Colles&#39; Fracture.</span>
+</div>
+
+<p><i>Clinical Features.</i>&mdash;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 (<a href="#fig_43">Fig.&nbsp;43</a>); and the wrist is<a class="pagenum" name="Pg_105" id="Pg_105"></a> 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.</p>
+
+<p>The general outline of the wrist and hand has been compared not
+inaptly to that of &ldquo;an inverted spoon.&rdquo; 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.</p>
+
+<p><i>Treatment.</i>&mdash;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 an&aelig;sthetic 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.</p>
+
+<p>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&deg;, but somewhat
+narrower, may be employed. The hand and forearm are in any case
+supported in a sling.</p>
+
+<p><a class="pagenum" name="Pg_106" id="Pg_106"></a>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.</p>
+
+<p>The various special splints recommended for the treatment of Colles'
+fracture, such as Carr's, Gordon's, the &ldquo;pistol splint,&rdquo; 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.</p>
+
+<p><i>Unreduced Colles' Fracture.</i>&mdash;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 &aelig;sthetic 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.</p>
+
+<p><a name="V_chauffeurs" id="V_chauffeurs"></a><b>Chauffeur's Fracture.</b>&mdash;A fracture of the lower end of the radius
+frequently occurs from the recoil of the crank, &ldquo;by back firing,&rdquo; 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 (<a href="#fig_46">Fig.&nbsp;46</a>). It is treated on
+the same lines as Colles' fracture.</p>
+
+<div class="figcenter" style="width: 550px;"><a class="pagenum" name="Pg_107" id="Pg_107"></a>
+<a name="fig_46" id="fig_46"></a>
+<img src="images/fig046.jpg" width="550" height="176" alt="Fig. 46.&mdash;Radiogram of Chauffeur&#39;s Fracture." title="" />
+<span class="caption"><span class="smcap">Fig. 46.</span>&mdash;Radiogram of Chauffeur&#39;s Fracture.</span>
+</div>
+
+<p>&nbsp;</p>
+
+<div class="figcenter" style="width: 500px;"><a class="pagenum" name="Pg_108" id="Pg_108"></a>
+<a name="fig_47" id="fig_47"></a>
+<img src="images/fig047.jpg" width="500" height="253" alt="Fig. 47.&mdash;Radiogram of Smith&#39;s Fracture." title="" />
+<span class="caption"><span class="smcap">Fig. 47.</span>&mdash;Radiogram of Smith&#39;s Fracture.<br /><br />
+(Sir George T. Beatson&#39;s case.)</span>
+</div>
+
+<p><a name="V_smiths" id="V_smiths"></a>A fracture of the lower end of the radius <i>with forward displacement
+of the carpal fragment</i>, was first described by R. W. Smith of Dublin
+(<i>Colles' fracture reversed</i>, or <b>Smith's fracture</b>) (<a href="#fig_47">Fig.&nbsp;47</a>). 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<a class="pagenum" name="Pg_109" id="Pg_109"></a> 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.</p>
+
+<p>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.</p>
+
+<p>The <i>treatment</i> is carried out on the same lines as in Colles'
+fracture.</p>
+
+<p><a name="V_longitudinal" id="V_longitudinal"></a><i>Longitudinal fractures</i> 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.</p>
+
+<p><a name="V_radius_epiphysis" id="V_radius_epiphysis"></a><b>Separation of the lower epiphysis</b> 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.</p>
+
+<p>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<a class="pagenum" name="Pg_110" id="Pg_110"></a> 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.</p>
+
+<p>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 (<a href="#fig_48">Fig.&nbsp;48</a>), calling for
+resection of the lower end of the ulna.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_48" id="fig_48"></a>
+<img src="images/fig048.jpg" width="400" height="207" alt="Fig. 48.&mdash;Manus Valga following separation of lower
+radial epiphysis in childhood." title="" />
+<span class="caption"><span class="smcap">Fig. 48.</span>&mdash;Manus Valga following separation of lower
+radial epiphysis in childhood.<br /><br />
+(Mr. H. Wade&#39;s case.)</span>
+</div>
+
+<p>The <i>treatment</i> is the same as for Colles' fracture.</p>
+
+<p><a name="V_fracture_ulna" id="V_fracture_ulna"></a><b>Fracture of the Lower End of the Ulna.</b>&mdash;The lower end of the <i>shaft</i>
+of the ulna is seldom fractured alone. The <i>styloid process</i>, as has
+already been pointed out, is frequently broken in association with
+Colles' and other fractures of the lower end of the radius.</p>
+
+<p><a name="V_ulna_epiphysis" id="V_ulna_epiphysis"></a>Separation of the <i>lower epiphysis</i> 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.</p>
+
+<p>The <i>treatment</i> is similar to that for the corresponding injuries of
+the radius.</p>
+
+<p>Simultaneous separation of the <i>epiphysis of both radius and ulna</i>
+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.</p>
+
+<p><a name="V_carpal" id="V_carpal"></a><b>Fracture of Carpal Bones.</b>&mdash;The use of the R&ouml;ntgen 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.</p>
+
+<p>The <i>navicular</i> (scaphoid) and <i>lunate</i> (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 (<a href="#fig_49">Fig.&nbsp;49</a>). Codman recommends taking pictures<a class="pagenum" name="Pg_111" id="Pg_111"></a> of
+the navicular by placing the two wrists of the patient in adduction,
+and of the lunate, in abduction.</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_49" id="fig_49"></a>
+<img src="images/fig049.jpg" width="350" height="373" alt="Fig. 49.&mdash;Radiogram showing Fracture of Navicular
+(Scaphoid) Bone." title="" />
+<span class="caption"><span class="smcap">Fig. 49.</span>&mdash;Radiogram showing Fracture of Navicular
+(Scaphoid) Bone.</span>
+</div>
+
+<p>The <i>treatment</i> 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.</p>
+
+
+<h3><a name="V_dislocation_wrist" id="V_dislocation_wrist"></a><span class="smcap">Dislocations in the Region of the Wrist</span></h3>
+
+<p>Dislocation may occur at the inferior radio-ulnar, the radio-carpal,
+mid-carpal, inter-carpal, or carpo-metacarpal joints, but the<a class="pagenum" name="Pg_112" id="Pg_112"></a> 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.</p>
+
+<p><a name="V_radio_ulnar" id="V_radio_ulnar"></a>Dislocation of the <b>inferior radio-ulnar</b> 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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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&mdash;<i>recurrent dislocation</i>.</p>
+
+<p><a name="V_radio_carpal" id="V_radio_carpal"></a>Dislocation at the <b>radio-carpal</b> articulation, usually spoken of as
+<i>dislocation of the wrist</i>, 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.</p>
+
+<p><i>Backward</i> 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 (<a href="#fig_50">Fig.&nbsp;50</a>). 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.</p>
+
+<p><i>Forward</i> 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<a class="pagenum" name="Pg_113" id="Pg_113"></a> depression on the
+dorsum. The attitude of the hand and fingers is usually one of
+flexion.</p>
+
+<p>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.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_50" id="fig_50"></a>
+<img src="images/fig050.jpg" width="400" height="254" alt="Fig. 50.&mdash;Dorsal Dislocation of Wrist at Radio-carpal
+Articulation, in a man, &aelig;t. 24, from a fall." title="" />
+<span class="caption"><span class="smcap">Fig. 50.</span>&mdash;Dorsal Dislocation of Wrist at Radio-carpal
+Articulation, in a man, &aelig;t. 24, from a fall.</span>
+</div>
+
+<p><a name="V_dislocation_carpal" id="V_dislocation_carpal"></a><b>Dislocation of Carpal Bones.</b>&mdash;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.</p>
+
+<p><a class="pagenum" name="Pg_114" id="Pg_114"></a>Of these injuries that most frequently observed is displacement of the
+<i>head of the capitate bone</i> (<i>os magnum</i>) 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.</p>
+
+<p>The <i>lunate</i> 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.</p>
+
+<p><a class="pagenum" name="Pg_115" id="Pg_115"></a>In a few cases the <i>navicular</i> has been displaced (<a href="#fig_51">Fig.&nbsp;51</a>), and has
+had to be subsequently replaced by operation. Separation of any of the
+other bones is rare.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_51" id="fig_51"></a>
+<img src="images/fig051.jpg" width="400" height="287" alt="Fig. 51.&mdash;Radiogram showing Forward Dislocation of
+Navicular (Scaphoid) Bone." title="" />
+<span class="caption"><span class="smcap">Fig. 51.</span>&mdash;Radiogram showing Forward Dislocation of
+Navicular (Scaphoid) Bone.</span>
+</div>
+
+<p><a name="V_carpo_metacarpal" id="V_carpo_metacarpal"></a><b>Carpo-metacarpal Dislocations.</b>&mdash;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.</p>
+
+<p><a name="V_sprain" id="V_sprain"></a><b>Sprain of the wrist</b> 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&mdash;Colles' fracture,
+separation of the lower radial epiphysis, dislocation of the wrist,
+and fractures and dislocations of the carpal bones.</p>
+
+<p>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.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+
+<h3><a name="V_fingers" id="V_fingers"></a><span class="smcap">Injuries of the Fingers</span></h3>
+
+<p><a name="V_fracture_finger" id="V_fracture_finger"></a><b>Fracture.</b>&mdash;<i>Fractures of the metacarpals of the fingers</i> are
+comparatively common. When they result from direct violence,<a class="pagenum" name="Pg_116" id="Pg_116"></a> 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.</p>
+
+<p>The shaft of the <i>metacarpal of the thumb</i> 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.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p>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 (<a href="#fig_52">Fig.&nbsp;52</a>). This should be worn for a week or ten days.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_52" id="fig_52"></a>
+<img src="images/fig052.jpg" width="400" height="556" alt="Fig. 52.&mdash;Extension apparatus for Oblique Fracture of
+Metacarpals." title="" />
+<span class="caption"><span class="smcap">Fig. 52.</span>&mdash;Extension apparatus for Oblique Fracture of
+Metacarpals.</span>
+</div>
+
+<p><b>Bennett's Fracture of the Base of the First Metacarpal Bone.</b>&mdash;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 &ldquo;stave of the thumb.&rdquo; It
+consists in an &ldquo;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&rdquo; (<a href="#fig_53">Fig.&nbsp;53</a>). We
+have frequently observed the fracture extend for a considerable
+distance along the palmar aspect of the shaft.</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_53" id="fig_53"></a>
+<img src="images/fig053.jpg" width="300" height="394" alt="Fig. 53.&mdash;Radiogram of Bennett&#39;s Fracture of Base of
+Metacarpal of Right Thumb." title="" />
+<span class="caption"><span class="smcap">Fig. 53.</span>&mdash;Radiogram of Bennett&#39;s Fracture of Base of
+Metacarpal of Right Thumb.</span>
+</div>
+
+<p>It usually results from severe force applied directly to the<a class="pagenum" name="Pg_117" id="Pg_117"></a> 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<a class="pagenum" name="Pg_118" id="Pg_118"></a> abduction and fine movements requiring close
+apposition of the thumb being specially interfered with.</p>
+
+<p>The <i>treatment</i> 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 (<a href="#fig_54">Fig.&nbsp;54</a> <span style="text-transform:lowercase;" class="smcap">A</span>). The apparatus is worn
+for three weeks, being carefully readjusted from time to time to
+maintain the extension<a class="pagenum" name="Pg_119" id="Pg_119"></a> and abduction. A moulded poroplastic splint
+added on the same principle may be employed, and is more comfortable
+(<a href="#fig_54">Fig.&nbsp;54</a> <span style="text-transform:lowercase;" class="smcap">B</span>). 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).</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_54" id="fig_54"></a>
+<img src="images/fig054.jpg" width="400" height="371" alt="Fig. 54.&mdash;A. Splint applied as used by Bennett. B.
+Poroplastic Moulded Splint for Bennett&#39;s Fracture." title="" />
+<span class="caption"><span class="smcap">Fig. 54.</span>&mdash;A. Splint applied as used by Bennett. B.
+Poroplastic Moulded Splint for Bennett&#39;s Fracture.</span>
+</div>
+
+<p><b>Fractures of phalanges</b> 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.</p>
+
+<p><i>Treatment.</i>&mdash;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 an&aelig;sthetise the patient to
+effect reduction. When it is particularly desirable to avoid
+deformity, an open operation may be advisable.</p>
+
+<p><a name="V_dislocation_finger" id="V_dislocation_finger"></a><b>Dislocation.</b>&mdash;<i>Dislocation of the Metacarpo-phalangeal Joint of the
+Thumb.</i>&mdash;The commonest dislocation at this joint is a<a class="pagenum" name="Pg_120" id="Pg_120"></a> <i>backward</i>
+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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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
+&ldquo;button-holing&rdquo; by the short flexor is probably of no importance.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>Dislocation <i>forward</i> 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.</p>
+
+<p>Reduction is easily effected by making traction on the phalanges and
+carrying out movements of flexion and extension.<a class="pagenum" name="Pg_121" id="Pg_121"></a> The deformity,
+however, is liable to be reproduced unless a retentive apparatus is
+securely applied.</p>
+
+<p>Dislocation of the thumb to one or other side is rare.</p>
+
+<p>Dislocations of the <i>metacarpo-phalangeal joint of the fingers</i> 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.</p>
+
+<p><i>Inter-phalangeal Dislocation.</i>&mdash;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.</p>
+
+<p><a name="V_mallet_finger" id="V_mallet_finger"></a><i>Persistent flexion of the terminal phalanx</i> of the thumb or fingers
+(<i>drop</i> or <i>mallet finger</i>) may result from violence applied to the
+end of the digit when in the extended position&mdash;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.</p>
+
+
+
+
+<h2><a class="pagenum" name="Pg_122" id="Pg_122"></a><a name="CHAPTER_VI" id="CHAPTER_VI"></a>CHAPTER VI
+<br />
+INJURIES IN THE REGION OF THE PELVIS, HIP-JOINT, AND THIGH</h2>
+
+<ul class="chap">
+  <li><a href="#VI_pelvis"><span class="smcap">Fractures of Pelvis</span>: <i>Varieties</i></a></li>
+  <li>&mdash;<a href="#VI_hip"><span class="smcap">Injuries in Region of Hip</span></a>:</li>
+  <li><a href="#VI_anatomy">Surgical anatomy</a>;</li>
+  <li><a href="#VI_head_femur"><i>Fracture of head of femur</i></a>;</li>
+  <li><a href="#VI_neck_femur"><i>Fracture of neck of femur</i></a>;</li>
+  <li><a href="#VI_trochanter"><i>Fracture below lesser trochanter</i></a></li>
+  <li>&mdash;<a href="#VI_dislocation_hip"><span class="smcap">Dislocation of Hip</span>: <i>Varieties</i></a></li>
+  <li>&mdash;<a href="#VI_sprain">Sprains</a></li>
+  <li>&mdash;<a href="#VI_contusion">Contusions</a></li>
+  <li>&mdash;<a href="#VI_shaft_femur"><span class="smcap">Fracture of Shaft of Femur</span></a>.</li>
+</ul>
+
+
+<h3><a name="VI_pelvis" id="VI_pelvis"></a><span class="smcap">Fracture of the Pelvis</span></h3>
+
+<p>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.</p>
+
+<p>In all, the prognosis depends upon the severity of the visceral
+lesions which so frequently complicate these injuries, rather than
+upon the fractures themselves.</p>
+
+<p><b>Fractures implicating the pelvic girdle as a whole</b> 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.</p>
+
+<p>As a rule, more than one part of the pelvis is broken, the situation
+of the lesions varying in different cases.</p>
+
+<p><i>Separation of the pubic symphysis</i> 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<a class="pagenum" name="Pg_123" id="Pg_123"></a> 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.</p>
+
+<p>The <i>pubic portion</i> of the pelvic ring is the most common seat of
+fracture. The bone gives way at its weakest points&mdash;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 (<a href="#fig_55">Fig.&nbsp;55</a>). 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 (<a href="#fig_55">Fig.&nbsp;55</a>), or with
+other fractures of the pelvic-bones.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_55" id="fig_55"></a>
+<img src="images/fig055.jpg" width="400" height="309" alt="Fig. 55.&mdash;Multiple Fracture of Pelvis through
+Horizontal and Descending Rami of both Pubes, and Longitudinal
+Fracture of left side of Sacrum." title="" />
+<span class="caption"><span class="smcap">Fig. 55.</span>&mdash;Multiple Fracture of Pelvis through
+Horizontal and Descending Rami of both Pubes, and Longitudinal
+Fracture of left side of Sacrum.</span>
+</div>
+
+<p>Injuries of the membranous urethra and bladder are frequent
+complications, less commonly the rectum, the vagina, or the iliac
+blood vessels are damaged.</p>
+
+<p><a class="pagenum" name="Pg_124" id="Pg_124"></a>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.</p>
+
+<p><i>The lateral and posterior aspects</i> 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.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_56" id="fig_56"></a>
+<img src="images/fig056.jpg" width="400" height="353" alt="Fig. 56.&mdash;Fracture of left Iliac Bone; and of both
+Pubic Arches." title="" />
+<span class="caption"><span class="smcap">Fig. 56.</span>&mdash;Fracture of left Iliac Bone; and of both
+Pubic Arches.</span>
+</div>
+
+<p><i>Treatment.</i>&mdash;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,<a class="pagenum" name="Pg_125" id="Pg_125"></a> which may be
+made in three pieces, for convenience in using the bed-pan and for the
+prevention of bed-sores.</p>
+
+<p>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.</p>
+
+<p>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 (<a href="#fig_57">Fig.&nbsp;57</a>).</p>
+
+<div class="figcenter" style="width: 500px;">
+<a name="fig_57" id="fig_57"></a>
+<img src="images/fig057.png" width="500" height="275" alt="Fig. 57.&mdash;Many-tailed Bandage and Binder for Fracture
+of Pelvic Girdle." title="" />
+<span class="caption"><span class="smcap">Fig. 57.</span>&mdash;Many-tailed Bandage and Binder for Fracture
+of Pelvic Girdle.</span>
+</div>
+
+<p>When there is displacement of fragments extension should be applied to
+both legs, with the limbs abducted and steadied by sand-bags.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>The <b>acetabulum</b> 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<a class="pagenum" name="Pg_126" id="Pg_126"></a> 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&mdash;the <i>central dislocation of the hip</i> of German writers&mdash;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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>Fracture of the <i>upper and back part of the rim</i> 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.</p>
+
+<p><b>Fracture of Individual Bones of the Pelvis.</b>&mdash;<i>Ilium.</i>&mdash;The expanded
+portion of the iliac bone is often broken by direct violence, the
+detached fragments varying greatly in size and position (<a href="#fig_56">Fig.&nbsp;56</a>).</p>
+
+<p>The whole or part of the <i>crest</i> may be separated by similar forms of
+violence.</p>
+
+<p>When the fracture implicates the <i>ala</i> 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.</p>
+
+<p>These fractures are treated by applying a roller bandage or broad
+strips of adhesive plaster over the seat of fracture, and by<a class="pagenum" name="Pg_127" id="Pg_127"></a> placing
+the patient in such a position as will relax the muscles attached to
+the displaced fragment&mdash;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.</p>
+
+<p>In young persons, the <i>anterior superior spine</i> has been torn off and
+displaced downwards by powerful contraction of the sartorius muscle;
+and the <i>anterior inferior spine</i> 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.</p>
+
+<p>Fracture of the <i>ischium</i> 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.</p>
+
+<p>A longitudinal fracture of the <i>sacrum</i> 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 <i>transversely</i> 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.</p>
+
+<p>Fracture of the <i>coccyx</i> 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 <i>coccydynia</i>, which may call for excision.</p>
+
+
+<h3><a name="VI_hip" id="VI_hip"></a><span class="smcap">Injuries in the Region of the Hip</span></h3>
+
+<p>These include the various fractures of the upper end of the femur;
+dislocation and sprain of the hip-joint; and contusion of the hip.</p>
+
+<p><a name="VI_anatomy" id="VI_anatomy"></a><a class="pagenum" name="Pg_128" id="Pg_128"></a><b>Surgical Anatomy.</b>&mdash;The strength of the hip-joint depends primarily on
+its osseous elements&mdash;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).</p>
+
+<p>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&mdash;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.</p>
+
+<p>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 <i>ilio-femoral or [inverted
+Y]-shaped ligament</i> 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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>For purposes of clinical diagnosis it is necessary to locate certain
+bony prominences, the most important being&mdash;(1) The <i>anterior superior
+iliac spine</i>, which is most readily recognised by running the fingers
+along<a class="pagenum" name="Pg_129" id="Pg_129"></a> Poupart's ligament towards it. (2) The <i>ischial tuberosity</i>,
+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 <i>great trochanter</i> is
+readily recognised on the lateral aspect of the hip. Its highest point
+or <i>tip</i> can best be felt by pressing over the gluteal muscles from
+above downwards.</p>
+
+<p><i>Clinical Tests.</i>&mdash;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 <i>N&eacute;laton's
+line</i> (<a href="#fig_58">Fig.&nbsp;58</a>).</p>
+
+<div class="figcenter" style="width: 500px;">
+<a name="fig_58" id="fig_58"></a>
+<img src="images/fig058.png" width="500" height="246" alt="Fig. 58.&mdash;N&eacute;laton&#39;s Line." title="" />
+<span class="caption"><span class="smcap">Fig. 58.</span>&mdash;N&eacute;laton&#39;s Line.</span>
+</div>
+
+<p><i>Bryant's test</i> (<a href="#fig_59">Fig.&nbsp;59</a>) 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.</p>
+
+<div class="figcenter" style="width: 500px;">
+<a name="fig_59" id="fig_59"></a>
+<img src="images/fig059.png" width="500" height="328" alt="Fig. 59.&mdash;Bryant&#39;s Line." title="" />
+<span class="caption"><span class="smcap">Fig. 59.</span>&mdash;Bryant&#39;s Line.</span>
+</div>
+
+<p><i>Chiene's test</i>, 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.</p>
+
+
+<h3><a name="VI_head_femur" id="VI_head_femur"></a><span class="smcap">Fracture of the Upper End of the Femur</span></h3>
+
+<p>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.</p>
+
+<p>Fracture of the <b>head of the femur</b> 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.</p>
+
+<p>The <b>epiphysis of the head</b>, which lies entirely within the<a class="pagenum" name="Pg_130" id="Pg_130"></a> capsule of
+the joint (<a href="#fig_60">Fig.&nbsp;60</a>), 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.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_60" id="fig_60"></a>
+<img src="images/fig060.png" width="400" height="407" alt="Fig. 60.&mdash;Section through Hip-Joint to show epiphyses
+at upper end of femur, and their relation to the joint." title="" />
+<span class="caption"><span class="smcap">Fig. 60.</span>&mdash;Section through Hip-Joint to show epiphyses
+at upper end of femur, and their relation to the joint.<br /><br />
+<i>a</i>, Epiphysis of head.<br />
+<i>b</i>, Epiphysis of great trochanter.<br />
+<i>c</i>, Epiphysis of small trochanter.<br />
+<i>d</i>, Capsular ligaments.<br /><br />
+(After Poland.)</span>
+</div>
+
+
+<h3><a name="VI_neck_femur" id="VI_neck_femur"></a><span class="smcap">Fracture of the Neck</span></h3>
+
+<p>It has long been customary to divide fractures of the neck of the
+femur into two groups&mdash;&ldquo;intra-&rdquo; and &ldquo;extra-capsular&rdquo;; 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 <i>through the narrow part of the neck</i>, which are
+nearly always purely intra-capsular; and (2) those occurring <i>through
+the base of the neck</i> in which the line of fracture lies inside the
+capsule in front, but outside of it behind.</p>
+
+<p><a class="pagenum" name="Pg_131" id="Pg_131"></a>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 (<a href="#fig_61">Fig.&nbsp;61</a>). 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.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_61" id="fig_61"></a>
+<img src="images/fig061.jpg" width="400" height="446" alt="Fig. 61.&mdash;Fracture through Narrow Part of Neck of Femur
+on section. The Neck of the bone has undergone absorption." title="" />
+<span class="caption"><span class="smcap">Fig. 61.</span>&mdash;Fracture through Narrow Part of Neck of Femur
+on section. The Neck of the bone has undergone absorption.</span>
+</div>
+
+<p><b>Fracture of the Narrow Part of the Neck</b> or <b>Intra-capsular
+Fracture</b>.&mdash;This fracture is most frequently met with in elderly
+persons, especially women, and is usually produced by comparatively
+slight forms of indirect violence&mdash;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.</p>
+
+<p>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<a class="pagenum" name="Pg_132" id="Pg_132"></a> 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.</p>
+
+<p>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 (<a href="#fig_62">Fig.&nbsp;62</a>).</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_62" id="fig_62"></a>
+<img src="images/fig062.jpg" width="350" height="488" alt="Fig. 62.&mdash;Impacted Fracture through Narrow Part of Neck
+of Femur." title="" />
+<span class="caption"><span class="smcap">Fig. 62.</span>&mdash;Impacted Fracture through Narrow Part of Neck
+of Femur.</span>
+</div>
+
+<p><i>Clinical Features.</i>&mdash;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.</p>
+
+<p>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 N&eacute;laton'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.</p>
+
+<p>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.</p>
+
+<p>The violence being as a rule indirect, there is at first little or<a class="pagenum" name="Pg_133" id="Pg_133"></a> no
+discoloration in the vicinity of the hip, but this may appear a few
+days later.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<div class="figcenter" style="width: 500px;">
+<a name="fig_63" id="fig_63"></a>
+<img src="images/fig063.jpg" width="500" height="194" alt="Fig. 63. Fracture of Neck of Right Femur, showing
+shortening, abduction, and eversion of limb." title="" />
+<span class="caption"><span class="smcap">Fig. 63.</span> Fracture of Neck of Right Femur, showing
+shortening, abduction, and eversion of limb.</span>
+</div>
+
+<p>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.</p>
+
+<p>In <i>impacted</i> 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<a class="pagenum" name="Pg_134" id="Pg_134"></a> impaction, as the
+interlocking of the bones favours the occurrence of osseous union.</p>
+
+<div class="figleft" style="width: 250px;">
+<a name="fig_64" id="fig_64"></a>
+<img src="images/fig064.jpg" width="250" height="435" alt="Fig. 64.&mdash;Fracture of Narrow Part of Neck of Femur. The
+neck has become absorbed, the head has not united, and a false joint
+has formed." title="" />
+<span class="caption"><span class="smcap">Fig. 64.</span>&mdash;Fracture of Narrow Part of Neck of Femur. The
+neck has become absorbed, the head has not united, and a false joint
+has formed.</span>
+</div>
+
+<p><i>Prognosis.</i>&mdash;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.</p>
+
+<p>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 (<a href="#fig_64">Fig.&nbsp;64</a>). Chronic changes
+of the nature of arthritis deformans may occur in and around such
+false joints.</p>
+
+<p>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<a class="pagenum" name="Pg_135" id="Pg_135"></a> antero-posterior thickening of
+the neck of the femur, and the femoral vessels may be pushed forward
+in Scarpa's triangle.</p>
+
+<p><i>Treatment.</i>&mdash;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&mdash;whether in the narrow part of the neck or at its base. &ldquo;The
+first indication is to save life, the second to get union, and the
+third to correct or diminish displacements&rdquo; (Stimson).</p>
+
+<p>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.</p>
+
+<p>When the general condition of the patient permits of it, an attempt
+should be made to secure bony union.</p>
+
+<p><i>Extension</i> is applied by one or other of the methods described for
+fracture of the shaft (<a href="#Pg_149">p.&nbsp;149</a>), so modified as to maintain the limb
+<i>in the abducted position</i>, 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.</p>
+
+<p><b>Fracture of the Neck of the Femur in Children.</b>&mdash;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.</p>
+
+<p>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 (<a href="#Pg_221">p.&nbsp;221</a>)<a class="pagenum" name="Pg_136" id="Pg_136"></a> or in a plaster-of-Paris case
+in the position of extreme abduction.</p>
+
+<p>If the condition is not recognised and treated, it is liable to be
+followed by the development of coxa vara (Royal Whitman) (<a href="#fig_65">Fig.&nbsp;65</a>).</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_65" id="fig_65"></a>
+<img src="images/fig065.jpg" width="300" height="358" alt="Fig. 65.&mdash;Coxa Vara following Fracture of Neck of Femur
+in a child." title="" />
+<span class="caption"><span class="smcap">Fig. 65.</span>&mdash;Coxa Vara following Fracture of Neck of Femur
+in a child.</span>
+</div>
+
+<p><b>Fracture through the Base of the Neck.</b>&mdash;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.</p>
+
+<p>Although often spoken of as &ldquo;extra-capsular,&rdquo; the line of<a class="pagenum" name="Pg_137" id="Pg_137"></a> 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 <i>impacted</i> variety (<a href="#fig_67">Fig.&nbsp;67</a>).</p>
+
+<table class="figure" summary="Fig 66, 67">
+<tr>
+<td class="figcenter" style="width: 300px;">
+<a name="fig_66" id="fig_66"></a>
+<img src="images/fig066.jpg" width="300" height="413" alt="Fig. 66.&mdash;Non-impacted Fracture through Base of Neck." title="" />
+<span class="caption"><span class="smcap">Fig. 66.</span>&mdash;Non-impacted Fracture through Base of Neck.</span>
+</td>
+
+<td style="width: 50px;">&nbsp;</td>
+
+<td class="figcenter" style="width: 300px;">
+<a name="fig_67" id="fig_67"></a>
+<img src="images/fig067.jpg" width="300" height="413" alt="Fig. 67.&mdash;Fracture through Base of Neck of Femur with
+Impaction into the Trochanters." title="" />
+<span class="caption"><span class="smcap">Fig. 67.</span>&mdash;Fracture through Base of Neck of Femur with
+Impaction into the Trochanters.</span>
+</td>
+</tr>
+</table>
+
+<p><i>Clinical Features.</i>&mdash;Although this fracture is commonly met with in
+strong adults, it may occur in the aged.</p>
+
+<p>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 <i>non-impacted</i> cases, may amount to 1<span class="frac_top">1</span>/<span class="frac_bottom">2</span> 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<a class="pagenum" name="Pg_138" id="Pg_138"></a> 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.</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_68" id="fig_68"></a>
+<img src="images/fig068.jpg" width="350" height="510" alt="Fig. 68.&mdash;Non-impacted Fracture through Base of Neck.
+Union has occurred with diminution of angle of neck&mdash;Coxa Vara." title="" />
+<span class="caption"><span class="smcap">Fig. 68.</span>&mdash;Non-impacted Fracture through Base of Neck.
+Union has occurred with diminution of angle of neck&mdash;Coxa Vara.</span>
+</div>
+
+<p>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 class="pagenum" name="Pg_139" id="Pg_139"></a> a mass
+consisting of the bony fragments may be felt, and is tender on
+pressure. Unnatural mobility with crepitus may be elicited.</p>
+
+<p>In the <i>impacted variety</i>, 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.</p>
+
+<p><i>Prognosis.</i>&mdash;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.</p>
+
+<p>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.</p>
+
+<p><i>Treatment.</i>&mdash;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 an&aelig;sthesia 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.</p>
+
+<p>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.</p>
+
+<p>Fracture of the <b>greater trochanter</b> 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 <i>epiphysis</i> 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.</p>
+
+<p><a name="VI_trochanter" id="VI_trochanter"></a><b>Fracture immediately below the lesser trochanter</b> may be produced by
+direct or by indirect violence, and the displacement<a class="pagenum" name="Pg_140" id="Pg_140"></a> 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<a class="pagenum" name="Pg_141" id="Pg_141"></a> proximal fragment may be increased by the displaced
+distal fragment pushing it forward.</p>
+
+<p>On account of the difficulty of controlling the short proximal
+fragment, union is liable to take place with considerable shortening
+and deformity (<a href="#fig_69">Fig.&nbsp;69</a>).</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_69" id="fig_69"></a>
+<img src="images/fig069.jpg" width="300" height="471" alt="Fig. 69.&mdash;Fracture of the Femur just below the Small
+Trochanter united, showing flexion and lateral rotation of upper
+fragment." title="" />
+<span class="caption"><span class="smcap">Fig. 69.</span>&mdash;Fracture of the Femur just below the Small
+Trochanter united, showing flexion and lateral rotation of upper
+fragment.</span>
+</div>
+
+<p><i>Treatment.</i>&mdash;When it is found, under an an&aelig;sthetic, 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.</p>
+
+<p>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 (<a href="#fig_77">Fig.&nbsp;77</a>) 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 (<a href="#fig_70">Fig.&nbsp;70</a>), with extension applied in
+the axis of the thigh, gives satisfactory results.</p>
+
+<div class="figcenter" style="width: 500px;">
+<a name="fig_70" id="fig_70"></a>
+<img src="images/fig070.jpg" width="500" height="202" alt="Fig. 70.&mdash;Adjustable Double-inclined Plane." title="" />
+<span class="caption"><span class="smcap">Fig. 70.</span>&mdash;Adjustable Double-inclined Plane.</span>
+</div>
+
+
+<h3><a name="VI_dislocation_hip" id="VI_dislocation_hip"></a><span class="smcap">Dislocation of the Hip</span></h3>
+
+<p>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<a class="pagenum" name="Pg_142" id="Pg_142"></a> 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 (<a href="#fig_71">Fig.&nbsp;71</a>).</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_71" id="fig_71"></a>
+<img src="images/fig071.png" width="350" height="514" alt="Fig. 71.&mdash;Diagram of the most common Dislocations of
+the Hip." title="" />
+<span class="caption"><span class="smcap">Fig. 71.</span>&mdash;Diagram of the most common Dislocations of
+the Hip.</span>
+</div>
+
+<p>The backward are much more common than the forward dislocations, in
+contrast to what obtains at the shoulder, where the forward varieties
+predominate.</p>
+
+<p>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
+<a href="#Pg_126">page&nbsp;126</a>.</p>
+
+<p>Like other dislocations, those of the hip may be complicated<a class="pagenum" name="Pg_143" id="Pg_143"></a> by
+laceration of muscles, blood vessels, or nerves, or by fracture of one
+or other of the bones in the vicinity.</p>
+
+<p><b>Dislocation on to the Dorsum Ilii.</b>&mdash;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 (<a href="#fig_73">Fig.&nbsp;73</a>). The
+articular surface is directed backward, while the trochanter looks
+forward.</p>
+
+<div class="figcenter" style="width: 500px;">
+<a name="fig_72" id="fig_72"></a>
+<img src="images/fig072.jpg" width="500" height="169" alt="Fig. 72.&mdash;Dislocation of Right Femur on to Dorsum
+Ilii." title="" />
+<span class="caption"><span class="smcap">Fig. 72.</span>&mdash;Dislocation of Right Femur on to Dorsum
+Ilii.</span>
+</div>
+
+<p><i>Clinical Features.</i>&mdash;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<span class="frac_top">1</span>/<span class="frac_bottom">2</span> to 2 inches, the
+trochanter being displaced above N&eacute;laton'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.</p>
+
+<p>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<a class="pagenum" name="Pg_144" id="Pg_144"></a> 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&mdash;a point in which this injury
+differs from fracture of the base of the neck of the femur.</p>
+
+<p>In a certain number of cases the lateral limb of the [inverted
+Y]-ligament is ruptured and the limb is everted&mdash;<i>dorsal dislocation
+with eversion</i>.</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_73" id="fig_73"></a>
+<img src="images/fig073.jpg" width="300" height="468" alt="Fig. 73.&mdash;Dislocation on to Dorsum Ilii. Note relation
+of neck of femur to tendons of obturator internus and gemelli
+(diagrammatic)." title="" />
+<span class="caption"><span class="smcap">Fig. 73.</span>&mdash;Dislocation on to Dorsum Ilii. Note relation
+of neck of femur to tendons of obturator internus and gemelli
+(diagrammatic).</span>
+</div>
+
+<p><b>Dislocation into the Vicinity of the Great Sciatic Notch</b>, or
+&ldquo;<i>dislocation below the tendon</i>.&rdquo;&mdash;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 (<a href="#fig_74">Fig.&nbsp;74</a>).</p>
+
+<p>The <i>clinical features</i> are the same as those of the dorsal variety,
+but, on the whole, are less marked.</p>
+
+<p><i>Differential Diagnosis.</i>&mdash;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.</p>
+
+<p><b>Dislocation into the Obturator Foramen</b> (<a href="#fig_71">Fig.&nbsp;71</a>).&mdash;This dislocation is
+produced by great force applied from behind while<a class="pagenum" name="Pg_145" id="Pg_145"></a> 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.</p>
+
+<p>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.</p>
+
+<p><i>Clinical Features.</i>&mdash;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.</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_74" id="fig_74"></a>
+<img src="images/fig074.jpg" width="300" height="455" alt="Fig. 74.&mdash;Dislocation into the vicinity of the
+Ischiatic Notch. Note relation of neck of femur to tendons of
+obturator and gemelli, &ldquo;Dislocation below the tendon&rdquo; (diagrammatic)." title="" />
+<span class="caption"><span class="smcap">Fig. 74.</span>&mdash;Dislocation into the vicinity of the
+Ischiatic Notch. Note relation of neck of femur to tendons of
+obturator and gemelli, &ldquo;Dislocation below the tendon&rdquo; (diagrammatic).</span>
+</div>
+
+<p><b>Dislocation on to the pubes</b> is a further degree of the obturator form
+(<a href="#fig_71">Fig.&nbsp;71</a>). 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.</p>
+
+<p>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.</p>
+
+<p><a class="pagenum" name="Pg_146" id="Pg_146"></a><i>Clinical Features.</i>&mdash;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.</p>
+
+<p><b>Treatment of Dislocation of the Hip.</b>&mdash;For the reduction of a
+dislocation of the hip complete an&aelig;sthesia 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.</p>
+
+<p>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 <i>to its fullest extent</i>.</p>
+
+<p>In the <i>backward</i> 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.</p>
+
+<p>For the reduction of the <i>forward</i> 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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>Changes of the nature of chronic arthritis are liable to occur in<a class="pagenum" name="Pg_147" id="Pg_147"></a> and
+around the joint in old and rheumatic subjects; and atrophy or
+paralysis of muscles may follow, if their nerves are implicated.</p>
+
+<p><b>Old-standing Dislocation.</b>&mdash;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.</p>
+
+<p><i>Congenital dislocation of the hip</i> is described with Deformities of
+the Extremities.</p>
+
+<p><a name="VI_sprain" id="VI_sprain"></a><b>Sprain</b> 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.</p>
+
+<p><a name="VI_contusion" id="VI_contusion"></a><b>Contusion</b> 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.</p>
+
+<p>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<a class="pagenum" name="Pg_148" id="Pg_148"></a> 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.</p>
+
+
+<h3><a name="VI_shaft_femur" id="VI_shaft_femur"></a><span class="smcap">Fracture of the Shaft of the Femur</span></h3>
+
+<p>This group includes all fractures between that immediately below the
+lesser trochanter and the supra-condylar fracture.</p>
+
+<div class="figleft" style="width: 250px;">
+<a name="fig_75" id="fig_75"></a>
+<img src="images/fig075.jpg" width="250" height="466" alt="Fig. 75.&mdash;Longitudinal section of Femur showing recent
+Fracture of Shaft with overriding of Fragments." title="" />
+<span class="caption"><span class="smcap">Fig. 75.</span>&mdash;Longitudinal section of Femur showing recent
+Fracture of Shaft with overriding of Fragments.</span>
+</div>
+
+<p><i>In adults</i>, 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 (<a href="#fig_75">Fig.&nbsp;75</a>). The most serious forms are those associated with
+gun-shot wounds.</p>
+
+<p>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.</p>
+
+<p><a class="pagenum" name="Pg_149" id="Pg_149"></a><i>Clinical Features.</i>&mdash;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 <span class="frac_top">1</span>/<span class="frac_bottom">2</span> inch to
+3 or 4 inches&mdash;averaging about 1 inch in adults&mdash;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.</p>
+
+<p>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.</p>
+
+<p><i>Treatment.</i>&mdash;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 <span class="frac_top">3</span>/<span class="frac_bottom">4</span> 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 an&aelig;sthetic 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.</p>
+
+<p>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<a class="pagenum" name="Pg_150" id="Pg_150"></a> means of a cord passing over a
+pulley fixed to an upright at the foot of the bed.</p>
+
+<p>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, <i>e.g.</i> the Balkan frame (<a href="#fig_81">Fig.&nbsp;81</a>).</p>
+
+<p>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 (<a href="#fig_81">Fig.&nbsp;81</a>).</p>
+
+<p>An alternative method of exerting traction directly through the bone
+is by means of Steinmann's apparatus (<a href="#fig_76">Fig.&nbsp;76</a>). 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<a class="pagenum" name="Pg_151" id="Pg_151"></a> 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.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_76" id="fig_76"></a>
+<img src="images/fig076.jpg" width="400" height="270" alt="Fig. 76.&mdash;Radiogram of Steinmann&#39;s Apparatus applied
+for Direct Extension to the Femur." title="" />
+<span class="caption"><span class="smcap">Fig. 76.</span>&mdash;Radiogram of Steinmann&#39;s Apparatus applied
+for Direct Extension to the Femur.</span>
+</div>
+
+<p><i>Hodgen's splint</i> 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.</p>
+
+<p>It consists of a wire frame (<a href="#fig_77">Fig.&nbsp;77</a>) 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<a class="pagenum" name="Pg_152" id="Pg_152"></a> 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.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_77" id="fig_77"></a>
+<img src="images/fig077.png" width="400" height="431" alt="Fig. 77.&mdash;Hodgen&#39;s Splint." title="" />
+<span class="caption"><span class="smcap">Fig. 77.</span>&mdash;Hodgen&#39;s Splint.</span>
+</div>
+
+<p>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 N&eacute;laton, 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 &ldquo;walking calliper splint&rdquo; which is fixed to the heel of
+the boot, may be worn when the patient gets up.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><i>Liston's long splint</i> is only employed as a temporary expedient for
+immobilising the fragments during transport; a Thomas' splint, if
+available, is better for this purpose.</p>
+
+<div class="figcenter" style="width: 259px;">
+<a name="fig_78" id="fig_78"></a>
+<img src="images/fig078.jpg" width="259" height="500" alt="Fig. 78.&mdash;Long Splint with Perineal Band." title="" />
+<span class="caption"><span class="smcap">Fig. 78.</span>&mdash;Long Splint with Perineal Band.</span>
+</div>
+
+<p><i>Operative treatment</i> 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 inter<a class="pagenum" name="Pg_153" id="Pg_153"></a>muscular 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<a class="pagenum" name="Pg_154" id="Pg_154"></a> out on the same lines as for simple
+fracture, but the retentive apparatus must be worn for a considerably
+longer period.</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_79" id="fig_79"></a>
+<img src="images/fig079.jpg" width="350" height="454" alt="Fig. 79.&mdash;Fracture of Thigh treated by Vertical
+Extension." title="" />
+<span class="caption"><span class="smcap">Fig. 79.</span>&mdash;Fracture of Thigh treated by Vertical
+Extension.</span>
+</div>
+
+<p><b>Fracture of the Femur in Children.</b>&mdash;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.</p>
+
+<p>When there is displacement, the deformity is similar to that in
+adults, and the treatment is carried out on the same lines.</p>
+
+<p>In young children the nursing is greatly facilitated by applying
+vertical extension to one or both lower extremities (<a href="#fig_79">Fig.&nbsp;79</a>). 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.</p>
+
+<p>The patient may be allowed out of bed in from three to four weeks,
+wearing a retentive apparatus.</p>
+
+<p>The shaft of the femur is sometimes fractured <i>during delivery</i>,
+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.</p>
+
+
+
+
+<h2><a class="pagenum" name="Pg_155" id="Pg_155"></a><a name="CHAPTER_VII" id="CHAPTER_VII"></a>CHAPTER VII
+<br />
+INJURIES IN THE REGION OF THE KNEE AND LEG</h2>
+
+<ul class="chap">
+  <li><a href="#VII_anatomy"><i>Surgical Anatomy</i></a></li>
+  <li>&mdash;<a href="#VII_femur"><span class="smcap">Fracture of Lower End of Femur</span></a>:</li>
+  <li><a href="#VII_femur_supra_condylar"><i>Supra-condylar</i></a>;</li>
+  <li><a href="#VII_femur_t_shaped"><i>T- or Y-shaped</i></a>;</li>
+  <li><a href="#VII_femur_epiphysis"><i>Separation of epiphysis</i></a>;</li>
+  <li><a href="#VII_femur_condyle"><i>Either condyle</i></a></li>
+  <li>&mdash;<a href="#VII_tibia"><span class="smcap">Fracture of Upper End of Tibia</span></a>:</li>
+  <li><a href="#VII_tibia_head"><i>Of head</i></a>;</li>
+  <li><a href="#VII_tibia_epiphysis"><i>Separation of epiphysis</i></a>;</li>
+  <li><a href="#VII_tibia_tubercle"><i>Avulsion of tubercle</i></a></li>
+  <li>&mdash;<a href="#VII_knee_dislocation"><span class="smcap">Dislocations of Knee</span></a>:</li>
+  <li><a href="#VII_knee_tibio_fibular"><i>Dislocations of superior tibio-fibular joint</i></a></li>
+  <li>&mdash;<a href="#VII_knee_derangements"><span class="smcap">Internal Derangements of Knee</span></a></li>
+  <li>&mdash;<a href="#VII_patella"><span class="smcap">Injuries of Patella</span></a>:</li>
+  <li><a href="#VII_patella_fracture"><i>Fractures</i></a>;</li>
+  <li><a href="#VII_patella_dislocation"><i>Dislocations</i></a></li>
+  <li>&mdash;<a href="#VII_leg"><span class="smcap">Injuries of Leg</span></a>:</li>
+  <li><a href="#VII_leg_both"><i>Fracture of both bones</i></a>;</li>
+  <li><a href="#VII_leg_tibia"><i>Fracture of tibia alone</i></a>;</li>
+  <li><a href="#VII_leg_fibia"><i>Fracture of fibula alone</i></a>.</li>
+</ul>
+
+
+<h3><span class="smcap">Injuries in the Region of the Knee</span></h3>
+
+<p>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.</p>
+
+<p><a name="VII_anatomy" id="VII_anatomy"></a><b>Surgical Anatomy.</b>&mdash;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.</p>
+
+<p>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<a class="pagenum" name="Pg_156" id="Pg_156"></a> peroneal (external popliteal) nerve passes behind and to
+the medial side of the biceps tendon.</p>
+
+<p>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 control<a class="pagenum" name="Pg_157" id="Pg_157"></a>ling 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.</p>
+
+<p>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
+(<a href="#fig_80">Fig.&nbsp;80</a>). The large bursa between the quadriceps muscle and the femur
+(<i>sub-crural bursa</i>) 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.</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_80" id="fig_80"></a>
+<img src="images/fig080.png" width="350" height="454" alt="Fig. 80.&mdash;Section of Knee-joint showing extent of
+Synovial Cavity." title="" />
+<span class="caption"><span class="smcap">Fig. 80.</span>&mdash;Section of Knee-joint showing extent of
+Synovial Cavity.<br /><br />
+<i>a</i>, Pre-patellar bursa.<br />
+<i>b</i>, Infra-patellar bursa.<br />
+<i>c</i>, Ligamentum mucosum.<br />
+<i>d</i>, Ligamentum patell&aelig;.<br />
+<i>e</i>, Posterior cruciate ligament.<br />
+<i>f</i>, Medial semilunar meniscus.<br /><br />
+(After Braune.)</span>
+</div>
+
+<p>A large bursa (<i>pre-patellar</i>) lies over the lower part of the patella
+and upper part of the ligamentum patell&aelig;; and a smaller one separates
+the ligamentum patell&aelig; from the tuberosity of the tibia. Several
+important burs&aelig; are found in the popliteal space, one of which&mdash;the
+semi-membranosus bursa&mdash;sometimes communicates with the knee-joint.</p>
+
+
+<h3><a name="VII_femur" id="VII_femur"></a><span class="smcap">Fracture of the Lower End Of the Femur</span></h3>
+
+<p>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.</p>
+
+<p><a name="VII_femur_supra_condylar" id="VII_femur_supra_condylar"></a><b>Supra-condylar</b> 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.</p>
+
+<p><i>Clinical features.</i>&mdash;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 an&aelig;sthetic should be given when necessary.</p>
+
+<p>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<a class="pagenum" name="Pg_158" id="Pg_158"></a> 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 <span class="frac_top">1</span>/<span class="frac_bottom">2</span> to 1 inch.</p>
+
+<p>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.</p>
+
+<p><a class="pagenum" name="Pg_159" id="Pg_159"></a><i>Treatment.</i>&mdash;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 an&aelig;sthesia.</p>
+
+<p>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 (<a href="#Pg_180">p.&nbsp;180</a>).</p>
+
+<p>In the majority, however, flexion is necessary, and a Thomas' knee
+splint with flexion attachment bent to an angle of 30&deg; (<a href="#fig_81">Fig.&nbsp;81</a>) 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 (<a href="#fig_70">Fig.&nbsp;70</a>).</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_81" id="fig_81"></a>
+<img src="images/fig081.jpg" width="350" height="329" alt="Fig. 81.&mdash;Extension applied by means of ice-tong
+callipers for Fracture of Femur." title="" />
+<span class="caption"><span class="smcap">Fig. 81.</span>&mdash;Extension applied by means of ice-tong
+callipers for Fracture of Femur.</span>
+</div>
+
+<p>Hodgen's splint, bent nearly to a right angle, may also be employed.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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 sequel&aelig; of these
+injuries.</p>
+
+<p>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.</p>
+
+<p>Operative interference may be called for to rectify deformities
+resulting from mal-union.</p>
+
+<p><a name="VII_femur_t_shaped" id="VII_femur_t_shaped"></a>The <b>T- or Y-shaped fracture</b> 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<a class="pagenum" name="Pg_160" id="Pg_160"></a> 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.</p>
+
+<p>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.</p>
+
+<p><a class="pagenum" name="Pg_161" id="Pg_161"></a>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.</p>
+
+<p><a name="VII_femur_epiphysis" id="VII_femur_epiphysis"></a><b>Separation of the lower epiphysis</b> is a comparatively common injury. It
+is seldom pure, a portion of the diaphysis<a class="pagenum" name="Pg_162" id="Pg_162"></a> 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
+(<a href="#fig_82">Fig.&nbsp;82</a>), 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.</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_82" id="fig_82"></a>
+<img src="images/fig082.jpg" width="300" height="350" alt="Fig. 82.&mdash;Radiogram of Separation of Lower Epiphysis of
+Femur, with backward displacement of the diaphysis; pressure on
+popliteal vessels caused sloughing of calf." title="" />
+<span class="caption"><span class="smcap">Fig. 82.</span>&mdash;Radiogram of Separation of Lower Epiphysis of
+Femur, with backward displacement of the diaphysis; pressure on
+popliteal vessels caused sloughing of calf.</span>
+</div>
+
+<p>&nbsp;</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_83" id="fig_83"></a>
+<img src="images/fig083.jpg" width="300" height="416" alt="Fig. 83.&mdash;Separation of Lower Epiphysis of Femur, with
+fracture of lower end of diaphysis." title="" />
+<span class="caption"><span class="smcap">Fig. 83.</span>&mdash;Separation of Lower Epiphysis of Femur, with
+fracture of lower end of diaphysis.</span>
+</div>
+
+<p>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.</p>
+
+<p><a name="VII_femur_condyle" id="VII_femur_condyle"></a><b>Either condyle</b> 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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+
+<div class="figcenter" style="width: 250px;"><a class="pagenum" name="Pg_163" id="Pg_163"></a>
+<a name="fig_84" id="fig_84"></a>
+<img src="images/fig084.jpg" width="250" height="415" alt="Fig. 84.&mdash;Radiogram of Fracture of Head of Tibia and
+Upper Third of Fibula." title="" />
+<span class="caption"><span class="smcap">Fig. 84.</span>&mdash;Radiogram of Fracture of Head of Tibia and
+Upper Third of Fibula.</span>
+</div>
+
+<h3><a name="VII_tibia" id="VII_tibia"></a><span class="smcap">Fracture of the Upper End of the Tibia</span></h3>
+
+<div class="figright" style="width: 200px;">
+<a name="fig_85" id="fig_85"></a>
+<img src="images/fig085.jpg" width="200" height="318" alt="Fig. 85.&mdash;Radiogram illustrating Schlatter&#39;s disease." title="" />
+<span class="caption"><span class="smcap">Fig. 85.</span>&mdash;Radiogram illustrating Schlatter&#39;s disease.</span>
+</div>
+
+<p><a name="VII_tibia_head" id="VII_tibia_head"></a><b>Fracture of the head of the tibia</b> 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<a class="pagenum" name="Pg_164" id="Pg_164"></a> 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.</p>
+
+<p>The ordinary clinical features of fracture are well marked, and the
+diagnosis is easy. From some unexplained cause this<a class="pagenum" name="Pg_165" id="Pg_165"></a> fracture may take
+a long time, sometimes several months, to consolidate.</p>
+
+<p><a name="VII_tibia_epiphysis" id="VII_tibia_epiphysis"></a><b>Separation of the upper epiphysis</b> 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.</p>
+
+<p><i>Treatment.</i>&mdash;After reduction under an an&aelig;sthetic these fractures are
+usually satisfactorily treated in a box splint (<a href="#fig_91">Fig.&nbsp;91</a>), carried
+sufficiently high to control the knee-joint. When the head of the
+tibia is comminuted or split obliquely, weight-extension&mdash;direct from
+the bone, the ice-tong callipers grasping the malleoli or the
+calcaneus&mdash;may be used. Massage and movement are employed from the
+outset.</p>
+
+<p><a name="VII_tibia_tubercle" id="VII_tibia_tubercle"></a>Avulsion of the <b>tuberosity of the tibia</b> occasionally occurs in youths,
+from violent contraction of the quadriceps&mdash;as in jumping. The limb is
+at once rendered powerless; the osseous nodule can be felt, and on
+moving it crepitus is elicited.</p>
+
+<p>This is best treated by pegging the tuberosity in position, and fixing
+the extended limb on an inclined plane to relax the quadriceps muscle.</p>
+
+<p>In young, athletic subjects, the tongue-like process of the epiphysis
+(<a href="#fig_85">Fig.&nbsp;85</a>), into which the ligamentum patell&aelig; is inserted, may be
+partly or completely torn away, giving rise to localised swelling, and
+pain which is aggravated by any muscular effort&mdash;<i>Schlatter's disease</i>
+or &ldquo;rugby knee.&rdquo; 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.</p>
+
+<p>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.</p>
+
+<p>The <b>upper end of the fibula</b> 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.</p>
+
+
+<h3><a name="VII_knee_dislocation" id="VII_knee_dislocation"></a><span class="smcap">Dislocations of the Knee</span></h3>
+
+<p>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.</p>
+
+<p>Rupture of the popliteal vessels, or pressure exerted on them<a class="pagenum" name="Pg_166" id="Pg_166"></a> 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.</p>
+
+<p>The varieties of dislocation are named in terms of the direction in
+which the tibia passes: forward, backward, medial, and lateral.</p>
+
+<p><b>Dislocation forward</b> 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.</p>
+
+<p><b>Dislocation backward</b> 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.</p>
+
+<p>The <b>medial and lateral dislocations</b> are generally incomplete, and are
+liable to be mistaken for separation of the lower epiphysis of the
+femur. When the tibia passes <i>medially</i>, 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.</p>
+
+<p>When the tibia is displaced <i>laterally</i>, the relative position of the
+prominences and depressions is reversed.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p>If, while the patient is fully an&aelig;sthetised, 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.</p>
+
+<p>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.</p>
+
+<p>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<a class="pagenum" name="Pg_167" id="Pg_167"></a> 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.</p>
+
+<p>In compound dislocations, and in those complicated by injury to the
+popliteal vessels, the question of amputation may have to be
+considered.</p>
+
+<p><a name="VII_knee_tibio_fibular" id="VII_knee_tibio_fibular"></a><b>Dislocation of the Superior Tibio-Fibular Articulation.</b>&mdash;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.</p>
+
+<p>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.</p>
+
+<p><b>Total Dislocation of Fibula.</b>&mdash;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&mdash;a condition which might be mistaken for
+a dislocation.</p>
+
+
+<h3><a name="VII_knee_derangements" id="VII_knee_derangements"></a><span class="smcap">Injuries of the Semilunar Menisci</span></h3>
+
+<p>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.</p>
+
+<p>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<a class="pagenum" name="Pg_168" id="Pg_168"></a> 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.</p>
+
+<p>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 &ldquo;internal derangements of
+the knee-joint&rdquo; separately, according to whether the meniscus is
+merely abnormally mobile, or is actually torn.</p>
+
+<p><b>Mobile Meniscus&mdash;Displacement of Medial Semilunar Cartilage</b> (<a href="#fig_86">Fig.&nbsp;86</a>).&mdash;The
+<i>medial</i> 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&mdash;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.</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_86" id="fig_86"></a>
+<img src="images/fig086.jpg" width="350" height="258" alt="Fig. 86.&mdash;Diagram of Longitudinal Tear of Posterior End
+of Right Medial Semilunar Meniscus." title="" />
+<span class="caption"><span class="smcap">Fig. 86.</span>&mdash;Diagram of Longitudinal Tear of Posterior End
+of Right Medial Semilunar Meniscus.</span>
+</div>
+
+<p>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.</p>
+
+<p>The mechanism by which this lesion is produced doubtless explains the
+greater frequency with which the <i>left</i> knee is affected, as most
+sudden movements are made from right to left, thus throwing the strain
+upon the left knee.</p>
+
+<p><i>Clinical Features.</i>&mdash;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<a class="pagenum" name="Pg_169" id="Pg_169"></a> 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 patell&aelig; 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.</p>
+
+<p>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 <i>between</i> the bones, in the sprain of the ligament the
+maximum tenderness is over its attachment to the bone, usually the
+tuberosity of the tibia.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p>Alternate flexion and extension combined with rotatory movements is
+sometimes successful. Several attempts are often necessary, and a
+general an&aelig;sthetic 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.</p>
+
+<p>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.</p>
+
+<p><b>Recurrent Displacement.</b>&mdash;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<a class="pagenum" name="Pg_170" id="Pg_170"></a> 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.</p>
+
+<p>The symptoms closely resemble those of a &ldquo;loose body,&rdquo; 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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><b>Displacement of the lateral meniscus</b> is comparatively rare. It is in
+every way comparable to displacement of the medial meniscus, and is
+treated on the same lines.</p>
+
+<p><b>Torn or Lacerated Meniscus.</b>&mdash;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 (<a href="#fig_86">Fig.&nbsp;86</a>). 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.</p>
+
+<p><a class="pagenum" name="Pg_171" id="Pg_171"></a>The <i>clinical features</i> 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.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+<p><b>Rupture of the Cruciate Ligaments.</b>&mdash;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).</p>
+
+<p><b>Sprains</b> 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&mdash;<i>sprain-fracture</i>. 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&mdash;&ldquo;floating patella&rdquo;&mdash;and, if firmly pressed upon, it may be made
+to rap against the trochlear surface.</p>
+
+<p><a class="pagenum" name="Pg_172" id="Pg_172"></a>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&mdash;less
+frequently over the medial condyle of the femur.</p>
+
+<p>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 (<i>traumatic hydrops</i>). 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&mdash;hence
+the name &ldquo;footballer's knee&rdquo; sometimes applied to the condition.</p>
+
+<p>A further cause of disability, following upon sprains of the knee, is
+<i>wasting of the quadriceps muscle</i>. 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.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p><a class="pagenum" name="Pg_173" id="Pg_173"></a>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 &ldquo;footballer's knee,&rdquo; 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.</p>
+
+
+<h3><a name="VII_patella" id="VII_patella"></a>INJURIES OF THE PATELLA</h3>
+
+<p><a name="VII_patella_fracture" id="VII_patella_fracture"></a><b>Fracture of the patella</b> is a comparatively common injury in adult
+males. Most frequently it is due to <i>muscular action</i> 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&mdash;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.</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_87" id="fig_87"></a>
+<img src="images/fig087.jpg" width="300" height="183" alt="Fig. 87.&mdash;Radiogram of Fracture of Patella." title="" />
+<span class="caption"><span class="smcap">Fig. 87.</span>&mdash;Radiogram of Fracture of Patella.</span>
+</div>
+
+<p>The degree of displacement of the fragments depends upon the extent to
+which the expansion of the quadriceps tendon is<a class="pagenum" name="Pg_174" id="Pg_174"></a> 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).</p>
+
+<div class="figleft" style="width: 250px;">
+<a name="fig_88" id="fig_88"></a>
+<img src="images/fig088.jpg" width="250" height="515" alt="Fig. 88.&mdash;Fracture of Patella, showing wide separation
+of fragments, which are united by a fibrous band." title="" />
+<span class="caption"><span class="smcap">Fig. 88.</span>&mdash;Fracture of Patella, showing wide separation
+of fragments, which are united by a fibrous band.<br /><br />
+(Anatomical Museum of the University of Edinburgh.)</span>
+</div>
+
+<p><i>Clinical Features.</i>&mdash;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.</p>
+
+<p><i>Prognosis.</i>&mdash;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 (<a href="#fig_88">Fig.&nbsp;88</a>), 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.</p>
+
+<p><i>Treatment.</i>&mdash;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,<a class="pagenum" name="Pg_175" id="Pg_175"></a> and in labouring men, particularly those who follow dangerous
+employments necessitating stability of the knee.</p>
+
+<p>As soon as the wound is healed,&mdash;in a week or ten days,&mdash;massage and
+movement of the limb are commenced, and the patient is encouraged to
+move his limb in bed. At the<a class="pagenum" name="Pg_176" id="Pg_176"></a> end of another week he may be allowed up
+with sticks or crutches.</p>
+
+<p><i>Non-operative Treatment.</i>&mdash;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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>When the fracture is caused by <i>direct violence</i>, 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.</p>
+
+<p><a class="pagenum" name="Pg_177" id="Pg_177"></a><i>Old-standing Fracture.</i>&mdash;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 patell&aelig;.</p>
+
+<p>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.</p>
+
+<p><a name="VII_patella_dislocation" id="VII_patella_dislocation"></a><b>Dislocation of the patella</b> 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.</p>
+
+<p>The <i>lateral</i> is the most common variety&mdash;the <i>medial</i> being rare.
+Either may be complete or incomplete. Sometimes the bone is rotated so
+that its edge rests on the front of the femur&mdash;<i>vertical</i> dislocation;
+and in a few cases it has been completely turned round, so that the
+articular surface is directed forwards.</p>
+
+<p><i>Clinical Features.</i>&mdash;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.</p>
+
+<p>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.</p>
+
+<p>As the displacement is liable to recur, the patient should wear a firm
+elastic bandage or a strong knee-cap.</p>
+
+<p><i>Permanent and recurrent dislocation of the patella</i> will be described
+later.</p>
+
+
+<h3><a name="VII_leg" id="VII_leg"></a><a class="pagenum" name="Pg_178" id="Pg_178"></a><span class="smcap">Fracture of the Bones of the Leg</span></h3>
+
+<p>The bones of the leg may be broken together or separately.</p>
+
+<p><a name="VII_leg_both" id="VII_leg_both"></a><b>Fracture of both Bones.</b>&mdash;The features of this injury depend to a large
+extent upon the nature of the violence producing it. In fracture by
+<i>direct</i> 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 (<a href="#fig_89">Fig.&nbsp;89</a>). There is little or no displacement, and such as
+there is is angular, and is determined by the direction of the
+fracturing force.</p>
+
+<table class="figure" summary="Fig 89, 90">
+<tr>
+<td class="figcenter" style="width: 150px;">
+<a name="fig_89" id="fig_89"></a>
+<img src="images/fig089.jpg" width="150" height="361" alt="Fig. 89.&mdash;Radiogram of Transverse Fracture of both
+Bones of Leg by direct violence." title="" />
+<span class="caption"><span class="smcap">Fig. 89.</span>&mdash;Radiogram of Transverse Fracture of both
+Bones of Leg by direct violence.</span>
+</td>
+
+<td style="width: 50px;">&nbsp;</td>
+
+<td class="figcenter" style="width: 150px;">
+<a name="fig_90" id="fig_90"></a>
+<img src="images/fig090.jpg" width="150" height="361" alt="Fig. 90.&mdash;Radiogram of Oblique Fracture of both Bones
+of Leg by indirect violence." title="" />
+<span class="caption"><span class="smcap">Fig. 90.</span>&mdash;Radiogram of Oblique Fracture of both Bones
+of Leg by indirect violence.</span>
+</td>
+</tr>
+</table>
+
+<p>When the violence is <i>indirect</i>, as from a fall on the feet, or a
+twist of the leg, the tibia usually gives way at the junction of<a class="pagenum" name="Pg_179" id="Pg_179"></a> its
+lower and middle thirds, and the fibula at a higher level (<a href="#fig_90">Fig.&nbsp;90</a>).
+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&mdash;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.</p>
+
+<p>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.</p>
+
+<p>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&mdash;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.</p>
+
+<p><i>Clinical Features.</i>&mdash;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&mdash;pain on distal pressure.</p>
+
+<p>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<a class="pagenum" name="Pg_180" id="Pg_180"></a> become infected, sloughing of the
+skin may take place and the fracture thus be rendered compound.</p>
+
+<p>The vessels and nerves of the leg are seldom seriously damaged.</p>
+
+<p><i>Treatment.</i>&mdash;If there is marked displacement, reduction is most
+satisfactorily accomplished under an&aelig;sthesia. 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<a class="pagenum" name="Pg_181" id="Pg_181"></a> 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.</p>
+
+<p>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.</p>
+
+<p>In the average case, the leg is supported between sand-bags,<a class="pagenum" name="Pg_182" id="Pg_182"></a> 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 (<a href="#fig_95">Fig.&nbsp;95</a>).</p>
+
+<p>As an emergency appliance, for example for purposes of transport, the
+<i>box splint</i> (<a href="#fig_91">Fig.&nbsp;91</a>) 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.</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_91" id="fig_91"></a>
+<img src="images/fig091.jpg" width="350" height="406" alt="Fig. 91.&mdash;Box Splint for Fractures of Leg." title="" />
+<span class="caption"><span class="smcap">Fig. 91.</span>&mdash;Box Splint for Fractures of Leg.</span>
+</div>
+
+<p>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.</p>
+
+<div class="figcenter" style="width: 225px;">
+<a name="fig_92" id="fig_92"></a>
+<img src="images/fig092.jpg" width="225" height="433" alt="Fig. 92.&mdash;Box Splint (applied)." title="" />
+<span class="caption"><span class="smcap">Fig. 92.</span>&mdash;Box Splint (applied).</span>
+</div>
+
+<p>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.</p>
+
+<p><a class="pagenum" name="Pg_183" id="Pg_183"></a>When the skin is damaged, as it so frequently is on the medial aspect
+of the tibia, means must be taken to prevent infection.</p>
+
+<p>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.</p>
+
+<p><i>Operative Treatment.</i>&mdash;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.</p>
+
+<p>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.</p>
+
+<p><i>Un-united fracture</i> 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.</p>
+
+<p><i>Mal-union</i>, on account of the disability it entails, may call for
+operative treatment in the form of osteotomy of one or both bones.</p>
+
+<p><i>Compound fractures</i> of the leg are common, and are treated on the
+lines already laid down for the treatment of compound fractures in
+general (<a href="#Pg_25">p.&nbsp;25</a>).</p>
+
+<p><a name="VII_leg_tibia" id="VII_leg_tibia"></a><b>Fracture of the tibia alone</b>, 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.</p>
+
+<p><a name="VII_leg_fibia" id="VII_leg_fibia"></a><b>Fracture of the fibula alone</b> 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<a class="pagenum" name="Pg_184" id="Pg_184"></a> 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.</p>
+
+<p>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 (<a href="#fig_95">Fig.&nbsp;95</a>).</p>
+
+
+
+
+<h2><a class="pagenum" name="Pg_185" id="Pg_185"></a><a name="CHAPTER_VIII" id="CHAPTER_VIII"></a>CHAPTER VIII
+<br />
+INJURIES IN REGION OF ANKLE AND FOOT</h2>
+
+<ul class="chap">
+  <li><a href="#VIII_anatomy">Surgical Anatomy</a></li>
+  <li>&mdash;<a href="#VIII_fractures"><span class="smcap">Fractures</span></a>:</li>
+  <li><a href="#VIII_potts"><i>Pott's fracture</i></a>;</li>
+  <li><a href="#VIII_potts_converse"><i>Converse of Pott's fracture</i></a>;</li>
+  <li><a href="#VIII_epiphysis"><i>Separation of lower epiphysis</i></a>;</li>
+  <li><a href="#VIII_fracture_talus"><i>Fracture of talus</i></a>;</li>
+  <li><a href="#VIII_fracture_calcaneus"><i>Fracture of calcaneus</i></a>;</li>
+  <li><a href="#VIII_fracture_other_tarsal"><i>Fractures of other tarsal bones</i></a>;</li>
+  <li><a href="#VIII_fracture_metatarsal"><i>Fractures of metatarsal bones</i></a>;</li>
+  <li><a href="#VIII_fracture_metatarsal"><i>Fractures of phalanges</i></a></li>
+  <li>&mdash;<a href="#VIII_dislocations"><span class="smcap">Dislocations</span></a>:</li>
+  <li><a href="#VIII_dislocation_ankle"><i>Of ankle joint</i></a>;</li>
+  <li><a href="#VIII_dislocation_tibio_fibular"><i>Of inferior tibio-fibular joint</i></a>;</li>
+  <li><a href="#VIII_dislocation_talus"><i>Complete dislocation of talus</i></a>;</li>
+  <li><a href="#VIII_dislocation_sub_taloid"><i>Sub-taloid dislocation</i></a>;</li>
+  <li><a href="#VIII_dislocation_medio_tarsal"><i>Medio-tarsal dislocation</i></a>;</li>
+  <li><a href="#VIII_dislocation_tarso_metatarsal"><i>Tarso-metatarsal dislocation</i></a>;</li>
+  <li><a href="#VIII_dislocation_toes"><i>Dislocations of toes</i></a>.</li>
+</ul>
+
+<p>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.</p>
+
+<p><a name="VIII_anatomy" id="VIII_anatomy"></a><b>Surgical Anatomy.</b>&mdash;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 <i>flexion</i> or
+<i>dorsiflexion</i> is meant that movement which approximates the dorsum of
+the foot to the front of the leg; while <i>extension</i> or <i>plantar
+flexion</i> means the drawing up of the heel so that the toes are
+pointed. In <i>inversion</i> 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 <i>eversion</i> the
+lateral edge of the foot is drawn up, the sole looking away from the
+middle line&mdash;analogous to pronation of the hand. <i>Adduction</i> indicates
+the rotation of the foot so that the toes are turned towards the
+middle line of the body; while in <i>abduction</i> the toes are turned away
+from the middle line.</p>
+
+<p>The most prominent bony landmarks in the region of the ankle are the
+two <i>malleoli</i>, 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 <i>medial process (internal
+tuberosity)</i> of the calcaneus; the <i>sustentaculum tali</i>, which lies
+about 1 inch vertically below the tip of the malleolus; the <i>tubercle
+of the navicular</i>, about 1 inch in front of the malleolus, and at a
+slightly lower level; the <i>first (internal) cuneiform</i>, and the base,
+shaft, and head of the <i>first metatarsal</i>.</p>
+
+<p>On the lateral side may be recognised the <i>lateral process (external
+tuberosity)</i> of the calcaneus; the <i>trochlear process (peroneal
+tubercle)</i> on the same bone; the <i>cuboid</i>; and the prominent base of
+the <i>fifth metatarsal</i>.</p>
+
+<p><a class="pagenum" name="Pg_186" id="Pg_186"></a>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.</p>
+
+<p>The <i>ankle-joint</i>, 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&mdash;&ldquo;the
+mid-tarsal or Chopart's joint.&rdquo;</p>
+
+<p>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.</p>
+
+<p>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
+(<a href="#fig_93">Fig.&nbsp;93</a>).</p>
+
+<div class="figcenter" style="width: 250px;">
+<a name="fig_93" id="fig_93"></a>
+<img src="images/fig093.png" width="250" height="474" alt="Fig. 93.&mdash;Section through Ankle-Joint showing relation
+of epiphyses to synovial cavity." title="" />
+<span class="caption"><span class="smcap">Fig. 93.</span>&mdash;Section through Ankle-Joint showing relation
+of epiphyses to synovial cavity.<br /><br />
+<i>a</i>, Lower epiphysis of tibia.<br />
+<i>b</i>, Lower epiphysis of fibula.<br />
+<i>c</i>, Talus.<br />
+<i>d</i>, Calcaneus.<br /><br />
+(After Poland.)</span>
+</div>
+
+
+<h3><a name="VIII_fractures" id="VIII_fractures"></a><span class="smcap">Fractures in the Region of the Ankle</span></h3>
+
+<p><a name="VIII_potts" id="VIII_potts"></a><b>Pott's Fracture.</b>&mdash;It must be understood that various lesions occurring
+in the region of the ankle-joint are included under the clinical term
+&ldquo;Pott's fracture.&rdquo; 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 <i>combined eversion and
+abduction</i> of the foot&mdash;produced, for example, by slipping off the
+kerbstone, or by jumping from a height and landing on the medial side
+of the foot.</p>
+
+<p>When forcible <i>eversion</i> 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<a class="pagenum" name="Pg_187" id="Pg_187"></a> 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 <i>Dupuytren's fracture</i>. When the bones
+are widely separated in Dupuytren's fracture the talus may be forced
+up between them.</p>
+
+<p><a class="pagenum" name="Pg_188" id="Pg_188"></a>When the movement of <i>abduction</i> 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.</p>
+
+<p><i>Clinical Features.</i>&mdash;In a considerable proportion of cases&mdash;in our
+experience in the majority&mdash;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.</p>
+
+<p>In others, however, the deformity is marked and characteristic (<a href="#fig_94">Fig.&nbsp;94</a>).
+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&mdash;both from side to side and antero-posteriorly&mdash;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.</p>
+
+<div class="figcenter" style="width: 275px;">
+<a name="fig_94" id="fig_94"></a>
+<img src="images/fig094.jpg" width="275" height="350" alt="Fig. 94.&mdash;Radiogram of Pott&#39;s Fracture with lateral
+displacement of foot." title="" />
+<span class="caption"><span class="smcap">Fig. 94.</span>&mdash;Radiogram of Pott&#39;s Fracture with lateral
+displacement of foot.</span>
+</div>
+
+<p>There is often considerable difficulty in distinguishing a <i>sprain</i> 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.</p>
+
+<p><i>Treatment.</i>&mdash;In those cases of fracture of the lower end of the
+fibula in which there is no marked displacement,&mdash;and they constitute
+a considerable proportion,&mdash;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&mdash;a point of great practical importance, because, if this
+is<a class="pagenum" name="Pg_189" id="Pg_189"></a> neglected, not only does union take place more slowly, but the
+stiffness of the ankle and &oelig;dema of the leg and foot which ensue,
+prolong the period of the patient's incapacity and endanger the
+usefulness of the limb.</p>
+
+<p>It is in cases of this kind that the <i>ambulatory method</i> of treatment
+yields its best results. When, in the course of two or three days, the
+swelling has subsided, a plaster-of-Paris case (<a href="#fig_95">Fig.&nbsp;95</a>) 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<a class="pagenum" name="Pg_190" id="Pg_190"></a> 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.</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_95" id="fig_95"></a>
+<img src="images/fig095.png" width="350" height="391" alt="Fig. 95.&mdash;Ambulant Splint of plaster of Paris." title="" />
+<span class="caption"><span class="smcap">Fig. 95.</span>&mdash;Ambulant Splint of plaster of Paris.</span>
+</div>
+
+<p>&nbsp;</p>
+
+<div class="figleft" style="width: 175px;">
+<a name="fig_96" id="fig_96"></a>
+<img src="images/fig096.jpg" width="175" height="450" alt="Fig. 96.&mdash;Dupuytren&#39;s Splint applied to correct
+eversion of foot." title="" />
+<span class="caption"><span class="smcap">Fig. 96.</span>&mdash;Dupuytren&#39;s Splint applied to correct
+eversion of foot.</span>
+</div>
+
+<p>When there is marked eversion of the foot, it may be necessary to
+administer a general an&aelig;sthetic to reduce the deformity; and to
+prevent recurrence of the displacement <i>Dupuytren's splint</i> (<a href="#fig_96">Fig.&nbsp;96</a>)
+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.</p>
+
+<p>When backward displacement of the heel is the prominent deformity,
+<i>Syme's horse-shoe</i> or <i>stirrup splint</i> (<a href="#fig_97">Fig.&nbsp;97</a>) 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<a class="pagenum" name="Pg_191" id="Pg_191"></a> 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.</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_97" id="fig_97"></a>
+<img src="images/fig097.png" width="350" height="276" alt="Fig. 97.&mdash;Syme&#39;s Horse-shoe Splint applied to correct
+backward displacement of foot." title="" />
+<span class="caption"><span class="smcap">Fig. 97.</span>&mdash;Syme&#39;s Horse-shoe Splint applied to correct
+backward displacement of foot.</span>
+</div>
+
+<p>&nbsp;</p>
+
+<div class="figright" style="width: 250px;">
+<a name="fig_98" id="fig_98"></a>
+<img src="images/fig098.jpg" width="250" height="306" alt="Fig. 98.&mdash;Radiogram of Fracture of lower end of Fibula,
+with separation of lower epiphysis of Tibia." title="" />
+<span class="caption"><span class="smcap">Fig. 98.</span>&mdash;Radiogram of Fracture of lower end of Fibula,
+with separation of lower epiphysis of Tibia.</span>
+</div>
+
+<p><i>Operative Treatment.</i>&mdash;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.</p>
+
+<p>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.</p>
+
+<p><a name="VIII_potts_converse" id="VIII_potts_converse"></a><b>The Converse of Pott's Fracture&mdash;sometimes called &ldquo;Pott's Fracture
+with Inversion.&rdquo;</b>&mdash;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.</p>
+
+<p>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.</p>
+
+<p><a name="VIII_epiphysis" id="VIII_epiphysis"></a><a class="pagenum" name="Pg_192" id="Pg_192"></a><b>Separation of the lower epiphysis of the tibia</b> 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 (<a href="#fig_98">Fig.&nbsp;98</a>), 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.</p>
+
+<p><a name="VIII_fracture_talus" id="VIII_fracture_talus"></a><b>Fracture of the talus</b> 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,<a class="pagenum" name="Pg_193" id="Pg_193"></a> 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
+R&ouml;ntgen rays. In interpreting radiograms of injuries in this region,
+care must be taken not to mistake the <i>os trigonum tarsi</i> 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.</p>
+
+<p><a name="VIII_fracture_calcaneus" id="VIII_fracture_calcaneus"></a>The <b>calcaneus</b> 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.</p>
+
+<p>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 &ldquo;a bag of bones.&rdquo; 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.</p>
+
+<p><i>Treatment.</i>&mdash;In simple comminuted fractures the patient should be
+an&aelig;sthetised, 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.</p>
+
+<p>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.</p>
+
+<p><i>The tuberosity of the calcaneus</i>, 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.</p>
+
+<p>A good functional result is usually obtained by relaxing the<a class="pagenum" name="Pg_194" id="Pg_194"></a> 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.</p>
+
+<p><a name="VIII_fracture_other_tarsal" id="VIII_fracture_other_tarsal"></a>The <b>other bones of the tarsus</b> are rarely fractured separately. The
+<i>tuberosity of the navicular</i> is sometimes torn away by violent
+traction on the ligaments attached to it.</p>
+
+<p><a name="VIII_fracture_metatarsal" id="VIII_fracture_metatarsal"></a><b>Fractures of the metatarsals and phalanges</b> usually result from direct
+violence, such as a crush of the foot, in which the soft parts are
+severely damaged. The use of the R&ouml;ntgen 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.</p>
+
+<p>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.</p>
+
+<p>Compound fractures are more common, and are to be treated on the same
+principles as govern such injuries elsewhere.</p>
+
+<p><i>A fracture of the base of the fifth metatarsal</i> 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&mdash;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 R&ouml;ntgen rays. Massage and
+movement are employed from the first.</p>
+
+
+<h3><a name="VIII_dislocations" id="VIII_dislocations"></a><span class="smcap">Dislocations in the Region of the Ankle</span></h3>
+
+<p><a name="VIII_dislocation_ankle" id="VIII_dislocation_ankle"></a><b>Dislocation of the Ankle-Joint.</b>&mdash;In describing dislocation of the
+talus from the tibio-fibular socket, the varieties are named according
+to the direction in which the foot passes&mdash;backward, forward,
+medially, laterally, or upward.</p>
+
+<p>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.</p>
+
+<p>The <i>backward</i> 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<a class="pagenum" name="Pg_195" id="Pg_195"></a> 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 (<a href="#fig_99">Fig.&nbsp;99</a>).</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_99" id="fig_99"></a>
+<img src="images/fig099.jpg" width="300" height="336" alt="Fig. 99.&mdash;Radiogram of Backward Dislocation of Ankle." title="" />
+<span class="caption"><span class="smcap">Fig. 99.</span>&mdash;Radiogram of Backward Dislocation of Ankle.<br /><br />
+(Professor Chiene&#39;s case.)</span>
+</div>
+
+<p>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.</p>
+
+<p><i>Forward</i> dislocation results from extreme dorsal flexion at the
+ankle-joint. The foot appears lengthened, the heel is less<a class="pagenum" name="Pg_196" id="Pg_196"></a> 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.</p>
+
+<p><i>Medial</i> or <i>lateral</i> dislocation is only possible after fracture of
+one or both malleoli, and may be looked upon as a complication of
+these injuries.</p>
+
+<p>In cases in which the interosseous ligament is ruptured, and in severe
+cases of Dupuytren's fracture, the talus may be driven <i>upwards</i>
+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.</p>
+
+<p><a name="VIII_dislocation_tibio_fibular" id="VIII_dislocation_tibio_fibular"></a>Dislocation of the <i>inferior tibio-fibular joint</i> 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.</p>
+
+<p><i>Treatment of Dislocation of Ankle.</i>&mdash;The patient having been
+an&aelig;sthetised, 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.</p>
+
+<p>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.</p>
+
+<p>The after-treatment consists in keeping the leg on a pillow between
+sand-bags, and carrying out the usual massage and movement.</p>
+
+<p>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.</p>
+
+<p><a name="VIII_dislocation_talus" id="VIII_dislocation_talus"></a><b>Dislocation of the talus</b> 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 <i>forward</i> 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 propor<a class="pagenum" name="Pg_197" id="Pg_197"></a>tion of cases the dislocation is compound,
+more or less of the talus being forced through the skin (<a href="#fig_100">Fig.&nbsp;100</a>).</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_100" id="fig_100"></a>
+<img src="images/fig100.jpg" width="350" height="337" alt="Fig. 100.&mdash;Compound Dislocation of the Talus." title="" />
+<span class="caption"><span class="smcap">Fig. 100.</span>&mdash;Compound Dislocation of the Talus.</span>
+</div>
+
+<p>When the foot is dorsiflexed at the moment of injury the displacement
+is <i>backward</i>, but this is rare, as is also <i>dislocation to one or
+other side</i>, and <i>dislocation by rotation</i>, 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.</p>
+
+<p>An attempt should be made to reduce the dislocation under an&aelig;sthesia,
+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<a class="pagenum" name="Pg_198" id="Pg_198"></a> admit of reduction, or to excise the talus.
+In most cases of compound dislocation also, this bone should be
+removed.</p>
+
+<p><a name="VIII_dislocation_sub_taloid" id="VIII_dislocation_sub_taloid"></a><b>Sub-taloid Dislocation.</b>&mdash;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 relation<a class="pagenum" name="Pg_199" id="Pg_199"></a>ship with the malleoli&mdash;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 <i>backward and medially</i>, 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.</p>
+
+<div class="figcenter" style="width: 275px;">
+<a name="fig_101" id="fig_101"></a>
+<img src="images/fig101.jpg" width="275" height="421" alt="Fig. 101.&mdash;Radiogram of Fracture-Dislocation of Talus." title="" />
+<span class="caption"><span class="smcap">Fig. 101.</span>&mdash;Radiogram of Fracture-Dislocation of Talus.</span>
+</div>
+
+<p>In the <i>backward and lateral</i> variety, the medial malleolus and head
+of the talus project unduly towards the medial side of the foot, which
+is abducted and everted.</p>
+
+<p>In neither variety is there any mechanical obstacle to movement at the
+ankle-joint.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+<p><a name="VIII_dislocation_medio_tarsal" id="VIII_dislocation_medio_tarsal"></a><b>Mid-tarsal or transverse tarsal dislocation</b>&mdash;that is, at the
+talo-navicular and calcaneo-cuboid articulations&mdash;is extremely rare.
+The distal segment of the foot is usually displaced towards the sole;
+the foot is foreshortened, the malleoli raised from the<a class="pagenum" name="Pg_200" id="Pg_200"></a> 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.</p>
+
+<p><a name="VIII_dislocation_tarso_metatarsal" id="VIII_dislocation_tarso_metatarsal"></a><b>Tarso-metatarsal Dislocations.</b>&mdash;One, several, or all of the
+metatarsals may be separated from the distal row of tarsal bones&mdash;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.</p>
+
+<p><a name="VIII_dislocation_toes" id="VIII_dislocation_toes"></a><b>Dislocation of the Toes.</b>&mdash;The great toe may be dislocated at its
+metatarso-phalangeal joint, the base of the proximal phalanx passing
+towards the dorsum (<a href="#fig_102">Fig.&nbsp;102</a>). Diagnosis and reduction are alike easy.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_102" id="fig_102"></a>
+<img src="images/fig102.jpg" width="400" height="237" alt="Fig. 102.&mdash;Radiogram of Dislocation of Toes." title="" />
+<span class="caption"><span class="smcap">Fig. 102.</span>&mdash;Radiogram of Dislocation of Toes.<br /><br />
+(Sir Montagu Cotterill&#39;s case.)</span>
+</div>
+
+<p><b>Inter-phalangeal</b> dislocations are rare and are easily reduced.</p>
+
+
+
+
+<h2><a class="pagenum" name="Pg_201" id="Pg_201"></a><a name="CHAPTER_IX" id="CHAPTER_IX"></a>CHAPTER IX
+<br />
+DISEASES OF INDIVIDUAL JOINTS</h2>
+
+
+<h3>THE SHOULDER-JOINT</h3>
+
+<p>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.</p>
+
+<p><b>Tuberculous Disease</b> 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<a class="pagenum" name="Pg_202" id="Pg_202"></a> 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.</p>
+
+<p>The primary lesion is either a caseating focus in one of the
+bones&mdash;most often in the upper end of the humerus&mdash;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.</p>
+
+<p>The <i>diagnosis</i> 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&mdash;by
+the absence of pain, and the flail-like character of the movements;
+(3) disease in the sub-deltoid bursa&mdash;by the absence of rigidity and
+other evidence of implication of the articular surfaces; and (4)
+sarcoma of the upper end of the humerus&mdash;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.</p>
+
+<p>While the <i>prognosis</i> 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.</p>
+
+<p><i>Treatment.</i>&mdash;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<a class="pagenum" name="Pg_203" id="Pg_203"></a> 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.</p>
+
+<p><b>Pyogenic Diseases.</b>&mdash;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.</p>
+
+<p><b>Arthritis Deformans.</b>&mdash;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.</p>
+
+<p><b>Neuro-arthropathies</b> of the shoulder are met with chiefly in
+syringomyelia. In some cases there is a large fluctuating<a class="pagenum" name="Pg_204" id="Pg_204"></a> 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 (<a href="#fig_104">Fig.&nbsp;104</a>).</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_103" id="fig_103"></a>
+<img src="images/fig103.jpg" width="300" height="368" alt="Fig. 103.&mdash;Arthropathy of Shoulder in Syringomyelia.
+The upper end of the humerus has disappeared and the movements are
+flail-like (cf. Fig. 104)." title="" />
+<span class="caption"><span class="smcap">Fig. 103.</span>&mdash;Arthropathy of Shoulder in Syringomyelia.
+The upper end of the humerus has disappeared and the movements are
+flail-like (cf. <a href="#fig_104">Fig.&nbsp;104</a>).</span>
+</div>
+
+<p>&nbsp;</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_104" id="fig_104"></a>
+<img src="images/fig104.jpg" width="300" height="311" alt="Fig. 104.&mdash;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)." title="" />
+<span class="caption"><span class="smcap">Fig. 104.</span>&mdash;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. <a href="#fig_103">Fig.&nbsp;103</a>).</span>
+</div>
+
+<p><b>Loose bodies</b> 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.</p>
+
+<p><b>Ankylosis</b> 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.</p>
+
+
+<h3><a class="pagenum" name="Pg_205" id="Pg_205"></a><span class="smcap">The Elbow-joint</span></h3>
+
+<p>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.</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_105" id="fig_105"></a>
+<img src="images/fig105.jpg" width="300" height="332" alt="Fig. 105.&mdash;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." title="" />
+<span class="caption"><span class="smcap">Fig. 105.</span>&mdash;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.</span>
+</div>
+
+<p><a class="pagenum" name="Pg_206" id="Pg_206"></a><b>Tuberculous disease</b> is the most common and important affection (<a href="#fig_106">Fig.&nbsp;106</a>).
+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.</p>
+
+<div class="figcenter" style="width: 250px;">
+<a name="fig_106" id="fig_106"></a>
+<img src="images/fig106.jpg" width="250" height="464" alt="Fig. 106.&mdash;Diffuse Tuberculous Thickening of Synovial
+Membrane of Elbow (white swelling) in a boy &aelig;t. 12." title="" />
+<span class="caption"><span class="smcap">Fig. 106.</span>&mdash;Diffuse Tuberculous Thickening of Synovial
+Membrane of Elbow (white swelling) in a boy &aelig;t. 12.</span>
+</div>
+
+<p>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<a class="pagenum" name="Pg_207" id="Pg_207"></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.</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_107" id="fig_107"></a>
+<img src="images/fig107.jpg" width="350" height="469" alt="Fig. 107.&mdash;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." title="" />
+<span class="caption"><span class="smcap">Fig. 107.</span>&mdash;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.</span>
+</div>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p><a class="pagenum" name="Pg_208" id="Pg_208"></a>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.</p>
+
+<p><b>Arthritis deformans</b> 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.</p>
+
+<p><b>Neuro-arthropathies</b> are met with chiefly in syringomyelia, and are
+attended with striking alterations in the shape of the bones and with
+abnormal mobility.</p>
+
+<p><b>Pyogenic diseases</b> result from staphylococcal osteomyelitis&mdash;chiefly of
+the humerus or ulna&mdash;and from gonorrh&oelig;a.</p>
+
+<p>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.</p>
+
+<p><b>Ankylosis</b> 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&mdash;<i>arthroplasty</i>.</p>
+
+
+<h3><span class="smcap">The Wrist-Joint</span></h3>
+
+<p>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.</p>
+
+<p><b>Tuberculous disease</b> 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.</p>
+
+<p>The attitude is one of slight flexion with drooping of the hand and
+fingers. The fingers become stiff as a result of adhesions in<a class="pagenum" name="Pg_209" id="Pg_209"></a> 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.</p>
+
+<p>The localisation of disease in individual bones or joints can be
+determined by the use of the X-rays.</p>
+
+<p><i>Treatment.</i>&mdash;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 an&aelig;sthetic 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.</p>
+
+<p><i>Other diseases of the wrist</i> are comparatively rare. They include
+pyogenic affections, such as those resulting from infective conditions
+in the palm of the hand, different types of gonorrh&oelig;al, 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.</p>
+
+
+<h3><span class="smcap">The Hip-joint</span></h3>
+
+<p>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.</p>
+
+<p>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<a class="pagenum" name="Pg_210" id="Pg_210"></a> 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.</p>
+
+
+<h3><span class="smcap">Tuberculous Disease</span></h3>
+
+<p>Tuberculous disease of the hip, morbus cox&aelig;, or &ldquo;hip-joint disease,&rdquo;
+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.</p>
+
+<p><b>Pathological Anatomy.</b>&mdash;Bone lesions bulk more largely in hip disease
+than they do in disease of other joints&mdash;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.</p>
+
+<p>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 &ldquo;wandering acetabulum&rdquo; (<a href="#fig_108">Fig.&nbsp;108</a>). The<a class="pagenum" name="Pg_211" id="Pg_211"></a>
+displacement of the femur resulting from these secondary changes is
+one of the causes of real shortening of the limb.</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_108" id="fig_108"></a>
+<img src="images/fig108.png" width="300" height="483" alt="Fig. 108.&mdash;Advanced Tuberculous Disease of Acetabulum
+with caries and perforation into pelvis." title="" />
+<span class="caption"><span class="smcap">Fig. 108.</span>&mdash;Advanced Tuberculous Disease of Acetabulum
+with caries and perforation into pelvis.<br /><br />
+(Anatomical Museum, University of Edinburgh.)</span>
+</div>
+
+<p><b>Clinical Features.</b>&mdash;It is customary to describe three stages in the
+progress of hip disease, but this is arbitrary and only adopted for
+convenience of description.</p>
+
+<p><i>Initial Stage.</i>&mdash;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.</p>
+
+<p>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<a class="pagenum" name="Pg_212" id="Pg_212"></a> 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 <i>rigidity</i>
+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.</p>
+
+<p><i>Second Stage.</i>&mdash;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 (<a href="#fig_109">Fig.&nbsp;109</a>).</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_109" id="fig_109"></a>
+<img src="images/fig109.jpg" width="400" height="444" alt="Fig. 109.&mdash;Early Tuberculous Disease of Right Hip-joint
+in a boy &aelig;t. 14, showing flexion, abduction, and apparent lengthening
+of the limb." title="" />
+<span class="caption"><span class="smcap">Fig. 109.</span>&mdash;Early Tuberculous Disease of Right Hip-joint
+in a boy &aelig;t. 14, showing flexion, abduction, and apparent lengthening
+of the limb.</span>
+</div>
+
+<p><a class="pagenum" name="Pg_213" id="Pg_213"></a>At first the attitude is maintained entirely by the action of muscles;
+but when it is prolonged, the muscles, fasci&aelig;, and ligaments undergo
+shortening, so that it becomes fixed.</p>
+
+<p>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 <i>apparent lengthening</i>
+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.</p>
+
+<div class="figcenter" style="width: 550px;">
+<a name="fig_110" id="fig_110"></a>
+<img src="images/fig110.jpg" width="550" height="166" alt="Fig. 110.&mdash;Disease of Left Hip: position of ease
+assumed by patient, showing moderate flexion and lordosis." title="" />
+<span class="caption"><span class="smcap">Fig. 110.</span>&mdash;Disease of Left Hip: position of ease
+assumed by patient, showing moderate flexion and lordosis.</span>
+</div>
+
+<p>&nbsp;</p>
+
+<div class="figcenter" style="width: 550px;">
+<a name="fig_111" id="fig_111"></a>
+<img src="images/fig111.jpg" width="550" height="189" alt="Fig. 111.&mdash;Disease of Left Hip: disappearance of
+lordosis on further flexion of the hip." title="" />
+<span class="caption"><span class="smcap">Fig. 111.</span>&mdash;Disease of Left Hip: disappearance of
+lordosis on further flexion of the hip.</span>
+</div>
+
+<p><a class="pagenum" name="Pg_214" id="Pg_214"></a>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 (<a href="#fig_112">Fig.&nbsp;112</a>).</p>
+
+<div class="figcenter" style="width: 550px;">
+<a name="fig_112" id="fig_112"></a>
+<img src="images/fig112.jpg" width="550" height="154" alt="Fig. 112.&mdash;Disease of Left Hip: exaggeration of
+lordosis produced by extending the limb." title="" />
+<span class="caption"><span class="smcap">Fig. 112.</span>&mdash;Disease of Left Hip: exaggeration of
+lordosis produced by extending the limb.</span>
+</div>
+
+<p>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.</p>
+
+<p>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<a class="pagenum" name="Pg_215" id="Pg_215"></a> by observing the angle
+between the thigh and the table (<a href="#fig_113">Fig.&nbsp;113</a>). This is known as &ldquo;Thomas'
+flexion test,&rdquo; and is founded upon the inability to extend the
+diseased hip without producing lordosis.</p>
+
+<div class="figcenter" style="width: 450px;">
+<a name="fig_113" id="fig_113"></a>
+<img src="images/fig113.jpg" width="450" height="228" alt="Fig. 113.&mdash;Thomas&#39; Flexion Test, showing angle of
+flexion at diseased (left) hip." title="" />
+<span class="caption"><span class="smcap">Fig. 113.</span>&mdash;Thomas&#39; Flexion Test, showing angle of
+flexion at diseased (left) hip.</span>
+</div>
+
+<p><i>Swelling</i> 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.</p>
+
+<div class="figleft" style="width: 200px;">
+<a name="fig_114" id="fig_114"></a>
+<img src="images/fig114.jpg" width="200" height="390" alt="Fig. 114.&mdash;Tuberculous Disease of Left Hip: third
+stage, showing adduction and shortening." title="" />
+<span class="caption"><span class="smcap">Fig. 114.</span>&mdash;Tuberculous Disease of Left Hip: third
+stage, showing adduction and shortening.</span>
+</div>
+
+<p><i>Third Stage.</i>&mdash;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 (<a href="#fig_114">Fig.&nbsp;114</a>). The
+<i>flexion</i> 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 <i>adduction</i> varies greatly
+in degree; when it is slight, as is most often the case, the toes of<a class="pagenum" name="Pg_216" id="Pg_216"></a>
+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
+<i>apparent shortening</i> 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.</p>
+
+<div class="figright" style="width: 150px;">
+<a name="fig_115" id="fig_115"></a>
+<img src="images/fig115.jpg" width="150" height="348" alt="Fig. 115.&mdash;Advanced Tuberculous Disease of Left
+Hip-joint in a girl &aelig;t. 14, showing flexion, adduction, shortening,
+and iliac abscess." title="" />
+<span class="caption"><span class="smcap">Fig. 115.</span>&mdash;Advanced Tuberculous Disease of Left
+Hip-joint in a girl &aelig;t. 14, showing flexion, adduction, shortening,
+and iliac abscess.</span>
+</div>
+
+<p>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.</p>
+
+<p>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
+<i>actual shortening</i>; it will also be found that the trochanter is
+displaced above N&eacute;laton's line, while above and behind the trochanter
+there is a prominent hard swelling corresponding to the enlarged
+acetabulum.</p>
+
+<p>There may, therefore, be a combination of real and apparent shortening
+together amounting to several inches (<a href="#fig_115">Fig.&nbsp;115</a>).</p>
+
+<p><a class="pagenum" name="Pg_217" id="Pg_217"></a>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.</p>
+
+<p>The most reasonable explanation of the attitudes assumed in hip
+disease is that given by K&ouml;nig. 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. K&ouml;nig'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&mdash;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.</p>
+
+<p>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.</p>
+
+<p><b>Abscess Formation in Hip Disease.</b>&mdash;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.</p>
+
+<p>An abscess may appear <i>in the thigh</i> in front or behind the joint. The
+<i>anterior abscess</i> 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<a class="pagenum" name="Pg_218" id="Pg_218"></a> femoral vessels have been eroded, and
+serious or even fatal h&aelig;morrhage has resulted. The <i>posterior abscess</i>
+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.</p>
+
+<p>Abscesses which form <i>within the pelvis</i> 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 (<a href="#fig_115">Fig.&nbsp;115</a>), 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.</p>
+
+<p>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 tox&aelig;mia; 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.</p>
+
+<p><b>Dislocation</b> 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 N&eacute;laton'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.</p>
+
+<p><b>Diagnosis of Hip Disease.</b>&mdash;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
+move<a class="pagenum" name="Pg_219" id="Pg_219"></a>ments 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,&mdash;<i>congenital dislocation</i>, <i>coxa
+vara</i>, and <i>paralysis following poliomyelitis</i>&mdash;but in all of these
+the movements are not nearly so restricted as they are in disease of
+the joint.</p>
+
+<p>In tuberculous disease of the <i>sacro-iliac joint</i>, while the pelvis
+may be tilted, and the limb apparently lengthened, the movements at
+the hip are retained. In tuberculous disease of the <i>great
+trochanter</i>, or of either of the <i>burs&aelig;</i> 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.</p>
+
+<p>In <i>psoas abscess</i> associated with spinal disease, or in <i>disease of
+the bursa underneath the psoas</i>, 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.</p>
+
+<p><i>New-growths</i> in the vicinity of the hip&mdash;especially central sarcoma
+of the upper end of the femur&mdash;are difficult to differentiate from hip
+disease without the help of the X-rays.</p>
+
+<p>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.</p>
+
+<p>The diagnosis <i>from other diseases of the hip-joint</i> is made by
+careful consideration of the history, symptoms, and X-ray appearances.</p>
+
+<p><b>Prognosis.</b>&mdash;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.</p>
+
+<p>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.</p>
+
+<p><a class="pagenum" name="Pg_220" id="Pg_220"></a>In cases which terminate fatally, death usually results from
+meningeal, pulmonary, or general tuberculosis, or from pyogenic
+complications and waxy degeneration.</p>
+
+<p><b>Treatment.</b>&mdash;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.</p>
+
+<p><i>Conservative Treatment.</i>&mdash;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.</p>
+
+<p><i>Extension by Weight and Pulley</i> (<a href="#fig_116">Fig.&nbsp;116</a>).&mdash;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.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_116" id="fig_116"></a>
+<img src="images/fig116.jpg" width="400" height="269" alt="Fig. 116.&mdash;Extension by adhesive plaster and Weight and
+Pulley." title="" />
+<span class="caption"><span class="smcap">Fig. 116.</span>&mdash;Extension by adhesive plaster and Weight and
+Pulley.</span>
+</div>
+
+<p>In restless children, in addition to the extension, a long splint is
+applied on the sound side and a sand-bag on the<a class="pagenum" name="Pg_221" id="Pg_221"></a> 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 (<a href="#fig_117">Fig.&nbsp;117</a>).</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_117" id="fig_117"></a>
+<img src="images/fig117.jpg" width="350" height="388" alt="Fig. 117.&mdash;Stiles&#39; Double Long Splint to admit of
+abduction of diseased limb." title="" />
+<span class="caption"><span class="smcap">Fig. 117.</span>&mdash;Stiles&#39; Double Long Splint to admit of
+abduction of diseased limb.</span>
+</div>
+
+<p>When the deformed attitude does not yield rapidly to extension, it
+should be corrected under an an&aelig;sthetic, and if the adductor tendons
+and fasci&aelig; are so contracted that this is difficult, they should be
+forcibly stretched or divided.</p>
+
+<p>The immediate correction of deformed attitudes under an&aelig;sthesia 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.</p>
+
+<p><a class="pagenum" name="Pg_222" id="Pg_222"></a><i>Ambulant Treatment.</i>&mdash;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' (<a href="#fig_118">Fig.&nbsp;118</a>) 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.</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_118" id="fig_118"></a>
+<img src="images/fig118.jpg" width="300" height="463" alt="Fig. 118.&mdash;Thomas&#39; Hip Splint applied for disease of
+Right Hip. Note patten under sound foot. The foot on the affected side
+is too near the ground." title="" />
+<span class="caption"><span class="smcap">Fig. 118.</span>&mdash;Thomas&#39; Hip Splint applied for disease of
+Right Hip. Note patten under sound foot. The foot on the affected side
+is too near the ground.</span>
+</div>
+
+<p>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<a class="pagenum" name="Pg_223" id="Pg_223"></a> from the double Thomas'
+splint employed for spinal disease, which extends from the occiput to
+the soles of the feet.</p>
+
+<p>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.</p>
+
+<p>Should an abscess develop, it is treated on the usual lines.</p>
+
+<p><i>Operative Interference.</i>&mdash;Widely diverse opinions are held on the
+question as to whether or not recourse should be had to operative
+interference.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><i>Amputation</i> 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.</p>
+
+<p><b>The Correction of Deformity resulting from Antecedent Disease of the
+Hip.</b>&mdash;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, fasci&aelig;, 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.</p>
+
+<p><a class="pagenum" name="Pg_224" id="Pg_224"></a><b>Bilateral Hip Disease.</b>&mdash;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&mdash;one variety of the
+&ldquo;scissor-leg&rdquo; or &ldquo;crossed-leg&rdquo; deformity&mdash;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.</p>
+
+
+<h3><span class="smcap">Other Diseases of the Hip-Joint</span></h3>
+
+<p><b>Pyogenic Diseases</b> 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.</p>
+
+<p>The <i>clinical features</i> 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.</p>
+
+<p>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.</p>
+
+<p><i>Treatment.</i>&mdash;In the acute stage the limb is extended by means of the
+weight and pulley, and kept at rest with the single or<a class="pagenum" name="Pg_225" id="Pg_225"></a> 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.</p>
+
+<p>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<a class="pagenum" name="Pg_226" id="Pg_226"></a> 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.</p>
+
+<p><b>Arthritis Deformans.</b>&mdash;This disease is comparatively common at the hip,
+either as a mon-articular affection or simultaneously with other
+joints.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_119" id="fig_119"></a>
+<img src="images/fig119.jpg" width="400" height="449" alt="Fig. 119.&mdash;Arthritis Deformans, showing erosion of
+cartilage and lipping of articular edge of head of femur." title="" />
+<span class="caption"><span class="smcap">Fig. 119.</span>&mdash;Arthritis Deformans, showing erosion of
+cartilage and lipping of articular edge of head of femur.</span>
+</div>
+
+<p><i>The changes in the joint</i> are characteristic of the dry form<a class="pagenum" name="Pg_227" id="Pg_227"></a> 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 (<a href="#fig_120">Fig.&nbsp;120</a>). 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 (<a href="#fig_121">Fig.&nbsp;121</a>).
+The acetabulum may &ldquo;wander&rdquo; 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.</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_120" id="fig_120"></a>
+<img src="images/fig120.jpg" width="350" height="545" alt="Fig. 120.&mdash;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." title="" />
+<span class="caption"><span class="smcap">Fig. 120.</span>&mdash;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.</span>
+</div>
+
+<div class="figleft" style="width: 150px;">
+<a name="fig_121" id="fig_121"></a>
+<img src="images/fig121.jpg" width="150" height="478" alt="Fig. 121.&mdash;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." title="" />
+<span class="caption"><span class="smcap">Fig. 121.</span>&mdash;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.</span>
+</div>
+
+<p>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 N&eacute;laton's line.</p>
+
+<p>The <i>clinical features</i> 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<a class="pagenum" name="Pg_228" id="Pg_228"></a> of sciatic pain may lead to the disease being regarded as
+sciatica.</p>
+
+<p>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.</p>
+
+<p><i>Treatment</i> 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.</p>
+
+<p>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, <i>cheilotomy</i> (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.</p>
+
+<p><b>Osteo-chondritis Deformans Juvenilis.</b>&mdash;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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><b>Neuro-Arthropathies.</b>&mdash;<i>Charcot's disease</i> 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<a class="pagenum" name="Pg_229" id="Pg_229"></a> 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.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+<p><i>Loose bodies in the hip</i> 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.</p>
+
+<p><i>Hysterical affections</i> of the hip resemble those in other joints.</p>
+
+
+<h3><span class="smcap">The Knee-Joint</span></h3>
+
+<p>The knee is more often the seat of disease than any other joint in the
+body.</p>
+
+<p>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 &ldquo;floated&rdquo; 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.</p>
+
+<p>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<a class="pagenum" name="Pg_230" id="Pg_230"></a> exaggerated growth, and
+give rise to pedunculated and other forms of loose body.</p>
+
+<p>The burs&aelig; 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.</p>
+
+<p>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&mdash;twenty-one to twenty-five years&mdash;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.</p>
+
+<p>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<a class="pagenum" name="Pg_231" id="Pg_231"></a> 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.</p>
+
+
+<h4><span class="smcap">Tuberculous Disease</span></h4>
+
+<p>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.</p>
+
+<p>When the synovial membrane is diseased, it tends to grow inwards over
+the articular surfaces (<a href="#fig_122">Fig.&nbsp;122</a>), 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.</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_122" id="fig_122"></a>
+<img src="images/fig122.jpg" width="350" height="242" alt="Fig. 122.&mdash;Tuberculous Synovial Membrane of Knee,
+spreading over articular surface of femur." title="" />
+<span class="caption"><span class="smcap">Fig. 122.</span>&mdash;Tuberculous Synovial Membrane of Knee,
+spreading over articular surface of femur.</span>
+</div>
+
+<div class="figright" style="width: 200px;">
+<a name="fig_123" id="fig_123"></a>
+<img src="images/fig123.jpg" width="200" height="290" alt="Fig. 123.&mdash;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." title="" />
+<span class="caption"><span class="smcap">Fig. 123.</span>&mdash;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.<br /><br />
+(Anatomical Museum, University of Edinburgh.)</span>
+</div>
+
+<p>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&mdash;especially
+the medial. Caseating foci are comparatively rare, but they sometimes
+attain a considerable size&mdash;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 (<a href="#fig_123">Fig.&nbsp;123</a>).</p>
+
+<p><b>Clinical Types.</b>&mdash;(1) <i>Hydrops</i> 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.</p>
+
+<p>It is met with chiefly in young adults. As the fluid accumulates it
+gradually stretches the capsule, and pushes the patella<a class="pagenum" name="Pg_232" id="Pg_232"></a> 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.</p>
+
+<p>Tuberculous hydrops is to be diagnosed from the effusion that results
+from repeated sprain, from the hydrops of loose body, gonorrh&oelig;a,
+arthritis deformans, Charcot's disease, and Brodie's abscess in the
+adjacent bone, and from the h&aelig;marthrosis met with in bleeders.</p>
+
+<p>(2) <i>Papillary or Nodular Tubercle of the Synovial Membrane.</i>&mdash;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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>The diagnosis is to be made from arthritis deformans, and in some
+cases from loose body of other than tuberculous origin.</p>
+
+<p>(3) <i>Cold abscess</i> or <i>empyema</i> of the knee is a rare condition, in
+which the joint becomes filled with pus. It usually results<a class="pagenum" name="Pg_233" id="Pg_233"></a> from a
+primary tuberculosis of the synovial membrane occurring in children
+reduced in health and the subject of tuberculosis elsewhere.</p>
+
+<p>(4) <i>Diffuse Thickening of the Synovial Membrane&mdash;White Swelling.</i>&mdash;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.</p>
+
+<p><a class="pagenum" name="Pg_234" id="Pg_234"></a>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&mdash;it may be to a right angle&mdash;the leg and foot
+are everted, and, in children, the tibia may be displaced backwards
+(<a href="#fig_124">Fig.&nbsp;124</a>). 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.</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_124" id="fig_124"></a>
+<img src="images/fig124.jpg" width="300" height="419" alt="Fig. 124.&mdash;Advanced Tuberculous Disease of Knee, with
+backward displacement of Tibia." title="" />
+<span class="caption"><span class="smcap">Fig. 124.</span>&mdash;Advanced Tuberculous Disease of Knee, with
+backward displacement of Tibia.</span>
+</div>
+
+<p>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.</p>
+
+<p>(5) <i>Primary Tuberculous Disease in the Bones of the Knee.</i>&mdash;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.</p>
+
+<p><b>The formation of peri-articular abscess</b> 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.</p>
+
+<p><b>Attitudes of the Limb in Knee-Joint Disease.</b>&mdash;The attitude most often
+assumed is that of <i>flexion</i>, with or without <i>eversion of the leg and
+foot</i>. 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<a class="pagenum" name="Pg_235" id="Pg_235"></a> of the biceps muscle. <i>Backward displacement of the
+tibia</i> 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.</p>
+
+<p>In certain cases, <i>genu valgum</i> 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.</p>
+
+<p><b>Treatment of Tuberculous Disease of the Knee.</b>&mdash;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.</p>
+
+<p><i>Conservative Treatment.</i>&mdash;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 hyper&aelig;mia 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 patell&aelig; or into the upper pouch when
+this is distended with fluid.</p>
+
+<p>If there is no pain or tendency to flexion, or when these have been
+overcome, the limb is put up in a Thomas' splint (<a href="#fig_125">Fig.&nbsp;125</a>) 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.</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_125" id="fig_125"></a>
+<img src="images/fig125.jpg" width="350" height="464" alt="Fig. 125.&mdash;Thomas&#39; Knee Splint applied. Note extension
+strapping applied to affected leg, and patten under sound foot." title="" />
+<span class="caption"><span class="smcap">Fig. 125.</span>&mdash;Thomas&#39; Knee Splint applied. Note extension
+strapping applied to affected leg, and patten under sound foot.</span>
+</div>
+
+<p>The indications for <i>operative treatment</i> 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.</p>
+
+<p>In adults, the operation consists in excising the joint; in children
+the aim is to remove the diseased tissues without damaging the
+epiphysial cartilages.</p>
+
+<p>Amputation is performed when the disease has relapsed after<a class="pagenum" name="Pg_236" id="Pg_236"></a> excision
+and there is persistent suppuration, and when life is threatened by
+the occurrence of tuberculosis in the lungs or elsewhere.</p>
+
+<p><b>Treatment of Deformities resulting from Antecedent Diseases of the
+Knee.</b>&mdash;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.</p>
+
+
+<h4><a class="pagenum" name="Pg_237" id="Pg_237"></a><span class="smcap">Other Diseases of the Knee-Joint</span></h4>
+
+<p><b>Pyogenic diseases</b> 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 <i>synovitis</i> associated with disease in
+the adjacent bone, <i>acute arthritis of infants</i>, joint suppuration in
+<i>py&aelig;mia</i>, <i>pyogenic arthritis</i> following upon penetrating wounds, and
+the affections which result from <i>gonorrh&oelig;al</i> or <i>pneumococcal</i>
+infection.</p>
+
+<p><i>Treatment.</i>&mdash;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
+hyper&aelig;mia 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.</p>
+
+<p><b>Arthritis deformans</b> 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 <i>villous arthritis</i>, 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<a class="pagenum" name="Pg_238" id="Pg_238"></a>
+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 &ldquo;lipping&rdquo;
+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.</p>
+
+<p>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.</p>
+
+<p><i>Bleeder's knee</i>, <i>Charcot's disease</i>, <i>hysterical knee</i>, and <i>loose
+bodies</i> in the joint have already been described.</p>
+
+
+<h3><span class="smcap">The Ankle-Joint</span></h3>
+
+<p>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 (<a href="#fig_93">Fig.&nbsp;93</a>). The talus is related to three
+articulations&mdash;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.</p>
+
+<p><b>Tuberculous Disease.</b>&mdash;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.</p>
+
+<p><i>Primary synovial disease</i> 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 (<a href="#fig_126">Fig.&nbsp;126</a>). The foot may retain its
+normal attitude, or the toes may be pointed and adducted. The calf
+muscles are wasted, there is little<a class="pagenum" name="Pg_239" id="Pg_239"></a> 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.</p>
+
+<div class="figcenter" style="width: 250px;">
+<a name="fig_126" id="fig_126"></a>
+<img src="images/fig126.jpg" width="250" height="388" alt="Fig. 126.&mdash;Tuberculous Disease in a man &aelig;t. 35, of six
+weeks&#39; duration." title="" />
+<span class="caption"><span class="smcap">Fig. 126.</span>&mdash;Tuberculous Disease in a man &aelig;t. 35, of six
+weeks&#39; duration.</span>
+</div>
+
+<p><a class="pagenum" name="Pg_240" id="Pg_240"></a><i>A primary focus in the bone</i> 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.</p>
+
+<p>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.</p>
+
+<p><i>Diagnosis.</i>&mdash;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.</p>
+
+<p><i>Treatment.</i>&mdash;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
+(<a href="#fig_125">Fig.&nbsp;125</a>). 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.</p>
+
+<p>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.</p>
+
+<p>Amputation is only called for in adults with rapidly progressing
+disease and diffuse suppuration, and in cases which have relapsed
+after excision.</p>
+
+<p>The other diseases of the ankle include <i>pyogenic</i>, <i>gonorrh&oelig;al</i>,
+<i>rheumatic</i>, <i>gouty</i>, and <i>hysterical</i> affections, <i>arthritis
+deformans</i>, and <i>Charcot's disease</i>. 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&mdash;sometimes associated with perforating ulcer of the
+sole.</p>
+
+<p>Tuberculous disease in the <b>tarsus</b>, <b>metatarsus</b>, and <b>phalanges</b> has been
+considered in the chapter on Diseases of Bone.</p>
+
+
+
+
+<h2><a class="pagenum" name="Pg_241" id="Pg_241"></a><a name="CHAPTER_X" id="CHAPTER_X"></a>CHAPTER X
+<br />
+DEFORMITIES OF THE EXTREMITIES</h2>
+
+<ul class="chap">
+  <li><a href="#X_deformities">The origin of deformities:</a></li>
+  <li><a href="#X_deformities_before">(1) Those arising before birth</a>;</li>
+  <li><a href="#X_deformities_during">(2) those produced during birth</a>; and</li>
+  <li><a href="#X_deformities_after">(3) those acquired after birth</a>.</li>
+</ul>
+
+<ul class="chap">
+  <li><a href="#X_palsies_children">Palsies of children</a>:</li>
+  <li><a href="#X_poliomyelitis"><i>Anterior Poliomyelitis</i></a>.</li>
+  <li><a href="#X_cerebral_palsies">Cerebral palsies: <i>Spastic paralysis</i></a>.</li>
+</ul>
+
+<ul class="chap">
+  <li><a href="#X_lower_extremity"><span class="smcap">The Lower Extremity</span></a>:</li>
+  <li><a href="#X_hip_dislocation">Congenital dislocation of hip</a></li>
+  <li>&mdash;<a href="#X_snapping_hip">Snapping hip</a></li>
+  <li>&mdash;<a href="#X_paralytic_deformities">Paralytic deformities</a></li>
+  <li>&mdash;<a href="#X_ankyloses_hip">Contracture and ankylosis of hip</a></li>
+  <li>&mdash;<a href="#X_coxa_vara">Coxa vara and coxa valga</a></li>
+  <li>&mdash;<a href="#X_knee_dislocation">Congenital dislocation of knee and patella</a></li>
+  <li>&mdash;<a href="#X_genu_recurvatum">Genu recurvatum</a></li>
+  <li>&mdash;<a href="#X_knee_poliomyelitis">Paralytic deformities</a></li>
+  <li>&mdash;<a href="#X_knee_ankylosis">Contracture and ankylosis of knee</a></li>
+  <li>&mdash;<a href="#X_genu_valgum">Genu valgum and genu varum</a></li>
+  <li>&mdash;<a href="#X_leg_deformities">Congenital deformities of leg</a></li>
+  <li>&mdash;<a href="#X_bow_leg">Bow-leg</a></li>
+  <li>&mdash;<a href="#X_club_foot">Club-foot</a>:</li>
+  <li><a href="#X_talipes_equino_varus"><i>Talipes equino-varus</i></a>;</li>
+  <li><a href="#X_pes_equinus"><i>Pes equinus</i></a>;</li>
+  <li><a href="#X_pes_calcaneus"><i>Pes calcaneus</i></a>;</li>
+  <li><i><a href="#X_pes_calcaneo_valgus">Pes calcaneo-valgus</a> and <a href="#X_pes_calcaneo_varus">varus</a></i>;</li>
+  <li><a href="#X_pes_cavus"><i>Pes cavus</i></a>;</li>
+  <li><a href="#X_flat_foot">Flat-foot and pes valgus</a></li>
+  <li>&mdash;<a href="#X_heel">Painful affections of heel</a></li>
+  <li>&mdash;<a href="#X_metatarsalgia">Metatarsalgia</a></li>
+  <li>&mdash;<a href="#X_hallux_valgus">Hallux valgus and bunion</a></li>
+  <li>&mdash;<a href="#X_hallux_varus">Hallux varus</a></li>
+  <li>&mdash;<a href="#X_hallux_rigidus">Hallux rigidus and flexus</a></li>
+  <li>&mdash;<a href="#X_hammer_toe">Hammer-toe</a></li>
+  <li>&mdash;<a href="#X_hypertrophy_toes">Hypertrophy of toes</a></li>
+  <li>&mdash;<a href="#X_supernumerary_toes">Supernumerary toes</a></li>
+  <li>&mdash;<a href="#X_webbed_toes">Webbed toes</a>.</li>
+</ul>
+
+<ul class="chap">
+  <li><a href="#X_upper_extremity"><span class="smcap">The Upper Extremity</span></a>:</li>
+  <li><a href="#X_absence_clavicle">Congenital absence of clavicle</a></li>
+  <li>&mdash;<a href="#X_elevation_scapula">Elevation of scapula</a></li>
+  <li>&mdash;<a href="#X_winged_scapula">Winged scapula</a></li>
+  <li>&mdash;<a href="#X_congenital_shoulder">Congenital paralytic deformities of shoulder</a></li>
+  <li>&mdash;<a href="#X_deformities_elbow">Deformities of elbow</a></li>
+  <li>&mdash;<a href="#X_club_hand">Club-hand</a></li>
+  <li>&mdash;<a href="#X_deformities_wrist">Deformities of wrist</a></li>
+  <li>&mdash;<a href="#X_deformities_wrist">Madelung's deformity</a></li>
+  <li>&mdash;<a href="#X_deformities_fingers">Deformities of fingers</a></li>
+  <li>&mdash;<a href="#X_dupuytren">Dupuytren's contraction</a></li>
+  <li>&mdash;<a href="#X_polydactylism">Polydactylism</a>.</li>
+</ul>
+
+<p><a name="X_deformities" id="X_deformities"></a>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.</p>
+
+<p><a name="X_deformities_before" id="X_deformities_before"></a>1. <i>Congenital deformities</i>&mdash;that is, those which originate <i>in utero</i>
+and are present at birth&mdash;are comparatively common and may be due to a
+variety of causes. Some result from errors of development&mdash;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 f&oelig;tus, usually associated with
+want of room in the uterus&mdash;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&mdash;<i>intra-uterine amputation</i>. Lastly, certain
+diseases of the f&oelig;tus, and particularly such as affect<a class="pagenum" name="Pg_242" id="Pg_242"></a> the
+skeleton&mdash;for example, achondroplasia&mdash;cause congenital deformities.</p>
+
+<p><a name="X_deformities_during" id="X_deformities_during"></a>2. <i>Deformities originating during birth</i> 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&mdash;Little's disease&mdash;resulting from tearing of blood vessels on
+the surface of the brain with h&aelig;morrhage and interference with the
+function of the cortical motor area.</p>
+
+<p><a name="X_deformities_after" id="X_deformities_after"></a>3. <i>Deformities acquired after birth</i> 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.</p>
+
+<p><a name="X_palsies_children" id="X_palsies_children"></a>The part played by the palsies of children in the surgical affections
+of the extremities necessitates a short description of their more
+important features.</p>
+
+<p><a name="X_poliomyelitis" id="X_poliomyelitis"></a><b>Anterior poliomyelitis</b> is the lesion underlying what was formerly
+known as <i>infantile paralysis</i>&mdash;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.</p>
+
+<div class="figcenter" style="width: 200px;">
+<a name="fig_127" id="fig_127"></a>
+<img src="images/fig127.jpg" width="200" height="471" alt="Fig. 127.&mdash;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." title="" />
+<span class="caption"><span class="smcap">Fig. 127.</span>&mdash;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.</span>
+</div>
+
+<p>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.</p>
+
+<p><a class="pagenum" name="Pg_243" id="Pg_243"></a>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 <i>over-stretched</i>, 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
+<i>the posture of the limb during convalescence</i>. 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<a class="pagenum" name="Pg_244" id="Pg_244"></a> 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&mdash;paralytic
+equino-varus&mdash;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 <i>erroneous deflection of
+the body weight</i>. 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.</p>
+
+<p>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&mdash;six or
+even twelve months&mdash;in a condition of relaxation. This test should be
+made, no matter how many months or years the muscle may have been
+paralysed.</p>
+
+<p>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.</p>
+
+<p>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, pre<a class="pagenum" name="Pg_245" id="Pg_245"></a>venting 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.</p>
+
+<p><i>Reposition, Manipulations, Supports.</i>&mdash;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.</p>
+
+<p><i>Division of Contractions.</i>&mdash;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.</p>
+
+<p><i>Removal of Skin.</i>&mdash;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.</p>
+
+<p><i>Tendon transplantation</i>, 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&mdash;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&mdash;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.</p>
+
+<p>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<a class="pagenum" name="Pg_246" id="Pg_246"></a> 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).</p>
+
+<p>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.</p>
+
+<p><i>Arthrodesis.</i>&mdash;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.</p>
+
+<p><i>Nerve anastomosis</i>, 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&mdash;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<a class="pagenum" name="Pg_247" id="Pg_247"></a> 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.</p>
+
+<p>In extreme cases in which the limb is hopelessly paralysed and
+useless, it may be <i>amputated</i> 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.</p>
+
+<p><a name="X_cerebral_palsies" id="X_cerebral_palsies"></a><b>Cerebral Palsies of Childhood&mdash;Spastic Paralysis.</b>&mdash;These may be due to
+arrest of development of the brain, to injuries of the head at birth,
+to meningeal h&aelig;morrhage, or to other lesions of the brain, with
+secondary degenerative changes in the spinal cord. The commonest cause
+is h&aelig;morrhage 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&mdash;<i>hemiplegia</i>, or both sides&mdash;<i>diplegia</i>; less commonly one
+extremity alone is involved&mdash;<i>monoplegia</i>. 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 <i>Little's disease</i>. 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 an&aelig;sthetic; the reflexes are exaggerated, and
+sometimes there are perverted involuntary movements (<i>athetosis</i>). The
+growth of the limb is impaired, and contracture deformities may
+supervene (<a href="#fig_131">Fig.&nbsp;131</a>). 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.</p>
+
+<p>The <i>treatment</i> 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 <i>resection of
+the posterior nerve roots</i> 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 con<a class="pagenum" name="Pg_248" id="Pg_248"></a>siderable 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.</p>
+
+<p>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.</p>
+
+<p><i>Lengthening the Tendons.</i>&mdash;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.</p>
+
+
+<h3><a name="X_lower_extremity" id="X_lower_extremity"></a>THE LOWER EXTREMITY</h3>
+
+
+<h4><a name="X_hip_dislocation" id="X_hip_dislocation"></a><span class="smcap">Congenital Dislocation of the Hip</span></h4>
+
+<p>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.</p>
+
+<p>The dislocation takes place in the early months of intra-uterine life,
+and may be associated with deficiency of the liquor amnii.</p>
+
+<p><b>Pathological Anatomy.</b>&mdash;<i>In the infant</i>, 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<a class="pagenum" name="Pg_249" id="Pg_249"></a> 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&mdash;<i>coxa vara</i> (<a href="#fig_129">Fig.&nbsp;129</a>); sometimes increased&mdash;<i>coxa
+valga</i>. 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.</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_128" id="fig_128"></a>
+<img src="images/fig128.jpg" width="350" height="277" alt="Fig. 128.&mdash;Radiogram of Double Congenital Dislocation
+of Hip in a girl &aelig;t. 4." title="" />
+<span class="caption"><span class="smcap">Fig. 128.</span>&mdash;Radiogram of Double Congenital Dislocation
+of Hip in a girl &aelig;t. 4.</span>
+</div>
+
+<p>&nbsp;</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_129" id="fig_129"></a>
+<img src="images/fig129.jpg" width="350" height="344" alt="Fig. 129.&mdash;Innominate Bone and upper end of Femur from
+a case of Congenital Dislocation of Hip." title="" />
+<span class="caption"><span class="smcap">Fig. 129.</span>&mdash;Innominate Bone and upper end of Femur from
+a case of Congenital Dislocation of Hip.</span>
+</div>
+
+<p>In <i>children who have walked</i>, the head of the femur is pushed farther
+upwards on the dorsum ilii; the capsule becomes<a class="pagenum" name="Pg_250" id="Pg_250"></a> 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<a class="pagenum" name="Pg_251" id="Pg_251"></a> 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.</p>
+
+<div class="figcenter" style="width: 200px;">
+<a name="fig_130" id="fig_130"></a>
+<img src="images/fig130.jpg" width="200" height="499" alt="Fig. 130.&mdash;Congenital Dislocation of Left Hip in a girl
+&aelig;t. 8. The patient is putting the whole weight on the dislocated
+limb." title="" />
+<span class="caption"><span class="smcap">Fig. 130.</span>&mdash;Congenital Dislocation of Left Hip in a girl
+&aelig;t. 8. The patient is putting the whole weight on the dislocated
+limb.</span>
+</div>
+
+<p><i>Clinical Features.</i>&mdash;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 <i>unilateral cases</i>, 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 N&eacute;laton'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<a class="pagenum" name="Pg_252" id="Pg_252"></a> 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.</p>
+
+<p><i>In bilateral cases</i> 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.</p>
+
+<p>Except in fat infants, the <i>diagnosis</i> 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. <i>Trendelenburg's test</i>
+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.</p>
+
+<p>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.</p>
+
+<p><i>Treatment.</i>&mdash;We are indebted to Paci, Schede, Calot, Lorenz, and
+Hoffa for the rational treatment which seeks to reduce the dislocation
+by manipulation.</p>
+
+<p><a class="pagenum" name="Pg_253" id="Pg_253"></a><b>Reduction by Manipulation</b> (<i>Method of Lorenz</i>).&mdash;The child is
+an&aelig;sthetised 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 N&eacute;laton'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.</p>
+
+<p>To keep the head in the socket, the limb must be maintained in the
+position of right-angled abduction and external rotation (90&deg;) 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.</p>
+
+<p><i>In bilateral cases</i> 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 &ldquo;frog position.&rdquo;</p>
+
+<p>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<a class="pagenum" name="Pg_254" id="Pg_254"></a> 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.</p>
+
+<p>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 fasci&aelig;
+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 <i>anterior transposition of the head of
+the femur</i>, is specially applicable to cases in which relapse has
+taken place after reduction, and to those above the age when reduction
+should be attempted.</p>
+
+<p><i>Reduction by open operation</i> 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.</p>
+
+<p><a name="X_snapping_hip" id="X_snapping_hip"></a><b>Snapping Hip</b> (<i>Hanche &agrave; ressort</i>).&mdash;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.</p>
+
+<p>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 fasci&aelig;
+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.</p>
+
+<p><a name="X_paralytic_deformities" id="X_paralytic_deformities"></a><a class="pagenum" name="Pg_255" id="Pg_255"></a><b>Paralytic Deformities of the Hip.</b>&mdash;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 fasci&aelig; and
+sartorius, the dislocation differs from the traumatic variety in that
+the head, although it leaves the<a class="pagenum" name="Pg_256" id="Pg_256"></a> 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.</p>
+
+<p>In <i>spastic paralysis</i> 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 (<a href="#fig_131">Fig.&nbsp;131</a>).</p>
+
+<div class="figcenter" style="width: 200px;">
+<a name="fig_131" id="fig_131"></a>
+<img src="images/fig131.jpg" width="200" height="378" alt="Fig. 131.&mdash;Contracture Deformities of Upper and Lower
+Limbs resulting from Spastic Cerebral Palsy in infancy." title="" />
+<span class="caption"><span class="smcap">Fig. 131.</span>&mdash;Contracture Deformities of Upper and Lower
+Limbs resulting from Spastic Cerebral Palsy in infancy.<br /><br />
+(Photograph taken after death by Dr. Thomson of Norwich.)</span>
+</div>
+
+<p><a name="X_ankyloses_hip" id="X_ankyloses_hip"></a><b>Contractures and Ankyloses of the Hip.</b>&mdash;Various forms of contracture
+are met with as a result of cicatricial contraction, or from
+shortening of the fasci&aelig;, muscles, and ligaments when the hip has been
+maintained in the flexed position for long periods&mdash;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.</p>
+
+
+<h4><a name="X_coxa_vara" id="X_coxa_vara"></a><span class="smcap">Coxa Vara and Coxa Valga</span></h4>
+
+<p>These deformities depend on abnormalities of the angle of the neck of
+the femur; the average or normal elevation is 125&deg; for the adult and
+135&deg; for the child; variations between 120&deg; and 140&deg; are considered
+normal. If the angle is less than 120&deg; the condition is one of coxa
+vara; if greater than 140&deg;, 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<a class="pagenum" name="Pg_257" id="Pg_257"></a> 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.</p>
+
+<p><b>Coxa Vara&mdash;Incurvation of the Neck of the Femur.</b>&mdash;There may be a
+simple adduction bend of the neck, the head sinking to, or even below,
+the level of the great trochanter (<a href="#fig_132">Fig.&nbsp;132</a>); 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.</p>
+
+<div class="figcenter" style="width: 600px;">
+<a name="fig_132" id="fig_132"></a>
+<img src="images/fig132.jpg" width="600" height="330" alt="Fig. 132.&mdash;Rachitic Coxa Vara." title="" />
+<span class="caption"><span class="smcap">Fig. 132.</span>&mdash;Rachitic Coxa Vara.<br /><br />
+(Sir Robert Jones&#39; case. Radiogram by Dr. Morgan.)</span>
+</div>
+
+<p><i>Adolescent Coxa Vara.</i>&mdash;This, the most common clinical type, is met
+with in boys between the ages of twelve and eighteen. The <i>unilateral</i>
+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&mdash;shortening with
+eversion and stiffness at the hip&mdash;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.</p>
+
+<p><i>When the condition is bilateral</i> 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 (<a href="#fig_134">Fig.&nbsp;134</a>), and in extreme cases the patient is
+only able to walk with the aid of crutches.</p>
+
+<p><i>Diagnosis.</i>&mdash;Pain in the hip and a limp in walking suggest <i>hip-joint
+disease</i>, 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 <i>congenital<a class="pagenum" name="Pg_258" id="Pg_258"></a> dislocation of the hip</i>
+the diagnosis can usually be made by the history, the examination of
+the joint and of its movements; and by the Trendelenburg test (<a href="#Pg_252">p.&nbsp;252</a>).
+In <i>sacro-iliac disease</i>, 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.</p>
+
+<p><i>Treatment.</i>&mdash;In the early stages, especially if there is pain and
+tenderness, the patient must lie up and extension is applied<a class="pagenum" name="Pg_259" id="Pg_259"></a> 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 an&aelig;sthesia, 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<a class="pagenum" name="Pg_260" id="Pg_260"></a>
+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.</p>
+
+<table class="figure" summary="Fig 133, 134.">
+<tr>
+<td class="figcenter" style="width: 200px;">
+<a name="fig_133" id="fig_133"></a>
+<img src="images/fig133.jpg" width="200" height="463" alt="Fig. 133.&mdash;Coxa Vara, showing adduction curvature of
+neck of femur associated with arthritis of the hip and knee." title="" />
+<span class="caption"><span class="smcap">Fig. 133.</span>&mdash;Coxa Vara, showing adduction curvature of
+neck of femur associated with arthritis of the hip and knee.</span>
+</td>
+
+<td style="width: 50px;">&nbsp;</td>
+
+<td class="figcenter" style="width: 150px;">
+<a name="fig_134" id="fig_134"></a>
+<img src="images/fig134.jpg" width="150" height="463" alt="Fig. 134.&mdash;Bilateral Coxa Vara, showing scissors-leg
+deformity." title="" />
+<span class="caption"><span class="smcap">Fig. 134.</span>&mdash;Bilateral Coxa Vara, showing scissors-leg
+deformity.</span>
+</td>
+</tr>
+</table>
+
+<p><a class="pagenum" name="Pg_261" id="Pg_261"></a>In cases of traumatic origin&mdash;epiphysial separation&mdash;Sprengel has
+obtained good results by forcibly abducting and internally rotating
+the limb under an an&aelig;sthetic, and then applying a plaster-case which
+extends down to the knee.</p>
+
+<p><b>Other Forms of Coxa Vara.</b>&mdash;In <i>rickety children</i>, 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.</p>
+
+<p>In <i>arthritis deformans</i> 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.</p>
+
+<p>In <i>osteomyelitis fibrosa</i>, 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.</p>
+
+<p>The <i>congenital variety</i> 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.</p>
+
+<p><b>Coxa Valga.</b>&mdash;Coxa valga is the reverse of coxa vara, the angle at the
+neck of the femur being over 140&deg;. 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 N&eacute;laton'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.</p>
+
+<p>In recent cases it may be possible under an&aelig;sthesia 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.</p>
+
+
+<h4><a class="pagenum" name="Pg_262" id="Pg_262"></a><span class="smcap">The Region of the Knee</span></h4>
+
+<p><a name="X_knee_dislocation" id="X_knee_dislocation"></a><b>Congenital dislocation</b> 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.</p>
+
+<p><b>Congenital absence of the patella</b> 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.</p>
+
+<p><b>Congenital Dislocation of the Patella Laterally.</b>&mdash;This may be
+persistent or intermittent. In the <i>persistent form</i> 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.</p>
+
+<p>In <i>the intermittent</i> or <i>recurrent</i> 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.</p>
+
+<p>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.</p>
+
+<p><a class="pagenum" name="Pg_263" id="Pg_263"></a>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.</p>
+
+<p>Lateral dislocation of the patella is met with in extreme forms of
+<i>knock-knee</i>, and after correction of this deformity by osteotomy, and
+its possible occurrence should be guarded against at the time of the
+operation.</p>
+
+<p><a name="X_genu_recurvatum" id="X_genu_recurvatum"></a><b>Genu Recurvatum.</b>&mdash;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.</p>
+
+<p>There are several varieties. In the <i>congenital form</i>, which is
+apparently due to a faulty attitude of the lower extremities <i>in
+utero</i>, 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 an&aelig;sthetic, and maintaining this
+attitude by means of plaster-of-Paris or splints until the growth of
+parts overcomes any tendency to relapse.</p>
+
+<p><i>Acquired Forms.</i>&mdash;The most common acquired form is the result of
+anterior poliomyelitis, and is described in the next section.</p>
+
+<p>The deformity may also be due to rickets which has caused a backward
+bend of the tibia immediately below its upper epiphysis&mdash;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.</p>
+
+<p>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.</p>
+
+<p><a name="X_knee_poliomyelitis" id="X_knee_poliomyelitis"></a><a class="pagenum" name="Pg_264" id="Pg_264"></a><b>Deformities of the Knee resulting from Anterior Poliomyelitis and from
+Spastic Paralysis.</b>&mdash;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.</p>
+
+<p>When the <i>quadriceps alone</i> 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 <i>genu recurvatum</i>.
+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.</p>
+
+<p>When the quadriceps is overcome by a <i>contraction of the hamstrings</i>,
+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.</p>
+
+<p><a name="X_knee_ankylosis" id="X_knee_ankylosis"></a><b>Contracture and Ankylosis at the Knee.</b>&mdash;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.</p>
+
+
+<h4><a name="X_genu_valgum" id="X_genu_valgum"></a><span class="smcap">Genu Valgum and Genu Varum</span></h4>
+
+<p>In the normal limb, a line drawn from the centre of the head of the
+femur to a point midway between the malleoli passes<a class="pagenum" name="Pg_265" id="Pg_265"></a> 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 (<a href="#fig_135">Fig.&nbsp;135</a>).</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_135" id="fig_135"></a>
+<img src="images/fig135.png" width="400" height="405" alt="Fig. 135." title="" />
+<span class="caption"><span class="smcap">Fig. 135.</span></span>
+</div>
+
+<p><b>Genu Valgum&mdash;Knock-knee.</b>&mdash;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.</p>
+
+<p><i>Etiology.</i>&mdash;The observations of Macewen and of Mikulicz, and
+information afforded by the R&ouml;ntgen 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.</p>
+
+<p><a class="pagenum" name="Pg_266" id="Pg_266"></a><i>Pathological Anatomy.</i>&mdash;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.</p>
+
+<div class="figcenter" style="width: 200px;">
+<a name="fig_136" id="fig_136"></a>
+<img src="images/fig136.jpg" width="200" height="505" alt="Fig. 136.&mdash;Female child with right-sided Genu Valgum,
+the result of Rickets. The pelvis is tilted, and the spine is curved." title="" />
+<span class="caption"><span class="smcap">Fig. 136.</span>&mdash;Female child with right-sided Genu Valgum,
+the result of Rickets. The pelvis is tilted, and the spine is curved.</span>
+</div>
+
+<p>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<a class="pagenum" name="Pg_267" id="Pg_267"></a> 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.</p>
+
+<div class="figcenter" style="width: 200px;">
+<a name="fig_137" id="fig_137"></a>
+<img src="images/fig137.jpg" width="200" height="488" alt="Fig. 137.&mdash;Female child with Rickety deformities of
+upper and lower extremities." title="" />
+<span class="caption"><span class="smcap">Fig. 137.</span>&mdash;Female child with Rickety deformities of
+upper and lower extremities.<br /><br />
+(Mr. D. M. Greig&#39;s case.)</span>
+</div>
+
+<p><i>Radiograms</i> reveal the changes in the bones (<a href="#fig_138">Fig.&nbsp;138</a>); 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.</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_138" id="fig_138"></a>
+<img src="images/fig138.jpg" width="300" height="301" alt="Fig. 138.&mdash;Radiogram of case of Double Genu Valgum in a
+child &aelig;t. 4." title="" />
+<span class="caption"><span class="smcap">Fig. 138.</span>&mdash;Radiogram of case of Double Genu Valgum in a
+child &aelig;t. 4.</span>
+</div>
+
+<p><i>Clinical Features.</i>&mdash;In the infantile form (<a href="#fig_139">Fig.&nbsp;139</a>) 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.</p>
+
+<div class="figcenter" style="width: 250px;">
+<a name="fig_139" id="fig_139"></a>
+<img src="images/fig139.jpg" width="250" height="372" alt="Fig. 139.&mdash;Genu Valgum in a child &aelig;t. 4. Patient
+standing." title="" />
+<span class="caption"><span class="smcap">Fig. 139.</span>&mdash;Genu Valgum in a child &aelig;t. 4. Patient
+standing.</span>
+</div>
+
+<p>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 (<a href="#fig_140">Fig.&nbsp;140</a>), 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<a class="pagenum" name="Pg_268" id="Pg_268"></a> limb is
+a little shorter than its fellow, but the patient compensates for this
+by depressing the pelvis on the affected side.</p>
+
+<div class="figcenter" style="width: 235px;">
+<a name="fig_140" id="fig_140"></a>
+<img src="images/fig140.jpg" width="235" height="372" alt="Fig. 140.&mdash;Genu Valgum. Same patient as Fig. 139.
+Sitting, to show disappearance of deformity on flexion of knee." title="" />
+<span class="caption"><span class="smcap">Fig. 140.</span>&mdash;Genu Valgum. Same patient as <a href="#fig_139">Fig.&nbsp;139.</a>
+Sitting, to show disappearance of deformity on flexion of knee.</span>
+</div>
+
+<p><i>Prognosis.</i>&mdash;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.</p>
+
+<p>The <i>treatment of knock-knee in children</i> 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<a class="pagenum" name="Pg_269" id="Pg_269"></a> under an&aelig;sthesia, 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.</p>
+
+<p>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 <i>osteotomy</i>.</p>
+
+<p>In <i>adolescent knock-knee</i> 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.</p>
+
+<p><a class="pagenum" name="Pg_270" id="Pg_270"></a>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><b>Other forms of genu valgum</b> are relatively rare. There is a congenital
+form arising from faulty position of the limbs <i>in utero</i>; a traumatic
+form following fracture or epiphysial separation in the region of the
+knee; and a paralytic form, usually<a class="pagenum" name="Pg_271" id="Pg_271"></a> 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.</p>
+
+<p><b>Genu Varum&mdash;Bow-knee.</b>&mdash;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 (<a href="#fig_141">Fig.&nbsp;141</a>). 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&mdash;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 <a href="#fig_141">Fig.&nbsp;141</a>.</p>
+
+<div class="figcenter" style="width: 250px;">
+<a name="fig_141" id="fig_141"></a>
+<img src="images/fig141.jpg" width="250" height="390" alt="Fig. 141.&mdash;Bow-knee in Rickety Child." title="" />
+<span class="caption"><span class="smcap">Fig. 141.</span>&mdash;Bow-knee in Rickety Child.</span>
+</div>
+
+<p>Treatment is carried out on the same lines as in genu valgum.</p>
+
+<p><a name="X_bow_leg" id="X_bow_leg"></a><b>Rickety Deformities of the Bones of the Leg&mdash;Bow-leg.</b>&mdash;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&mdash;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<a class="pagenum" name="Pg_272" id="Pg_272"></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.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p>The deformities of the bones of the leg in <i>inherited syphilis</i>,
+<i>ostitis deformans</i>, and <i>osteomalacia</i> have already been described.</p>
+
+<p><a name="X_leg_deformities" id="X_leg_deformities"></a><b>Congenital Deficiencies of the Bones of the Leg.</b>&mdash;The <i>tibia</i> 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
+R&ouml;ntgen 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.</p>
+
+<p>The <i>fibula</i> 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<a class="pagenum" name="Pg_273" id="Pg_273"></a> 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.</p>
+
+<p><i>Volkmann's Supra-malleolar Deformity.</i>&mdash;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.</p>
+
+
+<h4><span class="smcap">The Foot</span></h4>
+
+<p>Various deformities are met with in the region of the ankle and
+tarsus. The term &ldquo;talipes&rdquo; 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&mdash;<i>talipes equino-varus</i>. In <i>pes equinus</i> the foot is in the
+position of plantar-flexion, and the patient walks on the toes. In
+<i>pes calcaneus</i> 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, <i>pes calcaneo-valgus</i>, or with inversion, <i>pes
+calcaneo-varus</i>. When the instep is unduly arched, the terms <i>pes
+cavus</i>, <i>pes arcuatus</i> or <i>hollow claw-foot</i> are employed; while loss
+of the arch constitutes <i>flat-foot</i>, and eversion of the sole, <i>pes
+valgus</i>.</p>
+
+
+<h4><a name="X_club_foot" id="X_club_foot"></a><span class="smcap">Club-Foot</span></h4>
+
+<p><a name="X_talipes_equino_varus" id="X_talipes_equino_varus"></a><b>Talipes Equino-varus.</b>&mdash;This deformity may be congenital or acquired.</p>
+
+<p><a class="pagenum" name="Pg_274" id="Pg_274"></a><b>Congenital talipes equino-varus</b> (<a href="#fig_142">Fig.&nbsp;142</a>) 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 f&oelig;tal 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<a class="pagenum" name="Pg_275" id="Pg_275"></a>
+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.</p>
+
+<div class="figcenter" style="width: 250px;">
+<a name="fig_142" id="fig_142"></a>
+<img src="images/fig142.jpg" width="250" height="297" alt="Fig. 142.&mdash;Bilateral Congenital Club-foot in an
+infant." title="" />
+<span class="caption"><span class="smcap">Fig. 142.</span>&mdash;Bilateral Congenital Club-foot in an
+infant.</span>
+</div>
+
+<p><i>Pathological Anatomy.</i>&mdash;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.</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_143" id="fig_143"></a>
+<img src="images/fig143.jpg" width="350" height="244" alt="Fig. 143.&mdash;Radiogram of Bilateral Congenital Club-foot
+in an infant." title="" />
+<span class="caption"><span class="smcap">Fig. 143.</span>&mdash;Radiogram of Bilateral Congenital Club-foot
+in an infant.</span>
+</div>
+
+<p>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.</p>
+
+<p>The changes in the soft parts follow the general law that tissues
+which are relaxed become shortened, while those that<a class="pagenum" name="Pg_276" id="Pg_276"></a> 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.</p>
+
+<p><i>Clinical Features.</i>&mdash;<i>In children who have not walked</i>, 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.</p>
+
+<p>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&mdash;a feature which
+is distinctive of the congenital form of club-foot.</p>
+
+<p><i>In children who have walked</i>, 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 burs&aelig; are formed. These burs&aelig; 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.</p>
+
+<p><i>In adults</i>, these features are further aggravated, and there are
+permanent changes in the bones (<a href="#fig_144">Fig.&nbsp;144</a>).</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_144" id="fig_144"></a>
+<img src="images/fig144.jpg" width="300" height="341" alt="Fig. 144.&mdash;Congenital Talipes Equino-varus in a man &aelig;t.
+24; seen from behind." title="" />
+<span class="caption"><span class="smcap">Fig. 144.</span>&mdash;Congenital Talipes Equino-varus in a man &aelig;t.
+24; seen from behind.</span>
+</div>
+
+<p><i>Treatment.</i>&mdash;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<a class="pagenum" name="Pg_277" id="Pg_277"></a> 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.</p>
+
+<p>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.</p>
+
+<p><a class="pagenum" name="Pg_278" id="Pg_278"></a><i>Tenotomy and Forcible Correction under An&aelig;sthesia.</i>&mdash;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.</p>
+
+<p>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.</p>
+
+<p><i>Resection of a wedge from the tarsus</i> (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.</p>
+
+<p><i>Removal of the talus</i> is an alternative operation to resection of the
+tarsus, and may yield equally good results.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><a class="pagenum" name="Pg_279" id="Pg_279"></a>Finally, <i>amputation</i> may be called for when other methods have
+failed, and the patient is unable to put the foot to the ground
+because of suppurating burs&aelig; and ulceration of the skin.</p>
+
+<p><b>Acquired Talipes Equino-varus.</b>&mdash;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.</p>
+
+<p>At first the joints are flaccid, and the attitude can easily be
+corrected by manipulation. In course of time, however, the opposing
+muscles&mdash;those inserted into the tendo Achillis, the tibialis
+posterior, and the long flexors of the toes&mdash;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.</p>
+
+<p>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.</p>
+
+<p>The <i>treatment</i> of paralytic equino-varus, short of operation, has
+been referred to under anterior poliomyelitis (<a href="#Pg_242">p.&nbsp;242</a>). 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.</p>
+
+<p>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.</p>
+
+<p>As using the limb hastens the restoration of function, the child
+should be got on to his feet as soon as possible.</p>
+
+<p>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<a class="pagenum" name="Pg_280" id="Pg_280"></a> 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.</p>
+
+<p>The occurrence of <b>varus without equinus</b> is so exceptional as not to
+call for separate description.</p>
+
+<p><a name="X_pes_equinus" id="X_pes_equinus"></a><b>Pes Equinus.</b>&mdash;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
+(<a href="#fig_145">Fig.&nbsp;145</a>). 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.</p>
+
+<div class="figcenter" style="width: 250px;">
+<a name="fig_145" id="fig_145"></a>
+<img src="images/fig145.jpg" width="250" height="490" alt="Fig. 145.&mdash;Bilateral Pes Equinus in a boy &aelig;t. 7, the
+result of Spastic Paralysis." title="" />
+<span class="caption"><span class="smcap">Fig. 145.</span>&mdash;Bilateral Pes Equinus in a boy &aelig;t. 7, the
+result of Spastic Paralysis.</span>
+</div>
+
+<p>In <i>poliomyelitis</i> the deformity is most often unilateral (<a href="#fig_146">Fig.&nbsp;146</a>),
+while in <i>spastic paralysis</i> it is frequently bilateral (<a href="#fig_145">Fig.&nbsp;145</a>),
+and is usually accompanied by excessive arching of the foot&mdash;pes
+cavus&mdash;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&mdash;&ldquo;clawing of the toes.&rdquo;</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_146" id="fig_146"></a>
+<img src="images/fig146.jpg" width="300" height="291" alt="Fig. 146.&mdash;Extreme form of Pes Equinus in a girl &aelig;t. 8,
+the result of Anterior Poliomyelitis." title="" />
+<span class="caption"><span class="smcap">Fig. 146.</span>&mdash;Extreme form of Pes Equinus in a girl &aelig;t. 8,
+the result of Anterior Poliomyelitis.</span>
+</div>
+
+<div class="figleft" style="width: 149px;">
+<a name="fig_147" id="fig_147"></a>
+<img src="images/fig147.jpg" width="149" height="550" alt="Fig. 147.&mdash;Skeleton of Foot from case of Pes Equinus
+due to Poliomyelitis." title="" />
+<span class="caption"><span class="smcap">Fig. 147.</span>&mdash;Skeleton of Foot from case of Pes Equinus
+due to Poliomyelitis.</span>
+</div>
+
+<p><i>Clinical Features.</i>&mdash;In the mildest cases the patient is able to
+bring the foot to a right angle. In average cases the heel<a class="pagenum" name="Pg_281" id="Pg_281"></a> 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 (<a href="#fig_146">Fig.&nbsp;146</a>). The patient suffers from
+painful corns and callosities, and from inflammation of burs&aelig; 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.</p>
+
+<p>The talus projects on the dorsum, the anterior part of its trochlear
+surface escapes from the tibio-fibular socket, and the<a class="pagenum" name="Pg_282" id="Pg_282"></a> calcaneus is
+drawn up so that it comes into contact with the bones of the leg (<a href="#fig_147">Fig.&nbsp;147</a>).</p>
+
+<p>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 fasci&aelig;, 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.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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 <a href="#fig_147">Fig.&nbsp;147</a>.</p>
+
+<p>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.</p>
+
+<p><a name="X_pes_calcaneus" id="X_pes_calcaneus"></a><b>Pes Calcaneus.</b>&mdash;In this deformity the foot is dorsiflexed at the
+ankle-joint. It is sometimes combined with eversion of the foot&mdash;<i>pes
+calcaneo-valgus</i>, or with inversion&mdash;<i>pes calcaneo-varus</i>.</p>
+
+<p><a class="pagenum" name="Pg_283" id="Pg_283"></a>Pes calcaneus may be congenital or acquired. In the <i>congenital form</i>
+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.</p>
+
+<p>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&mdash;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.</p>
+
+<p>In the <i>acquired form</i>, 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&mdash;pes cavus&mdash;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.</p>
+
+<p>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.</p>
+
+<p>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<a class="pagenum" name="Pg_284" id="Pg_284"></a> 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.</p>
+
+<p><a name="X_pes_calcaneo_valgus" id="X_pes_calcaneo_valgus"></a><b>Pes Calcaneo-valgus.</b>&mdash;This deformity, which consists in a combination
+of dorsiflexion at the ankle and eversion of the foot, is as common as
+pure calcaneus (<a href="#fig_148">Figs.&nbsp;148</a> and <a href="#fig_149">149</a>); 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.</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_148" id="fig_148"></a>
+<img src="images/fig148.png" width="350" height="339" alt="Fig. 148.&mdash;Pes Calcaneo-valgus with excessive arching
+of foot." title="" />
+<span class="caption"><span class="smcap">Fig. 148.</span>&mdash;Pes Calcaneo-valgus with excessive arching
+of foot.</span>
+</div>
+
+<p>&nbsp;</p>
+
+<div class="figcenter" style="width: 250px;">
+<a name="fig_149" id="fig_149"></a>
+<img src="images/fig149.jpg" width="250" height="343" alt="Fig. 149.&mdash;Pes Calcaneo-valgus, the result of
+Poliomyelitis." title="" />
+<span class="caption"><span class="smcap">Fig. 149.</span>&mdash;Pes Calcaneo-valgus, the result of
+Poliomyelitis.</span>
+</div>
+
+<p><a name="X_pes_calcaneo_varus" id="X_pes_calcaneo_varus"></a><b>Pes Calcaneo-varus.</b>&mdash;In this rare deformity the heel is depressed and
+the sole of the foot looks inwards.</p>
+
+<p><a name="X_pes_cavus" id="X_pes_cavus"></a><b>Pes Cavus.</b>&mdash;In this deformity, which is known also as <i>hollow
+claw-foot</i>, <i>pes arcuatus</i>, or <i>pes excavatus</i>, the longitudinal arch
+of the foot is exaggerated as a result of the approximation of the
+balls of the toes to the heel (<a href="#fig_150">Fig.&nbsp;150</a>). 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.</p>
+
+<p>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.</p>
+
+<p><a class="pagenum" name="Pg_285" id="Pg_285"></a><i>Treatment</i> 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.</p>
+
+
+<div class="figcenter" style="width: 300px;"><a class="pagenum" name="Pg_286" id="Pg_286"></a>
+<a name="fig_150" id="fig_150"></a>
+<img src="images/fig150.jpg" width="300" height="302" alt="Fig. 150.&mdash;Pes Cavus in association with Pes Equinus,
+the result of Poliomyelitis." title="" />
+<span class="caption"><span class="smcap">Fig. 150.</span>&mdash;Pes Cavus in association with Pes Equinus,
+the result of Poliomyelitis.</span>
+</div>
+
+<p>&nbsp;</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_151" id="fig_151"></a>
+<img src="images/fig151.jpg" width="350" height="241" alt="Fig. 151.&mdash;Radiogram of Foot of adult, showing the
+changes in the bones in Pes Cavus." title="" />
+<span class="caption"><span class="smcap">Fig. 151.</span>&mdash;Radiogram of Foot of adult, showing the
+changes in the bones in Pes Cavus.</span>
+</div>
+
+<h4><a name="X_flat_foot" id="X_flat_foot"></a><span class="smcap">Flat-Foot&mdash;Pes Planus and Pes Valgus</span></h4>
+
+<p>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.<a class="pagenum" name="Pg_287" id="Pg_287"></a> The term
+<i>pes planus</i> is applicable when there is merely loss of the arch; <i>pes
+valgus</i> 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, gonorrh&oelig;al, and tabetic.</p>
+
+<p><b>Static or Adolescent Flat-foot.</b>&mdash;This, by far the most common and
+important variety (<a href="#fig_152">Fig.&nbsp;152</a>), 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.</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_152" id="fig_152"></a>
+<img src="images/fig152.jpg" width="300" height="286" alt="Fig. 152.&mdash;Adolescent Flat-foot." title="" />
+<span class="caption"><span class="smcap">Fig. 152.</span>&mdash;Adolescent Flat-foot.</span>
+</div>
+
+<p>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<a class="pagenum" name="Pg_288" id="Pg_288"></a> which entails much
+standing&mdash;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 &ldquo;the
+attitude of rest,&rdquo; 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&mdash;especially the inferior calcaneo-navicular&mdash;are stretched
+and lengthened. In something like 80 per cent. there is the combined
+deformity&mdash;pes plano-valgus&mdash;in those who apply for treatment.</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_153" id="fig_153"></a>
+<img src="images/fig153.jpg" width="350" height="225" alt="Fig. 153.&mdash;Flat-foot, showing loss of arch." title="" />
+<span class="caption"><span class="smcap">Fig. 153.</span>&mdash;Flat-foot, showing loss of arch.</span>
+</div>
+
+<p><i>Clinical Features.</i>&mdash;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<a class="pagenum" name="Pg_289" id="Pg_289"></a> than when it has
+developed, and at this stage it is not so easily recognised, and is
+apt to be called &ldquo;rheumatism.&rdquo; 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.</p>
+
+<p>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.</p>
+
+<p>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<a class="pagenum" name="Pg_290" id="Pg_290"></a> 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 (<a href="#fig_154">Fig.&nbsp;154</a>). 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.</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_154" id="fig_154"></a>
+<img src="images/fig154.png" width="300" height="314" alt="Fig. 154.&mdash;Imprint of Normal and of Flat Foot." title="" />
+<span class="caption"><span class="smcap">Fig. 154.</span>&mdash;Imprint of Normal and of Flat Foot.</span>
+</div>
+
+<p><i>Skiagrams</i> are useful for showing displacement of bones and
+differences between sitting and standing, and for recording the
+results of treatment.</p>
+
+<p><i>Prophylaxis of Flat-foot.</i>&mdash;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<a class="pagenum" name="Pg_291" id="Pg_291"></a> medial side of the boot is kept
+straight and the end of the boot is opposite the big toe.</p>
+
+<p><i>Treatment.</i>&mdash;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 an&aelig;sthesia; a fourth, in which the bones
+are so displaced and altered in shape that correction is impossible
+without operation.</p>
+
+<p><i>Cases of the First Degree.</i>&mdash;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<a class="pagenum" name="Pg_292" id="Pg_292"></a> 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.</p>
+
+<p>In <i>cases of the second degree</i>, 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.</p>
+
+<p>In <i>cases of the third degree</i>, the deformity is corrected under an
+an&aelig;sthetic. 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.</p>
+
+<p>In <i>cases of the fourth degree</i>, 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.</p>
+
+<p><b>Spasmodic Flat-foot.</b>&mdash;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 an&aelig;sthetic; and in this position it is
+encased in plaster-of-Paris. Jones resects an inch of each of the
+peroneal tendons about 2<span class="frac_top">1</span>/<span class="frac_bottom">2</span> 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.</p>
+
+<p><b>Paralytic Flat-foot</b> (<a href="#fig_155">Fig.&nbsp;155</a>).&mdash;In typical cases this results from
+poliomyelitis affecting the tibial muscles. When other<a class="pagenum" name="Pg_293" id="Pg_293"></a> groups of
+muscles are affected at the same time, compound deformities, such as
+pes calcaneo-valgus, are more likely to result.</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_155" id="fig_155"></a>
+<img src="images/fig155.jpg" width="350" height="397" alt="Fig. 155.&mdash;Bilateral Pes Valgus and Hallux Valgus in a
+girl &aelig;t. 15, the result of Anterior Poliomyelitis." title="" />
+<span class="caption"><span class="smcap">Fig. 155.</span>&mdash;Bilateral Pes Valgus and Hallux Valgus in a
+girl &aelig;t. 15, the result of Anterior Poliomyelitis.</span>
+</div>
+
+<p>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.</p>
+
+<p><b>Traumatic flat-foot</b> 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<a class="pagenum" name="Pg_294" id="Pg_294"></a> 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.</p>
+
+<p><b>Other Forms of Flat-foot.</b>&mdash;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 gonorrh&oelig;a,
+arthritis deformans, tuberculosis, and Charcot's disease; the
+gonorrh&oelig;al 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 f&oelig;tus
+<i>in utero</i>. 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.</p>
+
+<p><b>Pes Transverso-planus.</b>&mdash;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.</p>
+
+<p><a name="X_heel" id="X_heel"></a><b>Painful Affections of the Heel.</b>&mdash;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 (<a href="#fig_156">Fig.&nbsp;156</a>).
+The condition is usually bilateral. Complete relief is obtained by
+removing the spur by operation.</p>
+
+<p>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.</p>
+
+<p><a name="X_metatarsalgia" id="X_metatarsalgia"></a><a class="pagenum" name="Pg_295" id="Pg_295"></a><b>Metatarsalgia.</b>&mdash;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&mdash;pes transverso-planus&mdash;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.</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_156" id="fig_156"></a>
+<img src="images/fig156.jpg" width="300" height="370" alt="Fig. 156.&mdash;Radiogram of Spur on under aspect of
+Calcaneus." title="" />
+<span class="caption"><span class="smcap">Fig. 156.</span>&mdash;Radiogram of Spur on under aspect of
+Calcaneus.</span>
+</div>
+
+<p><i>Treatment.</i>&mdash;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<a class="pagenum" name="Pg_296" id="Pg_296"></a> 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.</p>
+
+<p><a name="X_hallux_valgus" id="X_hallux_valgus"></a><b>Hallux Valgus and Bunion.</b>&mdash;<i>Hallux valgus</i> 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 (<a href="#fig_155">Figs.&nbsp;155</a>, <a href="#fig_157">157</a>). 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 <i>bunion</i>. 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.</p>
+
+<div class="figcenter" style="width: 250px;">
+<a name="fig_157" id="fig_157"></a>
+<img src="images/fig157.jpg" width="250" height="359" alt="Fig. 157.&mdash;Radiogram of Hallux Valgus. The sesamoid
+bone is seen displaced towards middle line of the foot." title="" />
+<span class="caption"><span class="smcap">Fig. 157.</span>&mdash;Radiogram of Hallux Valgus. The sesamoid
+bone is seen displaced towards middle line of the foot.</span>
+</div>
+
+<p>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<a class="pagenum" name="Pg_297" id="Pg_297"></a> 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.</p>
+
+<p>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 (<a href="#fig_157">Fig.&nbsp;157</a>). 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.</p>
+
+<p>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.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+<p>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<a class="pagenum" name="Pg_298" id="Pg_298"></a> 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.</p>
+
+<p><a name="X_hallux_varus" id="X_hallux_varus"></a><b>Hallux Varus or Pigeon-toe</b> (<a href="#fig_158">Fig.&nbsp;158</a>).&mdash;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.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_158" id="fig_158"></a>
+<img src="images/fig158.jpg" width="400" height="244" alt="Fig. 158.&mdash;Radiogram of Hallux Varus or Pigeon-toe." title="" />
+<span class="caption"><span class="smcap">Fig. 158.</span>&mdash;Radiogram of Hallux Varus or Pigeon-toe.</span>
+</div>
+
+<p><a name="X_hallux_rigidus" id="X_hallux_rigidus"></a><b>Hallux Rigidus and Hallux Flexus</b> (<a href="#fig_159">Fig.&nbsp;159</a>).&mdash;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&mdash;<i>hallux
+rigidus</i>&mdash;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 <i>hallux dolorosus</i> is applied.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_159" id="fig_159"></a>
+<img src="images/fig159.jpg" width="400" height="282" alt="Fig. 159.&mdash;Hallux Rigidus and Flexus in a boy &aelig;t. 17.
+There is a suppurating corn over the head of the first metatarsal
+bone." title="" />
+<span class="caption"><span class="smcap">Fig. 159.</span>&mdash;Hallux Rigidus and Flexus in a boy &aelig;t. 17.
+There is a suppurating corn over the head of the first metatarsal
+bone.</span>
+</div>
+
+<p>As the disease progresses, the toe is drawn towards the sole and
+becomes permanently flexed&mdash;<i>hallux flexus</i>&mdash;and any attempt at
+dorsiflexion is attended with pain.</p>
+
+<p>The condition is met with chiefly in adolescent males, is<a class="pagenum" name="Pg_299" id="Pg_299"></a> 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.</p>
+
+<p>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.</p>
+
+<p><i>Treatment.</i>&mdash;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<a class="pagenum" name="Pg_300" id="Pg_300"></a> 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 an&aelig;sthesia, 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.</p>
+
+<p><a name="X_hammer_toe" id="X_hammer_toe"></a><b>Hammer-toe.</b>&mdash;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.</p>
+
+<p>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 (<a href="#fig_160">Fig.&nbsp;160</a>), 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 (<a href="#fig_160">Fig.&nbsp;160</a>). The skin over the head of the
+first phalanx being<a class="pagenum" name="Pg_301" id="Pg_301"></a> pressed upon by the boot usually presents a corn,
+under which a bursa forms (<a href="#fig_161">Fig.&nbsp;161</a>). 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&mdash;hence the
+supposed resemblance to the head of a hammer.</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_160" id="fig_160"></a>
+<img src="images/fig160.jpg" width="350" height="249" alt="Fig. 160.&mdash;Hammer-toe." title="" />
+<span class="caption"><span class="smcap">Fig. 160.</span>&mdash;Hammer-toe.</span>
+</div>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<div class="figcenter" style="width: 450px;">
+<a name="fig_161" id="fig_161"></a>
+<img src="images/fig161.png" width="450" height="201" alt="Fig. 161.&mdash;Section of Hammer-toe." title="" />
+<span class="caption"><span class="smcap">Fig. 161.</span>&mdash;Section of Hammer-toe.<br /><br />
+<i>a</i>, Corn.<br />
+<i>b</i>, Bursa over first inter-phalangeal joint.</span>
+</div>
+
+<p>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&mdash;Spitzy also divides the flexor tendons and
+capsule&mdash;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<a class="pagenum" name="Pg_302" id="Pg_302"></a> 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.</p>
+
+<p>The term <i>Gampsodactyly</i> 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.</p>
+
+<p><a name="X_hypertrophy_toes" id="X_hypertrophy_toes"></a><b>Hypertrophy of the Toes.</b>&mdash;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 (<a href="#fig_162">Fig.&nbsp;162</a>). 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 (<a href="#fig_162">Fig.&nbsp;162</a>). The treatment consists
+in<a class="pagenum" name="Pg_303" id="Pg_303"></a> amputating as much of the toe as will allow of an ordinary boot
+being worn.</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_162" id="fig_162"></a>
+<img src="images/fig162.jpg" width="300" height="381" alt="Fig. 162.&mdash;Congenital Hypertrophy of Left Lower
+Extremity in a boy &aelig;t. 5. The second and third toes are fused." title="" />
+<span class="caption"><span class="smcap">Fig. 162.</span>&mdash;Congenital Hypertrophy of Left Lower
+Extremity in a boy &aelig;t. 5. The second and third toes are fused.</span>
+</div>
+
+<p><a name="X_supernumerary_toes" id="X_supernumerary_toes"></a><b>Supernumerary Toes</b> (<i>Polydactylism</i>).&mdash;These vary from mere appendages
+of skin to fully developed toes (<a href="#fig_163">Fig.&nbsp;163</a>); if they interfere with the
+wearing of boots they should be removed.</p>
+
+<p><a name="X_webbed_toes" id="X_webbed_toes"></a><b>Webbing of the Toes</b> (<i>Syndactylism</i>).&mdash;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.</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_163" id="fig_163"></a>
+<img src="images/fig163.jpg" width="300" height="255" alt="Fig. 163.&mdash;Supernumerary Great Toe." title="" />
+<span class="caption"><span class="smcap">Fig. 163.</span>&mdash;Supernumerary Great Toe.<br /><br />
+(Photograph lent by Sir George T. Beatson.)</span>
+</div>
+
+
+<h3><a name="X_upper_extremity" id="X_upper_extremity"></a>THE UPPER EXTREMITY</h3>
+
+<p><a name="X_absence_clavicle" id="X_absence_clavicle"></a><b>Congenital Absence of the Clavicle.</b>&mdash;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.</p>
+
+<p><a name="X_elevation_scapula" id="X_elevation_scapula"></a><b>Displacements of the Scapula.</b>&mdash;<i>Congenital Elevation of the Scapula</i>
+(Sprengel's shoulder, 1891).&mdash;This abnormality is rare,<a class="pagenum" name="Pg_304" id="Pg_304"></a> 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
+vertebr&aelig;, 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 vertebr&aelig; and in the ribs are shown in skiagrams.
+In the more common type, the scapula seems to be held in its elevated
+position by shorten<a class="pagenum" name="Pg_305" id="Pg_305"></a>ing 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.</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_164" id="fig_164"></a>
+<img src="images/fig164.jpg" width="300" height="432" alt="Fig. 164.&mdash;Congenital elevation of Left Scapula in a
+girl: also shows hairy mole over Sacrum." title="" />
+<span class="caption"><span class="smcap">Fig. 164.</span>&mdash;Congenital elevation of Left Scapula in a
+girl: also shows hairy mole over Sacrum.<br /><br />
+(Mr. D. M. Greig&#39;s case.)</span>
+</div>
+
+<p>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.</p>
+
+<p>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<a class="pagenum" name="Pg_306" id="Pg_306"></a> is drawn down to its proper position, and the parts are fixed by
+plaster bandages.</p>
+
+<p><a name="X_winged_scapula" id="X_winged_scapula"></a><i>Winged Scapula.</i>&mdash;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 (<a href="#fig_165">Fig.&nbsp;165</a>). 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 <i>point d'appui</i>, its contraction merely results in
+tilting the angle of the scapula backward (<a href="#fig_165">Fig.&nbsp;165</a>).</p>
+
+<div class="figcenter" style="width: 250px;">
+<a name="fig_165" id="fig_165"></a>
+<img src="images/fig165.jpg" width="250" height="315" alt="Fig. 165.&mdash;Winged Scapula; the patient is holding the
+arms out in front." title="" />
+<span class="caption"><span class="smcap">Fig. 165.</span>&mdash;Winged Scapula; the patient is holding the
+arms out in front.</span>
+</div>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p>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).</p>
+
+<p><i>Displacement of the scapula upwards and laterally</i> 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.</p>
+
+<p><a name="X_congenital_shoulder" id="X_congenital_shoulder"></a><b>Congenital Dislocation of the Shoulder.</b>&mdash;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.<a class="pagenum" name="Pg_307" id="Pg_307"></a> 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 <i>vice versa</i>.</p>
+
+<p><a class="pagenum" name="Pg_308" id="Pg_308"></a><b>Habitual Dislocation</b> is described on <a href="#Pg_65">p.&nbsp;65</a>.</p>
+
+<p><b>Paralytic Deformities&mdash;Paralytic Dislocation of the Shoulder.</b>&mdash;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&mdash;especially the deltoid and
+lateral rotators&mdash;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.</p>
+
+<p>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.</p>
+
+<div class="figcenter" style="width: 250px;">
+<a name="fig_166" id="fig_166"></a>
+<img src="images/fig166.jpg" width="250" height="440" alt="Fig. 166.&mdash;Arrested Growth and Wasting of Tissues of
+Right Upper Extremity, the result of Anterior Poliomyelitis in
+childhood." title="" />
+<span class="caption"><span class="smcap">Fig. 166.</span>&mdash;Arrested Growth and Wasting of Tissues of
+Right Upper Extremity, the result of Anterior Poliomyelitis in
+childhood.</span>
+</div>
+
+<p><a name="X_deformities_elbow" id="X_deformities_elbow"></a><b>Congenital Dislocations at the Elbow.</b>&mdash;<i>The head of the radius</i> may be
+dislocated forwards, backwards, or laterally&mdash;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.</p>
+
+<p><b>Cubitus Valgus</b> and <b>Cubitus Varus</b>.&mdash;When the normal arm hangs by the
+side with the palm of the hand directed forward,<a class="pagenum" name="Pg_309" id="Pg_309"></a> the forearm and
+upper arm form an angle which is open outwards&mdash;known as the &ldquo;carrying
+angle&rdquo;; 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 <i>cubitus valgus</i>. 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.</p>
+
+<p><a class="pagenum" name="Pg_310" id="Pg_310"></a><i>Cubitus varus</i> 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.</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_167" id="fig_167"></a>
+<img src="images/fig167.jpg" width="300" height="375" alt="Fig. 167.&mdash;Lower end of Humerus from case of Cubitus
+Varus." title="" />
+<span class="caption"><span class="smcap">Fig. 167.</span>&mdash;Lower end of Humerus from case of Cubitus
+Varus.</span>
+</div>
+
+<p><b>Synostosis of the superior radio-ulnar joint</b> 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.</p>
+
+<p><b>Volkmann's isch&aelig;mic contracture</b> of the muscles of the forearm,
+resulting in the production of claw-hand, is described in Volume I.,
+p. 415.</p>
+
+<p><b>Deformities of the Forearm and Hand.</b>&mdash;The <i>radius</i> 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&mdash;one variety of<a class="pagenum" name="Pg_311" id="Pg_311"></a> <i>club-hand</i>. 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 (<a href="#fig_171">Fig.&nbsp;171</a>). 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.</p>
+
+<p>Congenital deficiency of the <i>ulna</i> is extremely rare.</p>
+
+<p><b>Intra-uterine amputation</b> by constriction of amniotic bands sometimes
+occurs (<a href="#fig_168">Figs.&nbsp;168</a>, <a href="#fig_169">169</a>).</p>
+
+<table class="figure" summary="Fig 167, 168">
+<tr>
+<td class="figcenter" style="width: 214px;">
+<a name="fig_168" id="fig_168"></a>
+<img src="images/fig168.jpg" width="214" height="400" alt="Fig. 168.&mdash;Intra-uterine Amputation of Forearm." title="" />
+<span class="caption"><span class="smcap">Fig. 168.</span>&mdash;Intra-uterine Amputation of Forearm.</span>
+</td>
+
+<td style="width: 50px;">&nbsp;</td>
+
+<td class="figcenter" style="width: 211px;">
+<a name="fig_169" id="fig_169"></a>
+<img src="images/fig169.jpg" width="211" height="400" alt="Fig. 169.&mdash;Radiogram of Arm of patient shown in Fig.
+168." title="" />
+<span class="caption"><span class="smcap">Fig. 169.</span>&mdash;Radiogram of Arm of patient shown in <a href="#fig_168">Fig.&nbsp;168</a>.</span>
+</td>
+</tr>
+</table>
+
+<p><b>Drop Wrist from Anterior Poliomyelitis.</b>&mdash;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.</p>
+
+<div class="figcenter" style="width: 200px;">
+<a name="fig_170" id="fig_170"></a>
+<img src="images/fig170.jpg" width="200" height="538" alt="Fig. 170.&mdash;Congenital absence of Left Radius and Tibia
+in a child &aelig;t. 8." title="" />
+<span class="caption"><span class="smcap">Fig. 170.</span>&mdash;Congenital absence of Left Radius and Tibia
+in a child &aelig;t. 8.<br /><br />
+(Mr. D. M. Greig&#39;s case.)</span>
+</div>
+
+<p>In <i>spastic paralysis</i> the most pronounced deformity is flexion of the
+forearm and pronation and flexion of the hand (<a href="#fig_166">Fig.&nbsp;166</a>). 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<a class="pagenum" name="Pg_312" id="Pg_312"></a> 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. &ldquo;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&rdquo; (Tubby and Jones).</p>
+
+<p><a name="X_club_hand" id="X_club_hand"></a><b>Congenital Club-hand.</b>&mdash;This rare deformity corresponds to congenital
+club-foot, and probably arises in the same way.<a class="pagenum" name="Pg_313" id="Pg_313"></a> 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.</p>
+
+<p>A deformity resembling this, <i>acquired club-hand</i>, 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&mdash;<i>manus valga</i> or <i>vara</i>. The treatment consists in
+resecting a portion of the longer bone.</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_171" id="fig_171"></a>
+<img src="images/fig171.jpg" width="300" height="310" alt="Fig. 171.&mdash;Club-hand, the result of imperfect
+development of radius. The thumb is absent." title="" />
+<span class="caption"><span class="smcap">Fig. 171.</span>&mdash;Club-hand, the result of imperfect
+development of radius. The thumb is absent.<br /><br />
+(Photograph lent by Sir George T. Beatson.)</span>
+</div>
+
+<p><a name="X_deformities_wrist" id="X_deformities_wrist"></a><b>Madelung's Deformity of the Wrist.</b>&mdash;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.</p>
+
+<p>When <i>operative treatment</i> is called for, it takes the form of
+osteotomy of the radius and ulna about an inch or more above their
+articular surfaces.</p>
+
+<p><b>Congenital dislocation of the wrist</b> is rare.</p>
+
+<p><a name="X_deformities_fingers" id="X_deformities_fingers"></a><b>Deformities of the Fingers.</b>&mdash;Various forms of <i>congenital dislocation</i>
+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.</p>
+
+<p><i>Congenital lateral deviation of the phalanges</i> 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.</p>
+
+<p><i>Congenital contraction of the fingers</i> 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 (<a href="#fig_172">Fig.&nbsp;172</a>), and is usually bilateral. The second and
+third phalanges are flexed towards<a class="pagenum" name="Pg_314" id="Pg_314"></a> 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
+&ldquo;hook-finger,&rdquo; 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.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_173" id="fig_173"></a>
+<a name="fig_172" id="fig_172"></a>
+<img src="images/fig172.jpg" width="400" height="157" alt="Fig. 172.&mdash;Congenital Contraction of Ring and Little
+Fingers." title="" />
+<span class="caption"><span class="smcap">Fig. 172.</span>&mdash;Congenital Contraction of Ring and Little
+Fingers.</span>
+</div>
+
+<p>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.</p>
+
+<p><a name="X_dupuytren" id="X_dupuytren"></a><b>Dupuytren's Contraction.</b>&mdash;This is an acquired deformity resulting from
+contraction of the palmar fascia and its digital prolongations (<a href="#fig_173">Fig.&nbsp;173</a>).
+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&mdash;such as a hammer or shovel
+or whip&mdash;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.</p>
+
+<div class="figcenter" style="width: 200px;">
+<img src="images/fig173.jpg" width="200" height="346" alt="Fig. 173.&mdash;Dupuytren&#39;s Contraction." title="" />
+<span class="caption"><span class="smcap">Fig. 173.</span>&mdash;Dupuytren&#39;s Contraction.</span>
+</div>
+
+<p>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<a class="pagenum" name="Pg_315" id="Pg_315"></a> 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.</p>
+
+<p>The condition is easily diagnosed from congenital contraction by the
+fact that in the latter the proximal phalanx is dorsiflexed.</p>
+
+<p><a class="pagenum" name="Pg_316" id="Pg_316"></a><i>Treatment.</i>&mdash;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.</p>
+
+<p>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.</p>
+
+<p>After healing has occurred, massage and movements must be persevered
+with, and a splint (<a href="#fig_174">Fig.&nbsp;174</a>) 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.</p>
+
+<div class="figcenter" style="width: 250px;">
+<a name="fig_174" id="fig_174"></a>
+<img src="images/fig174.jpg" width="250" height="407" alt="Fig. 174.&mdash;Splint used after Operation for Dupuytren&#39;s
+Contraction." title="" />
+<span class="caption"><span class="smcap">Fig. 174.</span>&mdash;Splint used after Operation for Dupuytren&#39;s
+Contraction.</span>
+</div>
+
+<p><a name="X_polydactylism" id="X_polydactylism"></a><b>Supernumerary Fingers (Polydactylism).</b>&mdash;These may coexist with
+supernumerary toes, and the condition is often met with<a class="pagenum" name="Pg_317" id="Pg_317"></a> 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 (<a href="#fig_175">Fig.&nbsp;175</a>).
+In the majority of cases the superfluous finger should be
+removed.</p>
+
+<div class="figcenter" style="width: 250px;">
+<a name="fig_175" id="fig_175"></a>
+<img src="images/fig175.jpg" width="250" height="359" alt="Fig. 175.&mdash;Supernumerary Thumb." title="" />
+<span class="caption"><span class="smcap">Fig. 175.</span>&mdash;Supernumerary Thumb.<br /><br />
+(Photograph lent by Sir George T. Beatson.)</span>
+</div>
+
+<p><b>Congenital Deficiencies in the Number of Fingers.</b>&mdash;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 <i>in utero</i>&mdash;the so-called intra-uterine amputation.</p>
+
+<p><b>Webbing of Fingers (Syndactylism).</b>&mdash;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.</p>
+
+<p><b>Congenital Hypertrophy of the Fingers.</b>&mdash;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<a class="pagenum" name="Pg_318" id="Pg_318"></a> 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.</p>
+
+<p><b>Trigger Finger</b> (<a href="#fig_176">Fig.&nbsp;176</a>).&mdash;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.</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_176" id="fig_176"></a>
+<img src="images/fig176.jpg" width="300" height="362" alt="Fig. 176.&mdash;Trigger Finger." title="" />
+<span class="caption"><span class="smcap">Fig. 176.</span>&mdash;Trigger Finger.<br /><br />
+(Photograph lent by Sir George T. Beatson.)</span>
+</div>
+
+<p><b>Drop</b> or <b>mallet finger</b> is described on <a href="#Pg_121">p.&nbsp;121</a>.</p>
+
+
+
+
+<h2><a class="pagenum" name="Pg_319" id="Pg_319"></a><a name="CHAPTER_XI" id="CHAPTER_XI"></a>CHAPTER XI
+<br />
+THE SCALP</h2>
+
+<ul class="chap">
+  <li><a href="#XI_anatomy">Surgical Anatomy</a></li>
+  <li>&mdash;<a href="#XI_injuries">Injuries</a>:</li>
+  <li><a href="#XI_contusion"><i>Contusion</i></a>;</li>
+  <li><a href="#XI_haematoma"><i>H&aelig;matoma</i></a>;</li>
+  <li><a href="#XI_cephal_haematoma"><i>Cephal-h&aelig;matoma</i></a>;</li>
+  <li><a href="#XI_wounds"><i>Wounds</i></a>;</li>
+  <li><a href="#XI_avulsion"><i>Avulsion</i></a></li>
+  <li>&mdash;<a href="#XI_diseases">Diseases</a>:</li>
+  <li><a href="#XI_infective"><i>Infective conditions</i></a>;</li>
+  <li><a href="#XI_cystic">Cystic and solid tumours</a>;</li>
+  <li><a href="#XI_swellings">Air-containing swellings</a>;</li>
+  <li><a href="#XI_vascular">Vascular tumours</a>.</li>
+</ul>
+
+<p><a name="XI_anatomy" id="XI_anatomy"></a><b>Surgical Anatomy.</b>&mdash;The <i>skin</i> of the scalp is intimately united to the
+<i>epicranial aponeurosis</i> 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 <i>pericranium</i> 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.</p>
+
+<p>The <i>blood supply</i> 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.</p>
+
+<p>The <i>venous return</i> is through the frontal, temporal, and occipital
+veins. These have free communications, through the <i>emissary veins</i>,
+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
+<i>mastoid</i>, <i>condyloid</i>, and <i>occipital</i>, passing to the transverse
+(lateral) sinus; the <i>parietal</i>, which enters the superior sagittal
+(longitudinal) sinus; and a branch from the nose which traverses the
+foramen c&aelig;cum and enters the anterior end of the superior sagittal
+sinus.</p>
+
+<p>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.</p>
+
+<p><a class="pagenum" name="Pg_320" id="Pg_320"></a>The <i>lymph vessels</i> pass to the parotid, occipital, mastoid, and
+submaxillary groups of glands, the different areas of drainage being
+ill-defined.</p>
+
+
+<h3><a name="XI_injuries" id="XI_injuries"></a><span class="smcap">Injuries of the Scalp</span></h3>
+
+<p><a name="XI_contusion" id="XI_contusion"></a><b>Subcutaneous Injuries.</b>&mdash;<i>In simple contusion</i> 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.</p>
+
+<p><a name="XI_haematoma" id="XI_haematoma"></a><i>H&aelig;matoma of the scalp</i> 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 h&aelig;matoma 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.</p>
+
+<p>Even a large h&aelig;matoma 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.</p>
+
+<p>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.</p>
+
+<p><a name="XI_cephal_haematoma" id="XI_cephal_haematoma"></a>These effusions are to be distinguished from the <i>cephal-h&aelig;matoma</i>, 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&mdash;usually the parietal&mdash;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<a class="pagenum" name="Pg_321" id="Pg_321"></a> absorption of the extravasated blood. This condition is to
+be diagnosed from traumatic cephal-hydrocele (<a href="#Pg_390">p.&nbsp;390</a>).</p>
+
+<p><a name="XI_wounds" id="XI_wounds"></a><b>Wounds of the Scalp.</b>&mdash;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.</p>
+
+<p>The deeper the wound, the greater is the risk. If the epicranial
+aponeurosis is divided, the &ldquo;dangerous area&rdquo; 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.</p>
+
+<p>The usual varieties of wounds&mdash;incised, punctured, contused, and
+lacerated&mdash;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.</p>
+
+<p>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
+h&aelig;morrhage, 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.</p>
+
+<p><i>Gun-shot wounds</i> of the scalp are usually associated with damage to
+the skull and brain. A spent shot, however, may<a class="pagenum" name="Pg_322" id="Pg_322"></a> pierce the scalp, and
+then, glancing off the bone, lodge in the soft parts.</p>
+
+<p><a name="XI_avulsion" id="XI_avulsion"></a><i>Complete Avulsion.</i>&mdash;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.</p>
+
+<p><i>Treatment of recent Scalp Wounds.</i>&mdash;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&mdash;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 h&aelig;morrhage 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.</p>
+
+<p><b>Complications of Scalp Wounds.</b>&mdash;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 sequel&aelig;
+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 &oelig;dema
+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.</p>
+
+<p>The onset of infection is indicated by restlessness, throbbing pain
+and heat in the wound, a feeling of chilliness or the occur<a class="pagenum" name="Pg_323" id="Pg_323"></a>rence of a
+rigor, and tension of the stitches from &oelig;dema of the surrounding
+tissues. The &oelig;dema 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.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p><i>Erysipelas of the scalp</i> 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 foss&aelig;. It tends to be limited by the
+attachments of deep fasci&aelig;, 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.</p>
+
+
+<h3><a name="XI_diseases" id="XI_diseases"></a><span class="smcap">Diseases of the Scalp</span></h3>
+
+<p><a name="XI_infective" id="XI_infective"></a><b>Infective Conditions.</b>&mdash;It is not uncommon for <i>localised abscesses</i> 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. <i>Suppuration</i> following upon injuries
+has already been referred to.</p>
+
+<p><i>Boils and carbuncles</i> are not common on the hairy part of the scalp.
+<i>Lupus</i> rarely originates on the scalp, although it may spread thither
+from the face. <i>Syphilitic</i> 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. <i>Eczema
+capitis</i> 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.</p>
+
+<p><a name="XI_cystic" id="XI_cystic"></a><b>Cystic and Solid Tumours.</b>&mdash;A great variety of swellings is met with in
+the scalp.</p>
+
+<p><a class="pagenum" name="Pg_324" id="Pg_324"></a><i>Sebaceous cysts</i> or <i>wens</i> are of frequent occurrence, and have been
+described in Volume I.</p>
+
+<p>A <i>dermoid cyst</i> 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.</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_177" id="fig_177"></a>
+<img src="images/fig177.jpg" width="300" height="396" alt="Fig. 177.&mdash;Multiple Wens." title="" />
+<span class="caption"><span class="smcap">Fig. 177.</span>&mdash;Multiple Wens.<br /><br />
+(Photograph lent by Sir George T. Beatson.)</span>
+</div>
+
+<p><i>Serous cysts</i> 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.</p>
+
+<p><i>Adenomas</i> 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 f&oelig;tid discharge, and may be<a class="pagenum" name="Pg_325" id="Pg_325"></a> mistaken for epithelioma; they
+are also liable to become the seat of epithelioma. They are treated by
+excision.</p>
+
+<p>Large, flat <i>papillomas</i> 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.</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_178" id="fig_178"></a>
+<img src="images/fig178.jpg" width="300" height="379" alt="Fig. 178.&mdash;Adenoma of Scalp." title="" />
+<span class="caption"><span class="smcap">Fig. 178.</span>&mdash;Adenoma of Scalp.</span>
+</div>
+
+<p>The <i>plexiform neuroma</i> forms a loose soft tumour situated in the
+course of one or more branches of the trigeminal nerve,<a class="pagenum" name="Pg_326" id="Pg_326"></a> 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
+<i>pachydermatocele</i> (V. Mott).</p>
+
+<p>A <i>sarcoma</i> usually has its origin in the bones of the skull, and only
+implicates the scalp secondarily.</p>
+
+<p><i>Epithelioma</i> 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.</p>
+
+<p><i>Rodent cancer</i> may originate on the scalp, but usually spreads
+thither from the face.</p>
+
+<p>In operating for extensive tumours of the scalp the h&aelig;morrhage 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.</p>
+
+<p><a name="XI_swellings" id="XI_swellings"></a><b>Air-containing Swellings</b>&mdash;<i>Pneumatocele Capitis.</i>&mdash;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.</p>
+
+<p><i>Emphysema of the scalp</i> 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.</p>
+
+<p><a name="XI_vascular" id="XI_vascular"></a><b>Vascular Tumours.</b>&mdash;<i>N&aelig;vi</i> on the scalp present the same features as
+elsewhere. If placed over one of the fontanelles, a n&aelig;vus may derive
+pulsation from the brain, and so simulate a meningocele.</p>
+
+<p><i>Cirsoid aneurysm</i> 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
+h&aelig;morrhage, may take place.</p>
+
+<p><a class="pagenum" name="Pg_327" id="Pg_327"></a>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.</p>
+
+<p><i>Traumatic aneurysm</i> 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.</p>
+
+<p><i>Arterio-venous aneurysm</i> 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.</p>
+
+
+
+
+<h2><a class="pagenum" name="Pg_328" id="Pg_328"></a><a name="CHAPTER_XII" id="CHAPTER_XII"></a>CHAPTER XII
+<br />
+THE CRANIUM AND ITS CONTENTS</h2>
+
+<ul class="chap">
+  <li><a href="#XII_anatomy">Anatomy and physiology</a></li>
+  <li>&mdash;<a href="#XII_cerebral_localisation">Cerebral localisation</a></li>
+  <li>&mdash;<a href="#XII_lumbar_puncture">Lumbar puncture</a>.</li>
+  <li><a href="#XII_head_injuries"><span class="smcap">Head Injuries</span></a></li>
+  <li>&mdash;<a href="#XII_concussion">Concussion</a></li>
+  <li>&mdash;<a href="#XII_cerebral_irritation">Cerebral irritation</a></li>
+  <li>&mdash;<a href="#XII_compression">Compression</a></li>
+  <li>&mdash;<a href="#XII_intra_cranial_haemorrhage">Contusion and laceration of the brain, and traumatic intra-cranial h&aelig;morrhage</a>:</li>
+  <li><a href="#XII_middle_meningeal_haemorrhage"><i>Middle meningeal h&aelig;morrhage</i></a>;</li>
+  <li><i><a href="#XII_inter_carotid">H&aelig;morrhage from internal carotid</a> and <a href="#XII_venous_sinuses">venous sinuses</a></i></li>
+  <li>&mdash;<a href="#XII_newly_born">Intra-cranial h&aelig;morrhage of the newly born. Cerebral &oelig;dema</a></li>
+  <li>&mdash;<a href="#XII_wounds_brain">Wounds of brain</a></li>
+  <li>&mdash;<a href="#XII_after_effects">After-effects of head injuries</a></li>
+  <li>&mdash;<a href="#XII_epilespy">Traumatic epilepsy</a> and <a href="#XII_insanity">insanity</a></li>
+  <li>&mdash;<a href="#XII_infective_complications">Infective complications</a>.</li>
+</ul>
+
+<p><a name="XII_anatomy" id="XII_anatomy"></a><b>Anatomy and Physiology.</b>&mdash;The <i>Cranium</i> is irregularly ovoid in shape,
+and its floor is broken up by various projections to form three
+separate foss&aelig;&mdash;anterior, middle, and posterior&mdash;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.</p>
+
+<p>The <i>outer</i> 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 <i>inner</i> 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&mdash;the
+<i>diplo&euml;</i>&mdash;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.</p>
+
+<p><i>The Membranes of the Brain.</i>&mdash;The <i>dura mater</i> 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&mdash;the <i>sub-dural space</i>&mdash;lies the
+<i>arachno-pial membrane</i>, consisting of an outer (<i>arachnoid</i>) layer
+which envelops the brain but does not pass into the sulci, and a
+highly vascular inner layer&mdash;the <i>pia mater</i>&mdash;which closely invests
+the brain and lines its entire surface.</p>
+
+<p><a class="pagenum" name="Pg_329" id="Pg_329"></a>The space between these layers&mdash;the <i>sub-arachnoid space</i>&mdash;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.</p>
+
+<p>The <i>cerebro-spinal fluid</i> 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 &ldquo;cisterns&rdquo; 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.</p>
+
+<p>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 h&aelig;morrhage,
+abscess, tumour, or depressed fracture, room is made up to a certain
+point for the extraneous matter by displacement of cerebro-spinal
+fluid.</p>
+
+<p><i>Vascular supply.</i>&mdash;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 <i>volume</i> 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
+<i>velocity</i> 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.</p>
+
+<p><b>Nerve Elements.</b>&mdash;The nervous system is composed of a multitude of
+units, called <i>neurones</i>, each neurone consisting of a nucleated cell,
+with branching protoplasmic processes or <i>dendrites</i> and one
+<i>axis-cylinder</i> or <i>axon</i>. 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&mdash;chromatolysis.</p>
+
+<p>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<a class="pagenum" name="Pg_330" id="Pg_330"></a> called a cell-station or <i>synapsis</i>. In this way
+the various sections of the nervous system are kept in association
+with one another and with the rest of the body.</p>
+
+<p><i>Motor Functions and Mechanism.</i>&mdash;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 pr&aelig;central 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) (<a href="#fig_179">Fig.&nbsp;179</a>).</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_179" id="fig_179"></a>
+<a href="images/fig179-large.jpg">
+<img src="images/fig179.jpg" width="400" height="394" alt="Fig. 179.&mdash;Relations of the Motor and Sensory Areas to
+the Convolutions and to Chiene&#39;s Lines." title="" /></a>
+<span class="caption"><span class="smcap">Fig. 179.</span>&mdash;Relations of the Motor and Sensory Areas to
+the Convolutions and to Chiene&#39;s Lines.<br /><br />
+(After Cunningham.)<br />
+<a href="images/fig179-large.jpg">VIEW LARGER IMAGE</a></span>
+</div>
+
+<p>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&mdash;for
+example, the centre for the mouth, tongue, and vocal cords is larger
+than that for the muscles of the trunk.</p>
+
+<p>The motor centres have been localised on the surface of the brain with
+approximate accuracy. For example, above the superior genu of the
+pr&aelig;central gyrus, the centres governing the hip, knee, and toes are
+grouped; opposite the genu are the centres for the movements of the<a class="pagenum" name="Pg_331" id="Pg_331"></a>
+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.</p>
+
+<p><b>The Motor Tracts.</b>&mdash;It is now generally accepted that there are two
+paths by which motor impulses pass from the brain: one&mdash;the
+<i>rubro-spinal tract</i>&mdash;which controls the more elemental movements of
+the body, such as standing, walking, breathing, etc.; the other&mdash;the
+<i>pyramidal tract</i>&mdash;developed later in the evolution of the nervous
+system, and concerned with the finer and more skilled movements.</p>
+
+<p>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 (<a href="#fig_180">Figs.&nbsp;180</a> and <a href="#fig_195">195</a>). 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.</p>
+
+<p>From the internal capsule, the motor fibres pass as the <i>pyramidal
+tract</i> 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.</p>
+
+<p>At the <i>decussation of the pyramids</i> 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 <i>crossed
+pyramidal tract</i>. The remaining fibres pass down as the <i>direct
+pyramidal tract</i>, and decussate in the cord near their termination.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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&mdash;this system of
+cells, axons, and dendritic processes forming an <i>upper neurone</i>. From
+this synapsis the <i>lower neurone</i> 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.</p>
+
+<p>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<a class="pagenum" name="Pg_332" id="Pg_332"></a> 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.</p>
+
+<p><b>Sensory Functions and Mechanism.</b>&mdash;Three kinds of sensory impulses pass
+from the periphery to the brain; (1) deep, or muscular sensibility,
+(2) protopathic sensibility, and (3) epicritic sensibility.</p>
+
+<p><i>Deep sensibility</i> includes the recognition of (<i>a</i>) deep pressure,
+say by the blunt end of a pencil; (<i>b</i>) the position of a joint on
+passive movement (joint sense); (<i>c</i>) 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 an&aelig;sthetic.</p>
+
+<p><i>Protopathic sensibility</i> 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.</p>
+
+<p><i>Epicritic sensibility</i> is the most highly specialised and permits of
+the recognition of light touch, <i>e.g.</i>, 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.</p>
+
+<p>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.</p>
+
+<p>From the cell station in the optic thalamus the fibres proceed to the
+<i>cortical sensory centres</i>, 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.</p>
+
+<p>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.</p>
+
+<div class="figcenter" style="width: 350px;"><a class="pagenum" name="Pg_333" id="Pg_333"></a>
+<a name="fig_180" id="fig_180"></a>
+<a href="images/fig180-large.png">
+<img src="images/fig180.png" width="350" height="619" alt="Fig. 180.&mdash;Diagram of the Course of Motor and Sensory
+Nerve Fibres." title="" /></a>
+<span class="caption"><span class="smcap">Fig. 180.</span>&mdash;Diagram of the Course of Motor and Sensory
+Nerve Fibres.<br />
+<a href="images/fig180-large.png">VIEW LARGER IMAGE</a></span>
+</div>
+
+<p><b>Effects of Lesions of the Motor and Sensory Mechanisms.</b>&mdash;Lesions of
+the <i>motor mechanism</i> 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 <i>destroyed</i> or merely <i>irritated</i>,
+say by the pressure of a tumour. Irritative lesions in general produce
+muscular spasms or convulsions, while destructive lesions cause
+paralysis. The essential<a class="pagenum" name="Pg_334" id="Pg_334"></a> differences in the effects of destructive
+lesions of upper and lower neurones may be indicated thus:&mdash;</p>
+
+<table summary="Differences in the effects of destructive lesions.">
+<thead>
+<tr>
+  <th><i>Upper Neurone Lesion.</i></th>
+  <th><i>Lower Neurone Lesion.</i></th>
+</tr>
+</thead>
+<tbody>
+<tr>
+  <td style="padding-right: 2em;">Spastic paralysis of voluntary muscles.</td>
+  <td>Flaccid paralysis of voluntary muscles.</td>
+</tr>
+<tr>
+  <td>No marked wasting of paralysed muscles.</td>
+  <td>Marked wasting of paralysed muscles.</td>
+</tr>
+<tr>
+  <td>No reaction of degeneration.</td>
+  <td>Reaction of degeneration.</td>
+</tr>
+<tr>
+  <td>Exaggeration of reflexes.</td>
+  <td>Loss of reflexes.</td>
+</tr>
+</tbody>
+</table>
+
+<p>Irritative lesions of the sensory mechanism cause numbness and
+tingling (par&aelig;sthesia); more extensive paralytic lesions produce
+an&aelig;sthesia, astereognosis, loss of muscle sense, loss of pain, or
+inability to distinguish temperature, according to the tracts that are
+affected.</p>
+
+<p><i>Lesions of the Upper Motor Neurone</i> may occur in any part of its
+course. <i>Localised lesions of the motor cortex</i> of an irritative kind,
+for example, a patch of meningitis, a tumour, meningeal h&aelig;morrhage, 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&mdash;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.</p>
+
+<p>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&mdash;<i>cortical hemiplegia</i>; more
+generally the lesion affects one or more groups of muscles, and
+occasionally all the muscles of one limb are paralysed&mdash;<i>cortical
+monoplegia</i>. 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 par&aelig;sthesia and an&aelig;sthesia.</p>
+
+<p>Lesions in the <i>centrum ovale</i>, 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.</p>
+
+<p>Lesions in the region of the <i>internal capsule</i> 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,
+hemian&aelig;sthesia and hemianopia, and sometimes disturbances of hearing,
+smell, and taste.</p>
+
+<p>A lesion of the <i>crus</i> may in like manner produce spastic hemiplegia
+and hemian&aelig;sthesia 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.</p>
+
+<p>Lesions of the <i>corpora quadrigemina</i> 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.</p>
+
+<p><a class="pagenum" name="Pg_335" id="Pg_335"></a>The symptoms produced by lesions of the <i>pons and medulla</i> vary
+according to the position of the lesion. If it is unilateral, there
+may be spastic hemiplegia and hemian&aelig;sthesia 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.</p>
+
+<p><i>Cerebellar</i> 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.</p>
+
+<p>A unilateral lesion of the <i>spinal cord</i> 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 an&aelig;sthesia in the structures
+supplied from the damaged section of the cord&mdash;incomplete owing to the
+overlapping by other sensory nerves. Just above the lesion there is
+irritation of spinal nerves, and hyper&aelig;sthesia 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.</p>
+
+<p><b>Other Special Centres.</b>&mdash;The cortical centres for <i>vision</i> lie on the
+median surfaces of the occipital lobes in the neighbourhood of the
+calcarine fissure. Each half-vision centre&mdash;for there is one in each
+occipital lobe&mdash;receives the fibres from the same side of both retin&aelig;.
+Destruction of one half-vision centre produces the condition known as
+<i>homonymous hemianopia</i>, 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.</p>
+
+<p><i>Auditory impulses</i> are received in the posterior part of the superior
+temporal convolution.</p>
+
+<p><i>Aphasia.</i>&mdash;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.</p>
+
+<p><a class="pagenum" name="Pg_336" id="Pg_336"></a>The <i>olfactory</i> and <i>gustatory</i> centres are situated in the uncus
+close to the pituitary fossa.</p>
+
+<p>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 &ldquo;silent&rdquo; 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 &ldquo;apraxia,&rdquo;
+<i>i.e.</i>, 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.</p>
+
+<p><a name="XII_cerebral_localisation" id="XII_cerebral_localisation"></a><b>Cerebral Localisation.</b>&mdash;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.</p>
+
+<p><b>Relation of Cerebral Centres to the Surface.</b>&mdash;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&mdash;the
+glabella, the external occipital protuberance, the lateral angular
+process, and the root of the zygoma&mdash;are taken, and connected by
+lines, which are further subdivided&mdash;<i>always being bisected</i>. <a href="#fig_179">Figs.&nbsp;179</a>
+and <a href="#fig_181">181</a> 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
+&ldquo;mid-point.&rdquo; The posterior half of the line MO is bisected in T,
+constituting the &ldquo;three-quarters point,&rdquo; and the posterior<a class="pagenum" name="Pg_337" id="Pg_337"></a> half TO is
+bisected in S&mdash;&ldquo;the seven-eighths point.&rdquo; 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&mdash;AB, which is now bisected in C, and from C the line
+CD is drawn parallel to AM.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_181" id="fig_181"></a>
+<img src="images/fig181.jpg" width="400" height="311" alt="Fig. 181.&mdash;Chiene&#39;s Method of Cerebral Localisation." title="" />
+<span class="caption"><span class="smcap">Fig. 181.</span>&mdash;Chiene&#39;s Method of Cerebral Localisation.</span>
+</div>
+
+<p>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 pr&aelig;central 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 (<a href="#fig_181">Fig.&nbsp;181</a>).</p>
+
+<p>The <i>fissure of Rolando</i> or <i>central sulcus</i> may be marked out by
+taking a point half an inch behind the mid-point (M) (<a href="#fig_181">Fig.&nbsp;181</a>), and
+drawing a line downwards and forwards for a distance of about three
+and a half inches, at an angle of 67.5&deg; with the line GO. The angle of
+67.5&deg; can be readily determined by folding a square piece of paper on
+itself so as to<a class="pagenum" name="Pg_338" id="Pg_338"></a> make a triangle. The angle at the fold equals 45&deg;. 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&deg; each. Three of
+these angles taken together make up the 67.5&deg;. 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).</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_182" id="fig_182"></a>
+<a href="images/fig182-large.jpg">
+<img src="images/fig182.jpg" width="400" height="364" alt="Fig. 182.&mdash;To illustrate the site of various operations
+on the skull." title="" /></a>
+<span class="caption"><span class="smcap">Fig. 182.</span>&mdash;To illustrate the site of various operations
+on the skull.<br />
+<a href="images/fig182-large.jpg">VIEW LARGER IMAGE</a></span>
+</div>
+
+
+<h3><a name="XII_lumbar_puncture" id="XII_lumbar_puncture"></a><span class="smcap">Lumbar Puncture</span></h3>
+
+<p>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.</p>
+
+<p><i>Technique.</i>&mdash;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 class="pagenum" name="Pg_339" id="Pg_339"></a> a horizontal line across the back at the
+level of the highest part of the iliac crests (<a href="#fig_183">Fig.&nbsp;183</a>). The space
+between the fourth and fifth lumbar vertebr&aelig; 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 ur&aelig;mia, it may
+escape in a jet.</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_183" id="fig_183"></a>
+<img src="images/fig183.jpg" width="350" height="371" alt="Fig. 183.&mdash;Localisation of site for introduction of
+needle in Lumbar Puncture." title="" />
+<span class="caption"><span class="smcap">Fig. 183.</span>&mdash;Localisation of site for introduction of
+needle in Lumbar Puncture.</span>
+</div>
+
+<p>The <i>normal cerebro-spinal fluid</i> is clear and colourless, has a
+specific gravity of 1004&ndash;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.</p>
+
+<p><i>Diagnostic Puncture.</i>&mdash;Examination of the fluid withdrawn has proved
+useful in diagnosis in cases of intra-cranial and intra-spinal
+h&aelig;morrhage, in various forms of meningitis, in cerebral abscess, and
+in some cases of cerebral tumour.</p>
+
+<p>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
+h&aelig;morrhage, 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 h&aelig;morrhage there is no blood in the
+cerebro-spinal fluid.</p>
+
+<p>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<a class="pagenum" name="Pg_340" id="Pg_340"></a>
+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.</p>
+
+<p>In a few cases of malignant tumour of the spinal cord and its
+membranes, characteristic cells have been found in the fluid after
+centrifugalising.</p>
+
+<p>In ur&aelig;mia there is a diminution of chlorides, and an increase of
+phosphates and sulphates.</p>
+
+<p>The Wasserman test is sometimes positive in the cerebro-spinal fluid,
+when it is negative in the blood.</p>
+
+<p><i>Therapeutic Puncture.</i>&mdash;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.
+Carri&egrave;re has found it beneficial in some cases of ur&aelig;mia. 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.</p>
+
+<p>This route is sometimes selected for the induction of spinal
+an&aelig;sthesia, and for the injection of antitoxin in cases of tetanus.</p>
+
+
+<h3><a name="XII_head_injuries" id="XII_head_injuries"></a><span class="smcap">Head Injuries</span></h3>
+
+<p>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 pro<a class="pagenum" name="Pg_341" id="Pg_341"></a>tection 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.</p>
+
+<p>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.</p>
+
+<p>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 &ldquo;no injury of the head is so trivial as to be despised or so
+serious as to be despaired of.&rdquo; Injuries at first sight apparently
+slight may prove fatal from h&aelig;morrhage or infection; on the other
+hand, recovery has followed injuries of great severity&mdash;for example,
+the famous &ldquo;American crowbar case,&rdquo; 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.</p>
+
+<p>It is convenient to consider the injuries of the brain before those of
+the skull.</p>
+
+
+<h3><span class="smcap">Traumatic Lesions of the Brain</span></h3>
+
+<p>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&mdash;indeed they may be very extensive&mdash;in
+the absence of fracture.</p>
+
+<p>Several degrees are recognised.</p>
+
+<p>(1) Numerous minute <i>petechial h&aelig;morrhages</i> 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 &ldquo;concussion.&rdquo; We have found, on microscopic
+examination in such cases, in addition to these small extravasations,
+collections of colloid bodies, patches<a class="pagenum" name="Pg_342" id="Pg_342"></a> of miliary sclerosis, and
+chromatolysis and vacuolation of nerve-cells.<a name="FNanchor_3_3" id="FNanchor_3_3"></a><a href="#Footnote_3_3" class="fnanchor">[3]</a></p>
+
+<p class="footnote"><a name="Footnote_3_3" id="Footnote_3_3"></a><a href="#FNanchor_3_3"><span class="label">[3]</span></a> Miles, <i>Laboratory Reports, Royal College of Physicians,
+Edinburgh</i>, vol. iv.</p>
+
+<p>(2) In more severe cases there are often several <i>visible areas of
+extravasation</i>, most commonly in the grey matter of the cortex (<a href="#fig_184">Fig.&nbsp;184</a>).
+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 &ldquo;red softening&rdquo; of the brain matter, beyond which are numerous
+minute capillary h&aelig;morrhages. 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&mdash;the
+so-called point of <i>contre-coup</i>. The symptoms vary with the size and
+site of the extravasations. It is probable that the phenomena of
+&ldquo;cerebral irritation&rdquo; are to be explained by the occurrence of such
+h&aelig;morrhages 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 h&aelig;morrhages are extensive and numerous,
+symptoms of compression may ensue, and these are aggravated when
+&oelig;dema of the brain is superadded.</p>
+
+<p>Localised h&aelig;morrhages 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&deg; or even
+108&deg; F., and a modified form of Cheyne-Stokes respiration is present.</p>
+
+<p>(3) Still more gross lesions, in the form of distinct <i>lacerations</i>,
+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 (<a href="#fig_184">Fig.&nbsp;184</a>). In a compound fracture, brain
+matter may be extruded through the opening in the skull.</p>
+
+<p>(4) The extravasated blood may burst <i>into the lateral<a class="pagenum" name="Pg_343" id="Pg_343"></a> ventricles</i>,
+in which case the pulse becomes small and rapid&mdash;130, 160, or even
+170. The respiration also is rapid&mdash;45 to 60&mdash;and greatly embarrassed,
+and the temperature suddenly rises to 103&deg; or 104&deg; F., and continues
+to rise till death ensues.</p>
+
+<p>(5) <i>Traumatic &OElig;dema.</i>&mdash;It is not uncommon for a diffuse
+&oelig;dematous 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.</p>
+
+<p><i>Mechanism.</i>&mdash;The explanation of these widespread h&aelig;morrhages 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.</p>
+
+<div class="figcenter" style="width: 301px;">
+<a name="fig_184" id="fig_184"></a>
+<img src="images/fig184.jpg" width="301" height="400" alt="Fig. 184.&mdash;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." title="" />
+<span class="caption"><span class="smcap">Fig. 184.</span>&mdash;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.<br /><br />
+(After Sir Jonathan Hutchinson.)</span>
+</div>
+
+<p><a class="pagenum" name="Pg_344" id="Pg_344"></a><i>Repair.</i>&mdash;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 &ldquo;h&aelig;morrhagic cyst.&rdquo; We have experimentally confirmed
+Duret's observations and agree with his conclusions.</p>
+
+
+<h3><span class="smcap">Clinical Manifestations of Injuries to the Brain</span></h3>
+
+<p>For convenience, the clinical manifestations of cerebral injury are
+usually described under the terms &ldquo;concussion,&rdquo; &ldquo;cerebral irritation,&rdquo;
+and &ldquo;compression,&rdquo; 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.</p>
+
+<p><a name="XII_concussion" id="XII_concussion"></a><b>Concussion of the Brain or Cerebral Shock.</b>&mdash;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 an&aelig;mia 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.</p>
+
+<p>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.</p>
+
+<p>The <i>clinical features</i> 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.</p>
+
+<p><a class="pagenum" name="Pg_345" id="Pg_345"></a>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&deg; F., or even lower. The skin is cold and pallid and covered with
+clammy sweat, and the features are pinched and pale.</p>
+
+<p>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.</p>
+
+<p>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&deg; or 100&deg; F., and in some cases remains
+elevated for a few days. In most cases it falls again to 97&deg; or 97.5&deg;,
+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.</p>
+
+<p>In cases complicated by gross brain lesions the symptoms of concussion
+may imperceptibly merge into those of compression or there may be a
+&ldquo;lucid interval&rdquo; of some hours duration.</p>
+
+<p><i>After-Effects of Concussion.</i>&mdash;The majority of patients recover
+completely. A number complain for a time of headache, languor,
+muscular weakness, and incapacity for sustained effort&mdash;<i>traumatic
+neurasthenia</i>. 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<a class="pagenum" name="Pg_346" id="Pg_346"></a> 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.</p>
+
+<p>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.</p>
+
+<p><i>Treatment.</i>&mdash;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 h&aelig;morrhage 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.</p>
+
+<p><a name="XII_cerebral_irritation" id="XII_cerebral_irritation"></a><b>Cerebral Irritation.</b>&mdash;In some cases of injury to the
+head&mdash;particularly of the anterior part and the parietal region&mdash;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. &ldquo;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<a class="pagenum" name="Pg_347" id="Pg_347"></a> 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.</p>
+
+<p>&ldquo;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.</p>
+
+<p>&ldquo;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....&rdquo;</p>
+
+<p>The <i>treatment</i> consists in keeping the patient quiet, in a darkened
+room, on much the same lines as for concussion.</p>
+
+<p><a name="XII_compression" id="XII_compression"></a><b>Compression of the Brain.</b>&mdash;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 h&aelig;morrhage, &oelig;dema, 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.</p>
+
+<p><i>Clinical Features.</i>&mdash;The following description refers to compression
+due to h&aelig;morrhage 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 h&aelig;morrhage 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.</p>
+
+<p>The first symptoms are of an irritative character&mdash;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&deg;, or even to 95&deg; F. Vomiting is not
+infrequent.</p>
+
+<p>As the pressure increases, paralytic symptoms ensue. The patient
+gradually loses consciousness, and passes into a condition<a class="pagenum" name="Pg_348" id="Pg_348"></a> 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&deg; or even 95&deg; F., in the course of three or
+four hours usually rises (100.5&deg; or 102.5&deg; F.). If the temperature
+reaches 104&deg; F., or higher, the condition usually proves fatal.
+Sometimes it rises as high as 106&deg; or 108&deg; F.&mdash;<i>cerebral hyperpyrexia</i>
+(<a href="#fig_185">Fig.&nbsp;185</a>). Retention of urine from paralysis of the bladder, and
+involuntary defecation from paralysis of the sphincter ani, are
+common.</p>
+
+<div class="figcenter" style="width: 379px;">
+<a name="fig_185" id="fig_185"></a>
+<img src="images/fig185.jpg" width="379" height="500" alt="Fig. 185.&mdash;Two Charts of Pyrexia in Head Injuries." title="" />
+<span class="caption"><span class="smcap">Fig. 185.</span>&mdash;Two Charts of Pyrexia in Head Injuries.</span>
+</div>
+
+<p>During the progress of the symptoms there is frequently evidence of
+direct pressure upon definite cortical centres or cranial nerves,
+giving rise to <i>focal symptoms</i>. 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.</p>
+
+<p>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.</p>
+
+<p><a class="pagenum" name="Pg_349" id="Pg_349"></a>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.</p>
+
+<p>A similar train of symptoms may ensue in cases of head injury as a
+result of <i>pyogenic infection</i> having given rise to meningitis or
+abscess with accumulation of inflammatory exudate.</p>
+
+<p><i>Pathology.</i>&mdash;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 an&aelig;mic and the respiration fails; during the
+rise the medulla is again supplied with blood, and breathing is
+resumed (Eyster).</p>
+
+<p>The parts of the brain directly pressed upon become an&aelig;mic, 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.</p>
+
+<p><i>Depressed Bone as a Cause of Compression.</i>&mdash;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<a class="pagenum" name="Pg_350" id="Pg_350"></a> attributed either to associated
+h&aelig;morrhage, or to interference with the circulation and consequent
+&oelig;dema which the displaced bone produces. Fragments of bone may,
+however, aggravate the symptoms by irritating the cerebral tissue on
+which they impinge.</p>
+
+<p><i>Foreign Bodies.</i>&mdash;The r&ocirc;le 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.</p>
+
+<p><i>Differential Diagnosis.</i>&mdash;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, ur&aelig;mic 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.</p>
+
+<p>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 (<a href="#Pg_338">p.&nbsp;338</a>).</p>
+
+<p>In the absence of evidence of a head injury, the stomach<a class="pagenum" name="Pg_351" id="Pg_351"></a> 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.</p>
+
+<p>In h&aelig;morrhage 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 &ldquo;an apoplectic shock,&rdquo; and the fact that he is up in
+years and shows signs of arterial degeneration and of cardiac
+hypertrophy which would favour such h&aelig;morrhage, are presumptive
+evidence that the lesion is not traumatic.</p>
+
+<p>If a history is forthcoming that the patient is an epileptic, there is
+a strong presumption that the symptoms are those of <i>epileptic coma</i>.</p>
+
+<p>In <i>alcoholic poisoning</i> 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.</p>
+
+<p>In <i>opium poisoning</i> 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.</p>
+
+<p>In the <i>coma</i> of <i>ur&aelig;mia</i> or of <i>diabetes</i> there is no true paralysis,
+nor is there stertor. The urine contains albumin or sugar, and there
+may be &oelig;dema of the feet and legs.</p>
+
+<p><i>Prognosis.</i>&mdash;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&deg; 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.</p>
+
+<p>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.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+<p><a class="pagenum" name="Pg_352" id="Pg_352"></a><b>Traumatic &OElig;dema.</b>&mdash;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 h&aelig;morrhage in that it is less
+severe and is not steadily progressive.</p>
+
+<p>When the symptoms are localised, the condition is probably due to
+&oelig;dematous infiltration of the injured portion of brain; when
+generalised, to increased intra-cranial tension from serous effusion
+into the arachno-pial space.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+
+<h3><a name="XII_intra_cranial_haemorrhage" id="XII_intra_cranial_haemorrhage"></a><span class="smcap">Intra-cranial H&aelig;morrhage</span></h3>
+
+<p>Apart from the h&aelig;morrhage 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 (<i>extra-dural h&aelig;morrhage</i>), or inside the dura (<i>intra-dural
+h&aelig;morrhage</i>).</p>
+
+<p><a name="XII_middle_meningeal_haemorrhage" id="XII_middle_meningeal_haemorrhage"></a><b>Middle Meningeal H&aelig;morrhage.</b>&mdash;The commonest cause of extra-dural
+h&aelig;morrhage is laceration of the middle meningeal artery. This
+artery&mdash;a branch of the internal maxillary&mdash;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 (<a href="#fig_186">Fig.&nbsp;186</a>). 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<a class="pagenum" name="Pg_353" id="Pg_353"></a>
+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.).</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_186" id="fig_186"></a>
+<a href="images/fig186-large.jpg">
+<img src="images/fig186.jpg" width="400" height="411" alt="Fig. 186.&mdash;Relations of the Middle Meningeal Artery and
+Lateral Sinus to the surface as indicated by Chiene&#39;s Lines." title="" /></a>
+<span class="caption"><span class="smcap">Fig. 186.</span>&mdash;Relations of the Middle Meningeal Artery and
+Lateral Sinus to the surface as indicated by Chiene&#39;s Lines.<br /><br />
+(After Cunningham.)<br />
+<a href="images/fig186-large.jpg">VIEW LARGER IMAGE</a></span>
+</div>
+
+<p>It is probable that the size of the h&aelig;morrhage 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 (<a href="#fig_187">Fig.&nbsp;187</a>). 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&mdash;on the principle of the hydraulic
+press&mdash;sufficient to continue the separation.</p>
+
+<div class="figcenter" style="width: 324px;">
+<a name="fig_187" id="fig_187"></a>
+<img src="images/fig187.jpg" width="324" height="400" alt="Fig. 187.&mdash;Extra-Dural Clot resulting from h&aelig;morrhage
+from the Middle Meningeal Artery." title="" />
+<span class="caption"><span class="smcap">Fig. 187.</span>&mdash;Extra-Dural Clot resulting from h&aelig;morrhage
+from the Middle Meningeal Artery.</span>
+</div>
+
+<p><i>Clinical Features.</i>&mdash;The typical characteristics of middle<a class="pagenum" name="Pg_354" id="Pg_354"></a> meningeal
+h&aelig;morrhage 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 &ldquo;lucid interval&rdquo; helps
+to distinguish the symptoms due to middle meningeal h&aelig;morrhage 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 h&aelig;morrhage, as blood is present in the fluid
+withdrawn in the latter, but not in the former.</p>
+
+<p>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<a class="pagenum" name="Pg_355" id="Pg_355"></a> 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&deg; 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 h&aelig;morrhage at the base.</p>
+
+<p>When the h&aelig;morrhage 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.</p>
+
+<p>In some cases of middle meningeal h&aelig;morrhage 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.</p>
+
+<p>If the fracture is compound, the blood can escape, and therefore the
+pressure symptoms are less evident or may be entirely absent.</p>
+
+<p>It is a fact of some medico-legal importance that h&aelig;morrhage 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 <i>traumatic apoplexy</i>.</p>
+
+<p><i>Treatment.</i>&mdash;Immediate operation is imperatively called for, not only
+to arrest the h&aelig;morrhage and remove the clot, but also to ward off the
+&oelig;dema 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.</p>
+
+<p>If the bleeding cannot otherwise be arrested it may be necessary to
+ligate the external carotid artery. It has been<a class="pagenum" name="Pg_356" id="Pg_356"></a> suggested by J. B.
+Murphy that, when the patient is seen while the symptoms of
+compression are coming on, instead of trephining, the h&aelig;morrhage from
+the meningeal vessels should be arrested by applying a ligature to the
+external carotid, under local an&aelig;sthesia.</p>
+
+<p><a name="XII_inter_carotid" id="XII_inter_carotid"></a>Injury to the <b>internal carotid</b> 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.</p>
+
+<p><a name="XII_venous_sinuses" id="XII_venous_sinuses"></a>Injuries of the <b>venous sinuses</b> 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
+h&aelig;morrhage 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.</p>
+
+<p>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.</p>
+
+<p><a name="XII_newly_born" id="XII_newly_born"></a><b>Intra-cranial H&aelig;morrhage in the Newly-Born.</b>&mdash;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.</p>
+
+<p><a class="pagenum" name="Pg_357" id="Pg_357"></a>This condition is most frequently met with in a first-born child&mdash;and
+more often in boys than in girls&mdash;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.</p>
+
+<p>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.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p>For the immediate relief of increased intra-cranial tension, the daily
+withdrawal of 10&ndash;12 c.c. of cerebro-spinal fluid by lumbar punctures
+may be employed, or a sub-temporal decompression operation may be
+performed.</p>
+
+
+<h3><a name="XII_wounds_brain" id="XII_wounds_brain"></a><span class="smcap">Wounds of the Brain</span></h3>
+
+<p><b>Wounds of the Brain.</b>&mdash;<i>Incised</i> 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,<a class="pagenum" name="Pg_358" id="Pg_358"></a> and the liability to
+infection, render such wounds extremely dangerous.</p>
+
+<p><i>Punctured wounds</i> 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.</p>
+
+<p><i>Bullet wounds</i> 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.</p>
+
+<p>Aseptic foreign bodies, especially bullets, may remain embedded in the
+brain without producing symptoms.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+
+<h3><a name="XII_after_effects" id="XII_after_effects"></a><span class="smcap">After-effects of Head Injuries</span></h3>
+
+<p>Various after-effects may follow injuries of the head. Thus, for
+example, <i>chronic interstitial changes</i> (sclerosis) may spread from an
+area of cicatrisation in the brain; or <i>softening</i> may ensue, either
+in the form of pale areas of necrosis (white softening) or of
+h&aelig;morrhagic patches (red softening). The symptoms vary with the area
+implicated. <i>Adhesions</i> between the brain and its membranes may
+produce severe headache and attacks of vertigo, especially on the
+patient making sudden exertion.</p>
+
+<p>After a head injury, the patient's whole mental attitude is sometimes
+changed, so that he becomes irritable, unstable, and incapacitated for
+brain-work&mdash;<i>traumatic neurasthenia</i>. In some cases self-control is
+lost, and alcoholic and drug habits are developed.</p>
+
+<p><a name="XII_epilespy" id="XII_epilespy"></a><b>Traumatic epilepsy</b> may ensue as a result of some circumscribed
+cortical lesion, such as a spicule of bone projecting into<a class="pagenum" name="Pg_359" id="Pg_359"></a> the
+cortex, the presence of adhesions between the membranes and the brain,
+a cicatrix in the brain tissue leading to sclerosis or a h&aelig;morrhagic
+cyst in the membranes or cerebral tissue.</p>
+
+<p>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 &ldquo;signal symptom&rdquo;&mdash;for example, jerking of the thumb, conjugate
+deviation of the eyes, or motor aphasia&mdash;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 &ldquo;status epilepticus,&rdquo; 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.</p>
+
+<p><i>Treatment.</i>&mdash;The administration of bromides is only palliative.
+Operation is indicated only when the &ldquo;signal symptom&rdquo; 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&mdash;sometimes referred to
+as the &ldquo;epileptic habit&rdquo;&mdash;has not developed. The operation consists in
+opening the skull freely, and removing any discoverable cause of
+irritation&mdash;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.</p>
+
+<p>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.</p>
+
+<p><a name="XII_insanity" id="XII_insanity"></a><a class="pagenum" name="Pg_360" id="Pg_360"></a><b>Traumatic insanity</b> 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.</p>
+
+<p><a name="XII_infective_complications" id="XII_infective_complications"></a><i>Meningitis</i>, <i>sinus thrombosis</i>, and <i>cerebral abscess</i> may follow
+upon any form of head injury attended with infection. The clinical
+features&mdash;save for the history of a trauma&mdash;correspond so closely with
+those of the same conditions occurring apart from injury, that they
+are most conveniently considered together (<a href="#Pg_374">p.&nbsp;374</a>).</p>
+
+
+
+
+<h2><a class="pagenum" name="Pg_361" id="Pg_361"></a><a name="CHAPTER_XIII" id="CHAPTER_XIII"></a>CHAPTER XIII
+<br />
+INJURIES OF THE SKULL</h2>
+
+<ul class="chap">
+  <li><a href="#XIII_contusions">Contusions</a></li>
+  <li>&mdash;<a href="#XIII_fractures"><span class="smcap">Fractures</span></a></li>
+  <li>&mdash;<a href="#XIII_vault">Of the vault</a>:</li>
+  <li><a href="#XIII_varieties"><i>Varieties</i></a></li>
+  <li>&mdash;<a href="#XIII_base">Of the Base</a>:</li>
+  <li><a href="#XIII_anterior_fossa"><i>Anterior fossa</i></a></li>
+  <li>&mdash;<a href="#XIII_middle_fossa"><i>Middle fossa</i></a></li>
+  <li>&mdash;<a href="#XIII_posterior_fossa"><i>Posterior fossa</i></a>.</li>
+</ul>
+
+<p>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.</p>
+
+<p><a name="XIII_contusions" id="XIII_contusions"></a><b>Contusion</b> 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&mdash;scalp,
+meningeal vessels, or brain&mdash;overshadows the osseous lesion, which of
+itself is comparatively unimportant.</p>
+
+
+<h3><a name="XIII_fractures" id="XIII_fractures"></a>FRACTURES OF THE SKULL</h3>
+
+<p>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.</p>
+
+
+<h4><a name="XIII_vault" id="XIII_vault"></a><span class="smcap">Fractures of the Vault</span></h4>
+
+<p><b>Mechanism.</b>&mdash;When the skull is broken by <i>direct</i> 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 &ldquo;blunt&rdquo;
+object&mdash;for example, a batten falling from a height&mdash;the force is
+applied over a wider area and the elastic skull bends before it. If
+the limits of its<a class="pagenum" name="Pg_362" id="Pg_362"></a> 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&mdash;&ldquo;<i>fracture by bending</i>.&rdquo; 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&mdash;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.</p>
+
+<p>Fractures by <i>indirect</i> violence&mdash;that is, fractures in which the bone
+breaks at a point other than the seat of impact&mdash;are almost always due
+to violence inflicted with a blunt object, and acting over a wide
+area&mdash;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&mdash;that is, the part directly
+struck&mdash;happens to be less elastic than the part which bulges, it
+gives way, and a fracture by &ldquo;bending&rdquo; results; but if the bulging
+part is the less elastic, it bursts outwards&mdash;<i>fracture by</i>
+&ldquo;<i>bursting</i>.&rdquo; The term &ldquo;fracture by <i>contre-coup</i>&rdquo; has been
+incorrectly applied to such fractures when the area of bulging happens
+to be opposite to the seat of impact. <i>Contre-coup</i>, properly
+so-called, is only possible in a perfectly spherical body, which, of
+course, the skull is not.</p>
+
+<p>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.</p>
+
+<p><i>Repair.</i>&mdash;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<a class="pagenum" name="Pg_363" id="Pg_363"></a> 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.</p>
+
+<p><a name="XIII_varieties" id="XIII_varieties"></a><b>Varieties.</b>&mdash;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&mdash;for example, the kick of a horse or the blow of a
+hammer&mdash;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.</p>
+
+<p><b>Fissured fractures</b> 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.</p>
+
+<p><i>Diagnosis.</i>&mdash;A normal suture may be mistaken for a fissured fracture.
+A suture, however, may generally be recognised by<a class="pagenum" name="Pg_364" id="Pg_364"></a> 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
+&ldquo;hollow-cask&rdquo; sound may be detected in some cases of fissured fracture
+of the vault.</p>
+
+<p>Fissured fractures as such call for no <i>treatment</i>. When compound, the
+wound must be disinfected; and intra-cranial complications, such as
+meningeal h&aelig;morrhage, laceration of the brain, or infection, are to be
+treated on the lines already described.</p>
+
+<p><b>Punctured fractures</b> 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.</p>
+
+<p><i>Diagnosis.</i>&mdash;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.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p><b>Depressed and Comminuted Fractures.</b>&mdash;As these varieties almost always
+occur in combination, they are best considered together. The terms
+&ldquo;indentation fracture,&rdquo; &ldquo;gutter fracture,&rdquo; &ldquo;pond fracture,&rdquo; have been
+applied to different forms of de<a class="pagenum" name="Pg_365" id="Pg_365"></a>pressed fracture, according to the
+degree of damage to the bone and the disposition of the fragments
+(<a href="#fig_188">Figs.&nbsp;188</a>, <a href="#fig_189">189</a>, <a href="#fig_190">190</a>). These fractures may be simple or compound.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_188" id="fig_188"></a>
+<img src="images/fig188.jpg" width="400" height="348" alt="Fig. 188.&mdash;Depressed Fracture of Frontal
+Bones&mdash;involving the air sinus on both sides&mdash;with a fissured fracture
+radiating from it." title="" />
+<span class="caption"><span class="smcap">Fig. 188.</span>&mdash;Depressed Fracture of Frontal
+Bones&mdash;involving the air sinus on both sides&mdash;with a fissured fracture
+radiating from it.<br /><br />
+(From Professor Harvey Littlejohn&#39;s collection.)</span>
+</div>
+
+<p>&nbsp;</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_189" id="fig_189"></a>
+<img src="images/fig189.jpg" width="400" height="196" alt="Fig. 189.&mdash;Depressed and Comminuted Fracture of Right
+Parietal Bone: Pond Fracture. The patient sustained the injury twenty
+years before death." title="" />
+<span class="caption"><span class="smcap">Fig. 189.</span>&mdash;Depressed and Comminuted Fracture of Right
+Parietal Bone: Pond Fracture. The patient sustained the injury twenty
+years before death.</span>
+</div>
+
+<p>&nbsp;</p>
+
+<div class="figcenter" style="width: 389px;">
+<a name="fig_190" id="fig_190"></a>
+<img src="images/fig190.jpg" width="389" height="400" alt="Fig. 190.&mdash;Pond Fracture of Left Frontal Bone, produced
+during delivery." title="" />
+<span class="caption"><span class="smcap">Fig. 190.</span>&mdash;Pond Fracture of Left Frontal Bone, produced
+during delivery.<br /><br />
+(From a photograph lent by Mr. J. H. Nicoll.)</span>
+</div>
+
+<p><a class="pagenum" name="Pg_366" id="Pg_366"></a>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.</p>
+
+<p><i>Diagnosis.</i>&mdash;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.</p>
+
+<p>A h&aelig;matoma 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 h&aelig;matoma, and unless great care is
+taken the fracture may be overlooked.</p>
+
+<p><i>Treatment.</i>&mdash;All are agreed that compound depressed and comminuted
+fractures&mdash;whether associated with cerebral symp<a class="pagenum" name="Pg_367" id="Pg_367"></a>toms or not&mdash;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 sequel&aelig; ensuing is not
+sufficient to justify a prophylactic operation of such severity as
+trephining.</p>
+
+<p>The operation is described in <i>Operative Surgery</i>, p. 93.</p>
+
+
+<h4><a name="XIII_base" id="XIII_base"></a><span class="smcap">Fractures of the Base</span></h4>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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,<a class="pagenum" name="Pg_368" id="Pg_368"></a> and tends to take place at the part
+which has least elasticity&mdash;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 (<a href="#fig_191">Fig.&nbsp;191</a>). On the other hand, when the
+pressure is antero-posterior, the fracture tends to be longitudinal;
+and when oblique, it tends to be diagonal.</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_191" id="fig_191"></a>
+<img src="images/fig191.jpg" width="300" height="450" alt="Fig. 191.&mdash;Transverse Fracture through Middle Fossa of
+Base of Skull." title="" />
+<span class="caption"><span class="smcap">Fig. 191.</span>&mdash;Transverse Fracture through Middle Fossa of
+Base of Skull.</span>
+</div>
+
+<p>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<a class="pagenum" name="Pg_369" id="Pg_369"></a> the base to be
+continued for a considerable distance on to the vault.</p>
+
+<p>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
+foss&aelig; are usually rendered compound by tearing of the mucous membrane
+of the nose, the pharynx, or the ear.</p>
+
+<p>Basal fractures are frequently associated with contusion and
+laceration of the brain, and also with injuries of one or more of the
+cranial nerves.</p>
+
+<p><a name="XIII_anterior_fossa" id="XIII_anterior_fossa"></a><b>Fracture of the anterior fossa</b> 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.</p>
+
+<p><i>Clinical Features.</i>&mdash;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 h&aelig;morrhage 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.</p>
+
+<p>Fracture of the anterior fossa is often accompanied by extravasation
+of blood into the orbit, pushing forward the eyeball and infiltrating
+the conjunctiva (<i>sub-conjunctival ecchymosis</i>). 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 h&aelig;morrhage shows at once both under the
+conjunctiva and in the upper lid. If the frontal sinus is opened, air
+may infiltrate the scalp.</p>
+
+<p><a class="pagenum" name="Pg_370" id="Pg_370"></a>The olfactory, optic, oculo-motor, pathetic, ophthalmic division of
+the trigeminal, and the abducens nerves are all liable to be
+implicated.</p>
+
+<p><i>Diagnosis.</i>&mdash;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&mdash;for
+example, in association with an ordinary black eye, or with fracture
+of the orbital ridge or of the zygomatic (malar) bone.</p>
+
+<p>Finally, paralysis of the cranial nerves may result from pressure of
+blood-clot, or from the nerves being torn without the skull being
+fractured.</p>
+
+<p><a name="XIII_middle_fossa" id="XIII_middle_fossa"></a><b>Fracture of the middle fossa</b> 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.</p>
+
+<p><i>Clinical features.</i>&mdash;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 h&aelig;morrhage and the
+formation of new bone.</p>
+
+<p><i>Diagnosis.</i>&mdash;Care must be taken not to mistake blood which has passed
+into the ear from a scalp wound, or which has its<a class="pagenum" name="Pg_371" id="Pg_371"></a> 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<a name="FNanchor_4_4" id="FNanchor_4_4"></a><a href="#Footnote_4_4" class="fnanchor">[4]</a> that blood and cerebro-spinal fluid may escape along the
+sheath of the acoustic nerve without the bone being broken.</p>
+
+<p class="footnote"><a name="Footnote_4_4" id="Footnote_4_4"></a><a href="#FNanchor_4_4"><span class="label">[4]</span></a> Miles, <i>Edinburgh Medical Journal</i>, 1895.</p>
+
+<p><a name="XIII_posterior_fossa" id="XIII_posterior_fossa"></a><b>Fracture of the posterior fossa</b> 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.</p>
+
+<p><i>Clinical Features.</i>&mdash;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.</p>
+
+<p><i>Diagnosis of Basal Fractures.</i>&mdash;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.</p>
+
+<p>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.</p>
+
+<p><a class="pagenum" name="Pg_372" id="Pg_372"></a><i>Prognosis in Basal Fractures.</i>&mdash;The prognosis depends upon the
+severity of the cerebral lesions, and on the occurrence of traumatic
+&oelig;dema 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 h&aelig;morrhage. 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&mdash;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.</p>
+
+<p><i>Treatment.</i>&mdash;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; Quen&uacute; strongly recommends repeated puncture in serious
+cases. In a few cases this procedure has been followed by sudden
+death.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+
+
+
+<h2><a class="pagenum" name="Pg_373" id="Pg_373"></a><a name="CHAPTER_XIV" id="CHAPTER_XIV"></a>CHAPTER XIV
+<br />
+DISEASES OF THE BRAIN AND MEMBRANES</h2>
+
+<ul class="chap">
+  <li><a href="#XIV_pyogenic">Pyogenic diseases</a></li>
+  <li>&mdash;<a href="#XIV_meningitis">Meningitis: <i>Varieties</i></a></li>
+  <li>&mdash;<a href="#XIV_abscess">Abscess: <i>Varieties</i></a></li>
+  <li>&mdash;<a href="#XIV_sinus_phlebitis">Sinus phlebitis</a></li>
+  <li>&mdash;<a href="#XIV_intra_cranial_tuberculosis">Intra-cranial tuberculosis</a>.</li>
+  <li><a href="#XIV_cephaloceles">Cephaloceles</a></li>
+  <li>&mdash;<a href="#XIV_meningocele"><i>Meningocele</i></a></li>
+  <li>&mdash;<a href="#XIV_encephaloceles"><i>Encephalocele</i></a></li>
+  <li>&mdash;<a href="#XIV_hydrencephalocele"><i>Hydrencephalocele</i></a></li>
+  <li>&mdash;<a href="#XIV_traumatic_cephal_hydrocele">Traumatic cephal-hydrocele</a></li>
+  <li>&mdash;<a href="#XIV_hydrocephalus">Hydrocephalus; <i>Varieties</i></a></li>
+  <li>&mdash;<a href="#XIV_micrencephaly">Micrencephaly</a>.</li>
+  <li><a href="#XIV_cerebral_tumours">Cerebral tumours</a>.</li>
+  <li><a href="#XIV_tumours_pituitary_body">Tumours of the pituitary body</a>.</li>
+  <li><a href="#XIV_epilepsy">Epilepsy</a></li>
+  <li>&mdash;<a href="#XIV_hernia_cerebri">Hernia cerebri</a>.</li>
+  <li><a href="#XIV_cranial_nerve">Surgical affections of cranial nerves</a></li>
+  <li>&mdash;<a href="#XIV_cervical_sympathetic">Cervical sympathetic</a>.</li>
+</ul>
+
+
+<h3><a name="XIV_pyogenic" id="XIV_pyogenic"></a><span class="smcap">Pyogenic Diseases</span></h3>
+
+<p>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.</p>
+
+<p>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&mdash;particularly the pneumococcus, the bacillus f&oelig;tidus, the
+bacillus coli, the bacillus pyocyaneus, and the diplococcus
+intracellularis.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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<a class="pagenum" name="Pg_374" id="Pg_374"></a> 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.</p>
+
+
+<h3><a name="XIV_meningitis" id="XIV_meningitis"></a><span class="smcap">Meningitis</span></h3>
+
+<p><b>Pachymeningitis.</b>&mdash;This term is applied when the infection involves the
+dura mater&mdash;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.</p>
+
+<p>The layer of the dura in contact with the affected portion of bone is
+inflamed, thickened, and covered with a layer of
+granulations&mdash;<i>external pachymeningitis</i>&mdash;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.</p>
+
+<p>In the majority of cases, however, suppuration occurs between the dura
+and the bone&mdash;<i>suppurative pachymeningitis</i>&mdash;and leads to the
+formation of an <i>extra-dural abscess</i> (<a href="#fig_192">Fig.&nbsp;192</a>). When this<a class="pagenum" name="Pg_375" id="Pg_375"></a> 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 &oelig;dematous&mdash;a condition which Percival
+Pott, in 1760, first observed to be characteristic of extra-dural
+suppuration, hence the name, <i>Pott's puffy tumour</i>, applied to it
+(<a href="#fig_193">Fig.&nbsp;193</a>). 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.</p>
+
+<div class="figcenter" style="width: 500px;">
+<a name="fig_192" id="fig_192"></a>
+<img src="images/fig192.jpg" width="500" height="247" alt="Fig. 192.&mdash;Diagram of Extra-Dural Abscess." title="" />
+<span class="caption"><span class="smcap">Fig. 192.</span>&mdash;Diagram of Extra-Dural Abscess.</span>
+</div>
+
+<p>&nbsp;</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_193" id="fig_193"></a>
+<img src="images/fig193.jpg" width="400" height="341" alt="Fig. 193.&mdash;Pott&#39;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." title="" />
+<span class="caption"><span class="smcap">Fig. 193.</span>&mdash;Pott&#39;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.</span>
+</div>
+
+<p>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<a class="pagenum" name="Pg_376" id="Pg_376"></a> 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.</p>
+
+<p><i>Treatment.</i>&mdash;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
+&oelig;dematous 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.</p>
+
+<p><b>Lepto-meningitis.</b>&mdash;If the infection spreads to the adjacent
+arachno-pia (<i>localised lepto-meningitis</i>), adhesions usually form,
+and shut off the infected area from the general arachno-pial space.</p>
+
+<p>Pus may form among these adhesions, constituting a <i>sub-dural
+abscess</i>, and may infiltrate the superficial layers of the cortex
+(<i>purulent encephalitis</i>, or <i>meningo-encephalitis</i>) (<a href="#fig_194">Fig.&nbsp;194</a>). 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.</p>
+
+<div class="figcenter" style="width: 500px;">
+<a name="fig_194" id="fig_194"></a>
+<img src="images/fig194.jpg" width="500" height="211" alt="Fig. 194.&mdash;Diagram of Sub-Dural Abscess." title="" />
+<span class="caption"><span class="smcap">Fig. 194.</span>&mdash;Diagram of Sub-Dural Abscess.</span>
+</div>
+
+<p><i>Acute General Lepto-Meningitis.</i>&mdash;In bone lesions, particularly
+compound fractures, infection of the arachno-pia may take place<a class="pagenum" name="Pg_377" id="Pg_377"></a>
+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 (<i>basal meningitis</i>),
+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 (<i>serous lepto-meningitis</i>), 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 (<i>purulent
+lepto-meningitis</i>). 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 (<i>encephalitis</i>).</p>
+
+<p><i>Clinical features.</i>&mdash;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&deg;
+to 105&deg; 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.</p>
+
+<p>Vomiting of the cerebral type&mdash;that is, unattended with nausea and not
+related to the taking of food or to gastric disturbance&mdash;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.</p>
+
+<p>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 &oelig;dematous and swollen.</p>
+
+<p>Gradually the patient becomes unconscious, shows signs of<a class="pagenum" name="Pg_378" id="Pg_378"></a> increasing
+intra-cranial tension, slowing of the pulse, and laboured respiration,
+and the condition almost always proves fatal within three or four
+days.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p><i>Cerebro-spinal Meningitis.</i>&mdash;This form of meningitis, which is due to
+the <i>diplococcus intracellularis</i>, 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.</p>
+
+<p>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.</p>
+
+
+<h3><a name="XIV_abscess" id="XIV_abscess"></a><span class="smcap">Cerebral and Cerebellar Abscess</span></h3>
+
+<p><b>Abscess due to Middle Ear Disease.</b>&mdash;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 fre<a class="pagenum" name="Pg_379" id="Pg_379"></a>quently met with in the white matter of the centrum
+ovale than in the cortex, and in the majority of cases the abscess is
+single.</p>
+
+<p>The <i>pus</i> 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 f&oelig;tid odour. In quantity it varies from a few
+drops to several ounces.</p>
+
+<p>The <i>arachno-pia</i> over an abscess usually has a turbid and milky
+appearance.</p>
+
+<p>In an acute abscess the surrounding <i>brain tissue</i> 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
+&ldquo;latent,&rdquo; giving rise to no symptoms for many weeks or even months.</p>
+
+<p><i>Clinical features.</i>&mdash;The <i>initial</i> 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.</p>
+
+<p>As a <i>localised abscess</i> 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 &ldquo;slowly, briefly, but, as a
+rule, correctly&rdquo; (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.</p>
+
+<p>There is no actual paresis, but there is a &ldquo;gradual diminution of the
+ability to apply his strength.&rdquo; The superficial reflexes are late of
+disappearing and the disturbance is unilateral. The optic discs are
+moderately swollen. &ldquo;The face is expressionless, passive, and cloudy.
+It may assume a meaningless smile, with which the features are not
+lit; it is too mechanical&rdquo; (Macewen).</p>
+
+<p><i>Differential Diagnosis.</i>&mdash;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<a class="pagenum" name="Pg_380" id="Pg_380"></a> 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 &oelig;dematous and are more
+swollen than in abscess, and the condition is equally marked on the
+two sides.</p>
+
+<p><i>Localisation of Cerebral Abscess&mdash;Temporal Abscess.</i>&mdash;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.</p>
+
+<p>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&mdash;leg, arm, face&mdash;the pressure is on the nerve fibres passing
+through the internal capsule (<a href="#fig_195">Fig.&nbsp;195</a>). The<a class="pagenum" name="Pg_381" id="Pg_381"></a> paralysis may be spastic
+in lesions of the cortex or internal capsule; if it is flaccid the
+lesion is almost certainly cortical.</p>
+
+<div class="figcenter" style="width: 354px;">
+<a name="fig_195" id="fig_195"></a>
+<img src="images/fig195.jpg" width="354" height="400" alt="Fig. 195.&mdash;Diagram illustrating Sequence of Paralysis,
+caused by abscess in temporal lobe. (After Macewen.)" title="" />
+<span class="caption"><span class="smcap">Fig. 195.</span>&mdash;Diagram illustrating Sequence of Paralysis,
+caused by abscess in temporal lobe. (After Macewen.)</span>
+</div>
+
+<p>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.</p>
+
+<p>Abscess in the <i>parietal lobe</i> gives rise to paralysis of the face and
+limbs on the opposite side of the body. Abscess in the <i>occipital
+lobe</i> produces interference with the visual functions. An abscess in
+the <i>frontal lobe</i> 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&mdash;apraxia&mdash;or the motor speech centre may be implicated.</p>
+
+<p><i>Terminal Stage.</i>&mdash;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.</p>
+
+<p>When the <i>abscess bursts into the ventricles</i>, the patient suddenly
+becomes much worse and dies within a few hours. &ldquo;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&deg; to 105&deg; 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&rdquo;
+(Macewen).</p>
+
+<p>Spontaneous evacuation of a temporal abscess may take place through
+the middle ear.</p>
+
+<p><b>Cerebellar Abscess.</b>&mdash;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<a class="pagenum" name="Pg_382" id="Pg_382"></a> 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 an&aelig;sthesia.</p>
+
+<p><i>Treatment.</i>&mdash;The abscess having been localised, the skull must be
+opened and the pus removed.</p>
+
+<p><b>Abscess from causes other than Middle Ear Disease.</b>&mdash;From the <i>nasal
+passages</i>, 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.</p>
+
+<p>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.</p>
+
+<p>In <i>infected compound fractures</i>, 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.</p>
+
+<p>There is evidence that an abscess may form in the brain after a simple
+contusion without fracture or other external injury (Ehrenvooth).</p>
+
+<p>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<a class="pagenum" name="Pg_383" id="Pg_383"></a> 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.</p>
+
+<p>The treatment consists in opening up the original wound, removing any
+depressed bone or foreign body that may be present, and establishing
+drainage.</p>
+
+<p><i>Bronchiectasis</i> 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.</p>
+
+<p><i>Disease of the bones of the skull</i>, such as osteomyelitis or
+syphilis, may be followed by cerebral abscess.</p>
+
+<p>Abscesses of <i>py&aelig;mic</i> origin are usually multiple, and may occur both
+in the cerebrum and in the cerebellum; they are not amenable to
+surgical treatment.</p>
+
+
+<h3><a name="XIV_sinus_phlebitis" id="XIV_sinus_phlebitis"></a><span class="smcap">Sinus Phlebitis</span></h3>
+
+<p>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.</p>
+
+<p>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&mdash;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 c&aelig;cum.</p>
+
+<p>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.</p>
+
+<p>The infective process may spread backward along tributary vessels, and
+so give rise to cerebral or cerebellar abscess, or to<a class="pagenum" name="Pg_384" id="Pg_384"></a> purulent
+meningitis; or it may spread into the internal jugular vein and lead
+to the development of a diffuse purulent cellulitis along its course.</p>
+
+<p>General py&aelig;mic 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.</p>
+
+<p><i>Clinical Features.</i>&mdash;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&deg;
+to 106&deg; F. (<a href="#fig_196">Fig.&nbsp;196</a>). The pulse is rapid, small, and thready. Loss of
+appetite, vomiting, and diarrh&oelig;a are almost constant symptoms.</p>
+
+<div class="figcenter" style="width: 500px;">
+<a name="fig_196" id="fig_196"></a>
+<img src="images/fig196.jpg" width="500" height="327" alt="Fig. 196.&mdash;Chart of case of Sinus Phlebitis following
+middle ear disease in a boy &aelig;t. 13." title="" />
+<span class="caption"><span class="smcap">Fig. 196.</span>&mdash;Chart of case of Sinus Phlebitis following
+middle ear disease in a boy &aelig;t. 13.</span>
+</div>
+
+<p><b>Phlebitis of Individual Sinuses.</b>&mdash;The <i>transverse</i> (<i>lateral</i> or
+<i>sigmoid sinus</i>), 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.<a class="pagenum" name="Pg_385" id="Pg_385"></a> 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 &oelig;dema 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.</p>
+
+<p>Three clinical types of sinus phlebitis are recognised&mdash;pulmonary,
+abdominal, and meningeal&mdash;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.</p>
+
+<p>In the <i>pulmonary type</i> evidence of infection of the lungs appears
+towards the end of the second week, in the form of dyspn&oelig;a, cough,
+and pain in the side, coarse moist r&acirc;les, and dark f&oelig;tid sputum.
+Death usually takes place from gangrene of the lung. The brain
+functions may remain active to the end.</p>
+
+<p>In the <i>abdominal type</i> 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.</p>
+
+<p>When the disease is of the <i>meningeal type</i>, 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.</p>
+
+<p>The <i>prognosis</i> is always grave, on account of the risk of general
+infection.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p>The <i>superior sagittal</i> or <i>longitudinal sinus</i> is liable to be
+infected from pyogenic lesions of the scalp. There are no<a class="pagenum" name="Pg_386" id="Pg_386"></a> symptoms
+that are pathognomonic, but &oelig;dema of the scalp with turgescence of
+its veins, epistaxis, and convulsions followed by paralysis, are those
+most likely to be met with.</p>
+
+<p>The <i>cavernous sinus</i> is usually implicated by spread of the process
+from other sinuses&mdash;for instance, from the petrosal or transverse
+(lateral) sinuses&mdash;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&mdash;exophthalmos, &oelig;dema of the eyelids, and paralysis
+of the ocular nerves&mdash;are due to pressure on the structures entering
+the orbit.</p>
+
+<p>Operative interference is seldom feasible in phlebitis of the superior
+sagittal (longitudinal) or cavernous sinuses.</p>
+
+<p><a name="XIV_intra_cranial_tuberculosis" id="XIV_intra_cranial_tuberculosis"></a><b>Intra-cranial Tuberculosis.</b>&mdash;<i>Tuberculous meningitis</i> 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 (<i>acute
+hydrocephalus</i>).</p>
+
+<p>At first the <i>symptoms</i> of irritation of the brain predominate: severe
+headache, photophobia, inequality of the pupils, stiffness of the
+neck, cutaneous hyper&aelig;sthesia, vomiting and convulsions. Kernig's
+sign&mdash;pain on flexing the hip while the knee is extended, and
+inability to extend the knee while in the sitting posture&mdash;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.</p>
+
+<p>The only surgical measure that is justifiable is lumbar puncture,
+which often affords marked relief of symptoms, although the benefit is
+only temporary.</p>
+
+<p><i>Localised tuberculous nodules</i> 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<a class="pagenum" name="Pg_387" id="Pg_387"></a> they are usually
+multiple; in adults they may be single&mdash;the so-called &ldquo;solitary
+tubercle.&rdquo; 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.</p>
+
+<p>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.</p>
+
+<p><b>Intra-cranial Syphilis.</b>&mdash;<i>Syphilitic meningitis</i> 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.</p>
+
+<p><i>Localised gummata</i> are described with tumours of the brain.</p>
+
+
+<h3><a name="XIV_cephaloceles" id="XIV_cephaloceles"></a><span class="smcap">Cephaloceles</span></h3>
+
+<p>The term &ldquo;cephalocele&rdquo; 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.</p>
+
+<p>Several varieties are recognised. They are known as (1)<a class="pagenum" name="Pg_388" id="Pg_388"></a>
+<i>meningocele</i>, which consists of a protrusion of a cul-de-sac of the
+arachno-pial membrane, containing cerebro-spinal fluid; (2)
+<i>encephalocele</i>, in which a portion of the brain is protruded in
+addition to the membranes; and (3) <i>hydrencephalocele</i>, in which the
+protruded portion of brain includes a part of one of the ventricles.</p>
+
+<p><a name="XIV_meningocele" id="XIV_meningocele"></a><i>Clinical Features.</i>&mdash;The <i>meningocele</i> is commonest in the occipital
+region, where it escapes through a cleft in the bone between the
+foramen magnum and the occipital protuberance (<a href="#fig_197">Fig.&nbsp;197</a>). 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 n&aelig;void. 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.</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_197" id="fig_197"></a>
+<img src="images/fig197.jpg" width="350" height="400" alt="Fig. 197.&mdash;Occipital Meningocele." title="" />
+<span class="caption"><span class="smcap">Fig. 197.</span>&mdash;Occipital Meningocele.<br /><br />
+(From a photograph lent by Sir George T. Beatson.)</span>
+</div>
+
+<p>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.<a class="pagenum" name="Pg_389" id="Pg_389"></a> Infection may also occur
+from eczema or from excoriation of the overlying skin.</p>
+
+<p><a name="XIV_encephaloceles" id="XIV_encephaloceles"></a><i>Encephaloceles</i> 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.</p>
+
+<p><a name="XIV_hydrencephalocele" id="XIV_hydrencephalocele"></a>The <i>hydrencephalocele</i> 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 (<a href="#fig_198">Fig.&nbsp;198</a>).</p>
+
+<div class="figcenter" style="width: 335px;">
+<a name="fig_198" id="fig_198"></a>
+<img src="images/fig198.jpg" width="335" height="400" alt="Fig. 198.&mdash;Frontal Hydrencephalocele." title="" />
+<span class="caption"><span class="smcap">Fig. 198.</span>&mdash;Frontal Hydrencephalocele.<br /><br />
+(From a photograph lent by Sir George T. Beatson.)</span>
+</div>
+
+<p>Cephaloceles have to be diagnosed from dermoid cysts, n&aelig;vi (<a href="#fig_199">Fig.&nbsp;199</a>),
+cephal-hydrocele, and cephal-h&aelig;matoma. 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.</p>
+
+<div class="figcenter" style="width: 400px;"><a class="pagenum" name="Pg_390" id="Pg_390"></a>
+<a name="fig_199" id="fig_199"></a>
+<img src="images/fig199.jpg" width="400" height="393" alt="Fig. 199.&mdash;N&aelig;vus at Root of Nose, simulating
+Cephalocele." title="" />
+<span class="caption"><span class="smcap">Fig. 199.</span>&mdash;N&aelig;vus at Root of Nose, simulating
+Cephalocele.<br /><br />
+(From a photograph lent by Sir George T. Beatson.)</span>
+</div>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p>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.</p>
+
+<p><a name="XIV_traumatic_cephal_hydrocele" id="XIV_traumatic_cephal_hydrocele"></a><b>Traumatic Cephal-hydrocele.</b>&mdash;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.</p>
+
+
+<h3><a name="XIV_hydrocephalus" id="XIV_hydrocephalus"></a><a class="pagenum" name="Pg_391" id="Pg_391"></a><span class="smcap">Hydrocephalus</span></h3>
+
+<p>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 <i>external</i>, and in the latter an
+<i>internal hydrocephalus</i>. Hydrocephalus may be acute or chronic.</p>
+
+<p><b>Acute hydrocephalus</b> 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.</p>
+
+<p><b>Chronic Hydrocephalus.</b>&mdash;<i>Chronic external hydrocephalus</i> 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.</p>
+
+<p><i>Chronic internal hydrocephalus</i>, 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 communica<a class="pagenum" name="Pg_392" id="Pg_392"></a>tion 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.</p>
+
+<p>The cerebral tissue is greatly thinned out, but the cerebellum and
+cranial nerves usually remain unaffected.</p>
+
+<p>The appearance of the patient is characteristic (<a href="#fig_200">Fig.&nbsp;200</a>). 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.</p>
+
+<div class="figcenter" style="width: 500px;">
+<a name="fig_200" id="fig_200"></a>
+<img src="images/fig200.jpg" width="500" height="263" alt="Fig. 200.&mdash;Hydrocephalus in a child &aelig;t. 3-1/2." title="" />
+<span class="caption"><span class="smcap">Fig. 200.</span>&mdash;Hydrocephalus in a child &aelig;t. 3<span class="frac_top">1</span>/<span class="frac_bottom">2</span>.</span>
+</div>
+
+<p>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.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p>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<a class="pagenum" name="Pg_393" id="Pg_393"></a> 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.</p>
+
+<p><a name="XIV_micrencephaly" id="XIV_micrencephaly"></a><b>Micrencephaly.</b>&mdash;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.</p>
+
+
+<h3><a name="XIV_cerebral_tumours" id="XIV_cerebral_tumours"></a><span class="smcap">Cerebral Tumours</span></h3>
+
+<p>As a comparatively small proportion of tumours of the brain&mdash;using the
+term &ldquo;tumour&rdquo; in its widest sense&mdash;are amenable to surgical treatment,
+it is only necessary here to refer to those aspects of this subject
+that have a distinctively surgical bearing.</p>
+
+<p>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, h&aelig;morrhagic,
+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.</p>
+
+<p><i>Clinical Features.</i>&mdash;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.</p>
+
+<p>The earliest and most prominent of the <i>general symptoms</i> 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,<a class="pagenum" name="Pg_394" id="Pg_394"></a> general convulsions, and signs of mental
+deterioration are also present in a considerable proportion of cases.</p>
+
+<p>In addition, certain <i>localising symptoms</i> may be present. When, for
+example, the tumour is situated in the <i>cortex of the Rolandic area</i>,
+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.</p>
+
+<p>When the tumour is <i>sub-cortical</i>, 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.</p>
+
+<p>Tumours situated in the region of <i>the internal capsule</i>, and <i>in the
+deeper parts of the brain</i>, 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.</p>
+
+<p>Tumours and cysts <i>in the cerebellum</i> give rise to symptoms similar to
+those of cerebellar abscess (<a href="#Pg_381">p.&nbsp;381</a>).</p>
+
+<p>Tumours <i>in the cerebello-pontine angle</i>, 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.</p>
+
+<p>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<a class="pagenum" name="Pg_395" id="Pg_395"></a> 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 h&aelig;morrhage
+into a soft tumour, such as glioma.</p>
+
+<p>The <i>diagnosis</i> of the pathological nature of a cerebral tumour is
+generally &ldquo;hardly more than a guess&rdquo; (Gowers). At the same time it may
+be borne in mind that <i>syphilitic gummata</i> 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.</p>
+
+<p><i>Tuberculous masses</i> 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.</p>
+
+<p><i>Endothelioma</i> 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.</p>
+
+<p><i>Glioma</i> 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 h&aelig;morrhage is
+liable to occur into the substance of the tumour, causing a sudden
+aggravation of the symptoms.</p>
+
+<p><i>Sarcoma</i> 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.</p>
+
+<p>The <i>prognosis</i> is grave in all forms of brain tumour. Even in
+syphilitic growths, although the more urgent symptoms may<a class="pagenum" name="Pg_396" id="Pg_396"></a> 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 h&aelig;morrhage, from acute &oelig;dema, or
+from implication of vital centres.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p>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.</p>
+
+<p>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 &ldquo;decompression operation&rdquo;
+(<i>Operative Surgery</i>, p. 108). The relief that follows such operations
+is often remarkable.</p>
+
+<p>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.</p>
+
+<p>When surgical treatment is contra-indicated, all that can be done is
+to palliate the symptoms by bromides, opium, phenacetin, caffein, and
+other drugs.</p>
+
+<p><a name="XIV_tumours_pituitary_body" id="XIV_tumours_pituitary_body"></a><b>Tumours of the Pituitary Body</b> or <b>Hypophysis Cerebri</b>.&mdash;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 (<i>hyperpituitarism</i>), signs of acromegaly may
+ensue. Diminution of function (<i>hypopituitarism</i>) is attended with
+infantilism, a rapid deposition of fat in the subcutaneous tissue, and
+a decrease or loss of the genital functions. In women, amenorrh&oelig;a
+is an<a class="pagenum" name="Pg_397" id="Pg_397"></a> early and constant symptom. Intense drowsiness is a marked
+feature in some cases.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><a name="XIV_epilepsy" id="XIV_epilepsy"></a><b>Epilepsy.</b>&mdash;The surgical aspects of Jacksonian epilepsy following head
+injuries have already been considered (<a href="#Pg_358">p.&nbsp;358</a>). 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.</p>
+
+<p><a name="XIV_hernia_cerebri" id="XIV_hernia_cerebri"></a><b>Hernia Cerebri.</b>&mdash;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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>The <i>treatment</i> 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<a class="pagenum" name="Pg_398" id="Pg_398"></a> 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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+
+<h3><a name="XIV_cranial_nerve" id="XIV_cranial_nerve"></a><span class="smcap">Surgical Affections of the Cranial Nerve</span></h3>
+
+<p>Irritation, or paralysis, of one or more of the cranial nerves may
+result from lesions implicating their centres or trunks.</p>
+
+<p>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 (<a href="#Pg_334">p.&nbsp;334</a>). The lesions of the
+cerebral centres with which nerve symptoms are most frequently
+associated are: laceration of the brain, h&aelig;morrhage, meningitis,
+tumour, and syphilitic gumma.</p>
+
+<p>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<a class="pagenum" name="Pg_399" id="Pg_399"></a> from
+blood-clot, or more probably to the onset of meningitis or of
+ascending neuritis.</p>
+
+<p>I. The branches of the <i>Olfactory Nerve</i> 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 (<i>anosmia</i>). H&aelig;morrhage 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.</p>
+
+<p>II. <i>Optic Nerve.</i>&mdash;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.</p>
+
+<p>Lesions implicating the cortical centre for sight in the occipital
+lobe give rise to hemianopia&mdash;that is, loss of sight in the lateral
+halves of the fields of vision of both eyes&mdash;colour-blindness,
+subjective sensations of light and colour, and other eye symptoms.</p>
+
+<p>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.</p>
+
+<p>III. <i>Oculo-Motor Nerve.</i>&mdash;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&mdash;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 hemi<a class="pagenum" name="Pg_400" id="Pg_400"></a>spheres the third nerve is
+frequently paralysed. Its cortical centre lies in close proximity to
+the centre for the face (<a href="#fig_179">Fig.&nbsp;179</a>).</p>
+
+<p>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.</p>
+
+<p>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
+&ldquo;opthalmoplegia externa&rdquo;; it is usually due to syphilitic disease in
+the floor of the third ventricle.</p>
+
+<p>IV. The <i>Trochlear</i> or <i>Patheticus Nerve</i>, 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.</p>
+
+<p>V. <i>Trigeminal Nerve.</i>&mdash;The most important surgical affection of this
+nerve is &ldquo;trigeminal neuralgia,&rdquo; 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
+an&aelig;sthesia 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 an&aelig;sthetic condition of the eye, are allowed to remain
+and cause irritation.</p>
+
+<p>VI. <i>Abducens Nerve.</i>&mdash;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.</p>
+
+<p>VII. <i>Facial Nerve.</i>&mdash;Paralysis of the facial muscles, more or less
+complete, is the most characteristic symptom of lesions of this nerve.</p>
+
+<p><i>Paralysis of the Cerebral Type.</i>&mdash;When the fibres of the nerve are
+implicated in any part of their course between the cortical<a class="pagenum" name="Pg_401" id="Pg_401"></a> 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.</p>
+
+<p>This form of facial paralysis may be due to the pressure of an
+intra-cranial tumour, abscess, or h&aelig;morrhage, 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.</p>
+
+<p><i>Paralysis of the Peripheral Type.</i>&mdash;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.</p>
+
+<p>The majority of cases are of the so-called &ldquo;rheumatic&rdquo; 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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><i>Symptoms.</i>&mdash;In complete unilateral <i>facial paralysis</i> (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<a class="pagenum" name="Pg_402" id="Pg_402"></a>
+obliterated. When the patient speaks or smiles, the face is drawn to
+the sound side (<a href="#fig_201">Fig.&nbsp;201</a>). 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.</p>
+
+<div class="figcenter" style="width: 312px;">
+<a name="fig_201" id="fig_201"></a>
+<img src="images/fig201.jpg" width="312" height="350" alt="Fig. 201.&mdash;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." title="" />
+<span class="caption"><span class="smcap">Fig. 201.</span>&mdash;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.<br /><br />
+(From a photograph lent by Dr. Edwin Bramwell.)</span>
+</div>
+
+<p>When the paralysis is bilateral, the symmetrical appearance of the
+face renders the condition liable to be overlooked.</p>
+
+<p><i>Treatment.</i>&mdash;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<a class="pagenum" name="Pg_403" id="Pg_403"></a> 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.</p>
+
+<p>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.</p>
+
+<p><i>Facial Spasm.</i>&mdash;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)&mdash;blepharospasm. This
+condition may be induced reflexly from irrigation of the trigeminal
+nerve, notably of branches that supply the nasal cavities and the
+teeth.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+<p>VIII. <i>Acoustic</i> or <i>Auditory Nerve</i>.&mdash;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.</p>
+
+<p>IX. The <i>Glosso-pharyngeal Nerve</i> 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 &oelig;dema of the glottis may supervene.</p>
+
+<p>X. The <i>Vagus</i> or <i>Pneumogastric Nerve</i> is seldom injured within the
+cranial cavity.</p>
+
+<p>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.</p>
+
+<p><a class="pagenum" name="Pg_404" id="Pg_404"></a>Division of the main trunk, or of its recurrent branch on one side,
+results in paralysis of the corresponding posterior crico-aryt&aelig;noid
+muscle&mdash;the muscle that opens the glottis. This condition is known as
+unilateral <i>abductor paralysis</i>, 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.</p>
+
+<p>The vagus and recurrent nerves have been successfully sutured after
+having been divided accidentally.</p>
+
+<p>XI. <i>Accessory</i> or <i>Spinal Accessory Nerve</i>.&mdash;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 <i>paralysis of the trapezius</i>. 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.</p>
+
+<p>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.</p>
+
+<p>XII. <i>Hypoglossal Nerve.</i>&mdash;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&mdash;for
+example, in cut throat, or during the operation for ligation of the
+lingual artery, or the removal of diseased lymph glands.</p>
+
+<p><a class="pagenum" name="Pg_405" id="Pg_405"></a>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.</p>
+
+<p><a name="XIV_cervical_sympathetic" id="XIV_cervical_sympathetic"></a><b>The Cervical Sympathetic.</b>&mdash;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 (<a href="#Pg_417">p.&nbsp;417</a>) or
+of the first dorsal nerve root.</p>
+
+<p>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&mdash;&ldquo;loss of
+the cilio-spinal reflex.&rdquo; 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.</p>
+
+
+
+
+<h2><a class="pagenum" name="Pg_406" id="Pg_406"></a><a name="CHAPTER_XV" id="CHAPTER_XV"></a>CHAPTER XV
+<br />
+DISEASES OF THE CRANIAL BONES</h2>
+
+<ul class="chap">
+  <li><a href="#XV_periostitis">Suppurative periostitis and osteomyelitis</a></li>
+  <li>&mdash;<a href="#XV_tuberculosis">Tuberculosis</a></li>
+  <li>&mdash;<a href="#XV_syphilis">Syphilis</a></li>
+  <li>&mdash;<a href="#XV_tumours">Tumours</a>.</li>
+</ul>
+
+<p><a name="XV_periostitis" id="XV_periostitis"></a><b>Suppurative Periostitis and Osteomyelitis.</b>&mdash;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&mdash;a point of importance
+in treatment.</p>
+
+<p>The illness is usually ushered in by a rigor, and this is soon
+followed by other signs of suppuration&mdash;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 &oelig;dema of the overlying area of the scalp&mdash;spoken of
+as <i>Pott's puffy tumour</i>&mdash;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 pro<a class="pagenum" name="Pg_407" id="Pg_407"></a>trusion of the contents of the skull&mdash;hernia
+cerebri; should the patient survive, the gap becomes filled in by a
+dense fibrous membrane which is fused with the dura mater.</p>
+
+<p>Serious complications, in the form of meningitis, cerebral abscess,
+sinus phlebitis, and general py&aelig;mia, are liable to develop at any time
+during the progress of the infection, and we have seen py&aelig;mia develop
+after the suppuration in the skull had been recovered from.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p>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.</p>
+
+<p><a name="XV_tuberculosis" id="XV_tuberculosis"></a><b>Tuberculosis</b> of the cranial vault is usually met with in children. The
+disease commences in the diplo&euml;, 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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><a name="XV_syphilis" id="XV_syphilis"></a><b>Syphilis.</b>&mdash;Syphilitic affections occur during the tertiary period of
+the disease, and usually implicate the frontal and parietal bones
+(<a href="#fig_202">Fig.&nbsp;202</a>). They are described in Volume I., p. 462.</p>
+
+<div class="figcenter" style="width: 298px;">
+<a name="fig_202" id="fig_202"></a>
+<img src="images/fig202.jpg" width="298" height="400" alt="Fig. 202.&mdash;Skull of woman illustrating the appearances
+of Tertiary Syphilis of Frontal Bone&mdash;Corona Veneris&mdash;in the healed
+condition." title="" />
+<span class="caption"><span class="smcap">Fig. 202.</span>&mdash;Skull of woman illustrating the appearances
+of Tertiary Syphilis of Frontal Bone&mdash;Corona Veneris&mdash;in the healed
+condition.</span>
+</div>
+
+<p><a name="XV_tumours" id="XV_tumours"></a><b>Tumours.</b>&mdash;<i>Osteoma</i> of the skull has been described with diseases of
+bone (Volume I., p. 481).</p>
+
+<p><a class="pagenum" name="Pg_408" id="Pg_408"></a><i>Sarcoma.</i>&mdash;All forms of sarcoma are met with, implicating the bones
+of the skull. They may originate in the pericranium, in the diplo&euml;, or
+in the dura mater, and usually involve the bones of the vault. They
+sometimes occur in children (<a href="#fig_203">Fig.&nbsp;203</a>).</p>
+
+<div class="figcenter" style="width: 352px;">
+<a name="fig_203" id="fig_203"></a>
+<img src="images/fig203.jpg" width="352" height="500" alt="Fig. 203.&mdash;Sarcoma of Orbital Plate of Frontal Bone in
+a child at age of 11 months, and 18 months." title="" />
+<span class="caption"><span class="smcap">Fig. 203.</span>&mdash;Sarcoma of Orbital Plate of Frontal Bone in
+a child at age of 11 months, and 18 months.<br /><br />
+(Mr. D. M. Greig&#39;s case.)</span>
+</div>
+
+<p><a class="pagenum" name="Pg_409" id="Pg_409"></a>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.</p>
+
+<p>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.</p>
+
+<p>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 h&aelig;morrhage which attends it, or because of the extent of the
+disease.</p>
+
+<p>The bones of the skull may become the seat of <i>secondary growths</i> by
+the direct spread of cancer from the soft parts, <i>e.g.</i> rodent cancer
+(<a href="#fig_204">Fig.&nbsp;204</a>), 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&mdash;cancerous osteomalacia&mdash;softening<a class="pagenum" name="Pg_410" id="Pg_410"></a> 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.</p>
+
+<div class="figcenter" style="width: 305px;">
+<a name="fig_204" id="fig_204"></a>
+<img src="images/fig204.jpg" width="305" height="400" alt="Fig. 204.&mdash;Destruction of Bones of Left Orbit, caused
+by Rodent Cancer. The patient died of septic meningitis." title="" />
+<span class="caption"><span class="smcap">Fig. 204.</span>&mdash;Destruction of Bones of Left Orbit, caused
+by Rodent Cancer. The patient died of septic meningitis.<br /><br />
+(Mr. D. M. Greig&#39;s case.)</span>
+</div>
+
+
+
+
+<h2><a class="pagenum" name="Pg_411" id="Pg_411"></a><a name="CHAPTER_XVI" id="CHAPTER_XVI"></a>CHAPTER XVI
+<br />
+THE VERTEBRAL COLUMN AND SPINAL CORD</h2>
+
+<ul class="chap">
+  <li><a href="#XVI_anatomy">Surgical Anatomy</a></li>
+  <li>&mdash;<a href="#XVI_spinal_cord">Injuries of the spinal cord</a>:</li>
+  <li><a href="#XVI_concussion"><i>Concussion</i></a>;</li>
+  <li><a href="#XVI_haematorrachis"><i>Traumatic h&aelig;matorrachis</i></a>;</li>
+  <li><a href="#XVI_haematomyelia"><i>Traumatic h&aelig;matomyelia</i></a>;</li>
+  <li><a href="#XVI_total_lesions"><i>Total transverse lesions at different levels</i></a>;</li>
+  <li><a href="#XVI_partial_lesions"><i>Partial lesions</i></a>;</li>
+  <li><a href="#XVI_railway_spine">&ldquo;<i>Railway spine</i>&rdquo;</a></li>
+  <li>&mdash;<a href="#XVI_vertebral_column">Injuries of the vertebral column</a>:</li>
+  <li><a href="#XVI_sprain"><i>Sprain</i></a>;</li>
+  <li><a href="#XVI_isolated_dislocation"><i>Isolated dislocation of articular processes</i></a>;</li>
+  <li><a href="#XVI_isolated_fracture"><i>Isolated fracture of arches and spinous processes</i></a>;</li>
+  <li><a href="#XVI_compression_fracture"><i>Compression fracture of bodies</i></a></li>
+  <li>&mdash;<a href="#XVI_traumatic_spondylitis">Traumatic spondylitis</a></li>
+  <li>&mdash;<a href="#XVI_fracture_dislocation">Fracture-dislocation</a></li>
+  <li>&mdash;<a href="#XVI_penetrating_wounds">Penetrating wounds</a>.</li>
+</ul>
+
+<p><a name="XVI_anatomy" id="XVI_anatomy"></a><b>Surgical Anatomy.</b>&mdash;The veretebral column is the central axis of the
+skeleton, and affords a protecting casement for the spinal cord.</p>
+
+<p>The spine is movable in all directions&mdash;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 lamin&aelig;.</p>
+
+<p>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.</p>
+
+<p>Through the skin it is often difficult to identify with certainty the
+individual spinous processes. The spine of the seventh cervical
+vertebra,&mdash;vertebra prominens&mdash;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 vertebr&aelig; 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 vertebr&aelig; and its transverse
+process.</p>
+
+<p>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 vertebr&aelig; lie, roughly speaking, opposite the lower edge of
+their respective bodies; those of the remaining thoracic vertebr&aelig; lie
+opposite<a class="pagenum" name="Pg_412" id="Pg_412"></a> the body of the vertebr&aelig; below; while the spines of the
+lumbar vertebr&aelig; lie opposite the middle of their corresponding bodies.</p>
+
+<p>The <i>vertebral canal</i> 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.</p>
+
+<p>The <i>membranes</i> 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.</p>
+
+<p>The <i>spinal cord</i> extends from the foramen magnum to the level of the
+disc between the first and second lumbar vertebr&aelig;. 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.</p>
+
+<p>One pair of spinal nerves leaves each &ldquo;segment&rdquo; 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&mdash;from the second lumbar vertebra onward&mdash;they run parallel with
+the filum terminale and together constitute the cauda equina.</p>
+
+<p>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).</p>
+
+<p><i>Functions.</i>&mdash;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 (<a href="#Pg_331">p.&nbsp;331</a>).</p>
+
+<p>In the grey matter there are groups of nerve-cells&mdash;&ldquo;centres&rdquo;&mdash;which
+govern certain reflex movements. The most important of these&mdash;the
+centres for the rectal, the vesical, and the patellar reflexes&mdash;are
+situated in the lumbar enlargement.</p>
+
+<p>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.</p>
+
+
+<h3><a name="XVI_spinal_cord" id="XVI_spinal_cord"></a><a class="pagenum" name="Pg_413" id="Pg_413"></a>INJURIES OF THE SPINAL MEDULLA OR CORD</h3>
+
+<p>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
+H&aelig;morrhage; Total Transverse Lesions; Partial Lesions of the Cord and
+Nerve Roots; and &ldquo;Railway Spine.&rdquo;</p>
+
+<p><a name="XVI_concussion" id="XVI_concussion"></a><b>Concussion of the Spinal Cord.</b>&mdash;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 &oelig;dema or vascular
+engorgement, and possibly an arterial an&aelig;mia; in other cases there is
+definite evidence of injury, of the nature of contusion, minute
+h&aelig;morrhages 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&mdash;total transverse
+lesion,&mdash;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.</p>
+
+<p>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.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+<p><b>Traumatic Spinal H&aelig;morrhage.</b>&mdash;H&aelig;morrhage into the vertebral canal is a
+common accompaniment of all forms of<a class="pagenum" name="Pg_414" id="Pg_414"></a> injury to the spine, but the
+lower cervical region is the common seat of the severe type of
+h&aelig;morrhage 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&mdash;between it and the
+dura&mdash;(extra-medullary), or into its substance (intra-medullary).</p>
+
+<p><a name="XVI_haematorrachis" id="XVI_haematorrachis"></a><i>Extra-medullary H&aelig;morrhage&mdash;H&aelig;matorrachis.</i>&mdash;The symptoms associated
+with extra-medullary h&aelig;morrhage are at first of an irritative
+kind&mdash;muscular cramps and jerkings, radiating pains along the course
+of the nerves pressed upon, and hyper&aelig;sthesia. 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 h&aelig;morrhage that the paralysis comes on gradually. When
+the effusion is in the cervical region&mdash;the commonest situation&mdash;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&mdash;<i>gravitation paraplegia</i> (Thorburn). There
+is blood in the cerebro-spinal fluid.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+<p><a name="XVI_haematomyelia" id="XVI_haematomyelia"></a><i>Intra-medullary H&aelig;morrhage&mdash;H&aelig;matomyelia.</i>&mdash;Traumatic h&aelig;morrhage 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.</p>
+
+<p>The severity of the <i>clinical features</i> depends upon the extent of the
+lesion. In contrast with what results in extra-medullary h&aelig;morrhage,
+the symptoms are paralytic from the outset.</p>
+
+<p>When the h&aelig;morrhage is only sufficient to cause <i>pressure</i> 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 an&aelig;sthesia for temperature<a class="pagenum" name="Pg_415" id="Pg_415"></a> and pain, while tactile
+sensibility is preserved. There is retention of urine and f&aelig;ces, and
+in young men, priapism. As the fibres which supply the dilator pupill&aelig;
+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.</p>
+
+<p>When the blood extravasated in the cord causes disintegration of its
+substance, there is complete paralysis with atrophy, and an&aelig;sthesia 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, <i>e.g.</i> 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.</p>
+
+<p>Except that operative treatment is contra-indicated, the <i>treatment</i>
+is the same as for extra-medullary h&aelig;morrhage, and at a later period
+measures may be employed to relieve the spastic condition of the
+muscles.</p>
+
+<p><a name="XVI_total_lesions" id="XVI_total_lesions"></a><b>Total Transverse Lesions.</b>&mdash;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 vertebr&aelig; is only partial and
+temporary, the cord may be completely torn across. Similar lesions may
+result from stabs or bullet-wounds.</p>
+
+<p>From the records of cases in which the vertebr&aelig; were injured by modern
+rifle bullets, even although the bony walls of the spinal canal had
+not been fractured and no h&aelig;morrhage had occurred within the spinal
+canal, the cord in the vicinity was degenerated into a &ldquo;custard-like
+material&rdquo; incapable of any conducting power (Makins). According to
+Stevenson, &ldquo;this must have been due to the vibratory concussion
+communicated to it by the passage of the bullet at a high rate of
+velocity.&rdquo; The importance of this observation lies in the fact that in
+such cases no benefit can follow operative interference.</p>
+
+<p>The <i>clinical features</i> 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<a class="pagenum" name="Pg_416" id="Pg_416"></a> recumbent, any
+irregularity in the spinous processes or lamin&aelig; 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.</p>
+
+<p><i>Immediate Symptoms.</i>&mdash;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 hyper&aelig;sthesia may be
+mapped out above the an&aelig;sthetic 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.</p>
+
+<p>Retention of urine and retention or incontinence of f&aelig;ces are constant
+symptoms. In young men priapism is common&mdash;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.</p>
+
+<p>Unless regularly emptied by the catheter, the bladder becomes
+distended, and there is dribbling of urine&mdash;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 scapul&aelig;, the heels, and
+the elbows.</p>
+
+<p><i>Later symptoms</i> 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.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p><b>Injuries of the Cord at Different Levels.</b>&mdash;<i>Cervical
+Region.</i>&mdash;Complete lesions of the <i>first four cervical segments</i>&mdash;that
+is, above the level of the disc between the third and fourth cervical
+vertebr&aelig;&mdash;are always rapidly, if not instantaneously, fatal, as
+respiration is at once arrested by the destruction of<a class="pagenum" name="Pg_417" id="Pg_417"></a> the fibres
+which go to form the phrenic nerve. It is from this cause that death
+results in judicial hanging.</p>
+
+<p>In lesions between the <i>fifth cervical and first thoracic segments
+inclusive</i>, 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 (<a href="#fig_205">Fig.&nbsp;205</a>). 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<a class="pagenum" name="Pg_418" id="Pg_418"></a> 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&mdash;a symptom which is always of grave
+omen.</p>
+
+<div class="figcenter" style="width: 429px;">
+<a name="fig_205" id="fig_205"></a>
+<a href="images/fig205-large.jpg">
+<img src="images/fig205.jpg" width="429" height="500" alt="Fig. 205.&mdash;Distribution of the Segments of the Spinal
+Cord." title="" /></a>
+<span class="caption"><span class="smcap">Fig. 205.</span>&mdash;Distribution of the Segments of the Spinal
+Cord.<br /><br />
+(After Kocher.)<br />
+<a href="images/fig205-large.jpg">VIEW LARGER IMAGE</a></span>
+</div>
+
+<p>When the lesion is confined to the <i>sixth cervical segment</i>, 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 (<a href="#fig_206">Fig.&nbsp;206</a>). Sensation is retained along the radial side of
+the limb.</p>
+
+<div class="figcenter" style="width: 350px;">
+<a name="fig_206" id="fig_206"></a>
+<img src="images/fig206.jpg" width="350" height="238" alt="Fig. 206.&mdash;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." title="" />
+<span class="caption"><span class="smcap">Fig. 206.</span>&mdash;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.</span>
+</div>
+
+<p>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.</p>
+
+<p>When the lesion is confined to <i>the first thoracic segment</i>, 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 an&aelig;sthesia as high as the level of the second interspace,
+and along the distribution of the ulnar nerve (<a href="#fig_205">Fig.&nbsp;205</a>); the
+respiration is entirely diaphragmatic; and the ocular changes
+depending on paralysis of the cervical sympathetic are present.</p>
+
+<p><a class="pagenum" name="Pg_419" id="Pg_419"></a><i>Thoracic Region.</i>&mdash;In injuries of the thoracic region&mdash;second to
+eleventh thoracic segments inclusive&mdash;the an&aelig;sthesia 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
+an&aelig;sthetic area there is a zone of hyper&aelig;sthesia, and the patient
+complains of a sensation as if a band were tightly tied round the
+body&mdash;&ldquo;girdle-pain.&rdquo;</p>
+
+<p>The motor paralysis and the an&aelig;sthesia 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 f&aelig;ces 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.</p>
+
+<p>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.</p>
+
+<p><i>Lumbo-sacral Region.</i>&mdash;All the spinal segments representing the
+lumbar, sacral, and coccygeal nerves lie between the level of the
+eleventh thoracic and first lumbar vertebr&aelig;. Injuries of the lower
+thoracic and upper lumbar vertebr&aelig;, therefore, may produce complete
+paralysis within the area of distribution of the lumbar and sacral
+plexuses. The an&aelig;sthesia reaches to about the level of the umbilicus.
+There is incontinence of urine and f&aelig;ces 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.</p>
+
+<p><i>Conus Medullaris.</i>&mdash;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, an&aelig;sthesia 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.</p>
+
+<p><i>Cauda Equina.</i>&mdash;As the cord terminates opposite the lower border of
+the first lumbar vertebra, injuries below this level<a class="pagenum" name="Pg_420" id="Pg_420"></a> 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
+an&aelig;sthesia 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 f&aelig;ces. The prognosis is more favourable than
+in lesions affecting the cord itself, and the only risk to life is the
+occurrence of infective complications.</p>
+
+<p><a name="XVI_partial_lesions" id="XVI_partial_lesions"></a><b>Partial Lesions of the Cord and Nerve Roots.</b>&mdash;Partial lesions, such as
+bruises, lacerations, or incomplete ruptures, are always attended with
+h&aelig;morrhage 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.</p>
+
+<p>When the <i>nerve roots</i> 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.</p>
+
+<p>In <i>partial lesions of the cord</i> 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&mdash;feet and legs&mdash;suffer more than the proximal&mdash;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.</p>
+
+<p>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<a class="pagenum" name="Pg_421" id="Pg_421"></a> defer
+judgment until it is determined whether the abolition of the reflexes
+is temporary or permanent.</p>
+
+<p>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 hyper&aelig;sthesia
+on one side and an&aelig;sthesia on the other.</p>
+
+<p>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.</p>
+
+<p>In partial lesions, the difficulties of diagnosis are sometimes
+increased by the occurrence of h&aelig;morrhage 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
+h&aelig;morrhage pass off, but those due to the tearing of the cord persist.</p>
+
+<p>The <i>prognosis</i> 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&mdash;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.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+<p>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&mdash;a concussion of the cord alone, a total
+transverse lesion and a partial lesion of the<a class="pagenum" name="Pg_422" id="Pg_422"></a> 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.</p>
+
+<p><a name="XVI_railway_spine" id="XVI_railway_spine"></a>&ldquo;<b>Railway Spine.</b>&rdquo;&mdash;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.</p>
+
+<p><i>Clinical Features.</i>&mdash;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.</p>
+
+<p>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 hyper&aelig;sthesia 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<a class="pagenum" name="Pg_423" id="Pg_423"></a> 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.</p>
+
+<p>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.</p>
+
+<p>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&mdash;whether favourable to him or not&mdash;his health is usually
+restored by the general tonic treatment employed for neurasthenia.</p>
+
+
+<h3><a name="XVI_vertebral_column" id="XVI_vertebral_column"></a>INJURIES OF THE VERTEBRAL COLUMN</h3>
+
+<p><i>Partial</i> 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 <i>complete</i> lesions are total dislocations and
+fracture-dislocations.</p>
+
+<p>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.</p>
+
+<p>Twists and dislocations are most common in the cervical region, that
+is, in the part of the spine where the forward range of
+movement&mdash;flexion&mdash;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.</p>
+
+<p>In all lesions accompanied by displacement, the upper segment of the
+spine is displaced forwards.</p>
+
+<p><a name="XVI_sprain" id="XVI_sprain"></a><b>Twists</b> or <b>sprains</b> are produced by movements that suddenly put the
+ligamentous and muscular structures of the spine on the stretch&mdash;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<a class="pagenum" name="Pg_424" id="Pg_424"></a> 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 vertebr&aelig; may be stretched or
+lacerated, and as a result radiating pains may be felt in the area of
+their distribution.</p>
+
+<p>In the <i>cervical</i> region, distortion usually results either from
+forcible extension of the neck&mdash;for example from a violent blow or
+fall on the forehead forcing the head backwards&mdash;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
+vertebr&aelig; 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.</p>
+
+<p>In the <i>lumbar</i> 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.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p><a name="XVI_isolated_dislocation" id="XVI_isolated_dislocation"></a><b>Isolated Dislocation of Articular Processes.</b>&mdash;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.</p>
+
+<p>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<a class="pagenum" name="Pg_425" id="Pg_425"></a> 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 vertebr&aelig; 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 vertebr&aelig;. As the bodies are not separated, damage
+to the cord is exceptional. The lesion can usually be recognised in a
+radiogram.</p>
+
+<p><i>Treatment.</i>&mdash;Reduction should be attempted at once, before the
+vertebr&aelig; become fixed in their abnormal position. Under an&aelig;sthesia
+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.</p>
+
+<p><a name="XVI_isolated_fracture" id="XVI_isolated_fracture"></a><b>Isolated Fractures of the Arches, Spinous and Transverse
+Processes.</b>&mdash;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.</p>
+
+<div class="figleft" style="width: 200px;">
+<a name="fig_207" id="fig_207"></a>
+<img src="images/fig207.jpg" width="200" height="393" alt="Fig. 207.&mdash;Compression Fracture of Bodies of Third and
+Fourth Lumbar Vertebr&aelig;. Woman, &aelig;t. 28, who fell three storeys and
+landed on the buttocks." title="" />
+<span class="caption"><span class="smcap">Fig. 207.</span>&mdash;Compression Fracture of Bodies of Third and
+Fourth Lumbar Vertebr&aelig;. Woman, &aelig;t. 28, who fell three storeys and
+landed on the buttocks.</span>
+</div>
+
+<p>In many cases there are no symptoms of damage to the cord or spinal
+nerves, but when both lamin&aelig; 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.</p>
+
+<p>The use of the X-rays has shown that one or more of the <i>transverse
+processes of the lumbar vertebr&aelig;</i> may be chipped off by direct
+violence. The symptoms are pain and tenderness in<a class="pagenum" name="Pg_426" id="Pg_426"></a> 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.</p>
+
+<p><a name="XVI_compression_fracture" id="XVI_compression_fracture"></a><b>Isolated Fracture of the Bodies&mdash;&ldquo;Compression Fracture.&rdquo;</b>&mdash;The
+&ldquo;compression fracture&rdquo; consists in a crushing from above downwards of
+the bodies&mdash;and the bodies only&mdash;of one or more vertebr&aelig;. 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 vertebr&aelig; while the spine is flexed.</p>
+
+<p>If the patient lands on his head, the compression fracture usually
+involves the lower cervical or upper thoracic vertebr&aelig;. When he lands
+on his buttocks or feet it is usually the lumbar or the lower thoracic
+vertebr&aelig; that are fractured (<a href="#fig_207">Fig.&nbsp;207</a>).</p>
+
+<p>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
+vertebr&aelig; 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<a class="pagenum" name="Pg_427" id="Pg_427"></a> the one that is crushed. The cord usually escapes, but the
+nerves emerging in relation to the damaged vertebr&aelig; may be bruised,
+and this gives rise to girdle-pain.</p>
+
+<p>Local tenderness is elicited on pressing over the affected vertebr&aelig;.
+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.</p>
+
+<p>The <i>treatment</i> consists in taking the pressure off the injured
+vertebr&aelig; 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.</p>
+
+<div class="figright" style="width: 200px;">
+<a name="fig_208" id="fig_208"></a>
+<img src="images/fig208.jpg" width="200" height="396" alt="Fig. 208.&mdash;Fracture&mdash;Dislocation of Ninth Thoracic
+Vertebra, showing downward and forward displacement of upper segment,
+and compression of cord by upper edge of lower segment." title="" />
+<span class="caption"><span class="smcap">Fig. 208.</span>&mdash;Fracture&mdash;Dislocation of Ninth Thoracic
+Vertebra, showing downward and forward displacement of upper segment,
+and compression of cord by upper edge of lower segment.<br /><br />
+(Anatomical Museum, University of Edinburgh.)</span>
+</div>
+
+<p><a name="XVI_traumatic_spondylitis" id="XVI_traumatic_spondylitis"></a><b>Traumatic Spondylitis.</b>&mdash;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 vertebr&aelig;. While the condition is
+progressive, the prominent vertebr&aelig; 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.</p>
+
+<p><a name="XVI_fracture_dislocation" id="XVI_fracture_dislocation"></a><b>Dislocation and Fracture-Dislocation.</b>&mdash;It is seldom possible at the
+bedside to distinguish between a complete dislocation of the spine and
+a fracture-dislocation. <i>Fracture-dislocation</i> is by far the more
+common lesion of the two, and is the injury popularly known as a
+&ldquo;broken back.&rdquo; It may occur in any part of the column, but is most
+frequently met with in the<a class="pagenum" name="Pg_428" id="Pg_428"></a> 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 <i>the angle of flexion and not at the point struck</i>. 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 (<a href="#fig_208">Fig.&nbsp;208</a>).
+In almost every case the cord is damaged beyond repair.</p>
+
+<p><i>Total dislocation</i>, 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.</p>
+
+<p><i>Clinical Features.</i>&mdash;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 pro<a class="pagenum" name="Pg_429" id="Pg_429"></a>jection 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
+vertebr&aelig;. 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 (<a href="#Pg_416">p.&nbsp;416</a>).</p>
+
+<p><i>Treatment.</i>&mdash;An attempt may be made to reduce the displacement under
+an&aelig;sthesia, 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<a class="pagenum" name="Pg_430" id="Pg_430"></a>
+results than are obtained by reduction and extension. The usual
+precautions must be taken to prevent cystitis and bed-sores.</p>
+
+<p>Total fracture-dislocation between the <i>atlas</i> and <i>epistropheus</i>
+(axis), if attended with displacement, is instantaneously fatal (<a href="#fig_209">Fig.&nbsp;209</a>).
+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.</p>
+
+<div class="figcenter" style="width: 500px;">
+<a name="fig_209" id="fig_209"></a>
+<img src="images/fig209.jpg" width="500" height="451" alt="Fig. 209.&mdash;Fracture of Odontoid Process of Axis
+Vertebra." title="" />
+<span class="caption"><span class="smcap">Fig. 209.</span>&mdash;Fracture of Odontoid Process of Axis
+Vertebra.</span>
+</div>
+
+<p><a name="XVI_penetrating_wounds" id="XVI_penetrating_wounds"></a><b>Penetrating Wounds.</b>&mdash;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,
+&oelig;sophagus, 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.</p>
+
+<p><i>Treatment.</i>&mdash;The wound of the soft parts is treated on the usual
+lines. When the spinous processes and lamin&aelig; 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.</p>
+
+<p>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.</p>
+
+
+
+
+<h2><a class="pagenum" name="Pg_431" id="Pg_431"></a><a name="CHAPTER_XVII" id="CHAPTER_XVII"></a>CHAPTER XVII
+<br />
+DISEASES OF THE VERTEBRAL COLUMN AND SPINAL CORD</h2>
+
+<ul class="chap">
+  <li><a href="#XVII_potts_disease"><span class="smcap">Pott's Disease</span>: <i>Pathology</i></a>;</li>
+  <li><a href="#XVII_clinical_features"><i>Clinical features</i></a></li>
+  <li>&mdash;<a href="#XVII_potts_regions">Pott's disease as it affects different regions of the spine</a></li>
+  <li>&mdash;<a href="#XVII_sacro_iliac">Disease of the sacro-iliac joint</a>;</li>
+  <li><a href="#XVII_syphilitic_spine">Syphilitic disease of spine</a>;</li>
+  <li><a href="#XVII_tumour_spine">Tumours of vertebr&aelig;</a>;</li>
+  <li><a href="#XVII_hysterical_spine">Hysterical spine</a>;</li>
+  <li><a href="#XVII_acute_osteomyelitis">Acute osteomyelitis</a>;</li>
+  <li><a href="#XVII_acute_osteomyelitis">Rheumatic spondylitis</a>;</li>
+  <li><a href="#XVII_arthritits_deformans">Arthritis deformans</a>;</li>
+  <li><a href="#XVII_coccydynia">Coccydynia</a>;</li>
+  <li><a href="#XVII_tumours_cord">Tumours of cord and membranes</a></li>
+  <li>&mdash;<a href="#XVII_spinal_meningitis">Spinal meningitis</a>;</li>
+  <li><a href="#XVII_spinal_myelitis">Spinal myelitis</a></li>
+  <li>&mdash;<a href="#XVII_congenital_deformities">Congenital deformities</a>:</li>
+  <li><a href="#XVII_spina_bifida"><i>Spina bifida</i></a>;</li>
+  <li><a href="#XVII_sacro_coccygeal_tumours"><i>Congenital sacro-coccygeal tumours</i></a>.</li>
+  <li><a href="#XVII_sacro_coccygeal_sinuses">Congenital sacro-coccygeal sinuses and fistul&aelig;</a>.</li>
+</ul>
+
+
+<h3><a name="XVII_potts_disease" id="XVII_potts_disease"></a><span class="smcap">Tuberculous Disease of the Spine&mdash;Pott's Disease</span></h3>
+
+<p>Percival Pott, in 1779, first described a disease of the vertebral
+column which is characterised by erosion and destruction of the bodies
+of the vertebr&aelig;. 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.</p>
+
+<p><b>Morbid Anatomy.</b>&mdash;The tuberculous process may affect any portion of the
+spine, and as a rule is limited to one region; several vertebr&aelig; are
+usually simultaneously involved. The disease may begin either in the
+interior of the bodies of the vertebr&aelig;&mdash;tuberculous osteomyelitis&mdash;or
+in the deeper layer of the periosteum on the anterior surface of the
+bones&mdash;tuberculous periostitis.</p>
+
+<div class="figleft" style="width: 175px;">
+<a name="fig_210" id="fig_210"></a>
+<img src="images/fig210.jpg" width="175" height="300" alt="Fig. 210.&mdash;Tuberculous Osteomyelitis affecting several
+vertebr&aelig; at Thoracico-lumbar Junction." title="" />
+<span class="caption"><span class="smcap">Fig. 210.</span>&mdash;Tuberculous Osteomyelitis affecting several
+vertebr&aelig; at Thoracico-lumbar Junction.</span>
+</div>
+
+<p><i>Osteomyelitis</i> 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 vertebr&aelig;,
+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<a class="pagenum" name="Pg_432" id="Pg_432"></a> 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.</p>
+
+<p>The compression of the diseased vertebr&aelig; 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 vertebr&aelig; project and form
+a prominence in the middle line of the back. When, as is usually the
+case, only two or three vertebr&aelig; are implicated, this prominence takes
+the form of a sharp angular projection, while if a series of vertebr&aelig;
+are involved, the deformity is of the nature of a gentle backward
+curve (<a href="#fig_210">Fig.&nbsp;210</a>).</p>
+
+<p>The <i>periosteal form</i> 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 vertebr&aelig;, 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 vertebr&aelig;.<a class="pagenum" name="Pg_433" id="Pg_433"></a> 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 vertebr&aelig;
+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.</p>
+
+<p><i>Effects on the Spinal Cord and Nerve Roots.</i>&mdash;In some cases the cord
+and nerve roots are pressed upon by an &oelig;dematous 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&mdash;<i>tuberculous pachymeningitis</i>. Less frequently a collection of
+pus forms between the bone and the dura, and presses the cord back
+against the lamin&aelig;. 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
+vertebr&aelig;&mdash;a condition comparable to a fracture-dislocation of the
+spine.</p>
+
+<p>The severity of the symptoms is aggravated by the occurrence of
+inflammation of the cord&mdash;<i>myelitis</i>&mdash;which is not due to tuberculous
+disease, but to interference with its blood-supply from the associated
+meningitis.</p>
+
+<p><i>Repair.</i>&mdash;When the progress of the disease is arrested, the natural
+cure of the condition is brought about by the bodies of the affected
+vertebr&aelig; becoming fused by osseous ankylosis (<a href="#fig_211">Fig.&nbsp;211</a>). 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.</p>
+
+<div class="figcenter" style="width: 381px;">
+<a name="fig_211" id="fig_211"></a>
+<img src="images/fig211.jpg" width="381" height="400" alt="Fig. 211.&mdash;Osseous Ankylosis of Bodies (a) of Dorsal
+Vertebr&aelig;, (b) of Lumbar Vertebr&aelig; following Pott&#39;s disease. There is
+marked kyphosis at the seat of the disease and compensatory lordosis
+above and below." title="" />
+<span class="caption"><span class="smcap">Fig. 211.</span>&mdash;Osseous Ankylosis of Bodies (a) of Dorsal
+Vertebr&aelig;, (b) of Lumbar Vertebr&aelig; following Pott&#39;s disease. There is
+marked kyphosis at the seat of the disease and compensatory lordosis
+above and below.<br /><br />
+(Museum of the Royal College of Surgeons, Edinburgh.)</span>
+</div>
+
+<p>&nbsp;</p>
+
+<div class="figcenter" style="width: 299px;">
+<a name="fig_212" id="fig_212"></a>
+<img src="images/fig212.jpg" width="299" height="400" alt="Fig. 212.&mdash;Radiogram of Museum Specimen of Pott&#39;s
+disease in a Child; the disease is located at the thoracico-lumbar
+junction." title="" />
+<span class="caption"><span class="smcap">Fig. 212.</span>&mdash;Radiogram of Museum Specimen of Pott&#39;s
+disease in a Child; the disease is located at the thoracico-lumbar
+junction.<br /><br />
+(Dr. Hope Fowler.)</span>
+</div>
+
+<p>In rare cases the disease affects only the articular or the spinous
+processes, producing superficial caries and a localised abscess.</p>
+
+<p><a name="XVII_clinical_features" id="XVII_clinical_features"></a><b>Clinical Features.</b>&mdash;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.</p>
+
+<p><i>Pain.</i>&mdash;In the earliest stages, the patient complains of a feeling of
+tiredness, which prevents him walking far or standing for<a class="pagenum" name="Pg_434" id="Pg_434"></a> 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 (<a href="#fig_214">Figs.&nbsp;214</a>, <a href="#fig_217">217</a>). 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 vertebr&aelig;, and takes the form of
+headache, neuralgic pains in the arms or side, girdle-pain, or<a class="pagenum" name="Pg_435" id="Pg_435"></a>
+belly-ache, according to the seat of the lesion. Tenderness may be
+elicited on pressing over the spinous or transverse processes of the
+diseased vertebr&aelig;, 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<a class="pagenum" name="Pg_436" id="Pg_436"></a> suffering. It is to
+be borne in mind that in some cases the disease is not attended with
+any pain.</p>
+
+<p><i>Rigidity.</i>&mdash;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 vertebr&aelig; implicated move <i>en bloc</i> instead
+of gliding on one another. This rigidity of the diseased portion of
+the column with &ldquo;boarding&rdquo; of the muscles of the back is one of the
+earliest and most valuable diagnostic signs of Pott's disease.</p>
+
+<p><i>Deformity.</i>&mdash;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 vertebr&aelig; implicated. When the disease has destroyed the
+bodies of one or two vertebr&aelig;, a short, sharp, angular deformity
+results; when it affects the surface of several bones, a long, wide
+curvature.</p>
+
+<p>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 vertebr&aelig;.</p>
+
+<p><i>Abscess Formation.</i>&mdash;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 vertebr&aelig;. Pyogenic
+infection of such abscesses after they have burst externally
+constitutes one of the chief risks to life in Pott's disease.</p>
+
+<p><i>X-Ray Appearances.</i>&mdash;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 vertebr&aelig; 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<a class="pagenum" name="Pg_437" id="Pg_437"></a> lesion which is located at
+the &ldquo;angle.&rdquo; In children (<a href="#fig_213">Fig.&nbsp;213</a>) 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.</p>
+
+<div class="figcenter" style="width: 389px;">
+<a name="fig_213" id="fig_213"></a>
+<img src="images/fig213.jpg" width="389" height="400" alt="Fig. 213.&mdash;Radiogram of Child&#39;s Thorax, showing
+spindle-shaped shadow at site of Pott&#39;s disease of fourth, fifth, and
+sixth thoracic vertebr&aelig;." title="" />
+<span class="caption"><span class="smcap">Fig. 213.</span>&mdash;Radiogram of Child&#39;s Thorax, showing
+spindle-shaped shadow at site of Pott&#39;s disease of fourth, fifth, and
+sixth thoracic vertebr&aelig;.</span>
+</div>
+
+<p><i>Cord and Nerve Symptoms.</i>&mdash;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.<a class="pagenum" name="Pg_438" id="Pg_438"></a> 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.</p>
+
+<p>The sensory fibres usually escape, although in some cases there is
+partial an&aelig;sthesia 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 f&aelig;ces, as the patient loses
+control of the sphincters. Acute bed-sores are not uncommon.</p>
+
+<p>The symptoms referable to pressure on the <i>nerve roots</i> at their
+points of emergence are pain and hyper&aelig;sthesia 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.</p>
+
+<p>In the <b>diagnosis</b> 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.</p>
+
+<p><b>Treatment of Pott's Disease.</b>&mdash;In addition to the general treatment of
+tuberculosis, the essential factor consists in <i>immobilising the spine
+in the recumbent posture and in the attitude of hyper-extension</i>; this
+must be persisted in until the diseased vertebr&aelig; 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.</p>
+
+<p>Under conservative measures it is estimated that this reparative
+process entails an immobilisation of the spine of from one to three
+years; the <i>operative procedures introduced by Albe and Hibbs</i> bring
+about a bony ankylosis of the vertebr&aelig; 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.</p>
+
+<p>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 <i>Bradford frame</i>; 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<a class="pagenum" name="Pg_439" id="Pg_439"></a> interfere with such
+<i>extension</i> 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.</p>
+
+<p><i>Gauvain's &ldquo;wheel-barrow&rdquo; splint</i> and the <i>double Thomas' splint</i>
+(<a href="#fig_215">Fig.&nbsp;215</a>) are efficient substitutes, but <i>Phelps' box</i> has been
+discarded because it fails to secure immobilisation of the spine.</p>
+
+<p>When the stage of <i>convalescence</i> 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
+<i>plaster-of-Paris jacket</i>, 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 m&acirc;ch&eacute;, and other
+materials, reinforced by strips of metal, may be substituted for the
+plaster of Paris. Various forms of <i>jury-masts</i> and <i>collars</i> 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.</p>
+
+<p><i>Correction of the Angular Projection.</i>&mdash;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&mdash;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.</p>
+
+<p><i>Treatment of Abscess.</i>&mdash;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.</p>
+
+<p><i>Treatment of Cord-Complications.</i>&mdash;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 &oelig;dema, the symptoms usually yield with
+remarkable rapidity; if they persist, in spite of extension, for three
+to six weeks, recourse should be had to<a class="pagenum" name="Pg_440" id="Pg_440"></a> <i>laminectomy</i>; 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.</p>
+
+<p><b>Prognosis.</b>&mdash;As regards the <i>survival of persons who have suffered from
+Pott's disease</i>, and as having an important bearing on prognosis, it
+may be noted that surgical museums contain many specimens illustrating
+the &ldquo;cured&rdquo; stage of the disease, in which the bodies of the vertebr&aelig;,
+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 (<a href="#fig_211">Fig.&nbsp;211</a>), 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 &ldquo;cured&rdquo; cases of Pott's disease
+met with in everyday life, that the malady is one from which recovery
+may be expected.</p>
+
+<p>The cervical cases are recognised by the &ldquo;telescoping&rdquo; of the neck,
+the head and thorax being unduly approximated; the dorsal cases by the
+well-known <i>hump</i> or <i>hunch-back</i>, in which the spinous processes of
+the collapsed vertebr&aelig; 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.</p>
+
+
+<h3><a name="XVII_potts_regions" id="XVII_potts_regions"></a><span class="smcap">Pott's Disease as it affects Different Regions of the Spine</span></h3>
+
+<p><b>Upper Cervical Region, including Atlo-axoid Disease.</b>&mdash;When the disease
+affects the first and second cervical vertebr&aelig;, 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
+vertebr&aelig; are affected, the tendency to dislocation and<a class="pagenum" name="Pg_441" id="Pg_441"></a> compression of
+the cord is not so great, but a portion of bone may be displaced
+backwards and exert pressure on the cord.</p>
+
+<p>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
+vertebr&aelig; the patient often supports the chin on the hands (<a href="#fig_214">Fig.&nbsp;214</a>).</p>
+
+<div class="figcenter" style="width: 300px;">
+<a name="fig_214" id="fig_214"></a>
+<img src="images/fig214.jpg" width="300" height="400" alt="Fig. 214.&mdash;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." title="" />
+<span class="caption"><span class="smcap">Fig. 214.</span>&mdash;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.</span>
+</div>
+
+<p>An abscess may form between the vertebr&aelig; and the wall of the
+pharynx&mdash;<i>retro-pharyngeal abscess</i>&mdash;the pus accumulating<a class="pagenum" name="Pg_442" id="Pg_442"></a> 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 (<a href="#fig_214">Fig.&nbsp;214</a>). In some cases it comes to the
+surface in the sub-occipital region.</p>
+
+<div class="figleft" style="width: 115px;">
+<a name="fig_215" id="fig_215"></a>
+<img src="images/fig215.jpg" width="115" height="500" alt="Fig. 215.&mdash;Thomas&#39; Double Splint for Tuberculous
+disease of Spine." title="" />
+<span class="caption"><span class="smcap">Fig. 215.</span>&mdash;Thomas&#39; Double Splint for Tuberculous
+disease of Spine.</span>
+</div>
+
+<p>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.</p>
+
+<p>Sudden death may result when dislocation of the atlo-axoid joint takes
+place.</p>
+
+<p>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.</p>
+
+<p><i>Treatment.</i>&mdash;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 (<a href="#fig_215">Fig.&nbsp;215</a>).</p>
+
+<p>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<a class="pagenum" name="Pg_443" id="Pg_443"></a> with the risks of pus being inhaled into the
+air-passages and of pyogenic infection.</p>
+
+<p>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 vertebr&aelig; must be worn until the cure is
+complete.</p>
+
+<div class="figright" style="width: 165px;">
+<a name="fig_216" id="fig_216"></a>
+<img src="images/fig216.jpg" width="165" height="500" alt="Fig. 216.&mdash;Hunch-back Deformity following Pott&#39;s
+disease of Thoracic Vertebr&aelig;." title="" />
+<span class="caption"><span class="smcap">Fig. 216.</span>&mdash;Hunch-back Deformity following Pott&#39;s
+disease of Thoracic Vertebr&aelig;.<br /><br />
+(Photograph lent by Sir George T. Beatson.)</span>
+</div>
+
+<p><b>Cervico-thoracic Region.</b>&mdash;When the lower cervical and upper thoracic
+vertebr&aelig; 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 &oelig;sophagus 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.</p>
+
+<p><b>Thoracic or Dorsal Region.</b>&mdash;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 vertebr&aelig; by placing the palms<a class="pagenum" name="Pg_444" id="Pg_444"></a> of the hands on the edge of a
+chair so that the weight is borne by the arms.</p>
+
+<p>Angular deformity is often well marked, and may implicate several
+vertebr&aelig;. In order to maintain the head erect, the spine above and
+below the seat of disease becomes unduly arched forward&mdash;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.</p>
+
+<p><i>Dorsal Abscess.</i>&mdash;As already mentioned, the earliest stage of abscess
+is well seen in skiagrams (<a href="#fig_213">Fig.&nbsp;213</a>), 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 vertebr&aelig;, the pus may
+spread down through the pillars of the diaphragm and reach the sheath
+of the psoas muscle.</p>
+
+<p><i>Treatment</i> is on the usual lines.</p>
+
+<div class="figleft" style="width: 191px;">
+<a name="fig_217" id="fig_217"></a>
+<img src="images/fig217.png" width="191" height="400" alt="Fig. 217.&mdash;Attitude in Pott&#39;s disease of
+Thoracico-lumbar Region of Spine." title="" />
+<span class="caption"><span class="smcap">Fig. 217.</span>&mdash;Attitude in Pott&#39;s disease of
+Thoracico-lumbar Region of Spine.</span>
+</div>
+
+<p><b>Thoracico-lumbar Region.</b>&mdash;The symptoms are similar to those of disease
+in the thoracic region. Children while standing often assume a
+characteristic attitude&mdash;the hips and knees are slightly flexed, and
+the hands grasp the thighs just above the<a class="pagenum" name="Pg_445" id="Pg_445"></a> knees (<a href="#fig_217">Fig.&nbsp;217</a>). In this
+way the weight is partly taken off the affected vertebr&aelig; 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.</p>
+
+<p>The patient often complains of pain in the abdomen&mdash;which in children
+may be mistaken for a simple &ldquo;belly-ache&rdquo;&mdash;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.</p>
+
+<p><i>Psoas Abscess.</i>&mdash;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.</p>
+
+<p><i>Lumbar Abscess.</i>&mdash;Sometimes the pus travels along the posterior
+branches of the lumbar vessels and nerves to the lateral border of the
+sacro-spinalis (erector spin&aelig;) and comes to the surface in the space
+between the edges of the latissimus dorsi and external oblique
+muscles&mdash;the triangle of Petit.</p>
+
+<p>In rare cases it passes through the sacro-sciatic foramen and forms a
+swelling in the buttock (<i>sub-gluteal abscess</i>); or it may pass
+through the obturator foramen and reach the adductor region of the
+thigh or even the perineum.</p>
+
+<p><b>Lumbo-sacral Region.</b>&mdash;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 <i>iliac abscess</i> 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,<a class="pagenum" name="Pg_446" id="Pg_446"></a> the conjugate diameter at the brim being increased, while the
+transverse diameter at the outlet is diminished&mdash;kyphotic pelvis, and,
+in females, this may lead to complications in parturition.</p>
+
+<p><a name="XVII_sacro_iliac" id="XVII_sacro_iliac"></a><b>Tuberculous Disease of the Sacro-iliac Joint.</b>&mdash;This condition may
+occur as a primary affection, but is much more frequently secondary to
+disease in the ilium, sacrum, or lower lumbar vertebr&aelig;, 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 <i>iliac abscess</i> or may gravitate
+downwards in the hollow of the sacrum and emerge on the buttock
+through the sacro-sciatic foramen&mdash;<i>sub-gluteal abscess</i>. 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.</p>
+
+<p>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.</p>
+
+<p>The <i>prognosis</i> is unfavourable, particularly in cases complicated by
+extensive disease of the ilium with abscess formation and mixed
+infection.</p>
+
+<p><a class="pagenum" name="Pg_447" id="Pg_447"></a><i>Treatment.</i>&mdash;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.</p>
+
+<p><a name="XVII_syphilitic_spine" id="XVII_syphilitic_spine"></a><b>Syphilitic Disease of the Vertebr&aelig;.</b>&mdash;All the clinical features of
+Pott's disease may be simulated by gummatous disease of the vertebr&aelig;.
+This is usually met with in adults who have suffered from acquired
+syphilis; it is most common in the upper cervical vertebr&aelig;, 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.</p>
+
+<p><a name="XVII_tumour_spine" id="XVII_tumour_spine"></a><b>Malignant Disease of the Vertebr&aelig;.</b>&mdash;<i>Sarcoma</i> 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 vertebr&aelig;, as seen in skiagrams, are
+helpful in diagnosis. The growth may encroach upon the vertebral canal
+and cause pressure on the cord (<a href="#Pg_451">p.&nbsp;451</a>). In the sacrum&mdash;the most
+common site&mdash;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.</p>
+
+<p><i>Secondary cancer</i> is a common disease, particularly in cases of
+advanced scirrhus of the breast. It leads to extensive softening of
+the bodies of the vertebr&aelig;, 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 vertebr&aelig; affected, and along the course of
+the nerves emerging in the<a class="pagenum" name="Pg_448" id="Pg_448"></a> neighbourhood. If paralysis occurs from
+the cancerous bodies pressing upon the cord (<i>paraplegia dolorosa</i>),
+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.</p>
+
+<p><b>Actinomycosis</b>, <b>Blastomycosis</b>, and <b>Hydatid Cysts</b> also occur in the
+vertebr&aelig;, and are difficult to diagnose from tuberculous disease.</p>
+
+<p><b>Typhoid Spine.</b>&mdash;An acute infective condition of the vertebr&aelig;,
+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 vertebr&aelig;. The onset, which may
+be gradual or sudden, is attended with intense pain, and tenderness
+over the affected vertebr&aelig;. 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.</p>
+
+<p><a name="XVII_hysterical_spine" id="XVII_hysterical_spine"></a><b>Hysterical Spine.</b>&mdash;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&mdash;usually the
+cervico-thoracic or thoracico-lumbar region&mdash;and there is marked
+hyper&aelig;sthesia 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 vertebr&aelig;, 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.</p>
+
+<div class="figright" style="width: 210px;">
+<a name="fig_218" id="fig_218"></a>
+<img src="images/fig218.jpg" width="210" height="400" alt="Fig. 218.&mdash;Arthritis Deformans of Spine. The vertebr&aelig;
+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." title="" />
+<span class="caption"><span class="smcap">Fig. 218.</span>&mdash;Arthritis Deformans of Spine. The vertebr&aelig;
+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.<br /><br />
+(Anatomical Museum, University of Edinburgh.)</span>
+</div>
+
+<p><a name="XVII_acute_osteomyelitis" id="XVII_acute_osteomyelitis"></a><b>Acute osteomyelitis</b> of the vertebr&aelig; is a rare affection, and is met
+with in young subjects. It attacks the more mobile portions of the
+spine&mdash;cervical and lumbar&mdash;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 vertebr&aelig; attacked, and a
+marked degree of fever. Pus usually forms rapidly, but, being deeply
+placed, is not easily<a class="pagenum" name="Pg_449" id="Pg_449"></a> 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.</p>
+
+<p><a name="XVII_arthritits_deformans" id="XVII_arthritits_deformans"></a><b>Arthritis Deformans.</b>&mdash;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 gonorrh&oelig;a, 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 vertebr&aelig; (<a href="#fig_218">Fig.&nbsp;218</a>). The articulations
+between the ribs and the vertebr&aelig; show similar changes, and the
+ligaments of the several joints tend to undergo ossification, so that
+the bones are fused together.</p>
+
+<p>In the early stage the patient complains of pain and stiffness in the
+back; later the spine becomes rigid, and gradually<a class="pagenum" name="Pg_450" id="Pg_450"></a> 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.</p>
+
+<p>The disease may simulate tuberculous caries or malignant disease. The
+changes in the bones are demonstrated by the use of the X-rays.</p>
+
+<p>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.</p>
+
+<p><a name="XVII_coccydynia" id="XVII_coccydynia"></a><b>Coccydynia</b> 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.</p>
+
+<p><a name="XVII_tumours_cord" id="XVII_tumours_cord"></a><b>Tumours of the Spinal Cord and Membranes.</b>&mdash;Tumours may develop in the
+substance of the cord (<i>intra-medullary</i>), in the membranes
+(<i>meningeal</i>), or in the tissues between the dura and the bone
+(<i>extra-dural</i>); or the cord may be pressed upon by a tumour
+originating in the vertebr&aelig;. 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.</p>
+
+<p>Tumours growing <i>in the substance of the cord</i> are nearly as<a class="pagenum" name="Pg_451" id="Pg_451"></a> 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.</p>
+
+<p>The great majority of <i>meningeal</i> 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.</p>
+
+<p><i>Extra-dural</i> growths are comparatively rare. The forms usually met
+with are sarcoma and lipoma.</p>
+
+<p>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.</p>
+
+<p>The <i>symptoms</i> 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.</p>
+
+<p>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&mdash;a point of importance in diagnosis. The painful
+areas are an&aelig;sthetic, but the an&aelig;sthesia does not always reach to the
+level of the lesion. There may be a zone of hyper&aelig;sthesia at the upper
+limit of the an&aelig;sthesia, or in the area corresponding to the roots on
+which the tumour is situated, but there is never diffuse hyper&aelig;sthesia
+(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.</p>
+
+<p>The next symptom to appear is motor paresis, followed by complete
+paralysis, and later by contracture of the paralysed muscles&mdash;<i>spastic
+paraplegia</i>. 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.</p>
+
+<p>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-<a class="pagenum" name="Pg_452" id="Pg_452"></a>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 an&aelig;sthesia would appear to indicate; the
+vertebral canal, therefore, should be opened about four inches above
+the level of the an&aelig;sthesia.</p>
+
+<p>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.</p>
+
+<p><a name="XVII_spinal_meningitis" id="XVII_spinal_meningitis"></a><b>Chronic Spinal Meningitis.</b>&mdash;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 gonorrh&oelig;a, but in some cases no cause can be
+assigned for the lesion.</p>
+
+<p><i>Clinical Features.</i>&mdash;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
+an&aelig;sthesia, but there is relative an&aelig;sthesia for all forms of
+sensation, which extends as a rule as far as the sixth or eighth
+thoracic root.</p>
+
+<p>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.</p>
+
+<p><i>Treatment.</i>&mdash;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<a class="pagenum" name="Pg_453" id="Pg_453"></a> 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.</p>
+
+<p><b>Acute Spinal Meningitis.</b>&mdash;The spinal membranes may become implicated
+by direct spread in cases of acute intra-cranial lepto-meningitis, or
+they may be infected from without&mdash;for example, in gun-shot injuries
+or in cases of spina bifida.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>Once the condition has started little can be done to arrest its
+progress, but the symptoms may be relieved by repeated lumbar
+puncture.</p>
+
+<p><a name="XVII_spinal_myelitis" id="XVII_spinal_myelitis"></a><b>Spinal Myelitis.</b>&mdash;The term &ldquo;myelitis&rdquo; is applied to certain changes
+which occur in the spinal cord as a result, for example, of h&aelig;morrhage
+into its substance (<i>h&aelig;morrhagic myelitis</i>); or of pressure exerted on
+it by fragments of bone, blood-clot, tuberculous material, or new
+growths (<i>compression myelitis</i>).</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+
+<h3><a name="XVII_congenital_deformities" id="XVII_congenital_deformities"></a><span class="smcap">Congenital Deformities of the Spine</span></h3>
+
+<p><a name="XVII_spina_bifida" id="XVII_spina_bifida"></a><b>Spina Bifida.</b>&mdash;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 lamin&aelig;<a class="pagenum" name="Pg_454" id="Pg_454"></a> fail to take place. The cleft
+may implicate only the spinous processes, but as a rule the lamin&aelig;
+also are deficient. The defect usually extends over several vertebr&aelig;
+(<a href="#fig_219">Fig.&nbsp;219</a>). 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.</p>
+
+<table class="figure" summary="Fig 219, 220">
+<tr>
+<td class="figcenter" style="width: 220px;">
+<a name="fig_219" id="fig_219"></a>
+<img src="images/fig219.jpg" width="220" height="400" alt="Fig. 219.&mdash;Meningo-myelocele of Thoracico-lumbar
+Region." title="" />
+<span class="caption"><span class="smcap">Fig. 219.</span>&mdash;Meningo-myelocele of Thoracico-lumbar
+Region.</span>
+</td>
+
+<td style="width: 50px;">&nbsp;</td>
+
+<td class="figcenter" style="width: 220px;">
+<a name="fig_220" id="fig_220"></a>
+<img src="images/fig220.jpg" width="220" height="400" alt="Fig. 220.&mdash;Meningo-myelocele of Cervical Spine." title="" />
+<span class="caption"><span class="smcap">Fig. 220.</span>&mdash;Meningo-myelocele of Cervical Spine.</span>
+</td>
+</tr>
+</table>
+
+<p>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 (<a href="#fig_219">Fig.&nbsp;219</a>), but occurs also in the cervical (<a href="#fig_220">Fig.&nbsp;220</a>) 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.</p>
+
+<p><i>Varieties.</i>&mdash;Four varieties are usually described according to the
+character of the protrusion. They are analogous, to a certain extent,
+to the varieties of cephalocele (<a href="#Pg_387">p.&nbsp;387</a>). (1) <i>Spinal meningocele</i>, in
+which only the membranes, filled with cerebro-spinal fluid, are
+protruded. (2) <i>Meningo-myelocele</i>, the<a class="pagenum" name="Pg_455" id="Pg_455"></a> 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 (<a href="#fig_219">Figs.&nbsp;219</a>,
+<a href="#fig_220">220</a>). (3) <i>Syringo-myelocele</i>, 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 <i>myelocele</i>, 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.</p>
+
+<p><i>Clinical Features.</i>&mdash;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.</p>
+
+<div class="figcenter" style="width: 257px;">
+<a name="fig_221" id="fig_221"></a>
+<img src="images/fig221.jpg" width="257" height="400" alt="Fig. 221.&mdash;Meningo-myelocele in Thoracic Region." title="" />
+<span class="caption"><span class="smcap">Fig. 221.</span>&mdash;Meningo-myelocele in Thoracic Region.</span>
+</div>
+
+<p>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.</p>
+
+<p><i>Prognosis.</i>&mdash;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<a class="pagenum" name="Pg_456" id="Pg_456"></a> following on infection. The condition
+in some cases remains stationary for years, but spontaneous
+disappearance is rare.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p>Operative treatment is seldom to be recommended in a young child
+unless it is otherwise viable and the swelling is increasing<a class="pagenum" name="Pg_457" id="Pg_457"></a> 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.</p>
+
+<p>The term <b>spina bifida occulta</b> 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<a class="pagenum" name="Pg_458" id="Pg_458"></a> over the gap is often
+puckered and adherent, and is frequently covered with a growth of
+coarse hair.</p>
+
+<p>A mass of fat may project towards the surface, and when situated in
+the lumbo-sacral region may suggest a caudal appendage or tail (<a href="#fig_222">Fig.&nbsp;222</a>).</p>
+
+<div class="figcenter" style="width: 365px;">
+<a name="fig_222" id="fig_222"></a>
+<img src="images/fig222.jpg" width="365" height="400" alt="Fig. 222.&mdash;Tail-like Appendage over Spina Bifida
+Occulta in a boy &aelig;t. 5, and associated with incontinence of urine.
+Operation was followed by temporary retention." title="" />
+<span class="caption"><span class="smcap">Fig. 222.</span>&mdash;Tail-like Appendage over Spina Bifida
+Occulta in a boy &aelig;t. 5, and associated with incontinence of urine.
+Operation was followed by temporary retention.</span>
+</div>
+
+<p>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.<a class="pagenum" name="Pg_459" id="Pg_459"></a> 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.</p>
+
+<p><a name="XVII_sacro_coccygeal_tumours" id="XVII_sacro_coccygeal_tumours"></a><b>Congenital Sacro-coccygeal Tumours&mdash;Teratoma.</b>&mdash;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&mdash;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.</p>
+
+<p>Among other tumours met with in this region may be mentioned: the
+congenital <i>lipoma</i>&mdash;a small, rounded, fatty tumour which often
+suggests a caudal appendage (<a href="#fig_222">Fig.&nbsp;222</a>); the <i>sacral hygroma</i>, 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 <i>in utero</i> by
+the continued growth of the vertebral arch; dermoids, sarcoma, and
+lymphangioma.</p>
+
+<div class="figcenter" style="width: 342px;">
+<a name="fig_223" id="fig_223"></a>
+<img src="images/fig223.jpg" width="342" height="400" alt="Fig. 223.&mdash;Congenital Sacro-coccygeal Tumour." title="" />
+<span class="caption"><span class="smcap">Fig. 223.</span>&mdash;Congenital Sacro-coccygeal Tumour.<br /><br />
+(Photograph lent by Sir George T. Beatson.)</span>
+</div>
+
+<p>The <i>treatment</i> 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.</p>
+
+<p><a name="XVII_sacro_coccygeal_sinuses" id="XVII_sacro_coccygeal_sinuses"></a><b>Congenital Sacro-coccygeal Sinuses and Fistul&aelig;.</b>&mdash;The <i>post-anal
+dimple</i>, 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 <i>sinuses</i> 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.</p>
+
+<p>In some cases the depression communicates with the vertebral canal,
+constituting a complete <i>sacro-coccygeal fistula</i>, which may be lined
+with cylindrical or ciliated epithelium.</p>
+
+<p><a class="pagenum" name="Pg_460" id="Pg_460"></a>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 fistul&aelig;. They are
+best dealt with by complete excision, and as primary union cannot be
+expected, the wound should be treated by the open method.</p>
+
+
+
+
+<h2><a class="pagenum" name="Pg_461" id="Pg_461"></a><a name="CHAPTER_XVIII" id="CHAPTER_XVIII"></a>CHAPTER XVIII
+<br />
+DEVIATIONS OF THE VERTEBRAL COLUMN</h2>
+
+<ul class="chap">
+  <li><a href="#XVIII_lordosis"><span class="smcap">Lordosis</span></a></li>
+  <li>&mdash;<a href="#XVIII_kyphosis"><span class="smcap">Kyphosis</span></a></li>
+  <li>&mdash;<a href="#XVIII_scoliosis"><span class="smcap">Scoliosis</span></a></li>
+</ul>
+
+<p>Three main deviations of the vertebral column are described:
+<i>Lordosis</i>, in which it is unduly arched forwards; <i>Kyphosis</i>, in
+which it is unduly arched backwards; and <i>Scoliosis</i> or lateral
+deviations, in which the spine deviates to one side of the middle
+line.</p>
+
+<p><a name="XVIII_lordosis" id="XVIII_lordosis"></a><b>Lordosis</b> or <i>anterior curvature of the spine</i> 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.</p>
+
+<p>Lordosis elsewhere than in the lumbar segment is met with as a
+compensatory deviation to kyphotic or backward curvature of the spine:
+in <a href="#fig_211">Fig.&nbsp;211</a>, 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<a class="pagenum" name="Pg_462" id="Pg_462"></a> 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.</p>
+
+<p><a name="XVIII_kyphosis" id="XVIII_kyphosis"></a><b>Kyphosis</b> or <i>posterior curvature of the spine</i> with the convexity
+backwards, is met with at all periods of life, and results from a wide
+range of conditions.</p>
+
+<p>In infancy it is a common result of <i>general debility</i>. 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 &ldquo;round shoulders&rdquo;; 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.</p>
+
+<p>Another type of diffuse kyphosis without compensatory curvature is met
+with in <i>arthritis deformans</i>, 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.</p>
+
+<p><i>Partial or localised kyphosis</i>, on the other hand, is the result of
+organic changes in the bodies of the vertebr&aelig; 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 (<a href="#fig_211">Fig.&nbsp;211</a>). A
+similar but less marked type of kyphosis may follow upon compression
+fracture of the spine&mdash;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.</p>
+
+
+<h3><a name="XVIII_scoliosis" id="XVIII_scoliosis"></a><a class="pagenum" name="Pg_463" id="Pg_463"></a>SCOLIOSIS</h3>
+
+<p><b>Scoliosis</b> or <i>lateral curvature</i> 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.</p>
+
+<p><i>Static scoliosis</i>, 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,
+<i>e.g.</i>, 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 <a class="pagenum" name="Pg_464" id="Pg_464"></a>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 &ldquo;elevator&rdquo; inside
+the boot.</p>
+
+<p>When there is <i>shortening of the muscles on one side of the trunk</i>
+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 (<a href="#fig_224">Fig.&nbsp;224</a>) 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 (<a href="#fig_272">Fig.&nbsp;272</a>). <i>Unilateral paralysis</i> of
+<i>muscles</i> 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.</p>
+
+<div class="figcenter" style="width: 194px;">
+<a name="fig_224" id="fig_224"></a>
+<img src="images/fig224.jpg" width="194" height="400" alt="Fig. 224.&mdash;Scoliosis following upon Poliomyelitis
+affecting right arm and leg." title="" />
+<span class="caption"><span class="smcap">Fig. 224.</span>&mdash;Scoliosis following upon Poliomyelitis
+affecting right arm and leg.<br /><br />
+(Mr. D. M. Greig&#39;s case.)</span>
+</div>
+
+<p><a class="pagenum" name="Pg_465" id="Pg_465"></a><i>Asymmetry of the thorax</i>, 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.</p>
+
+<p><i>Attitudes</i> 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.</p>
+
+<p><i>Malformation</i> or <i>disease of the vertebr&aelig;</i> 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 (<a href="#fig_225">Fig.&nbsp;225</a>). In a few cases
+a rudimentary wedge-shaped vertebra has been revealed by the X-rays.</p>
+
+<div class="figcenter" style="width: 308px;">
+<a name="fig_225" id="fig_225"></a>
+<img src="images/fig225.jpg" width="308" height="400" alt="Fig. 225.&mdash;Rickety Scoliosis in a child &aelig;t. 2." title="" />
+<span class="caption"><span class="smcap">Fig. 225.</span>&mdash;Rickety Scoliosis in a child &aelig;t. 2.</span>
+</div>
+
+<p>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.</p>
+
+<p><b>Habitual or Postural Scoliosis.</b>&mdash;These names have been given to the
+type of scoliosis that develops in young girls and for which there is
+no mechanical explanation.</p>
+
+<div class="figleft" style="width: 248px;">
+<a name="fig_226" id="fig_226"></a>
+<img src="images/fig226.jpg" width="248" height="300" alt="Fig. 226.&mdash;Vertebr&aelig; from case of Scoliosis, showing
+alteration in shape of bones." title="" />
+<span class="caption"><span class="smcap">Fig. 226.</span>&mdash;Vertebr&aelig; from case of Scoliosis, showing
+alteration in shape of bones.</span>
+</div>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><a class="pagenum" name="Pg_466" id="Pg_466"></a>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.</p>
+
+<p><i>Morbid Anatomy.</i>&mdash;The original deviation or &ldquo;primary curve&rdquo; is
+usually in the thoracic region, and has its convexity directed towards
+the right side. To re-establish the equilibrium of the column,
+&ldquo;secondary&rdquo; or &ldquo;compensatory&rdquo; 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 vertebr&aelig; around a vertical
+axis, in such a way that their bodies look towards the convexity of
+the curve, while their spines, lamin&aelig;, and articular processes are
+directed towards the concavity (<a href="#fig_226">Fig.&nbsp;226</a>).</p>
+
+<p>As the deformity increases, the individual vertebr&aelig; 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 (<a href="#fig_228">Fig.&nbsp;228</a>). As the spine, lamin&aelig;, 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.</p>
+
+<p>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&mdash;the &ldquo;rib-hump&rdquo; (<a href="#fig_227">Fig.&nbsp;227</a>), while on the side of the
+concavity the chest is flattened and the ribs crowded together so that
+the intercostal spaces are diminished<a class="pagenum" name="Pg_467" id="Pg_467"></a> or even obliterated. The
+converse&mdash;flattening on the side of the concavity&mdash;is seen on the
+front of the chest.</p>
+
+<div class="figcenter" style="width: 306px;">
+<a name="fig_227" id="fig_227"></a>
+<img src="images/fig227.jpg" width="306" height="400" alt="Fig. 227.&mdash;Adolescent Scoliosis in a girl &aelig;t. 23." title="" />
+<span class="caption"><span class="smcap">Fig. 227.</span>&mdash;Adolescent Scoliosis in a girl &aelig;t. 23.</span>
+</div>
+
+<p>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.</p>
+
+<p>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<a class="pagenum" name="Pg_468" id="Pg_468"></a> cases the pelvis becomes
+obliquely contracted&mdash;a deformity known as the <i>scoliotic pelvis</i>.</p>
+
+<div class="figcenter" style="width: 295px;">
+<a name="fig_228" id="fig_228"></a>
+<img src="images/fig228.jpg" width="295" height="400" alt="Fig. 228.&mdash;Scoliosis with primary curve in Thoracic
+Region." title="" />
+<span class="caption"><span class="smcap">Fig. 228.</span>&mdash;Scoliosis with primary curve in Thoracic
+Region.</span>
+</div>
+
+<p>In spite of the marked deformity the spinal cord is never compressed.</p>
+
+<p><i>Clinical features.</i>&mdash;The development of scoliosis is always slow and
+insidious. As a rule, attention is first attracted to the<a class="pagenum" name="Pg_469" id="Pg_469"></a> deformity
+about the age of puberty, but in most cases it has existed for a
+considerable time before it is observed. The patient&mdash;usually a girl,
+although it also occurs in boys&mdash;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.</p>
+
+<p>The most common form of scoliosis met with in adolescents is a
+<i>primary thoracic curvature</i> with its convexity to the right (<a href="#fig_227">Fig.&nbsp;227</a>),
+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<a class="pagenum" name="Pg_470" id="Pg_470"></a> 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 &ldquo;growing out&rdquo;&mdash;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&mdash;the &ldquo;brachio-thoracic triangle&rdquo;&mdash;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.</p>
+
+<div class="figcenter" style="width: 295px;">
+<a name="fig_229" id="fig_229"></a>
+<img src="images/fig229.jpg" width="295" height="400" alt="Fig. 229.&mdash;Scoliosis showing rotation of bodies of
+vertebr&aelig;, and widening of intercostal spaces on side of convexity." title="" />
+<span class="caption"><span class="smcap">Fig. 229.</span>&mdash;Scoliosis showing rotation of bodies of
+vertebr&aelig;, and widening of intercostal spaces on side of convexity.</span>
+</div>
+
+<p>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.</p>
+
+<p>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 vertebr&aelig; 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.</p>
+
+<p><i>Diagnosis of Adolescent Scoliosis.</i>&mdash;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.</p>
+
+<p>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 scapul&aelig; 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.</p>
+
+<p>Pott's disease may be excluded by the absence of rigidity.<a class="pagenum" name="Pg_471" id="Pg_471"></a> 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.</p>
+
+<p><i>Treatment.</i>&mdash;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 vertebr&aelig; 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&deg;&ndash;110&deg; 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&deg; 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.</p>
+
+<p>In mild cases&mdash;that is, those in which the curvature is obliterated
+when the patient is suspended&mdash;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.</p>
+
+<p>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 <i>regaining the muscular sense</i>; 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 <i>the
+flexed position</i>, somewhat on the lines<a class="pagenum" name="Pg_472" id="Pg_472"></a> 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.</p>
+
+<hr style="width: 45%;" />
+
+<div class="figright" style="width: 178px;">
+<a name="fig_230" id="fig_230"></a>
+<img src="images/fig230.png" width="178" height="300" alt="Fig. 230.&mdash;Diagram of attitudes in Klapp&#39;s four-footed
+exercises for Scoliosis." title="" />
+<span class="caption"><span class="smcap">Fig. 230.</span>&mdash;Diagram of attitudes in Klapp&#39;s four-footed
+exercises for Scoliosis.</span>
+</div>
+
+<p><i>Exercises for Lateral Curvature.</i>&mdash;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.</p>
+
+<p><b>Special Exercises for Thoracic Curvature with convexity to right.</b>&mdash;1.
+<i>Stand</i> with arms by side; palms directed forward; shoulders braced
+back. This is referred to as the &ldquo;<i>best standing position</i>&rdquo; or
+<i>original position</i>. 2. Slowly raise arms from sides until level with
+shoulders, with palms directed forward; carry left arm straight
+upward&mdash;&ldquo;<i>the keynote position</i>.&rdquo; Then slowly lower left arm to level
+of shoulder; lower both arms into original position. 3. <i>Assume
+keynote position</i>: 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. <i>Keynote position</i>: slowly bend whole spine to
+right; resume keynote and original positions. 5. <i>Keynote position</i>:
+turn body forward sideways. 6. <i>Keynote position</i>: rise on to balls of
+toes. 7. <i>Keynote position</i>: rise on to balls of toes; bend knees;
+back to original position in reverse order. 8. <i>Patient suspended from
+bar or rings, the left end of the bar or left ring being three inches
+higher than the right.</i> (<i>a</i>) Draw right knee upwards and forwards
+against resistance. (<i>b</i>) Draw legs apart against resistance. (<i>c</i>)
+Draw legs together against resistance. 9. <i>Patient lying on back.</i>
+(<i>a</i>) Bend right knee- and hip-joints against resistance. (<i>b</i>) Extend
+right knee and hip against resistance. (<i>c</i>) Rotate right hip against
+resistance. 10. <i>Patient lying on face with pillow under chest</i>;
+slowly raise arms to keynote position. While limbs are firmly held by
+a nurse, raise the body backwards and to the right. 11. <i>Same
+position</i>: make swimming movements. 12. <i>Patient astride a narrow
+table or chair, without a back.</i> (<i>a</i>) Repeat exercises 3, 4, 5, and
+11. (<i>b</i>) Bend body forwards, backwards; and rotate to right and left
+against slight resistance made by nurse grasping patient's shoulders.</p>
+
+<p><i>Klapp's &ldquo;four-footed&rdquo; Exercises.</i>&mdash;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 &ldquo;all-fours&rdquo; attitude,
+the patient crawling in imitation of a quadruped, that is, in such a
+way that the<a class="pagenum" name="Pg_473" id="Pg_473"></a> 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 (<a href="#fig_230">Fig.&nbsp;230</a>). 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 &ldquo;quadruped gait&rdquo;; (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
+<i>double</i> curve, it is best neutralised by imitating the &ldquo;pacing&rdquo;
+action of a quadruped, <i>i.e.</i>, 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.</p>
+
+<p>Abbott has introduced a method of treatment applicable to cases in
+which the deformity has become permanent. Under general an&aelig;sthesia,
+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.</p>
+
+
+
+
+<h2><a class="pagenum" name="Pg_474" id="Pg_474"></a><a name="CHAPTER_XIX" id="CHAPTER_XIX"></a>CHAPTER XIX
+<br />
+THE FACE, ORBIT, AND LIPS</h2>
+
+<ul class="chap">
+  <li><a href="#XIX_face"><span class="smcap">Face</span></a></li>
+  <li>&mdash;<a href="#XIX_face_malformations">Congenital malformations</a>:</li>
+  <li><a href="#XIX_hare_lip"><i>Hare-lip and cleft palate</i></a>;</li>
+  <li><a href="#XIX_macrostoma"><i>Macrostoma</i></a>;</li>
+  <li><a href="#XIX_microstoma"><i>Microstoma</i></a>;</li>
+  <li><a href="#XIX_facial_cleft"><i>Facial cleft</i></a>;</li>
+  <li><a href="#XIX_mandibular_cleft"><i>Mandibular cleft</i></a></li>
+  <li>&mdash;<a href="#XIX_soft_parts">Injuries of soft parts</a>:</li>
+  <li><a href="#XIX_soft_wounds"><i>Wounds</i></a>;</li>
+  <li><a href="#XIX_soft_burns"><i>Burns</i></a></li>
+  <li>&mdash;<a href="#XIX_bacterial">Bacterial diseases</a>:</li>
+  <li><a href="#XIX_bacterial"><i>Boils</i></a>;</li>
+  <li><a href="#XIX_bacterial"><i>Anthrax</i></a>;</li>
+  <li><a href="#XIX_bacterial"><i>Glanders, etc.</i></a>;</li>
+  <li><a href="#XIX_lupus"><i>Lupus</i></a>;</li>
+  <li><a href="#XIX_syphilis"><i>Syphilis</i></a>.</li>
+  <li><a href="#XIX_tumours">Tumours</a>:</li>
+  <li><a href="#XIX_epithelioma"><i>Epithelioma</i></a>.</li>
+  <li><a href="#XIX_orbit"><span class="smcap">Orbit</span></a></li>
+  <li>&mdash;<a href="#XIX_orbit_injuries">Injuries</a>:</li>
+  <li><a href="#XIX_orbit_contusion"><i>Contusion</i></a>;</li>
+  <li><a href="#XIX_orbit_wounds"><i>Wounds</i></a>;</li>
+  <li><a href="#XIX_orbit_fracture"><i>Fractures</i></a></li>
+  <li>&mdash;<a href="#XIX_eyeball">Injuries of eyeball</a></li>
+  <li>&mdash;<a href="#XIX_orbital_cellulitis">Orbital cellulitis</a></li>
+  <li>&mdash;<a href="#XIX_orbit_tumours">Tumours</a>.</li>
+  <li><a href="#XIX_lips"><span class="smcap">Lips</span></a></li>
+  <li>&mdash;<a href="#XIX_lips_cracks"><i>Cracks</i></a>;</li>
+  <li><a href="#XIX_lips_induration"><i>Chronic induration</i></a>;</li>
+  <li><a href="#XIX_lips_tuberculous"><i>Tuberculous ulcers</i></a>;</li>
+  <li><a href="#XIX_lips_syphilitic"><i>Syphilitic lesions</i></a></li>
+  <li>&mdash;<a href="#XIX_naevi">Tumours: <i>N&aelig;vi</i></a>;</li>
+  <li><a href="#XIX_lymphangioma"><i>Lymphangioma</i></a>;</li>
+  <li><a href="#XIX_cysts"><i>Cysts</i></a>;</li>
+  <li><a href="#XIX_lips_epithelioma"><i>Epithelioma</i></a>.</li>
+</ul>
+
+
+<h3><a name="XIX_face" id="XIX_face"></a>THE FACE</h3>
+
+<p><a name="XIX_face_malformations" id="XIX_face_malformations"></a><span class="smcap">Congenital Malformations.</span>&mdash;The description of the various congenital
+malformations of the face will be simplified by a brief consideration
+of its development.</p>
+
+<p><i>Development.</i>&mdash;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 (<a href="#fig_231">Fig.&nbsp;231</a>). These processes surround
+a stellate depression, the primitive buccal cavity or stomatod&aelig;um,
+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&mdash;the nasal cleft or olfactory pit&mdash;into a lateral nasal
+process, and a mesial nasal process, at the outer angle of which a
+spheroidal elevation appears&mdash;the globular process.</p>
+
+<div class="figcenter" style="width: 500px;">
+<a name="fig_231" id="fig_231"></a>
+<img src="images/fig231.jpg" width="500" height="342" alt="Fig. 231.&mdash;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.)" title="" />
+<span class="caption"><span class="smcap">Fig. 231.</span>&mdash;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.)</span>
+</div>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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&mdash;the deeper portion of
+which persists<a class="pagenum" name="Pg_475" id="Pg_475"></a> 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.</p>
+
+
+<h4><a name="XIX_hare_lip" id="XIX_hare_lip"></a><span class="smcap">Hare-lip and Cleft Palate</span></h4>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><b>Median hare-lip</b> 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&mdash;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.</p>
+
+<p><a class="pagenum" name="Pg_476" id="Pg_476"></a><b>Lateral hare-lip</b> 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&mdash;<i>simple hare-lip</i> (<a href="#fig_232">Fig.&nbsp;232</a>) 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&mdash;<i>alveolar hare-lip</i>&mdash;partly or completely separating the mesial
+and lateral segments of the premaxillary bone (<a href="#fig_233">Fig.&nbsp;233</a>). These cases
+are usually combined with cleft palate (<a href="#fig_236">Fig.&nbsp;236</a>).</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_232" id="fig_232"></a>
+<img src="images/fig232.jpg" width="400" height="335" alt="Fig. 232.&mdash;Simple Hare-lip." title="" />
+<span class="caption"><span class="smcap">Fig. 232.</span>&mdash;Simple Hare-lip.</span>
+</div>
+
+<p>&nbsp;</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_233" id="fig_233"></a>
+<img src="images/fig233.jpg" width="400" height="431" alt="Fig. 233.&mdash;Unilateral Hare-lip with Cleft Alveolus." title="" />
+<span class="caption"><span class="smcap">Fig. 233.</span>&mdash;Unilateral Hare-lip with Cleft Alveolus.</span>
+</div>
+
+<p>When the hare-lip is <i>bilateral</i>, 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<a class="pagenum" name="Pg_477" id="Pg_477"></a> alveolar processes of the maxilla
+(<a href="#fig_234">Fig.&nbsp;234</a>), or it may be tilted forward so that the incisor teeth,
+when present, project beyond the level of the prolabium (<a href="#fig_235">Fig.&nbsp;235</a>). 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.</p>
+
+<div class="figcenter" style="width: 284px;">
+<a name="fig_234" id="fig_234"></a>
+<img src="images/fig234.jpg" width="284" height="400" alt="Fig. 234.&mdash;Double Hare-lip in a girl &aelig;t. 17." title="" />
+<span class="caption"><span class="smcap">Fig. 234.</span>&mdash;Double Hare-lip in a girl &aelig;t. 17.</span>
+</div>
+
+<p>&nbsp;</p>
+
+<div class="figcenter" style="width: 325px;">
+<a name="fig_235" id="fig_235"></a>
+<img src="images/fig235.jpg" width="325" height="400" alt="Fig. 235.&mdash;Double Hare-lip with Projection of Os
+Incisivum, in an infant before first dentition." title="" />
+<span class="caption"><span class="smcap">Fig. 235.</span>&mdash;Double Hare-lip with Projection of Os
+Incisivum, in an infant before first dentition.</span>
+</div>
+
+<p><b>Cleft Palate.</b>&mdash;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.</p>
+
+<p>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<a class="pagenum" name="Pg_478" id="Pg_478"></a> 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
+maxill&aelig;. These cases are combined with double hare-lip.</p>
+
+<p>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&mdash;usually the right&mdash;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 (<a href="#fig_236">Fig.&nbsp;236</a>).</p>
+
+<div class="figcenter" style="width: 295px;">
+<a name="fig_236" id="fig_236"></a>
+<img src="images/fig236.jpg" width="295" height="400" alt="Fig. 236.&mdash;Asymmetrical Cleft Palate extending through
+alveolar process on left side." title="" />
+<span class="caption"><span class="smcap">Fig. 236.</span>&mdash;Asymmetrical Cleft Palate extending through
+alveolar process on left side.</span>
+</div>
+
+<p><i>Clinical Features.</i>&mdash;<i>Single hare-lip</i> 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.</p>
+
+<p><a class="pagenum" name="Pg_479" id="Pg_479"></a>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.</p>
+
+<p>When the <i>hare-lip is double and combined with cleft palate</i>, 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.</p>
+
+<p>In those who survive, the voice has a peculiar nasal twang, as in
+phonation the air is expelled through the nose instead of<a class="pagenum" name="Pg_480" id="Pg_480"></a> 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.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p>Considerable difference of opinion exists as to when the cleft in the
+palate should be dealt with. Some surgeons, notably<a class="pagenum" name="Pg_481" id="Pg_481"></a> 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.</p>
+
+<p>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.</p>
+
+<p><i>Voice Training.</i>&mdash;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.</p>
+
+<p>In <i>adolescents</i> and <i>adults</i>, 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.</p>
+
+<p><a name="XIX_macrostoma" id="XIX_macrostoma"></a><b>Other Congenital Deformities of the Face.</b>&mdash;<i>Macrostoma</i> is an abnormal
+enlargement of the mouth in its transverse diameter, due to imperfect
+fusion of the maxillary and mandibular processes.</p>
+
+<p><a name="XIX_microstoma" id="XIX_microstoma"></a><i>Microstoma</i> 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.</p>
+
+<p><a name="XIX_facial_cleft" id="XIX_facial_cleft"></a><i>Facial cleft</i> 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.</p>
+
+<p><a name="XIX_mandibular_cleft" id="XIX_mandibular_cleft"></a><i>Mandibular cleft</i> 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.</p>
+
+<p>These various deformities are treated by plastic operations carried
+out on the same principles as for hare-lip.</p>
+
+<p><a class="pagenum" name="Pg_482" id="Pg_482"></a><i>Fistul&aelig; of the Lower Lip.</i>&mdash;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 fistul&aelig; frequently occur in several
+members of the same family, and are usually associated with hare-lip.
+The treatment consists in dissecting them out.</p>
+
+<p><a name="XIX_soft_parts" id="XIX_soft_parts"></a><b>Injuries of the Soft Parts of the Face.</b>&mdash;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.</p>
+
+<p><a name="XIX_soft_wounds" id="XIX_soft_wounds"></a>In <i>incised</i> 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.</p>
+
+<p><i>Punctured</i> 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.</p>
+
+<p><i>Contused and lacerated</i> 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 h&aelig;morrhage 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.</p>
+
+<p><a name="XIX_soft_burns" id="XIX_soft_burns"></a><a class="pagenum" name="Pg_483" id="Pg_483"></a><i>Cicatricial contraction</i> 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.</p>
+
+<p><a name="XIX_bacterial" id="XIX_bacterial"></a><b>Bacterial Disease.</b>&mdash;<i>Boils</i>, <i>carbuncles</i>, and <i>anthrax pustules</i>
+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 <i>glanders</i> and of <i>actinomycosis</i> may also
+occur on the face.</p>
+
+<p><a name="XIX_lupus" id="XIX_lupus"></a>The various forms of <i>tuberculous lupus</i> are met with more frequently
+on the face than in any other situation (<a href="#fig_237">Fig.&nbsp;237</a>). <i>Tuberculous
+disease of the facial bones</i>, particularly of the lateral half of the
+orbital margin at the junction of the<a class="pagenum" name="Pg_484" id="Pg_484"></a> zygomatic (malar) bone with the
+maxilla, is not uncommon in children.</p>
+
+<div class="figcenter" style="width: 367px;">
+<a name="fig_237" id="fig_237"></a>
+<img src="images/fig237.jpg" width="367" height="400" alt="Fig. 237.&mdash;Illustrating the deformities caused by Lupus
+Vulgaris, which dated from adolescence." title="" />
+<span class="caption"><span class="smcap">Fig. 237.</span>&mdash;Illustrating the deformities caused by Lupus
+Vulgaris, which dated from adolescence.<br /><br />
+(Mr. D. M. Greig&#39;s case.)</span>
+</div>
+
+<p><a name="XIX_syphilis" id="XIX_syphilis"></a>The primary lesion of <i>syphilis</i>, and the various forms of secondary
+and tertiary syphilides, may simulate tuberculous lupus, cancer, and
+other ulcerative conditions.</p>
+
+<p><a name="XIX_tumours" id="XIX_tumours"></a><b>Tumours.</b>&mdash;The simple tumours met with on the face include sebaceous
+and dermoid cysts, n&aelig;vus, plexiform neuroma and adenoma; the malignant
+forms include the squamous epithelioma, and rodent, paraffin, and
+melanotic cancers.</p>
+
+<p><a name="XIX_epithelioma" id="XIX_epithelioma"></a><i>Epithelioma</i> 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&mdash;the <i>crateriform ulcer</i>. 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.</p>
+
+<p>The face is the commonest seat of <i>rodent cancer</i> (Volume I., p. 395).</p>
+
+
+<h3><a name="XIX_orbit" id="XIX_orbit"></a>THE ORBIT</h3>
+
+<p><a name="XIX_orbit_injuries" id="XIX_orbit_injuries"></a><b>Injuries.</b>&mdash;<i>Wounds of the eyelids</i> 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.</p>
+
+<p><a name="XIX_orbit_contusion" id="XIX_orbit_contusion"></a><i>Contusion</i> of the eyelids and circum-orbital region&mdash;the ordinary
+&ldquo;black eye&rdquo;&mdash;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.<a class="pagenum" name="Pg_485" id="Pg_485"></a> 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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><a name="XIX_orbit_wounds" id="XIX_orbit_wounds"></a><i>Wounds</i> 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 h&aelig;matoma. 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 R&ouml;ntgen rays are useful in determining the presence
+and position of a foreign body.</p>
+
+<p>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&mdash;frontal, maxillary, and ethmoidal&mdash;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.</p>
+
+<p><a name="XIX_orbit_fracture" id="XIX_orbit_fracture"></a><i>Fracture of the margin</i> 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<a class="pagenum" name="Pg_486" id="Pg_486"></a> 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.</p>
+
+<p>The <i>roof</i> 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 foss&aelig; 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.</p>
+
+<p><a name="XIX_eyeball" id="XIX_eyeball"></a><b>Injuries of the Eyeball.</b>&mdash;These injuries may be divided into two
+groups&mdash;(1) those in which the globe is contused without its outer
+coat being ruptured, and (2) those in which the outer coat is
+ruptured.</p>
+
+<p>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 h&aelig;morrhage into the vitreous, rupture of the choroid, and
+detachment of the retina.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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,<a class="pagenum" name="Pg_487" id="Pg_487"></a> 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.</p>
+
+<p>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 &ldquo;sympathetic ophthalmia&rdquo; affecting the other eye.</p>
+
+<p><a name="XIX_orbital_cellulitis" id="XIX_orbital_cellulitis"></a><b>Orbital Cellulitis.</b>&mdash;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 foss&aelig; or
+their accessory air sinuses. Both orbits may be affected
+simultaneously.</p>
+
+<p><i>Clinical Features.</i>&mdash;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.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+<p><a name="XIX_orbit_tumours" id="XIX_orbit_tumours"></a><b>Tumours of the Orbit.</b>&mdash;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,<a class="pagenum" name="Pg_488" id="Pg_488"></a> 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&mdash;usually the ivory variety&mdash;may originate in the wall of the
+orbit, or may spread from the adjacent sinuses.</p>
+
+<p><i>Clinical Features.</i>&mdash;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.</p>
+
+<p>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.</p>
+
+<p>In all varieties of intra-orbital tumour exophthalmos is a prominent
+feature (<a href="#fig_238">Figs.&nbsp;238</a>, <a href="#fig_239">239</a>), and when the protrusion of the eyeball is
+marked the lids become swollen, &oelig;dematous, 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
+palpebr&aelig; superioris. In almost all cases there is also more or less
+visual<a class="pagenum" name="Pg_489" id="Pg_489"></a> 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.</p>
+
+<div class="figcenter" style="width: 290px;">
+<a name="fig_238" id="fig_238"></a>
+<img src="images/fig238.jpg" width="290" height="400" alt="Fig. 238.&mdash;Sarcoma of Orbit, causing exophthalmos and
+downward displacement of the eye, and projecting in temporal region." title="" />
+<span class="caption"><span class="smcap">Fig. 238.</span>&mdash;Sarcoma of Orbit, causing exophthalmos and
+downward displacement of the eye, and projecting in temporal region.</span>
+</div>
+
+<p>&nbsp;</p>
+
+<div class="figcenter" style="width: 340px;">
+<a name="fig_239" id="fig_239"></a>
+<img src="images/fig239.jpg" width="340" height="400" alt="Fig. 239.&mdash;Sarcoma of Eyelid in a child." title="" />
+<span class="caption"><span class="smcap">Fig. 239.</span>&mdash;Sarcoma of Eyelid in a child.<br /><br />
+(Mr. D. M. Greig&#39;s case.)</span>
+</div>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p>The <i>orbital dermoid</i> usually occurs at the lateral end of the<a class="pagenum" name="Pg_490" id="Pg_490"></a>
+supra-orbital ridge (<a href="#fig_240">Fig.&nbsp;240</a>). 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 an&aelig;sthesia.</p>
+
+<div class="figcenter" style="width: 315px;">
+<a name="fig_240" id="fig_240"></a>
+<img src="images/fig240.jpg" width="315" height="400" alt="Fig. 240.&mdash;Dermoid Cyst at outer angle of orbital
+margin." title="" />
+<span class="caption"><span class="smcap">Fig. 240.</span>&mdash;Dermoid Cyst at outer angle of orbital
+margin.</span>
+</div>
+
+<p><i>Orbital aneurysms</i> have already been described, Volume I., p. 317.</p>
+
+
+<h3><a name="XIX_lips" id="XIX_lips"></a>THE LIPS</h3>
+
+<p><i>Herpes</i> 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.</p>
+
+<p>A more severe staphylococcal infection may give rise to a carbuncular
+swelling with great &oelig;dema, and lead to infective phlebitis of the
+facial vein and general septic&aelig;mia. Excision of the focus is
+indicated.</p>
+
+<p>The lip is sometimes the seat of the malignant pustule of anthrax.</p>
+
+<p><a name="XIX_lips_cracks" id="XIX_lips_cracks"></a><a class="pagenum" name="Pg_491" id="Pg_491"></a>Painful <i>cracks and fissures</i> 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.</p>
+
+<p><a name="XIX_lips_induration" id="XIX_lips_induration"></a><i>Chronic Induration of the Lips (Strumous Lip).</i>&mdash;A chronic
+&oelig;dematous 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.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+<p>The term &ldquo;<i>double lip</i>&rdquo; 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.</p>
+
+<p><a name="XIX_lips_tuberculous" id="XIX_lips_tuberculous"></a><i>Tuberculous disease</i> may occur in the form of lupus or of ulcers. The
+<i>ulcers</i> generally occur in patients suffering from advanced pulmonary
+or laryngeal phthisis. They are usually superficial, may be single or
+multiple, and are exceedingly painful.</p>
+
+<p><a name="XIX_lips_syphilitic" id="XIX_lips_syphilitic"></a><i>Syphilitic Lesions.</i>&mdash;The upper lip is the most frequent seat of
+extra-genital chancre. The <i>chancre of the lip</i> 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.</p>
+
+<p><a class="pagenum" name="Pg_492" id="Pg_492"></a><i>Mucous patches</i> and <i>superficial ulcers</i> 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.</p>
+
+<p>Gummatous lesions occur on the lips, and are liable to be mistaken for
+epithelioma.</p>
+
+<p><a name="XIX_naevi" id="XIX_naevi"></a><i>Tumours.</i>&mdash;<i>N&aelig;vi</i> 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.</p>
+
+<p><a name="XIX_lymphangioma" id="XIX_lymphangioma"></a><i>Lymphangioma.</i>&mdash;The term <i>macrocheilia</i> is applied to a congenital
+hypertrophy of the lip (<a href="#fig_241">Fig.&nbsp;241</a>), 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.</p>
+
+<div class="figcenter" style="width: 398px;">
+<a name="fig_241" id="fig_241"></a>
+<img src="images/fig241.jpg" width="398" height="400" alt="Fig. 241.&mdash;Macrocheilia." title="" />
+<span class="caption"><span class="smcap">Fig. 241.</span>&mdash;Macrocheilia.<br /><br />
+(From a photograph lent by Sir H. J. Stiles.)</span>
+</div>
+
+<p>The <i>treatment</i> consists in removing a wedge-shaped portion of the
+swelling on the same lines as for &ldquo;strumous lip,&rdquo; or in employing
+electrolysis.</p>
+
+<p><a name="XIX_cysts" id="XIX_cysts"></a><a class="pagenum" name="Pg_493" id="Pg_493"></a><i>Mucous cysts</i> 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.</p>
+
+<p><a name="XIX_lips_epithelioma" id="XIX_lips_epithelioma"></a><b>Epithelioma of the lip</b> 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.</p>
+
+<p><a class="pagenum" name="Pg_494" id="Pg_494"></a>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 (<a href="#fig_242">Figs.&nbsp;242</a>, <a href="#fig_243">243</a>). 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 (<a href="#fig_244">Fig.&nbsp;244</a>). Metastasis to internal
+organs is rare. Unless removed by operation, the disease usually
+proves fatal in from three to three and a half years.</p>
+
+<div class="figcenter" style="width: 312px;">
+<a name="fig_242" id="fig_242"></a>
+<img src="images/fig242.jpg" width="312" height="400" alt="Fig. 242.&mdash;Squamous Epithelioma of Lower Lip in a man
+&aelig;t. 55." title="" />
+<span class="caption"><span class="smcap">Fig. 242.</span>&mdash;Squamous Epithelioma of Lower Lip in a man
+&aelig;t. 55.<br /><br />
+(Mr. D. M. Greig&#39;s case.)</span>
+</div>
+
+<p>&nbsp;</p>
+
+<div class="figcenter" style="width: 291px;">
+<a name="fig_243" id="fig_243"></a>
+<img src="images/fig243.jpg" width="291" height="400" alt="Fig. 243.&mdash;Advanced Epithelioma of Lower Lip." title="" />
+<span class="caption"><span class="smcap">Fig. 243.</span>&mdash;Advanced Epithelioma of Lower Lip.</span>
+</div>
+
+<p>&nbsp;</p>
+
+<div class="figcenter" style="width: 315px;">
+<a name="fig_244" id="fig_244"></a>
+<img src="images/fig244.jpg" width="315" height="400" alt="Fig. 244.&mdash;Recurrent Epithelioma in Glands of Neck
+adherent to mandible." title="" />
+<span class="caption"><span class="smcap">Fig. 244.</span>&mdash;Recurrent Epithelioma in Glands of Neck
+adherent to mandible.</span>
+</div>
+
+<p><a class="pagenum" name="Pg_495" id="Pg_495"></a>The <i>treatment</i> 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.</p>
+
+<p>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 an&aelig;sthetic.</p>
+
+<p>In inoperable cases benefit may follow the use of the X-rays, or of
+radium.</p>
+
+<p><i>Epithelioma of the upper lip</i> 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.</p>
+
+
+
+
+<h2><a class="pagenum" name="Pg_496" id="Pg_496"></a><a name="CHAPTER_XX" id="CHAPTER_XX"></a>CHAPTER XX
+<br />
+THE MOUTH, FAUCES, AND PHARYNX</h2>
+
+<ul class="chap">
+  <li><a href="#XX_stomatitis">Stomatitis</a></li>
+  <li>&mdash;<a href="#XX_roof_of_mouth">Roof of mouth</a>:</li>
+  <li><a href="#XX_roof_of_mouth"><i>Abscess</i></a>;</li>
+  <li><a href="#XX_gumma"><i>Gumma</i></a>;</li>
+  <li><a href="#XX_roof_tuberculous"><i>Tuberculous disease</i></a>;</li>
+  <li><a href="#XX_roof_tumours"><i>Tumours</i></a></li>
+  <li>&mdash;<a href="#XX_uvula">Elongation of uvula</a></li>
+  <li>&mdash;<a href="#XX_epithelioma">Epithelioma of floor of mouth</a></li>
+  <li>&mdash;<a href="#XX_tonsillitis">Tonsillitis: <i>Varieties</i></a></li>
+  <li>&mdash;<a href="#XX_hypertrophy_tonsils">Hypertrophy of tonsils</a></li>
+  <li>&mdash;<a href="#XX_calculus">Calculus</a></li>
+  <li>&mdash;<a href="#XX_syphilis">Syphilis</a> and <a href="#XX_tuberculosis">Tuberculosis</a></li>
+  <li>&mdash;<a href="#XX_tumours">Tumours</a></li>
+  <li>&mdash;<a href="#XX_abscess">Retro-pharyngeal abscess</a>.</li>
+</ul>
+
+
+<h3>THE MOUTH</h3>
+
+<p><a name="XX_stomatitis" id="XX_stomatitis"></a><b>Stomatitis.</b>&mdash;The term stomatitis is applied to any inflammation of the
+buccal mucous membrane. The <i>catarrhal</i> form is often associated with
+the presence of carious teeth or an infected wound; the mucous
+membrane is hyper&aelig;mic 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 <i>aphthous</i> 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 hyper&aelig;mic zone, which may become confluent and form small ulcers.
+The condition known as <i>thrush</i>, which closely resembles aphthous
+stomatitis, is met with in infants during the period of teething, and
+is due to the <i>o&iuml;dium albicans</i>, 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.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+<p><i>Ulcerative stomatitis</i> 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&mdash;<i>mercurial stomatitis</i>.<a class="pagenum" name="Pg_497" id="Pg_497"></a> 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&mdash;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.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+<p><i>Gangrenous stomatitis</i>, or cancrum oris (<a href="#fig_245">Fig.&nbsp;245</a>), has already been
+described (Volume I., p. 102).</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_245" id="fig_245"></a>
+<img src="images/fig245.jpg" width="400" height="357" alt="Fig. 245.&mdash;Cancrum Oris." title="" />
+<span class="caption"><span class="smcap">Fig. 245.</span>&mdash;Cancrum Oris.<br /><br />
+(Mr. D. M. Greig&#39;s case.)</span>
+</div>
+
+<p><a name="XX_roof_of_mouth" id="XX_roof_of_mouth"></a><a class="pagenum" name="Pg_498" id="Pg_498"></a><b>Roof of the Mouth.</b>&mdash;<i>Suppuration</i> 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.</p>
+
+<p><a name="XX_gumma" id="XX_gumma"></a>The <i>syphilitic gumma</i>, 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 (<a href="#fig_246">Fig.&nbsp;246</a>).
+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,<a class="pagenum" name="Pg_499" id="Pg_499"></a> 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.</p>
+
+<div class="figcenter" style="width: 330px;">
+<a name="fig_246" id="fig_246"></a>
+<img src="images/fig246.jpg" width="330" height="400" alt="Fig. 246.&mdash;Perforation of Palate, the result of
+Syphilis, and Gumma of Right Frontal Bone." title="" />
+<span class="caption"><span class="smcap">Fig. 246.</span>&mdash;Perforation of Palate, the result of
+Syphilis, and Gumma of Right Frontal Bone.<br /><br />
+(From Dr. Byrom Bramwell&#39;s Atlas of Clinical Medicine.)</span>
+</div>
+
+<p><a name="XX_roof_tuberculous" id="XX_roof_tuberculous"></a><i>Tuberculous</i> 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.</p>
+
+<p><a name="XX_roof_tumours" id="XX_roof_tumours"></a>Mucous cysts, dermoids, adenomas, lipomas, and fibromas are
+occasionally met with. <i>Papillomatous thickening</i> of the mucous
+membrane sometimes occurs in association with leucoplakia. It resists
+anti-syphilitic treatment, but yields to scraping with the sharp
+spoon. <i>Endotheliomas</i>, or <i>mixed tumours</i>, 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.</p>
+
+<p><i>Epithelioma</i> 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.</p>
+
+<p><a name="XX_uvula" id="XX_uvula"></a><b>Elongation of the uvula</b> 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.</p>
+
+<p><a name="XX_epithelioma" id="XX_epithelioma"></a><b>Epithelioma of the floor of the mouth</b> 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.</p>
+
+
+<h3><a class="pagenum" name="Pg_500" id="Pg_500"></a>THE TONSILS AND PHARYNX</h3>
+
+<p><b>Infective Conditions.</b>&mdash;The majority of the infective conditions
+included under the popular term &ldquo;sore throat&rdquo; 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.</p>
+
+<p><a name="XX_tonsillitis" id="XX_tonsillitis"></a><i>Catarrhal tonsillitis</i>&mdash;usually attributed by the laity to &ldquo;catching
+cold&rdquo;&mdash;is characterised by hyper&aelig;mia 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&mdash;for example, patients who have been long in hospital, or
+the resident staff of hospitals (<i>septic</i> or <i>hospital throat</i>), and
+particularly in persons of a &ldquo;rheumatic&rdquo; 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&deg;&ndash;102&deg; 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.</p>
+
+<p>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.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+<p>In <i>follicular tonsillitis</i>, 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,<a class="pagenum" name="Pg_501" id="Pg_501"></a> 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 L&ouml;ffler's bacillus.</p>
+
+<p>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.</p>
+
+<p>The <i>treatment</i> is carried out on the same lines as for the catarrhal
+form. In recurrent cases the tonsils should be removed.</p>
+
+<p><b>Acute Suppurative Tonsillitis and Peri-tonsillitis&mdash;Quinsy.</b>&mdash;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.</p>
+
+<p><i>Clinical Features.</i>&mdash;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 &oelig;dematous, 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<a class="pagenum" name="Pg_502" id="Pg_502"></a> 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.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p><a name="XX_hypertrophy_tonsils" id="XX_hypertrophy_tonsils"></a><b>Hypertrophy of the tonsils</b> 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.</p>
+
+<p>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.</p>
+
+<p><i>Clinical Features.</i>&mdash;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<a class="pagenum" name="Pg_503" id="Pg_503"></a> 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.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p><a name="XX_calculus" id="XX_calculus"></a><b>Calculi</b> 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.</p>
+
+<p><a name="XX_syphilis" id="XX_syphilis"></a><b>Syphilis.</b>&mdash;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.</p>
+
+<p>Early in secondary syphilis, mucous patches and superficial ulcers are
+frequently met with. Later, severe phaged&aelig;nic 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.</p>
+
+<p>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.</p>
+
+<p><a name="XX_tuberculosis" id="XX_tuberculosis"></a><b>Tuberculous</b> 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.</p>
+
+<p><a name="XX_tumours" id="XX_tumours"></a><a class="pagenum" name="Pg_504" id="Pg_504"></a><b>Tumours.</b>&mdash;<i>Innocent tumours</i>&mdash;fibroma, lipoma, myoma&mdash;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.</p>
+
+<p><i>Malignant Disease.</i>&mdash;The <i>tonsil</i> is frequently the primary seat of
+<i>lympho-sarcoma</i>, 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 &oelig;dematous,
+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 h&aelig;morrhage. The patient emaciates rapidly. The adjacent
+lymph glands are early infected.</p>
+
+<p>Removal by operation is seldom practicable, but the introduction of a
+tube containing radium for several days has in some cases proved
+beneficial.</p>
+
+<p><i>Carcinoma</i> is more common than sarcoma. It may take the form of
+<i>squamous epithelioma</i> or of <i>medullary cancer</i>, 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.</p>
+
+<p>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&mdash;pain during eating or drinking, salivation and f&oelig;tid
+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<a class="pagenum" name="Pg_505" id="Pg_505"></a> 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 h&aelig;morrhage, or from septic pneumonia.</p>
+
+<p>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.</p>
+
+<p>In advanced cases, it is only possible to relieve the patient's
+suffering by palliative measures. Antiseptic mouth-washes are used to
+diminish the f&oelig;tor 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
+dyspn&oelig;a.</p>
+
+<p><a name="XX_abscess" id="XX_abscess"></a><b>Retro-pharyngeal Abscess.</b>&mdash;The <i>chronic</i> retro-pharyngeal abscess
+associated with tuberculous disease of the cervical vertebr&aelig;, in which
+the pus accumulates behind the prevertebral fascia, has already been
+described (<a href="#Pg_441">p.&nbsp;441</a>).</p>
+
+<p>The <i>acute</i> 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&mdash;such as
+scarlet fever, measles, or chicken-pox&mdash;or may suffer from nasal
+excoriations or coryza. In some cases the irritation of dentition is
+the only discoverable cause.</p>
+
+<p>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 dyspn&oelig;a 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&mdash;symptoms which have led to the disease
+being mistaken for membranous laryngitis. In some cases a soft
+swelling<a class="pagenum" name="Pg_506" id="Pg_506"></a> 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.</p>
+
+<p>A <i>less acute</i> 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.</p>
+
+
+
+
+<h2><a class="pagenum" name="Pg_507" id="Pg_507"></a><a name="CHAPTER_XXI" id="CHAPTER_XXI"></a>CHAPTER XXI
+<br />
+THE JAWS, INCLUDING THE TEETH AND GUMS</h2>
+
+<ul class="chap">
+  <li><a href="#XXI_dental_caries"><span class="smcap">Teeth</span>: Dental caries</a></li>
+  <li>&mdash;<a href="#XXI_impacted_wisdom_tooth">Impacted wisdom tooth</a>.</li>
+  <li><a href="#XXI_gums"><span class="smcap">Gums</span>: Gingivitis;</a></li>
+  <li><a href="#XXI_pyorrhoea">Pyorrh&oelig;a alveolaris</a>;</li>
+  <li><a href="#XXI_hypertrophy">Hypertrophy</a>;</li>
+  <li><a href="#XXI_epithelioma">Epithelioma</a>.</li>
+  <li><a href="#XXI_jaws"><span class="smcap">Jaws</span></a>:</li>
+  <li><a href="#XXI_pyogenic_infection">Pyogenic affections: <i>Periostitis</i></a>;</li>
+  <li><a href="#XXI_osteomyelitis"><i>Osteomyelitis</i></a>;</li>
+  <li><a href="#XXI_jaws_tuberculosis">Tuberculosis</a>;</li>
+  <li><a href="#XXI_jaws_syphilis">Syphilis</a>;</li>
+  <li><a href="#XXI_actinomycosis">Actinomycosis</a></li>
+  <li>&mdash;<a href="#XXI_tumour_alveolar_process">Tumours: <i>Of alveolar process</i></a>;</li>
+  <li><a href="#XXI_tumour_maxilla"><i>Of maxilla</i></a>;</li>
+  <li><a href="#XXI_tumour_mandible"><i>Of mandible</i></a></li>
+  <li>&mdash;<a href="#XXI_fracture_maxilla">Fracture of maxilla</a></li>
+  <li>&mdash;<a href="#XXI_fracture_mandible">Fracture of mandible</a></li>
+  <li>&mdash;<a href="#XXI_temporo_mandibular">Affections of the temporo-mandibular articulation</a>:</li>
+  <li><a href="#XXI_dislocation_mandible"><i>Dislocation of the mandible</i></a>;</li>
+  <li><a href="#XXI_arthritis"><i>Acute arthritis</i></a>;</li>
+  <li><a href="#XXI_tuberculous_arthritis"><i>Tuberculous arthritis</i></a>;</li>
+  <li><a href="#XXI_arthritis_deformans"><i>Arthritis deformans</i></a>;</li>
+  <li><a href="#XXI_closure_jaws"><i>Closure of the jaws</i></a>.</li>
+</ul>
+
+<p><a name="XXI_dental_caries" id="XXI_dental_caries"></a><b>Dental caries</b> is a process of disintegration which begins in the
+enamel of a tooth&mdash;usually in the region of its neck&mdash;and gradually
+extends through the dentine till the pulp cavity is reached.</p>
+
+<p>Infection of the exposed pulp cavity may set up an acute purulent
+<i>pulpitis</i>. 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.</p>
+
+<p>The infection may spread from the tooth to the alveolo-dental
+periosteum, and set up a <i>periodontitis</i>. 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
+&oelig;dematous.</p>
+
+<p>Periodontitis is usually followed by the formation of an <i>alveolar
+abscess</i>. 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
+&ldquo;gum-boil.&rdquo; The pus may then burst through the gum, or may spread
+underneath the external periosteum of the jaw and lead to necrosis.</p>
+
+<p>In some cases the cheek becomes adherent to the gum and<a class="pagenum" name="Pg_508" id="Pg_508"></a> 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.</p>
+
+<p>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.</p>
+
+<p>A <i>cyst</i> 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.</p>
+
+<p><i>Odontomas</i> have already been described (Volume I., p. 192).</p>
+
+<p><a name="XXI_impacted_wisdom_tooth" id="XXI_impacted_wisdom_tooth"></a>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 <i>impaction of the wisdom tooth</i>
+(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.</p>
+
+<p><a name="XXI_gums" id="XXI_gums"></a><b>Affections of the Gums.</b>&mdash;Inflammation of the
+gums&mdash;<i>gingivitis</i>&mdash;usually occurs in association with a general
+stomatitis. The gums are swollen and spongy, and may show superficial
+ulceration, associated with bleeding and extreme f&oelig;tor 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<a class="pagenum" name="Pg_509" id="Pg_509"></a> the dental margin.
+The <i>treatment</i> 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.</p>
+
+<p><a name="XXI_pyorrhoea" id="XXI_pyorrhoea"></a><i>Pyorrh&oelig;a alveolaris</i> 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 an&aelig;mia, and other general
+conditions have been attributed to the absorption of toxic products.
+The <i>treatment</i> 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.</p>
+
+<p><a name="XXI_hypertrophy" id="XXI_hypertrophy"></a><i>Hypertrophy of the gums</i> 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).</p>
+
+<p>A localised hypertrophy&mdash;<i>polypus of the gum</i>&mdash;sometimes results from
+the irritation of a carious tooth, or from the pressure of an
+artificial denture, and may simulate an epulis (<a href="#Pg_513">p.&nbsp;513</a>). The swelling
+is usually pedunculated, and if cut away close to the alveolar margin
+does not tend to recur.</p>
+
+<p><a name="XXI_epithelioma" id="XXI_epithelioma"></a><i>Epithelioma</i> 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.<a class="pagenum" name="Pg_510" id="Pg_510"></a> The only treatment is
+early and complete removal of the growth and the adjacent segment of
+bone.</p>
+
+<p>Other tumours of the gums, such as angioma and papilloma, are rare.</p>
+
+
+<h3><a name="XXI_jaws" id="XXI_jaws"></a><span class="smcap">The Jaws</span></h3>
+
+<p><a name="XXI_pyogenic_infection" id="XXI_pyogenic_infection"></a><b>Pyogenic Infections.</b>&mdash;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&mdash;the <i>phosphorus necrosis</i> of the older writers.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_247" id="fig_247"></a>
+<img src="images/fig247.jpg" width="400" height="382" alt="Fig. 247.&mdash;Cario-necrosis of Mandible." title="" />
+<span class="caption"><span class="smcap">Fig. 247.</span>&mdash;Cario-necrosis of Mandible.</span>
+</div>
+
+<p><a name="XXI_osteomyelitis" id="XXI_osteomyelitis"></a><a class="pagenum" name="Pg_511" id="Pg_511"></a><i>Acute osteomyelitis</i> occasionally attacks the mandible, less
+frequently the maxilla. Pus rapidly forms under the periosteum, and a
+considerable area of bone may undergo necrosis.</p>
+
+<p>In <i>cancrum oris</i>, also, the bones are frequently attacked and may
+undergo necrosis.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+<p>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.</p>
+
+<p><a name="XXI_jaws_tuberculosis" id="XXI_jaws_tuberculosis"></a><b>Tuberculous disease</b> 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 &ldquo;phosphorus necrosis&rdquo; 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.</p>
+
+<p><a name="XXI_jaws_syphilis" id="XXI_jaws_syphilis"></a><b>Syphilitic</b> 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
+(<a href="#fig_248">Fig.&nbsp;248</a>). In either case the clinical importance of the condition
+lies in the fact that it is liable to be<a class="pagenum" name="Pg_512" id="Pg_512"></a> mistaken for a new growth,
+such as an osteo-sarcoma, or for actinomycosis.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_248" id="fig_248"></a>
+<img src="images/fig248.jpg" width="400" height="298" alt="Fig. 248.&mdash;Diffuse Syphilitic Disease of Mandible." title="" />
+<span class="caption"><span class="smcap">Fig. 248.</span>&mdash;Diffuse Syphilitic Disease of Mandible.</span>
+</div>
+
+<p><a name="XXI_actinomycosis" id="XXI_actinomycosis"></a><b>Actinomycosis.</b>&mdash;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.</p>
+
+<p>At the outset the patient complains of pain and tenderness referred to
+one or more carious teeth. Within a few weeks a swelling forms&mdash;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 &ldquo;sulphur grains&rdquo; 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.</p>
+
+<p>In the absence of the characteristic yellow granules, actinomycosis
+may readily be mistaken for tuberculous or syphilitic disease, or for
+sarcoma.</p>
+
+<p>The <i>treatment</i> consists in removing the diseased tissue with<a class="pagenum" name="Pg_513" id="Pg_513"></a> 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.</p>
+
+<p><a name="XXI_tumour_alveolar_process" id="XXI_tumour_alveolar_process"></a><b>Tumours of the Alveolar Process.&mdash;Epulis.</b>&mdash;The tumours that grow from
+the alveolar processes of the jaws appear at first sight to spring
+from the gums, hence the term <i>epulis</i>, 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&mdash;myeloma; in
+others new bone is formed in its substance&mdash;osteo-sarcoma.</p>
+
+<p>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 (<a href="#fig_249">Fig.&nbsp;249</a>). 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.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_249" id="fig_249"></a>
+<img src="images/fig249.jpg" width="400" height="245" alt="Fig. 249.&mdash;Epulis of Mandible." title="" />
+<span class="caption"><span class="smcap">Fig. 249.</span>&mdash;Epulis of Mandible.<br /><br />
+(Anatomical Museum, University of Edinburgh.)</span>
+</div>
+
+<p>The true alveolar tumour is to be diagnosed from a mass of redundant
+granulations such as may form in relation to a carious<a class="pagenum" name="Pg_514" id="Pg_514"></a> tooth, from a
+polypus or an epithelioma of the gum, a tumour of the body of the jaw,
+or an angioma.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+<p><a name="XXI_tumour_maxilla" id="XXI_tumour_maxilla"></a><b>Malignant Tumours of the Maxilla.</b>&mdash;All varieties of <i>sarcoma</i> and
+<i>carcinoma</i> 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.</p>
+
+<p>The <i>clinical features</i> vary according to whether the tumour
+originates on the anterior aspect of the bone, in the maxillary
+antrum, or on the posterior aspect.</p>
+
+<p>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.</p>
+
+<p>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,<a class="pagenum" name="Pg_515" id="Pg_515"></a> and if the ethmoid cells are invaded, it is also pushed
+outward; the palate may be depressed and the cheek projected (<a href="#fig_250">Figs.&nbsp;250</a>,
+<a href="#fig_251">251</a>).</p>
+
+<div class="figcenter" style="width: 335px;">
+<a name="fig_250" id="fig_250"></a>
+<img src="images/fig250.jpg" width="335" height="400" alt="Fig. 250.&mdash;Sarcoma of the Maxilla." title="" />
+<span class="caption"><span class="smcap">Fig. 250.</span>&mdash;Sarcoma of the Maxilla.</span>
+</div>
+
+<p>&nbsp;</p>
+
+<div class="figcenter" style="width: 340px;">
+<a name="fig_251" id="fig_251"></a>
+<img src="images/fig251.jpg" width="340" height="400" alt="Fig. 251.&mdash;Malignant Disease of Left Maxilla, which
+displaced the eyeball and caused double vision." title="" />
+<span class="caption"><span class="smcap">Fig. 251.</span>&mdash;Malignant Disease of Left Maxilla, which
+displaced the eyeball and caused double vision.</span>
+</div>
+
+<p>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.</p>
+
+<p>In all cases the tumour tends to infiltrate the surrounding tissues
+indiscriminately. There is severe pain referred to the<a class="pagenum" name="Pg_516" id="Pg_516"></a> distribution
+of the maxillary division of the trigeminal nerve. H&aelig;morrhage is
+liable to occur when exposed portions of the tumour ulcerate&mdash;for
+example in the nasal foss&aelig;. 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.</p>
+
+<p><i>Treatment of Malignant Disease.</i>&mdash;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<a class="pagenum" name="Pg_517" id="Pg_517"></a> 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.</p>
+
+<p><b>Simple tumours</b> are rare. <i>Fibroma</i> may originate in the periosteum or
+in the lining membrane of the maxillary sinus. It usually tends to
+assume the characters of sarcoma. <i>Chondroma</i> usually begins either on
+the nasal surface of the bone or in the maxillary sinus. <i>Osteoma</i>
+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.</p>
+
+<p><a name="XXI_tumour_mandible" id="XXI_tumour_mandible"></a><b>Tumours of the Mandible.</b>&mdash;The same varieties are met with as in the
+maxilla. The non-malignant forms&mdash;osteoma, chondroma, and fibroma&mdash;are
+rare.</p>
+
+<p>A <i>dentigerous cyst</i> 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<a class="pagenum" name="Pg_518" id="Pg_518"></a> is filled with a
+glairy mucoid fluid, and may contain one or more unerupted teeth (<a href="#fig_252">Fig.&nbsp;252</a>).
+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.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_252" id="fig_252"></a>
+<img src="images/fig252.jpg" width="400" height="172" alt="Fig. 252.&mdash;Dentigerous Cyst of Mandible containing
+rudimentary tooth." title="" />
+<span class="caption"><span class="smcap">Fig. 252.</span>&mdash;Dentigerous Cyst of Mandible containing
+rudimentary tooth.<br /><br />
+(From Sir Patrick Heron Watson&#39;s collection.)</span>
+</div>
+
+<p>The myeloid tumour or <i>myeloma</i> is comparatively common. It develops
+in the interior of the bone and expands the affected segment (<a href="#fig_253">Fig.&nbsp;253</a>).
+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.</p>
+
+<div class="figcenter" style="width: 394px;">
+<a name="fig_253" id="fig_253"></a>
+<img src="images/fig253.jpg" width="394" height="400" alt="Fig. 253.&mdash;Osseous Shell of Myeloma of Mandible." title="" />
+<span class="caption"><span class="smcap">Fig. 253.</span>&mdash;Osseous Shell of Myeloma of Mandible.<br /><br />
+(From Professor Annandale&#39;s collection.)</span>
+</div>
+
+<p>The <i>periosteal sarcoma</i> 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.</p>
+
+<p><i>Epithelioma</i> 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<a class="pagenum" name="Pg_519" id="Pg_519"></a> ascending
+ramus. In all cases the infection of the cervical lymph glands is a
+serious factor both in prognosis and treatment.</p>
+
+<p><i>Treatment.</i>&mdash;<i>Partial removal</i> 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&mdash;for example, to the alveolar
+process, the angle, the horizontal ramus, or the symphysis; in other
+cases, the whole bone must be removed.</p>
+
+
+<h3><span class="smcap">Injuries of the Jaws</span></h3>
+
+<p><a name="XXI_fracture_maxilla" id="XXI_fracture_maxilla"></a><b>Fracture of the Maxilla.</b>&mdash;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.</p>
+
+<p>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
+h&aelig;morrhage from the infra-orbital vessels, and an&aelig;sthesia 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.</p>
+
+<p>The <i>treatment</i> 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 (<a href="#fig_255">Fig.&nbsp;255</a>), or by adjusting a moulded lead or gutta-percha
+splint to the alveolus and palate.</p>
+
+<p>The <i>zygomatic (malar) bone</i> 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<a class="pagenum" name="Pg_520" id="Pg_520"></a> 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.</p>
+
+<p>The <i>zygomatic arch</i> 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.</p>
+
+<p><a name="XXI_fracture_mandible" id="XXI_fracture_mandible"></a><b>Fractures of the Mandible.</b>&mdash;The most common situation for fracture of
+the mandible is through the <i>body</i> of the bone in the vicinity of the
+canine tooth (<a href="#fig_254">Fig.&nbsp;254</a>). 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 foss&aelig;. 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.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_254" id="fig_254"></a>
+<img src="images/fig254.jpg" width="400" height="339" alt="Fig. 254.&mdash;Multiple Fracture of Mandible." title="" />
+<span class="caption"><span class="smcap">Fig. 254.</span>&mdash;Multiple Fracture of Mandible.<br /><br />
+(From Sir Patrick Heron Watson&#39;s collection.)</span>
+</div>
+
+<p>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<a class="pagenum" name="Pg_521" id="Pg_521"></a> 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.</p>
+
+<p>In adults, the bone may be broken at the <i>symphysis</i> as a result of
+lateral compression of the jaw&mdash;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.</p>
+
+<p>Fractures of the <i>angle</i> and through the <i>ramus</i> 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 <i>coronoid process</i> is rare.</p>
+
+<p>The <i>condyle</i> is usually fractured just below the insertion of the
+external pterygoid muscle (<a href="#fig_254">Fig.&nbsp;254</a>) 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 <i>towards</i> 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.</p>
+
+<p>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.</p>
+
+<p><i>Complications.</i>&mdash;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.<a class="pagenum" name="Pg_522" id="Pg_522"></a>
+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.</p>
+
+<p><i>Treatment.</i>&mdash;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 (<a href="#fig_255">Fig.&nbsp;255</a>). 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.</p>
+
+<div class="figcenter" style="width: 344px;">
+<a name="fig_255" id="fig_255"></a>
+<img src="images/fig255.jpg" width="344" height="400" alt="Fig. 255.&mdash;Four-tailed Bandage applied for Fracture of
+Mandible." title="" />
+<span class="caption"><span class="smcap">Fig. 255.</span>&mdash;Four-tailed Bandage applied for Fracture of
+Mandible.</span>
+</div>
+
+<p>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<a class="pagenum" name="Pg_523" id="Pg_523"></a> interfering with the action of the jaw (W. Guy).
+The use of an intra-oral frame obviates the necessity of wiring the
+fragments.</p>
+
+<p>Even in badly united fractures the original contour of the bone is
+eventually restored by the movements of the tongue moulding it into
+shape.</p>
+
+
+<h3><a name="XXI_temporo_mandibular" id="XXI_temporo_mandibular"></a><span class="smcap">Affections of the Temporo-mandibular Articulation</span></h3>
+
+<p><a name="XXI_dislocation_mandible" id="XXI_dislocation_mandible"></a><b>Dislocation of the Mandible.</b>&mdash;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&mdash;for example,
+in yawning, laughing, or vomiting&mdash;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.</p>
+
+<p>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 an&aelig;sthetised, or even in the attempt to take a big
+bite&mdash;say, of an apple. The dislocation that results from such causes
+is usually unilateral.</p>
+
+<p>In some persons the ligaments of the joint are unnaturally lax, and
+dislocation is liable to occur repeatedly from comparatively slight
+causes&mdash;<i>recurrent dislocation</i>.</p>
+
+<p><i>Clinical Features.</i>&mdash;The appearance of a patient suffering from
+<i>bilateral</i> 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.</p>
+
+<p>In <i>unilateral</i> dislocation the deformity is the same in character,
+but is less marked, and in mild cases its cause is<a class="pagenum" name="Pg_524" id="Pg_524"></a> liable to be
+overlooked. In most cases the chin deviates towards the sound side.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p><i>Old-standing Dislocation.</i>&mdash;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.</p>
+
+<p><i>Internal Derangements of the Temporo-mandibular Joint.</i>&mdash;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<a class="pagenum" name="Pg_525" id="Pg_525"></a> 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).</p>
+
+<p><a name="XXI_arthritis" id="XXI_arthritis"></a><b>Arthritis</b> of the temporo-mandibular joint occurs in two forms,
+non-suppurative and suppurative.</p>
+
+<p>The <i>non-suppurative</i> form is usually due to gonorrh&oelig;al 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.</p>
+
+<p>The <i>suppurative</i> 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 py&aelig;mic infection, as sometimes occurs after
+exanthematous fevers and in gonorrh&oelig;a. 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.</p>
+
+<p><a name="XXI_tuberculous_arthritis" id="XXI_tuberculous_arthritis"></a><b>Tuberculous arthritis</b> 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.</p>
+
+<p><a name="XXI_arthritis_deformans" id="XXI_arthritis_deformans"></a><b>Arthritis deformans</b> 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.<a class="pagenum" name="Pg_526" id="Pg_526"></a> 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.</p>
+
+<p><a name="XXI_closure_jaws" id="XXI_closure_jaws"></a><b>Closure or Fixation of the Mandible.</b>&mdash;<i>Temporary fixation</i> 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&mdash;for
+example, that associated with a<a class="pagenum" name="Pg_527" id="Pg_527"></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 an&aelig;sthetic
+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.</p>
+
+<p>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.</p>
+
+<p><i>Permanent fixation</i> 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.</p>
+
+<p>The <i>clinical features</i> 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 f&oelig;tor of the saliva and breath. When osseous
+ankylosis occurs in childhood, it leads to <i>arrest of development of
+the mandible</i>, which is small and markedly receding, so that the teeth
+do not oppose those of the maxilla (<a href="#fig_256">Fig.&nbsp;256</a>).</p>
+
+<div class="figcenter" style="width: 325px;">
+<a name="fig_256" id="fig_256"></a>
+<img src="images/fig256.jpg" width="325" height="400" alt="Fig. 256.&mdash;Defective development of Mandible from
+fixation of jaw due to tuberculous osteomyelitis in infancy." title="" />
+<span class="caption"><span class="smcap">Fig. 256.</span>&mdash;Defective development of Mandible from
+fixation of jaw due to tuberculous osteomyelitis in infancy.</span>
+</div>
+
+<p><i>Treatment.</i>&mdash;When the cause of the fixation is in the joint itself,
+the best treatment is to resect one or both condyles.</p>
+
+<p>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.</p>
+
+
+
+
+<h2><a class="pagenum" name="Pg_528" id="Pg_528"></a><a name="CHAPTER_XXII" id="CHAPTER_XXII"></a>CHAPTER XXII
+<br />
+THE TONGUE</h2>
+
+<ul class="chap">
+  <li><a href="#XXII_anatomy">Surgical Anatomy</a></li>
+  <li>&mdash;<a href="#XXII_wounds">Wounds</a></li>
+  <li>&mdash;<a href="#XXII_dental_ulcer">Dental ulcer</a></li>
+  <li>&mdash;<a href="#XXII_inflammatory_affections">Inflammatory affections</a>:</li>
+  <li><i><a href="#XXII_inflammatory_affections">Acute parenchymatous glossitis</a> and <a href="#XXII_hemi_glossitis">hemi-glossitis</a></i>;</li>
+  <li><a href="#XXII_mercurial_glossitis"><i>Mercurial glossitis</i></a>;</li>
+  <li><a href="#XXII_superficial_glossitis"><i>Chronic superficial glossitis</i></a>;</li>
+  <li><a href="#XXII_superficial_glossitis"><i>Leucoplakia</i></a>;</li>
+  <li><a href="#XXII_smokers_patch"><i>Smoker's patch</i></a></li>
+  <li>&mdash;<a href="#XXII_tuberculous_disease"><i>Tuberculous disease</i></a>;</li>
+  <li><a href="#XXII_syphilitic_affections"><i>Syphilitic affections</i></a>;</li>
+  <li><a href="#XXII_sclerosing_glossitis"><i>Sclerosing glossitis</i></a>;</li>
+  <li><a href="#XXII_gummas"><i>Gummas</i></a>;</li>
+  <li><a href="#XXII_ulcers"><i>Ulcers and fissures</i></a></li>
+  <li>&mdash;<a href="#XXII_tumours">Tumours</a>:</li>
+  <li><a href="#XXII_carcinoma"><i>Carcinoma</i></a>;</li>
+  <li><a href="#XXII_sarcoma"><i>Sarcoma</i></a>;</li>
+  <li><a href="#XXII_innocent_tumour"><i>Innocent tumours</i></a>;</li>
+  <li><a href="#XXII_innocent_tumour"><i>Cysts</i></a></li>
+  <li>&mdash;<a href="#XXII_thyreo_glossal_tumours">Thyreo-glossal tumours and cysts</a></li>
+  <li>&mdash;<a href="#XXII_malformations">Malformations</a>:</li>
+  <li><a href="#XXII_malformations"><i>Absence</i></a>;</li>
+  <li><a href="#XXII_bifid_tongue"><i>bifid tongue</i></a>;</li>
+  <li><a href="#XXII_tongue_tie"><i>Tongue-tie</i></a>;</li>
+  <li><a href="#XXII_excessive_frenum"><i>Excessive length of frenum</i></a>;</li>
+  <li><a href="#XXII_macroglossia"><i>Macroglossia</i></a>;</li>
+  <li><a href="#XXII_atrophy"><i>Atrophy</i></a></li>
+  <li>&mdash;<a href="#XXII_nervous_affections">Nervous affections</a>.</li>
+</ul>
+
+<p><a name="XXII_anatomy" id="XXII_anatomy"></a><b>Surgical Anatomy.</b>&mdash;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 <i>anterior</i> or
+<i>oral</i> part, and a <i>posterior</i> or <i>pharyngeal</i> part.</p>
+
+<p>The <i>oral part</i>, 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 papill&aelig;. A slight median depression is
+recognisable on the dorsum as far back as the vallate (circumvallate)
+papill&aelig;, which mark the boundary between the oral and pharyngeal
+parts. A double fold of mucous membrane&mdash;the <i>frenum</i>&mdash;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&mdash;<i>apical glands</i>&mdash;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&mdash;the <i>folia
+lingu&aelig;</i>, or <i>foliate papill&aelig;</i>.</p>
+
+<p>The <i>pharyngeal</i> 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 papill&aelig;, but contains numerous lymphoid follicles&mdash;the
+<i>lingual tonsil</i>. The <i>foramen c&aelig;cum</i> lies just behind the apex of the
+vallate papill&aelig; in the middle line.</p>
+
+<p>The chief artery, the <i>lingual</i>, 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 lingu&aelig;
+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 ven&aelig; comites of the lingual artery
+and its branches.</p>
+
+<p><a class="pagenum" name="Pg_529" id="Pg_529"></a>The <i>hypoglossal</i> is the motor nerve of the tongue. The <i>lingual</i>
+branch of the mandibular (inferior maxillary) supplies the anterior
+two-thirds with common sensation. It is accompanied by the <i>chorda
+tympani</i> branch of the facial, which probably carries the taste
+fibres. The <i>glosso-pharyngeal</i> supplies the posterior third of the
+tongue with both common and gustatory sensation.</p>
+
+<p>The <i>lymph vessels</i> 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.</p>
+
+<p><a name="XXII_wounds" id="XXII_wounds"></a><b>Wounds</b> 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 h&aelig;morrhage, particularly when
+the posterior part of the tongue is implicated and the wound
+penetrates deeply. Of the later complications, infections and
+secondary h&aelig;morrhage are the most serious, and they are most liable to
+occur when a foreign body is embedded in the tongue.</p>
+
+<p><i>Treatment.</i>&mdash;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 h&aelig;morrhage 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.</p>
+
+<p>To prevent infective complications any foreign body must be removed
+and an antiseptic mouth-wash regularly employed.</p>
+
+<p>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.</p>
+
+<p><a name="XXII_dental_ulcer" id="XXII_dental_ulcer"></a><b>Dental Ulcer.</b>&mdash;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.</p>
+
+<p><a name="XXII_inflammatory_affections" id="XXII_inflammatory_affections"></a><a class="pagenum" name="Pg_530" id="Pg_530"></a><b>Inflammatory Affections.</b>&mdash;<i>Acute Parenchymatous Glossitis</i> is usually
+due to the action of streptococci. Although it affects mainly the
+mucous membrane and submucous tissue, it causes a diffuse &oelig;dematous
+swelling of the whole organ, and this may extend to the ary-epiglottic
+folds and give rise to &oelig;dema of the glottis. As a rule it does not
+go on to suppuration.</p>
+
+<p>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.</p>
+
+<p>The <i>treatment</i> 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
+dyspn&oelig;a may call for laryngotomy. If an abscess forms it must be
+opened.</p>
+
+<p>A similar condition has been met with in patients who have contracted
+the &ldquo;<i>foot and mouth disease</i>&rdquo; of cattle. Vesicles form on the mucous
+membrane, and after bursting, ulcerate, and a mixed infection with
+streptococci occurs, leading to diffuse &oelig;dema. 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.</p>
+
+<p><a name="XXII_hemi_glossitis" id="XXII_hemi_glossitis"></a><i>Acute Hemi-glossitis.</i>&mdash;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
+(G&uuml;terbock).</p>
+
+<p><a name="XXII_mercurial_glossitis" id="XXII_mercurial_glossitis"></a><i>Mercurial Glossitis</i> may accompany mercurial stomatitis (<a href="#Pg_496">p.&nbsp;496</a>).</p>
+
+<p><a name="XXII_superficial_glossitis" id="XXII_superficial_glossitis"></a><i>Chronic Superficial Glossitis.</i>&mdash;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
+<i>leucoplakia</i> or <i>leucokeratosis</i>.</p>
+
+<p>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<a class="pagenum" name="Pg_531" id="Pg_531"></a> submucous tissue. The
+patches are irregularly lozenge-shaped, and when crowded together they
+present the appearance of a mosaic (<a href="#fig_257">Fig.&nbsp;257</a>). Similar patches are
+often present on the mucous membrane lining the cheek.</p>
+
+<div class="figcenter" style="width: 338px;">
+<a name="fig_257" id="fig_257"></a>
+<img src="images/fig257.jpg" width="338" height="400" alt="Fig. 257.&mdash;Leucoplakia of the Tongue." title="" />
+<span class="caption"><span class="smcap">Fig. 257.</span>&mdash;Leucoplakia of the Tongue.</span>
+</div>
+
+<p>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&mdash;for example, the chewing or smoking of tobacco,
+the drinking of raw spirits, friction by a rough tooth or
+tooth-plate&mdash;plays an important part in inducing or in aggravating the
+condition.</p>
+
+<p>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.</p>
+
+<p>The disease is most intractable and persistent, and even after
+disappearing for a time is liable to recur. After a variable<a class="pagenum" name="Pg_532" id="Pg_532"></a> number
+of years epithelioma is prone to develop, usually in one or other of
+the fissures which accompany the condition.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+<p><a name="XXII_smokers_patch" id="XXII_smokers_patch"></a>The &ldquo;<i>smoker's patch</i>&rdquo; consists of a small oval area on the front of
+the tongue from which the papill&aelig; 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
+<i>treatment</i> 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.</p>
+
+<p><a name="XXII_tuberculous_disease" id="XXII_tuberculous_disease"></a><b>Tuberculous Disease.</b>&mdash;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.</p>
+
+<p>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.</p>
+
+<p>The <i>tuberculous ulcer</i> 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 sub<a class="pagenum" name="Pg_533" id="Pg_533"></a>maxillary
+glands may be, but are not always, enlarged. The ulcer may heal, but
+tends to break down again.</p>
+
+<p>Unless there is advanced pulmonary disease or other contraindication
+to operation, the ulcer should be excised under local an&aelig;sthesia. 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 an&aelig;sthetics, and by attending to the
+hygiene of the mouth and removing all sources of irritation.</p>
+
+<p><a name="XXII_syphilitic_affections" id="XXII_syphilitic_affections"></a><b>Syphilitic Affections.</b>&mdash;A <i>primary lesion</i> 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.</p>
+
+<p>During the <i>secondary stage</i>&mdash;particularly in the later
+periods&mdash;mucous patches and ulcers are common, and they may assume a
+condylomatous or warty appearance.</p>
+
+<p>The <i>tertiary</i> manifestations in the tongue are sclerosing glossitis,
+gummas, and gummatous ulcers.</p>
+
+<p><a name="XXII_sclerosing_glossitis" id="XXII_sclerosing_glossitis"></a><i>Sclerosing glossitis</i> 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.</p>
+
+<p><a name="XXII_gummas" id="XXII_gummas"></a>A <i>gumma</i> 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&mdash;the superficial, and the deep or
+parenchymatous.</p>
+
+<p>A <i>superficial</i> 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 papill&aelig; but later becomes smooth. It tends to break down
+early, forming a superficial ulcer. Superficial gummas are often
+multiple.</p>
+
+<p>The <i>deep</i> or parenchymatous form varies in size from a hazel-nut to a
+walnut, and feels like a hard body in the substance of<a class="pagenum" name="Pg_534" id="Pg_534"></a> the tongue.
+The mucous membrane over the swelling is of normal colour, but is
+usually devoid of papill&aelig;. The gumma may remain for months unchanged,
+or may approach the surface, soften, and break down, leaving a deep,
+ragged ulcer.</p>
+
+<p><a name="XXII_ulcers" id="XXII_ulcers"></a><i>Syphilitic ulcers and fissures</i> 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.</p>
+
+<p>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.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+
+<h3><a name="XXII_tumours" id="XXII_tumours"></a><span class="smcap">New Growths</span></h3>
+
+<p><a name="XXII_carcinoma" id="XXII_carcinoma"></a><b>Carcinoma</b> is by far the most common form of new growth met with in the
+tongue, and it is almost invariably a squamous epithelioma.</p>
+
+<p>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<a class="pagenum" name="Pg_535" id="Pg_535"></a> appears to vary in different
+cases, and is probably lowest when the disease originates in a patch
+of leucoplakia or other pre-cancerous lesion.</p>
+
+<p>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.</p>
+
+<p><i>Clinical Features.</i>&mdash;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 f&oelig;tor of the breath.</p>
+
+<p>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.</p>
+
+<p>The neighbouring lymph glands&mdash;particularly those under the jaw and
+along the line of the carotid vessels&mdash;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
+h&aelig;morrhages, toxin absorption, or septic broncho-pneumonia.</p>
+
+<p><i>Differential Diagnosis.</i>&mdash;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<a class="pagenum" name="Pg_536" id="Pg_536"></a> 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 an&aelig;sthesia 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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p>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<a class="pagenum" name="Pg_537" id="Pg_537"></a> 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.</p>
+
+<p><i>Treatment of Inoperable Cases.</i>&mdash;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
+h&aelig;morrhage 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.</p>
+
+<p><a name="XXII_sarcoma" id="XXII_sarcoma"></a><b>Sarcoma</b> 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.</p>
+
+<p><a name="XXII_innocent_tumour" id="XXII_innocent_tumour"></a><b>Innocent Tumour and Cysts.</b>&mdash;<i>Lipoma</i>, <i>fibroma</i>, and various forms of
+<i>angioma</i> (<a href="#fig_258">Fig.&nbsp;258</a>) are occasionally met with. They are all of slow
+growth, and give rise to inconvenience chiefly by their bulk, and
+should be removed.</p>
+
+<div class="figcenter" style="width: 348px;">
+<a name="fig_258" id="fig_258"></a>
+<img src="images/fig258.jpg" width="348" height="400" alt="Fig. 258.&mdash;Papillomatous Angioma of left side of tongue
+in a woman aged 26." title="" />
+<span class="caption"><span class="smcap">Fig. 258.</span>&mdash;Papillomatous Angioma of left side of tongue
+in a woman aged 26.</span>
+</div>
+
+<p><i>Papilloma</i> 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.</p>
+
+<p><i>Dermoid</i> 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<a class="pagenum" name="Pg_538" id="Pg_538"></a> 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
+(<a href="#fig_259">Fig.&nbsp;259</a>). 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.</p>
+
+<div class="figcenter" style="width: 312px;">
+<a name="fig_259" id="fig_259"></a>
+<img src="images/fig259.jpg" width="312" height="400" alt="Fig. 259.&mdash;Dermoid Cyst in middle line of neck." title="" />
+<span class="caption"><span class="smcap">Fig. 259.</span>&mdash;Dermoid Cyst in middle line of neck.<br /><br />
+(Mr. J. W. Struthers&#39; case.)</span>
+</div>
+
+<p>A <i>sebaceous cyst</i> may reach such dimensions as to simulate a dermoid
+or thyreo-glossal cyst.</p>
+
+<p><i>Hydatid and cysticercus cysts</i> have also been met with in the tongue.</p>
+
+<p><a name="XXII_thyreo_glossal_tumours" id="XXII_thyreo_glossal_tumours"></a><b>Thyreo-glossal Tumours and Cysts.</b>&mdash;Tumours may develop in the
+embryonic tract which passes from the isthmus of the<a class="pagenum" name="Pg_539" id="Pg_539"></a> thyreoid gland
+to the foramen c&aelig;cum at the base of the tongue&mdash;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 c&aelig;cum
+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 h&aelig;morrhage. 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.</p>
+
+<p>When the lower end of the tract becomes cystic it forms a swelling in
+the neck (<a href="#Pg_583">p.&nbsp;583</a>).</p>
+
+<p><a name="XXII_malformations" id="XXII_malformations"></a><a class="pagenum" name="Pg_540" id="Pg_540"></a><b>Malformations.</b>&mdash;Complete or partial <i>absence</i> of the tongue is
+exceedingly rare.</p>
+
+<p><a name="XXII_bifid_tongue" id="XXII_bifid_tongue"></a>Occasionally the fore part of the tongue is <i>bifid</i>. 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.</p>
+
+<p><a name="XXII_tongue_tie" id="XXII_tongue_tie"></a><i>Congenital tongue-tie</i> 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.</p>
+
+<p><a name="XXII_excessive_frenum" id="XXII_excessive_frenum"></a><i>Excessive length</i> 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.</p>
+
+<p><a name="XXII_macroglossia" id="XXII_macroglossia"></a><i>Macroglossia</i> 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&mdash;lymphangiomatous macroglossia&mdash;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.</p>
+
+<p>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.</p>
+
+<p><a name="XXII_atrophy" id="XXII_atrophy"></a><i>Atrophy</i> 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.</p>
+
+<p><a name="XXII_nervous_affections" id="XXII_nervous_affections"></a><b>Nervous Affections of the Tongue.</b>&mdash;<i>Neuralgia</i> confined to the
+distribution of the lingual nerve is comparatively rare.<a class="pagenum" name="Pg_541" id="Pg_541"></a> It usually
+yields to medical treatment, but in inveterate cases it is sometimes
+necessary to resect the nerve.</p>
+
+<p>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<a class="pagenum" name="Pg_542" id="Pg_542"></a> 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.</p>
+
+<p><i>Spasm</i> 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.</p>
+
+<p><i>Paralysis</i> of the tongue&mdash;unilateral or bilateral&mdash;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 (<a href="#fig_260">Fig.&nbsp;260</a>), and speech and mastication
+may be interfered with. The paralysed half of the tongue subsequently
+undergoes atrophy, but the functional disability largely disappears.</p>
+
+<div class="figcenter" style="width: 298px;">
+<a name="fig_260" id="fig_260"></a>
+<img src="images/fig260.jpg" width="298" height="400" alt="Fig. 260.&mdash;Temporary Unilateral Paralysis of Tongue,
+from bruising of hypoglossal nerve during operation for tuberculous
+cervical glands." title="" />
+<span class="caption"><span class="smcap">Fig. 260.</span>&mdash;Temporary Unilateral Paralysis of Tongue,
+from bruising of hypoglossal nerve during operation for tuberculous
+cervical glands.</span>
+</div>
+
+
+
+
+<h2><a class="pagenum" name="Pg_543" id="Pg_543"></a><a name="CHAPTER_XXIII" id="CHAPTER_XXIII"></a>CHAPTER XXIII
+<br />
+THE SALIVARY GLANDS</h2>
+
+<ul class="chap">
+  <li><a href="#XXIII_anatomy">Surgical Anatomy</a></li>
+  <li>&mdash;<a href="#XXIII_injuries">Injuries</a></li>
+  <li>&mdash;<a href="#XXIII_salivary_fistulae">Salivary fistul&aelig;</a></li>
+  <li>&mdash;<a href="#XXIII_salivary_calculi">Salivary calculi</a></li>
+  <li>&mdash;<a href="#XXIII_infective_conditions">Infective conditions</a>:</li>
+  <li><a href="#XXIII_infective_conditions"><i>Parotitis</i></a>;</li>
+  <li><a href="#XXIII_inflammation_submaxillary"><i>Inflammation of submaxillary gland</i></a>;</li>
+  <li><a href="#XXIII_angina_ludovici"><i>Angina Ludovici</i></a>;</li>
+  <li><a href="#XXIII_inflammation_sublingual"><i>Inflammation of sublingual gland</i></a>;</li>
+  <li><a href="#XXIII_tuberculous_disease"><i>Tuberculous disease</i></a></li>
+  <li>&mdash;<a href="#XXIII_tumours">Tumours</a>:</li>
+  <li><a href="#XXIII_tumours"><i>Ranula</i></a>;</li>
+  <li><a href="#XXIII_mixed_tumours_parotid"><i>Mixed tumours of parotid</i></a>;</li>
+  <li><a href="#XXIII_sarcoma"><i>Sarcoma</i></a>;</li>
+  <li><a href="#XXIII_sarcoma"><i>Carcinoma</i></a>;</li>
+  <li><a href="#XXIII_tumours_submaxillary"><i>Tumours of submaxillary and sublingual glands</i></a>.</li>
+</ul>
+
+<p><a name="XXIII_anatomy" id="XXIII_anatomy"></a><b>Surgical Anatomy.</b>&mdash;<i>The parotid gland</i> 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 <i>parotid duct (Stenson's duct)</i> 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&mdash;that is,
+at a higher level than the facial nerve. Several lymph
+glands&mdash;pre-auricular&mdash;lie inside the capsule of the parotid just in
+front of the ear.</p>
+
+<p>The <i>submaxillary gland</i> 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 <i>submaxillary duct
+(Wharton's duct)</i> opens into the mouth by the side of the frenum of
+the tongue.</p>
+
+<p>The <i>sublingual gland</i> 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.</p>
+
+<p><a name="XXIII_injuries" id="XXIII_injuries"></a><b>Injuries.</b>&mdash;The <i>parotid</i> 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<a class="pagenum" name="Pg_544" id="Pg_544"></a> 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.</p>
+
+<p><i>The parotid duct</i> 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.</p>
+
+<p>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.</p>
+
+<div class="figright" style="width: 179px;">
+<a name="fig_261" id="fig_261"></a>
+<img src="images/fig261.jpg" width="179" height="400" alt="Fig. 261.&mdash;Series of Salivary Calculi." title="" />
+<span class="caption"><span class="smcap">Fig. 261.</span>&mdash;Series of Salivary Calculi.</span>
+</div>
+
+<p><a name="XXIII_salivary_fistulae" id="XXIII_salivary_fistulae"></a><b>Salivary Fistul&aelig;.</b>&mdash;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&mdash;<i>parotid fistula</i>&mdash;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.</p>
+
+<p>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.</p>
+
+<p><i>Fistula of the parotid duct</i> 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 fistul&aelig; 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.</p>
+
+<p><a name="XXIII_salivary_calculi" id="XXIII_salivary_calculi"></a><a class="pagenum" name="Pg_545" id="Pg_545"></a><b>Salivary Calculi.</b>&mdash;Salivary calculi are most commonly met with <i>in the
+submaxillary gland or its duct</i>. 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 (<a href="#fig_261">Fig.&nbsp;261</a>).</p>
+
+<p>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.</p>
+
+<p><a name="XXIII_infective_conditions" id="XXIII_infective_conditions"></a><span class="smcap">Infective Conditions.</span>&mdash;<b>Parotitis.</b>&mdash;Inflammation of the parotid gland
+may be non-suppurative or suppurative.</p>
+
+<p>Of the <i>non-suppurative</i> varieties the most common is the<a class="pagenum" name="Pg_546" id="Pg_546"></a> epidemic
+form known as <i>mumps</i>. 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,
+&oelig;dema 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.</p>
+
+<div class="figcenter" style="width: 318px;">
+<a name="fig_262" id="fig_262"></a>
+<img src="images/fig262.jpg" width="318" height="400" alt="Fig. 262.&mdash;Acute Suppurative Parotitis." title="" />
+<span class="caption"><span class="smcap">Fig. 262.</span>&mdash;Acute Suppurative Parotitis.</span>
+</div>
+
+<p>The parotid on one or both sides may suddenly become<a class="pagenum" name="Pg_547" id="Pg_547"></a> 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.</p>
+
+<p><i>Recurrent enlargement</i> 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.</p>
+
+<p>The treatment of these non-suppurative forms of parotitis consists in
+relieving the symptoms.</p>
+
+<p><i>Suppurative parotitis</i> 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.</p>
+
+<p>The <i>post-operative</i> form of parotitis is most frequently met with
+after laparotomy for such conditions as suppurative appendicitis,
+perforated gastric ulcer, ovarian cyst, and pyosalpinx.</p>
+
+<p>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.</p>
+
+<p>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, &oelig;dema, and fluctuation.<a class="pagenum" name="Pg_548" id="Pg_548"></a> 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 dyspn&oelig;a and dysphagia. It may find its way
+downwards towards the mediastinum, inwards towards the pharynx&mdash;where
+it constitutes one form of retro-pharyngeal abscess&mdash;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 h&aelig;morrhage 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 fistul&aelig; may form. Death
+may take place from tox&aelig;mia even before pus forms.</p>
+
+<p><i>Treatment.</i>&mdash;During the first two or three days hyper&aelig;mia 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.</p>
+
+<p><a name="XXIII_inflammation_submaxillary" id="XXIII_inflammation_submaxillary"></a>Acute infection of the <b>submaxillary gland</b> is met with under the same
+conditions as that of the parotid. Both glands are occasionally
+attacked at the same time.</p>
+
+<p><a name="XXIII_angina_ludovici" id="XXIII_angina_ludovici"></a>The acute phlegmonous peri-adenitis of the submaxillary gland, known
+as <i>angina Ludovici</i>, is referred to at <a href="#Pg_597">p.&nbsp;597</a>.</p>
+
+<p>The <i>treatment</i> consists in making incisions through the deep fascia
+in order to relieve the tension, or to let out pus if it has formed.</p>
+
+<p><a name="XXIII_inflammation_sublingual" id="XXIII_inflammation_sublingual"></a>Acute suppurative inflammation of the <b>sublingual gland</b> 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.</p>
+
+<p><a name="XXIII_tuberculous_disease" id="XXIII_tuberculous_disease"></a><b>Tuberculous disease</b> of the salivary glands is rare. It<a class="pagenum" name="Pg_549" id="Pg_549"></a> usually begins
+in the lymph glands within the capsule of the parotid or submaxillary,
+and spreads thence to the salivary gland tissue.</p>
+
+<p><a name="XXIII_tumours" id="XXIII_tumours"></a><span class="smcap">Tumours.</span>&mdash;<b>Cystic Tumours&mdash;Ranula.</b>&mdash;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.</p>
+
+<p>The <i>sublingual ranula</i> 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 (<a href="#Pg_539">p.&nbsp;539</a>).</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+<p>Cystic tumours, similar to the sublingual ranula, form in the other
+glands in the floor of the mouth&mdash;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&mdash;the so-called <i>congenital ranula</i>. It is usually due to an
+imperfect development of the duct of the submaxillary or sublingual
+gland.</p>
+
+<p><a name="XXIII_mixed_tumours_parotid" id="XXIII_mixed_tumours_parotid"></a><b>Solid Tumours&mdash;Mixed Tumours of the Parotid.</b>&mdash;The most important of
+the solid tumours met with in the salivary glands<a class="pagenum" name="Pg_550" id="Pg_550"></a> is the so-called
+&ldquo;mixed tumour of the parotid.&rdquo; 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<a class="pagenum" name="Pg_551" id="Pg_551"></a> 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.</p>
+
+<p>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.</p>
+
+<p><i>Clinical Features.</i>&mdash;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 (<a href="#fig_263">Figs.&nbsp;263</a>, <a href="#fig_264">264</a>). Only
+in rare cases does paralysis result from pressure on the facial nerve.</p>
+
+<div class="figcenter" style="width: 349px;">
+<a name="fig_263" id="fig_263"></a>
+<img src="images/fig263.jpg" width="349" height="400" alt="Fig. 263.&mdash;Mixed Tumour of Parotid." title="" />
+<span class="caption"><span class="smcap">Fig. 263.</span>&mdash;Mixed Tumour of Parotid.</span>
+</div>
+
+<p>&nbsp;</p>
+
+<div class="figcenter" style="width: 363px;">
+<a name="fig_264" id="fig_264"></a>
+<img src="images/fig264.jpg" width="363" height="400" alt="Fig. 264.&mdash;Mixed Tumour of the Parotid of over twenty
+years&#39; duration." title="" />
+<span class="caption"><span class="smcap">Fig. 264.</span>&mdash;Mixed Tumour of the Parotid of over twenty
+years&#39; duration.</span>
+</div>
+
+<p>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.</p>
+
+<p><a class="pagenum" name="Pg_552" id="Pg_552"></a>The <i>treatment</i> 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.</p>
+
+<p><a name="XXIII_sarcoma" id="XXIII_sarcoma"></a><b>Sarcoma and carcinoma</b> 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.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+<p><a name="XXIII_tumours_submaxillary" id="XXIII_tumours_submaxillary"></a>The <i>submaxillary and sublingual glands</i> 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.</p>
+
+
+
+
+<h2><a class="pagenum" name="Pg_553" id="Pg_553"></a><a name="CHAPTER_XXIV" id="CHAPTER_XXIV"></a>CHAPTER XXIV
+<br />
+THE EAR<a name="FNanchor_5_5" id="FNanchor_5_5"></a><a href="#Footnote_5_5" class="fnanchor">[5]</a></h2>
+
+<ul class="chap">
+  <li><a href="#XXIV_anatomy">Surgical Anatomy</a></li>
+  <li>&mdash;<a href="#XXIV_symptoms"><span class="smcap">Cardinal Symptoms of Ear Disease</span></a>:</li>
+  <li><a href="#XXIV_symptoms"><i>Impairment of hearing</i></a>;</li>
+  <li><a href="#XXIV_tinnitus_aurium"><i>Tinnitus aurium</i></a>;</li>
+  <li><a href="#XXIV_earache"><i>Earache</i></a>;</li>
+  <li><a href="#XXIV_giddiness"><i>Giddiness</i></a>;</li>
+  <li><a href="#XXIV_discharge"><i>Discharge</i></a></li>
+  <li>&mdash;<a href="#XXIV_hearing_tests">Hearing tests</a></li>
+  <li>&mdash;<a href="#XXIV_inspection_ear">Inspection of ear</a></li>
+  <li>&mdash;<a href="#XXIV_inflation_middle_ear">Inflation of middle ear</a>.</li>
+  <li><a href="#XXIV_affections_external_ear"><span class="smcap">Affections of External Ear</span></a>:</li>
+  <li><a href="#XXIV_deformities"><i>Deformities</i></a>;</li>
+  <li><a href="#XXIV_haematoma_auris"><i>H&aelig;matoma auris</i></a>;</li>
+  <li><i><a href="#XXIV_epithelioma">Epithelioma</a> and <a href="#XXIV_rodent_cancer">Rodent cancer</a></i>;</li>
+  <li><a href="#XXIV_impaction_wax"><i>Impaction of wax</i></a>;</li>
+  <li><a href="#XXIV_eczema"><i>Eczema</i></a>;</li>
+  <li><a href="#XXIV_boils"><i>Boils</i></a>;</li>
+  <li><a href="#XXIV_foreign_bodies"><i>Foreign bodies</i></a>.</li>
+  <li><a href="#XXIV_tympanic_membrane"><span class="smcap">Affections of Tympanic Membrane and Middle Ear</span></a>:</li>
+  <li><a href="#XXIV_rupture_membrane"><i>Rupture of membrane</i></a>;</li>
+  <li><a href="#XXIV_inflammation_middle_ear"><i>Acute inflammation of middle ear</i></a>;</li>
+  <li><a href="#XXIV_chronic_suppuration_middle_ear"><i>Chronic suppuration</i></a>;</li>
+  <li><a href="#XXIV_suppuration_mastoid"><i>Suppuration in the mastoid antrum and cells</i></a>.</li>
+</ul>
+
+<p class="footnote"><a name="Footnote_5_5" id="Footnote_5_5"></a><a href="#FNanchor_5_5"><span class="label">[5]</span></a> We desire here to acknowledge our indebtedness to Dr.
+Logan Turner for again revising this chapter.</p>
+
+<p><a name="XXIV_anatomy" id="XXIV_anatomy"></a><b>Surgical Anatomy.</b>&mdash;The anatomical subdivision of the ear into three
+parts&mdash;the external, middle, and internal ear&mdash;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&mdash;malleus,
+incus, and stapes&mdash;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
+foss&aelig;, 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.</p>
+
+<p>Physiologically the different parts of the auditory mechanism may be
+divided into (1) the <i>sound-conducting apparatus</i>, which includes the
+outer and middle ears; and (2) the <i>sound-perceiving apparatus</i>&mdash;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 &ldquo;obstructive&rdquo;; when the<a class="pagenum" name="Pg_554" id="Pg_554"></a> sound-perceiving apparatus is
+affected, the term &ldquo;nerve deafness&rdquo; is used. The semicircular canals,
+which are peripheral organs concerned in the maintenance of
+equilibration, form part of the inner ear apparatus.</p>
+
+<p><a name="XXIV_symptoms" id="XXIV_symptoms"></a><span class="smcap">Cardinal Symptoms of Ear Disease.</span>&mdash;The most important symptom of ear
+disease is <i>impairment of hearing</i>, 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 h&aelig;morrhage 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
+&ldquo;paracusis of Willis&rdquo;&mdash;a condition in which the patient hears better
+in a noise; &ldquo;diplacusis,&rdquo; or double hearing; and &ldquo;hyper&aelig;sthesia
+acustica,&rdquo; or painful impressions of sound.</p>
+
+<p><a name="XXIV_tinnitus_aurium" id="XXIV_tinnitus_aurium"></a><i>Tinnitus aurium</i>, 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 an&aelig;mia, Bright's disease, and heart
+disease may also be concerned in their production.</p>
+
+<p><a name="XXIV_earache" id="XXIV_earache"></a><i>Pain</i>, or <i>earache</i>, 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&mdash;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<a class="pagenum" name="Pg_555" id="Pg_555"></a>
+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.</p>
+
+<p><a name="XXIV_giddiness" id="XXIV_giddiness"></a><i>Vertigo</i>, or <i>giddiness</i>, 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
+&ldquo;static sense&rdquo; 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.</p>
+
+<p>Labyrinthine <i>nystagmus</i> 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.</p>
+
+<p><a name="XXIV_discharge" id="XXIV_discharge"></a><i>Discharge from the ear</i>, or <i>otorrh&oelig;a</i>, 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 d&eacute;bris. 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.</p>
+
+<p><a name="XXIV_hearing_tests" id="XXIV_hearing_tests"></a><b>The Hearing Tests.</b>&mdash;In testing the hearing, a definite routine method
+should be adopted, the watch, whisper, voice,<a class="pagenum" name="Pg_556" id="Pg_556"></a> 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.</p>
+
+<p><i>Tuning-fork Tests.</i>&mdash;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.</p>
+
+<p><a name="XXIV_inspection_ear" id="XXIV_inspection_ear"></a><b>Inspection of the Ear.</b>&mdash;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.</p>
+
+<p><a class="pagenum" name="Pg_557" id="Pg_557"></a>The <i>normal membrane</i> 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.</p>
+
+<p>Various departures from the normal may be observed. <i>Atrophy</i> 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
+<i>cicatrix</i> 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 <i>thickened membrane</i>
+presents an opaque white appearance. <i>Calcareous</i> or <i>chalky patches</i>
+are markedly white, and when probed are hard to the touch; they are
+often evidence of past suppuration. An <i>indrawn</i> 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 <i>inflamed</i>
+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 <i>perforation</i> is usually single, and
+varies in size from a small<a class="pagenum" name="Pg_558" id="Pg_558"></a> 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. <i>Granulations</i> in the
+tympanum appear as red fleshy masses of different sizes. When large
+they constitute <i>aural polypi</i>, 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.</p>
+
+<p><a name="XXIV_inflation_middle_ear" id="XXIV_inflation_middle_ear"></a><b>Inflation of the Middle Ear.</b>&mdash;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.</p>
+
+<p>In <i>Valsalva's inflation</i> 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.</p>
+
+<p><i>Politzer's Method.</i>&mdash;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.</p>
+
+<p><i>Inflation through the Eustachian Catheter.</i>&mdash;For this method, in
+addition to the Politzer's bag and the auscultating tube, a<a class="pagenum" name="Pg_559" id="Pg_559"></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.</p>
+
+<p>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.</p>
+
+<p>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<a class="pagenum" name="Pg_560" id="Pg_560"></a> 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.</p>
+
+
+<h3><a name="XXIV_affections_external_ear" id="XXIV_affections_external_ear"></a><span class="smcap">Affections of the External Ear</span></h3>
+
+<p><a name="XXIV_deformities" id="XXIV_deformities"></a><b>Deformities.</b>&mdash;The auricle, together with the external auditory meatus,
+may be <i>congenitally absent</i> on one or on both sides. The condition is
+not amenable to surgical treatment. <i>Double auricles</i> are occasionally
+met with; more frequently rudimentary <i>auricular appendages</i> 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.</p>
+
+<p><i>Outstanding ears</i> 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 <i>large
+ears</i> may be diminished in size by the removal of a V-shaped portion
+from the upper part of the auricle.</p>
+
+<p><a name="XXIV_haematoma_auris" id="XXIV_haematoma_auris"></a>The term <b>h&aelig;matoma auris</b> 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.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+<p><a name="XXIV_epithelioma" id="XXIV_epithelioma"></a><b>Epithelioma</b> may attack the auricle and extend along the external
+auditory meatus. It begins as a small abrasion which<a class="pagenum" name="Pg_561" id="Pg_561"></a> refuses to heal,
+and is attended with a constant f&oelig;tid 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.</p>
+
+<p><a name="XXIV_rodent_cancer" id="XXIV_rodent_cancer"></a><b>Rodent cancer</b> also may attack the outer ear.</p>
+
+<p><a name="XXIV_impaction_wax" id="XXIV_impaction_wax"></a><b>Impaction of Wax or Cerumen.</b>&mdash;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.</p>
+
+<p>The chief <i>symptom</i> 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.</p>
+
+<p>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.</p>
+
+<p><i>Treatment.</i>&mdash;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<a class="pagenum" name="Pg_562" id="Pg_562"></a> 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.</p>
+
+<p><a name="XXIV_eczema" id="XXIV_eczema"></a><b>Eczema of the external meatus</b> 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 d&eacute;bris. 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.</p>
+
+<p><i>Treatment</i> 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 &aelig;theris 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.</p>
+
+<p>Occasionally the vegetable parasite <i>aspergillus</i> 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.</p>
+
+<p><a name="XXIV_boils" id="XXIV_boils"></a><b>Furunculosis</b> or <b>Boils</b>.&mdash;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 &oelig;dema over the mastoid with displacement forwards of the
+pinna supervenes, and simulates acute inflammation of the mastoid.</p>
+
+<p><i>Treatment.</i>&mdash;If seen in the earliest stages, an attempt may be made
+to relieve the pain by the application of a 20 per cent.<a class="pagenum" name="Pg_563" id="Pg_563"></a> 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.</p>
+
+<p><a name="XXIV_foreign_bodies" id="XXIV_foreign_bodies"></a><b>Foreign Bodies.</b>&mdash;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&mdash;for example maggots, larv&aelig;,
+and insects; and the inanimate&mdash;for example beads, buttons, and peas.
+Pain, deafness, tinnitus, and giddiness may be produced, and such
+reflex symptoms as coughing and vomiting have resulted.</p>
+
+<p>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 an&aelig;sthetic so that a thorough examination may be made with the
+aid of good illumination. If previous attempts to remove the body have
+caused &oelig;dema 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, larv&aelig;, and
+insects should first be killed by instillations of alcohol and then
+syringed out.</p>
+
+
+<h3><a name="XXIV_tympanic_membrane" id="XXIV_tympanic_membrane"></a><span class="smcap">Affections of the Tympanic Membrane and Middle Ear</span></h3>
+
+<p><a name="XXIV_rupture_membrane" id="XXIV_rupture_membrane"></a><b>Traumatic Rupture of the Tympanic Membrane.</b>&mdash;Perforating wounds may
+result from direct violence caused by the patient&mdash;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<a class="pagenum" name="Pg_564" id="Pg_564"></a> 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.</p>
+
+<p><a name="XXIV_inflammation_middle_ear" id="XXIV_inflammation_middle_ear"></a><b>Acute Infection of the Middle Ear.</b>&mdash;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.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+<p><a name="XXIV_chronic_suppuration_middle_ear" id="XXIV_chronic_suppuration_middle_ear"></a><a class="pagenum" name="Pg_565" id="Pg_565"></a><b>Chronic Suppuration in the Middle Ear.</b>&mdash;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.</p>
+
+<p><i>Various complications</i> may arise in the course of chronic middle-ear
+disease, and so long as a person is the subject of a chronic
+otorrh&oelig;a, 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, h&aelig;morrhage 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 septic&aelig;mia and py&aelig;mia.</p>
+
+<p>The <i>treatment</i> 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<a class="pagenum" name="Pg_566" id="Pg_566"></a> the meatus with antiseptic gauze after
+washing out may be practised.</p>
+
+<p><a name="XXIV_suppuration_mastoid" id="XXIV_suppuration_mastoid"></a><b>Suppuration in the Tympanic Antrum and Mastoid Cells</b>, or <i>Acute
+Suppurative Mastoiditis</i>.&mdash;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&mdash;<i>Bezold's mastoiditis</i>. If the posterior wall or roof
+of the antrum is destroyed, intra-cranial complications are liable to
+ensue.</p>
+
+<p>The <i>clinical features</i> are pain behind the ear, tenderness on
+pressure or percussion over the mastoid, redness and &oelig;dematous
+swelling of the skin, and, when pus forms under the periosteum, the
+&oelig;dema may be so great as to displace the auricle downwards and
+forwards (<a href="#fig_265">Fig.&nbsp;265</a>). 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.</p>
+
+<div class="figcenter" style="width: 289px;">
+<a name="fig_265" id="fig_265"></a>
+<img src="images/fig265.jpg" width="289" height="400" alt="Fig. 265.&mdash;Acute Mastoid Disease, showing &oelig;dema and
+projection of auricle." title="" />
+<span class="caption"><span class="smcap">Fig. 265.</span>&mdash;Acute Mastoid Disease, showing &oelig;dema and
+projection of auricle.</span>
+</div>
+
+<p><i>Treatment.</i>&mdash;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&mdash;<i>Schwartze's operation</i>. When
+mastoid suppuration is associated with chronic middle-ear disease, it
+is usually necessary to perform the complete radical
+operation&mdash;<i>Stacke-Schwartze operation</i>. The operations are described
+in <i>Operative Surgery</i>, p. 98.</p>
+
+
+
+
+<h2><a class="pagenum" name="Pg_567" id="Pg_567"></a><a name="CHAPTER_XXV" id="CHAPTER_XXV"></a>CHAPTER XXV
+<br />
+THE NOSE AND NASO-PHARYNX<a name="FNanchor_6_6" id="FNanchor_6_6"></a><a href="#Footnote_6_6" class="fnanchor">[6]</a></h2>
+
+<ul class="chap">
+  <li><a href="#XXV_fracture_nasal_bones">Fracture of nasal bones</a></li>
+  <li>&mdash;<a href="#XXV_deformities_nose">Deformities of nose</a>:</li>
+  <li><a href="#XXV_deformities_nose"><i>Saddle nose</i></a>;</li>
+  <li><a href="#XXV_partial_destruction"><i>Partial and complete destruction of nose</i></a>;</li>
+  <li><a href="#XXV_restoration"><i>Restoration of nose</i></a>;</li>
+  <li><a href="#XXV_rhinophyma"><i>Rhinophyma</i></a></li>
+  <li>&mdash;<a href="#XXV_examination">Intra-nasal affections&mdash;Examination of the nasal cavities</a>:</li>
+  <li><a href="#XXV_anterior_rhinoscopy"><i>Anterior rhinoscopy</i></a>;</li>
+  <li><a href="#XXV_posterior_rhinoscopy"><i>Posterior rhinoscopy</i></a>;</li>
+  <li><a href="#XXV_digital_examination"><i>Digital examination</i></a>.</li>
+  <li><a href="#XXV_cardinal_symptoms"><span class="smcap">Cardinal Symptoms of Nasal Affections</span></a>:</li>
+  <li><a href="#XXV_nasal_obstruction">Nasal obstruction</a>:</li>
+  <li><a href="#XXV_erectile_swelling"><i>Erectile swelling of inferior turbinals</i></a>;</li>
+  <li><a href="#XXV_nasal_polypi"><i>Nasal polypi</i></a>;</li>
+  <li><a href="#XXV_malignant_tumours"><i>Malignant tumours</i></a>;</li>
+  <li><a href="#XXV_deviations"><i>Deviations, spines, and ridges of septum</i></a>;</li>
+  <li><a href="#XXV_haematoma_septum"><i>H&aelig;matoma of septum</i></a></li>
+  <li>&mdash;<a href="#XXV_nasal_discharge">Nasal discharge</a>:</li>
+  <li><a href="#XXV_foreign_bodies"><i>Foreign bodies</i></a>;</li>
+  <li><a href="#XXV_rhinoliths"><i>Rhinoliths</i></a>;</li>
+  <li><a href="#XXV_ozaena"><i>Oz&aelig;na</i></a>;</li>
+  <li><a href="#XXV_epistaxis"><i>Epistaxis</i></a>;</li>
+  <li><a href="#XXV_suppuration_accessory_sinuses"><i>Suppuration in accessory sinuses</i></a></li>
+  <li>&mdash;<a href="#XXV_anomalies_smell_taste">Anomalies of smell and taste</a>:</li>
+  <li><a href="#XXV_anomalies_smell_taste"><i>Anosmia</i></a>;</li>
+  <li><a href="#XXV_anomalies_smell_taste"><i>Parosmia</i></a></li>
+  <li>&mdash;<a href="#XXV_reflex_symptoms">Reflex symptoms of nasal origin</a></li>
+  <li>&mdash;<a href="#XXV_post_nasal_obstructions">Post-nasal obstruction</a>:</li>
+  <li><a href="#XXV_post_nasal_obstructions"><i>Adenoids</i></a></li>
+  <li>&mdash;<a href="#XXV_tumours_naso_pharynx">Tumours of naso-pharynx</a>.</li>
+</ul>
+
+<p class="footnote"><a name="Footnote_6_6" id="Footnote_6_6"></a><a href="#FNanchor_6_6"><span class="label">[6]</span></a> Revised by Dr. Logan Turner.</p>
+
+<p><a name="XXV_fracture_nasal_bones" id="XXV_fracture_nasal_bones"></a><b>Fracture of the Nasal Bones and Displacement of the Cartilages.</b>&mdash;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 maxill&aelig;. 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 h&aelig;matoma forms in the septum (<a href="#Pg_573">p.&nbsp;573</a>). 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.</p>
+
+<p>The <i>clinical features</i> 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&mdash;<i>traumatic saddle nose</i>. Within a few hours of the injury
+the swelling is often so great as to obscure the nature<a class="pagenum" name="Pg_568" id="Pg_568"></a> 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.</p>
+
+<p><i>Treatment.</i>&mdash;As the bones unite rapidly, it is of great importance
+that any displacement should be reduced without delay, and to
+facilitate this a general an&aelig;sthetic 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.</p>
+
+<p><a name="XXV_deformities_nose" id="XXV_deformities_nose"></a><b>Deformities of the Nose.</b>&mdash;The most common deformity is that known as
+the <i>sunken-bridge</i> or <i>saddle nose</i> (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.</p>
+
+<p>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<a class="pagenum" name="Pg_569" id="Pg_569"></a> rubber drainage tube introduced into
+each nostril maintains the contour of the nose till union has taken
+place.</p>
+
+<p>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.</p>
+
+<p><a name="XXV_partial_destruction" id="XXV_partial_destruction"></a>Portions of the al&aelig; 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.</p>
+
+<p>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.</p>
+
+<p><a name="XXV_restoration" id="XXV_restoration"></a>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 &ldquo;Indian operation&rdquo; 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<a class="pagenum" name="Pg_570" id="Pg_570"></a> 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.</p>
+
+<p><a name="XXV_rhinophyma" id="XXV_rhinophyma"></a>The term <b>Rhinophyma</b> has been applied by Hebra to a condition in which
+the skin of the tip and al&aelig; of the nose becomes thick and coarse, and
+presents large, irregular, tuberous masses on which the orifices of
+the sebaceous follicles are unduly evident&mdash;<i>potato</i> or <i>hammer nose</i>
+(<a href="#fig_266">Fig.&nbsp;266</a>). 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 <i>lipoma
+nasi</i>, formerly employed, is therefore misleading.</p>
+
+<div class="figcenter" style="width: 295px;">
+<a name="fig_266" id="fig_266"></a>
+<img src="images/fig266.jpg" width="295" height="400" alt="Fig. 266.&mdash;Rhinophyma or Lipoma Nasi in man &aelig;t. 65." title="" />
+<span class="caption"><span class="smcap">Fig. 266.</span>&mdash;Rhinophyma or Lipoma Nasi in man &aelig;t. 65.</span>
+</div>
+
+<p>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.</p>
+
+<p><a name="XXV_examination" id="XXV_examination"></a><b>Examination of the Nasal Cavities.</b>&mdash;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.</p>
+
+<p><a name="XXV_anterior_rhinoscopy" id="XXV_anterior_rhinoscopy"></a><i>Anterior Rhinoscopy.</i>&mdash;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:&mdash;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 (<a href="#fig_267">Fig.&nbsp;267</a>),
+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<a class="pagenum" name="Pg_571" id="Pg_571"></a> by anterior rhinoscopy, and between it and the
+middle turbinal is a narrow chink&mdash;the olfactory sulcus.</p>
+
+<div class="figcenter" style="width: 500px;">
+<a name="fig_267" id="fig_267"></a>
+<img src="images/fig267.jpg" width="500" height="334" alt="Fig. 267.&mdash;The outer wall of Left Nasal Chamber, after
+removal of the middle turbinated body. (After Logan Turner.)" title="" />
+<span class="caption"><span class="smcap">Fig. 267.</span>&mdash;The outer wall of Left Nasal Chamber, after
+removal of the middle turbinated body. (After Logan Turner.)</span>
+</div>
+
+<p><a name="XXV_posterior_rhinoscopy" id="XXV_posterior_rhinoscopy"></a><i>Posterior Rhinoscopy.</i>&mdash;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.</p>
+
+<p><a name="XXV_digital_examination" id="XXV_digital_examination"></a><i>Digital examination</i> 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.</p>
+
+<p><a name="XXV_cardinal_symptoms" id="XXV_cardinal_symptoms"></a><span class="smcap">Cardinal Symptoms of Nasal Affections.</span>&mdash;The chief symptoms of nasal
+disease are: nasal obstruction, nasal discharge, anomalies of smell
+and taste, and certain reflex phenomena.</p>
+
+<p><a class="pagenum" name="Pg_572" id="Pg_572"></a><b>Nasal Obstruction.</b>&mdash;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.</p>
+
+<p><a name="XXV_nasal_obstruction" id="XXV_nasal_obstruction"></a>Nasal obstruction may be due to <i>intra-nasal</i> or to <i>post-nasal</i>
+(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 h&aelig;matoma
+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.</p>
+
+<p><a name="XXV_erectile_swelling" id="XXV_erectile_swelling"></a><i>Erectile swelling</i> 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 an&aelig;sthetising 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.</p>
+
+<p><a name="XXV_nasal_polypi" id="XXV_nasal_polypi"></a><a class="pagenum" name="Pg_573" id="Pg_573"></a><i>Nasal polypi</i> 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 &oelig;dematous 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.</p>
+
+<p><a name="XXV_malignant_tumours" id="XXV_malignant_tumours"></a><i>Carcinoma</i> and <i>sarcoma</i> sometimes grow from the muco-periosteum in
+the region of the ethmoid. They tend to invade adjacent parts, giving
+rise to h&aelig;morrhage 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.</p>
+
+<p><a name="XXV_deviations" id="XXV_deviations"></a><i>Deviations, spines, and ridges of the septum</i> 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.</p>
+
+<p><a name="XXV_haematoma_septum" id="XXV_haematoma_septum"></a><i>H&aelig;matoma of the septum</i> 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<a class="pagenum" name="Pg_574" id="Pg_574"></a> 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.</p>
+
+<p><a name="XXV_nasal_discharge" id="XXV_nasal_discharge"></a><b>Nasal discharge</b> 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 gonorrh&oelig;al 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 f&oelig;tid atrophic rhinitis (oz&aelig;na) and syphilis, and
+in these conditions the discharge is associated with a most
+objectionable and distinctive f&oelig;tor. Pus from the maxillary sinus
+is often f&oelig;tid, and the odour is noticed by the patient; while the
+odour of oz&aelig;na is not recognised by the patient, although very obvious
+to others.</p>
+
+<p><a name="XXV_foreign_bodies" id="XXV_foreign_bodies"></a><b>Foreign bodies</b> 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 an&aelig;sthesia, 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<a class="pagenum" name="Pg_575" id="Pg_575"></a> 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.</p>
+
+<p><a name="XXV_rhinoliths" id="XXV_rhinoliths"></a><b>Rhinoliths.</b>&mdash;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.</p>
+
+<p><a name="XXV_ozaena" id="XXV_ozaena"></a><b>Oz&aelig;na</b>, or <b>f&oelig;tid atrophic rhinitis</b>, 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.</p>
+
+<p>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.</p>
+
+<p><a name="XXV_epistaxis" id="XXV_epistaxis"></a><b>Epistaxis.</b>&mdash;Bleeding from the nose may be due either to local or to
+general causes. Among the former may be cited<a class="pagenum" name="Pg_576" id="Pg_576"></a> 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 h&aelig;morrhage may occur are typhoid fever,
+an&aelig;mia, and purpura cardiac and renal disease, cirrhosis of the liver,
+and whooping-cough. Prolonged oozing of blood may be an evidence of
+h&aelig;mophilia. Nasal h&aelig;morrhage 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 al&aelig; 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 h&aelig;morrhage 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.</p>
+
+<p><a name="XXV_suppuration_accessory_sinuses" id="XXV_suppuration_accessory_sinuses"></a><b>Suppuration in the Accessory Nasal Sinuses.</b>&mdash;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.</p>
+
+<p>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,<a class="pagenum" name="Pg_577" id="Pg_577"></a> attention must be directed to
+the posterior ethmoidal cells and sphenoidal sinus (<a href="#fig_267">Fig.&nbsp;267</a>). 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.</p>
+
+<p>As the anterior group of sinuses is most frequently affected, and of
+these most commonly the <i>maxillary sinus</i>, 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.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+<p>Suppuration in the <i>frontal sinus</i> 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.</p>
+
+<p>The <i>treatment</i> 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 (<a href="#fig_267">Fig.&nbsp;267</a>) into the nose.</p>
+
+<p>The <i>anterior ethmoidal cells</i> (<a href="#fig_267">Fig.&nbsp;267</a>) are frequently affected in
+conjunction with the frontal, and sometimes with the<a class="pagenum" name="Pg_578" id="Pg_578"></a> 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.</p>
+
+<p>The <i>treatment</i> consists in extending the operation for the frontal or
+maxillary sinus so as to ensure drainage of the ethmoidal cells.</p>
+
+<p><i>Suppuration in the sphenoidal sinus</i> (<a href="#fig_267">Fig.&nbsp;267</a>) 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.</p>
+
+<p>The <i>posterior ethmoidal cells</i> (<a href="#fig_267">Fig.&nbsp;267</a>) 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.</p>
+
+<p><a name="XXV_anomalies_smell_taste" id="XXV_anomalies_smell_taste"></a><b>Anomalies of Smell and Taste.</b>&mdash;<i>Anosmia</i> 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 oz&aelig;na also the sense
+of smell is lost. <i>Parosmia</i>, 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.</p>
+
+<p><a name="XXV_reflex_symptoms" id="XXV_reflex_symptoms"></a><b>Reflex Symptoms of Nasal Origin.</b>&mdash;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.</p>
+
+<p><a name="XXV_post_nasal_obstructions" id="XXV_post_nasal_obstructions"></a><b>Post-nasal Obstruction&mdash;Adenoid Vegetations.</b>&mdash;The most common cause of
+post-nasal obstruction is hypertrophy of the<a class="pagenum" name="Pg_579" id="Pg_579"></a> normal lymphoid tissue
+which constitutes the naso-pharyngeal or Luschka's tonsil. <i>Adenoids</i>
+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 foss&aelig; of Rosenm&uuml;ller 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.</p>
+
+<p>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.</p>
+
+<p><i>Clinical Features.</i>&mdash;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 al&aelig; 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.</p>
+
+<p>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.</p>
+
+<p>Among the rarer conditions attributed to adenoids are asthma,
+inspiratory laryngeal stridor, persistent cough, chorea, and nocturnal
+enuresis.</p>
+
+<p>A <i>diagnosis</i> 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.</p>
+
+<p><i>Treatment.</i>&mdash;Thorough removal is the only satisfactory line of
+treatment, and this should be done under general an&aelig;sthesia. 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&mdash;Kuhn's or
+L&oelig;wenberg's&mdash;a tongue depressor, a<a class="pagenum" name="Pg_580" id="Pg_580"></a> gag, and one or two throat
+sponges on holders. The patient having been an&aelig;sthetised, 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
+foss&aelig; of Rosenm&uuml;ller 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.</p>
+
+<p>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.</p>
+
+<p><a name="XXV_tumours_naso_pharynx" id="XXV_tumours_naso_pharynx"></a><b>Tumours of the Naso-Pharynx.</b>&mdash;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&mdash;<i>naso-pharyngeal tumour</i> 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.</p>
+
+<p><i>Clinical Features.</i>&mdash;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<a class="pagenum" name="Pg_581" id="Pg_581"></a> expanded and the eyes are pushed
+outwards, giving rise to the deformity known as <i>frog-face</i>. 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
+an&aelig;mic. 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.</p>
+
+<p>Unless removed by operation these tumours prove fatal from h&aelig;morrhage,
+interference with respiration, or by perforating the base of the skull
+and giving rise to intra-cranial complications.</p>
+
+<p><i>Treatment.</i>&mdash;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 h&aelig;morrhage. 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 <i>Operative Surgery</i>, p. 153.</p>
+
+
+
+
+<h2><a class="pagenum" name="Pg_582" id="Pg_582"></a><a name="CHAPTER_XXVI" id="CHAPTER_XXVI"></a>CHAPTER XXVI
+<br />
+THE NECK</h2>
+
+<ul class="chap">
+  <li><a href="#XXVI_anatomy">Surgical Anatomy</a></li>
+  <li>&mdash;<a href="#XXVI_malformations">Malformations</a>:</li>
+  <li><a href="#XXVI_cervical_auricles"><i>Cervical auricles</i></a>;</li>
+  <li><a href="#XXVI_thyreo_glossal_cysts"><i>Thyreo-glossal cysts and fistul&aelig;</i></a>;</li>
+  <li><a href="#XXVI_lateral_fistula"><i>Lateral fistula</i></a></li>
+  <li>&mdash;<a href="#XXVI_cervical_ribs">Cervical ribs</a></li>
+  <li>&mdash;<a href="#XXVI_wry_neck">Wry-neck</a>:</li>
+  <li><a href="#XXVI_wry_neck_varieties"><i>Varieties</i></a>;</li>
+  <li><a href="#XXVI_cicatricial_contraction"><i>Cicatricial contraction</i></a></li>
+  <li>&mdash;<a href="#XXVI_injuries">Injuries</a>:</li>
+  <li><a href="#XXVI_contusion"><i>Contusions</i></a></li>
+  <li>&mdash;<a href="#XXVI_fracture_hyoid"><i>Fractures of hyoid, larynx, etc.</i></a>:</li>
+  <li><a href="#XXVI_cut_throat"><i>Cut-throat</i></a></li>
+  <li>&mdash;<a href="#XXVI_infective_conditions">Infective conditions</a>:</li>
+  <li><a href="#XXVI_cellulitis"><i>Diffuse cellulitis</i></a>;</li>
+  <li><a href="#XXVI_actinomycosis"><i>Actinomycosis</i></a>;</li>
+  <li><a href="#XXVI_boils"><i>Boils and Carbuncles</i></a></li>
+  <li>&mdash;<a href="#XXVI_tumours">Tumours</a>:</li>
+  <li><a href="#XXVI_cystic_tumours"><i>Cystic</i></a>:</li>
+  <li><a href="#XXVI_branchial_cysts"><i>Branchial cysts</i></a>;</li>
+  <li><a href="#XXVI_cystic_lymphangioma"><i>Cystic lymphangioma</i></a>;</li>
+  <li><a href="#XXVI_blood_cysts"><i>Blood cysts</i></a>;</li>
+  <li><a href="#XXVI_bursal_cysts"><i>Bursal cysts</i></a></li>
+  <li>&mdash;<a href="#XXVI_solid_tumours"><i>Solid</i></a>:</li>
+  <li><a href="#XXVI_lipoma"><i>Lipoma</i></a>;</li>
+  <li><a href="#XXVI_fibroma"><i>Fibroma</i></a>;</li>
+  <li><a href="#XXVI_osteoma"><i>Osteoma</i></a>;</li>
+  <li><a href="#XXVI_sarcoma"><i>Sarcoma</i></a>;</li>
+  <li><a href="#XXVI_carcinoma"><i>Carcinoma</i></a></li>
+  <li>&mdash;<a href="#XXVI_thymus_gland">The thymus gland</a></li>
+  <li>&mdash;<a href="#XXVI_carotid_gland">The carotid gland</a>.</li>
+</ul>
+
+<p><a name="XXVI_anatomy" id="XXVI_anatomy"></a><b>Surgical Anatomy.</b>&mdash;In the middle line the following structures may be
+recognised on palpation: (1) the <i>hyoid bone</i>, lying below and behind
+the body of the lower jaw, on a level with the fourth cervical
+vertebra; (2) the <i>hyo-thyreoid membrane</i>, behind which lies the base
+of the epiglottis and the upper opening of the larynx; (3) the
+<i>thyreoid cartilage</i>, to the angle of which the vocal cords are
+attached about its middle; (4) the <i>crico-thyreoid</i> membrane, across
+which run transversely the crico-thyreoid branches of the superior
+thyreoid arteries; (5) the <i>cricoid cartilage</i>, one of the most
+important landmarks in the neck. It lies opposite the disc between the
+fifth and sixth cervical vertebr&aelig;, and at this level the common
+carotid artery may be compressed against the <i>carotid tubercle</i> 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 &oelig;sophagus; 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&mdash;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 <i>trachea</i>
+lie above the level of the sternum, but they cannot be palpated
+individually. The <i>isthmus</i> 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
+<i>thyreoidea ima</i> artery&mdash;an inconstant branch of the anonyma
+(innominate) or of the aorta&mdash;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.</p>
+
+<p>In children under two years of age the <i>thymus gland</i> 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.</p>
+
+<p><a class="pagenum" name="Pg_583" id="Pg_583"></a><i>Cervical Fascia.</i>&mdash;This fascia completely envelops the neck, and from
+its deep aspect two strong processes&mdash;the prevertebral and pretracheal
+layers&mdash;pass transversely across the neck, dividing it into three main
+compartments. The posterior or <i>vertebral compartment</i> 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 <i>visceral compartment</i> contains
+the pharynx and &oelig;sophagus, 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 <i>muscular
+compartment</i> 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.</p>
+
+<p><a name="XXVI_malformations" id="XXVI_malformations"></a><b>Malformations of the Neck.</b>&mdash;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.</p>
+
+<p><a name="XXVI_cervical_auricles" id="XXVI_cervical_auricles"></a>The term <i>cervical auricles</i> 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.</p>
+
+<p><a name="XXVI_thyreo_glossal_cysts" id="XXVI_thyreo_glossal_cysts"></a><i>Thyreo-glossal Cysts and Fistul&aelig;.</i>&mdash;The thyreo-glossal <i>cyst</i> is
+developed in relation to the thyreo-glossal tract of His, which in
+early embryonic life extends from the foramen c&aelig;cum 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 (<a href="#Pg_538">p.&nbsp;538</a>). 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&mdash;sebaceous and dermoid
+cysts&mdash;and when giving rise to disfigurement they should be excised.</p>
+
+<p>Such a cyst may rupture on the surface, usually as a result of
+superadded infection, and give rise to a <i>thyreo-glossal</i> or <i>median<a class="pagenum" name="Pg_584" id="Pg_584"></a>
+fistula of the neck</i>. 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 c&aelig;cum, passing usually in front
+of, but sometimes through the substance of, the hyoid bone.
+Occasionally the fistula only extends as high as the hyoid.</p>
+
+<div class="figcenter" style="width: 315px;">
+<a name="fig_268" id="fig_268"></a>
+<img src="images/fig268.jpg" width="315" height="400" alt="Fig. 268.&mdash;Congenital Branchial Cyst in a woman &aelig;t. 33." title="" />
+<span class="caption"><span class="smcap">Fig. 268.</span>&mdash;Congenital Branchial Cyst in a woman &aelig;t. 33.<br /><br />
+(Microscopically the cyst was lined with squamous epithelium and the
+wall contained rudimentary salivary-gland tissue.)</span>
+</div>
+
+<p>The part of the tract near the tongue is lined by squamous<a class="pagenum" name="Pg_585" id="Pg_585"></a>
+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.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+<p><a name="XXVI_lateral_fistula" id="XXVI_lateral_fistula"></a>The <i>lateral fistula of the neck</i>&mdash;formerly described as a branchial
+fistula&mdash;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.</p>
+
+<p>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.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+<p><a name="XXVI_cervical_ribs" id="XXVI_cervical_ribs"></a><b>Cervical Ribs.</b>&mdash;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<a class="pagenum" name="Pg_586" id="Pg_586"></a> 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.</p>
+
+<p><i>Clinical Features.</i>&mdash;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.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_269" id="fig_269"></a>
+<img src="images/fig269.jpg" width="400" height="238" alt="Fig. 269.&mdash;Bilateral Cervical Ribs; the left one is the
+better developed." title="" />
+<span class="caption"><span class="smcap">Fig. 269.</span>&mdash;Bilateral Cervical Ribs; the left one is the
+better developed.</span>
+</div>
+
+<p>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.</p>
+
+<p>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<a class="pagenum" name="Pg_587" id="Pg_587"></a> be mistaken for brachial neuritis; it is relieved,
+however, by holding the arm above the head, for example, during sleep.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><i>Branchial cysts and branchial tumours</i> are described with tumours of
+the neck (<a href="#Pg_598">p.&nbsp;598</a>).</p>
+
+<p><a name="XXVI_wry_neck" id="XXVI_wry_neck"></a><span class="smcap">Wry-Neck or Torticollis.</span>&mdash;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.</p>
+
+<p><a name="XXVI_wry_neck_varieties" id="XXVI_wry_neck_varieties"></a>The most important form is due to faulty action of the cervical
+muscles, and three varieties of muscular wry-neck are recognised&mdash;(1)
+the acute or transient; (2) the chronic or permanent; and (3) the
+spasmodic.</p>
+
+<p><b>Acute</b> or <b>transient wry-neck</b>&mdash;so-called &ldquo;rheumatic torticollis&rdquo;&mdash;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 &ldquo;stiff
+neck,&rdquo; 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,<a class="pagenum" name="Pg_588" id="Pg_588"></a> twisting the face slightly towards the
+opposite side (<a href="#fig_270">Fig.&nbsp;270</a>). 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.</p>
+
+<div class="figcenter" style="width: 369px;">
+<a name="fig_270" id="fig_270"></a>
+<img src="images/fig270.jpg" width="369" height="400" alt="Fig. 270.&mdash;Transient Wry-neck, which came on suddenly
+after sitting in a draught, and passed off completely in a few days." title="" />
+<span class="caption"><span class="smcap">Fig. 270.</span>&mdash;Transient Wry-neck, which came on suddenly
+after sitting in a draught, and passed off completely in a few days.</span>
+</div>
+
+<p>In the <i>diagnosis</i> 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.</p>
+
+<p>The <i>treatment</i> consists in ensuring free action of the bowels and
+kidneys, in inducing hyper&aelig;mia by means of heat, and applying gentle
+massage. Salicylates and similar drugs are useful in relieving the
+pain.</p>
+
+<p><b>Permanent</b> or <b>true wry-neck</b> is due to an organic shortening of the
+sterno-mastoid muscle. The trapezius, the splenius, the scaleni, and
+the levator scapul&aelig; muscle may also undergo shortening, along with
+their investing sheaths derived from the cervical fascia.</p>
+
+<p>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.</p>
+
+<p>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 f&oelig;tus 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&mdash;<i>a h&aelig;matoma of the sterno-mastoid</i>&mdash;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.</p>
+
+<p><i>Clinical Features.</i>&mdash;Although the condition is usually described as
+&ldquo;congenital,&rdquo; 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<a class="pagenum" name="Pg_589" id="Pg_589"></a> characteristic (<a href="#fig_271">Fig.&nbsp;271</a>).
+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<a class="pagenum" name="Pg_590" id="Pg_590"></a> 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.</p>
+
+<div class="figcenter" style="width: 356px;">
+<a name="fig_271" id="fig_271"></a>
+<img src="images/fig271.jpg" width="356" height="400" alt="Fig. 271.&mdash;Congenital Wry-neck in a boy &aelig;t. 14." title="" />
+<span class="caption"><span class="smcap">Fig. 271.</span>&mdash;Congenital Wry-neck in a boy &aelig;t. 14.</span>
+</div>
+
+<p>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<a class="pagenum" name="Pg_591" id="Pg_591"></a> cases a lateral curvature,
+with the convexity towards the normal side, occurs in the cervical
+region, the vertebr&aelig; becoming wedge-shaped from side to side, and a
+compensatory curve may develop in the thoracic region (<a href="#fig_272">Fig.&nbsp;272</a>).</p>
+
+<div class="figcenter" style="width: 334px;">
+<a name="fig_272" id="fig_272"></a>
+<img src="images/fig272.jpg" width="334" height="400" alt="Fig. 272.&mdash;Congenital Wry-neck seen from behind to show
+scoliosis." title="" />
+<span class="caption"><span class="smcap">Fig. 272.</span>&mdash;Congenital Wry-neck seen from behind to show
+scoliosis.</span>
+</div>
+
+<p>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 fasci&aelig;.</p>
+
+<p><i>Treatment.</i>&mdash;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 orthop&aelig;dic measures.</p>
+
+<p>Subcutaneous tenotomy&mdash;at one time the favourite method of
+treatment&mdash;has been entirely replaced by the <i>open operation</i>, 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.</p>
+
+<p><b>Spasmodic wry-neck</b> 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.</p>
+
+<p>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&mdash;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.</p>
+
+<p><a class="pagenum" name="Pg_592" id="Pg_592"></a>The affection tends to become progressively worse until the patient is
+incapacitated for work or enjoyment. Sleep even may be interfered
+with.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p>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).</p>
+
+<p>Spasmodic wry-neck must be distinguished from the <b>hysterical</b> variety,
+which after lasting for weeks, or even months, may pass off
+completely, but, like other hysterical affections, is liable to recur.</p>
+
+<p>Deviations of the neck simulating torticollis may occur in cervical
+caries, and in unilateral dislocation of the spine.</p>
+
+<p><a name="XXVI_cicatricial_contraction" id="XXVI_cicatricial_contraction"></a>The <b>cicatricial contraction</b> 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.</p>
+
+
+<h3><a name="XXVI_injuries" id="XXVI_injuries"></a><span class="smcap">Injuries</span></h3>
+
+<p><a name="XXVI_contusion" id="XXVI_contusion"></a><b>Contusion</b> 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.</p>
+
+<p>The clinical importance of these injuries depends on the complications
+that may ensue; for example, extravasation of<a class="pagenum" name="Pg_593" id="Pg_593"></a> blood under the
+cervical fascia may press upon the air-passage and &oelig;sophagus 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
+&oelig;dema 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.</p>
+
+<p><a name="XXVI_fracture_hyoid" id="XXVI_fracture_hyoid"></a><b>Fractures of the Hyoid, Larynx, and Trachea.</b>&mdash;The <i>hyoid bone</i>, 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.</p>
+
+<p>The <i>thyreoid and cricoid cartilages</i> are also liable to be fractured
+in run-over accidents, particularly in old people after calcification
+or ossification has taken place.</p>
+
+<p>The <i>trachea</i> may be lacerated, or even completely torn from the
+larynx, by the same forms of injury as produce fracture of the
+laryngeal cartilages.</p>
+
+<p>The <i>clinical features</i> 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
+&oelig;dema 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.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p><a name="XXVI_cut_throat" id="XXVI_cut_throat"></a><b>Wounds&mdash;Cut-throat.</b>&mdash;The most important variety of wound of the neck
+met with in civil practice is that known<a class="pagenum" name="Pg_594" id="Pg_594"></a> as &ldquo;cut-throat&rdquo;&mdash;an injury
+usually inflicted with suicidal, less frequently with homicidal
+intent.</p>
+
+<p>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.</p>
+
+<p>Homicidal wounds are usually more directly transverse, and are of
+equal depth throughout. The main vessels are generally divided, the
+&oelig;sophagus and trachea opened into, and in some cases the vertebral
+canal is opened and the cord and its membranes injured.</p>
+
+<p><i>Clinical Features.</i>&mdash;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.</p>
+
+<p>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 h&aelig;morrhage 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.</p>
+
+<p>Occasionally, but rarely, the wound is made <i>above the hyoid bone</i>,
+and opens directly into the mouth. There may then be sharp h&aelig;morrhage
+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.</p>
+
+<p>The <i>hyo-thyreoid membrane</i> 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<a class="pagenum" name="Pg_595" id="Pg_595"></a> 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.</p>
+
+<p>In more severe cases the knife enters the <i>larynx</i> or the <i>trachea</i>.
+Sometimes the thyreoid cartilage is divided&mdash;as a rule only
+partly&mdash;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 h&aelig;morrhage
+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.</p>
+
+<p>In all cases there is more or less dyspn&oelig;a 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.</p>
+
+<p>The <i>prognosis</i> 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 &oelig;dema 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.</p>
+
+<p><i>Treatment.</i>&mdash;The first indication is to arrest h&aelig;morrhage, 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.</p>
+
+<p>If the food and air-passages are intact, any muscles that have been
+divided should be sutured.</p>
+
+<p>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.</p>
+
+<p>When the air-passage is opened, it is usually advisable to introduce a
+tracheotomy tube (<a href="#fig_273">Fig.&nbsp;273</a>), and pack gauze round it<a class="pagenum" name="Pg_596" id="Pg_596"></a> to avoid the
+risk of &oelig;dema of the glottis and to prevent blood entering the
+lungs. The soft tissues may then be brought together layer by layer.</p>
+
+<div class="figcenter" style="width: 314px;">
+<a name="fig_273" id="fig_273"></a>
+<img src="images/fig273.jpg" width="314" height="400" alt="Fig. 273.&mdash;Recovery from Suicidal Cut-throat after low
+tracheotomy and gastrostomy." title="" />
+<span class="caption"><span class="smcap">Fig. 273.</span>&mdash;Recovery from Suicidal Cut-throat after low
+tracheotomy and gastrostomy.<br /><br />
+(Mr. J. M. Graham&#39;s case.)</span>
+</div>
+
+<p>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 (<a href="#fig_273">Fig.&nbsp;273</a>).</p>
+
+<p><a class="pagenum" name="Pg_597" id="Pg_597"></a><i>Wounds of the thoracic duct</i> have been described with affections of
+the lymphatics (Volume I., p. 324), and <i>wounds of the brachial
+plexus</i> with injuries of individual nerves (Volume I., p. 360).</p>
+
+
+<h3><a name="XXVI_infective_conditions" id="XXVI_infective_conditions"></a><span class="smcap">Infective Conditions</span></h3>
+
+<p><a name="XXVI_cellulitis" id="XXVI_cellulitis"></a><b>Cellulitis</b> 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 py&aelig;mia. The pus tends to spread widely throughout
+the neck, infiltrating the connective-tissue spaces around the blood
+vessels, the air-passages, and the &oelig;sophagus. 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.</p>
+
+<p>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&mdash;which
+goes by the name of <i>angina Ludovici</i>&mdash;is usually met with in adults,
+and appears to originate in some infective focus in the mouth.</p>
+
+<p><i>Clinical Features.</i>&mdash;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
+&oelig;dema of the glottis, and tracheotomy may be urgently called for.
+Swallowing may also be affected by pressure on the pharynx and
+&oelig;sophagus. Pressure on the important nerves traversing the neck may
+give rise to irritative or paralytic symptoms. The main vessels may
+become thrombosed or eroded&mdash;particularly when the cellulitis is
+associated with scarlet fever&mdash;and in the latter case copious
+h&aelig;morrhage may follow incision of the abscess.</p>
+
+<p>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 tox&aelig;mia.</p>
+
+<p><i>Treatment.</i>&mdash;In the earliest stages hot fomentations or<a class="pagenum" name="Pg_598" id="Pg_598"></a> 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 h&aelig;morrhage occurs it
+may be necessary to ligate the main artery lower in the neck.</p>
+
+<p><a name="XXVI_actinomycosis" id="XXVI_actinomycosis"></a><b>Actinomycosis</b> 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.</p>
+
+<p><a name="XXVI_boils" id="XXVI_boils"></a><b>Boils and carbuncles</b> frequently occur on the back of the neck, where
+the skin is thick and coarse and is rubbed by the collar.</p>
+
+<p>The affections of the <i>cervical lymph glands</i> have already been
+described (Volume I., p. 330).</p>
+
+
+<h3><a name="XXVI_tumours" id="XXVI_tumours"></a><span class="smcap">Tumours</span></h3>
+
+<p><a name="XXVI_cystic_tumours" id="XXVI_cystic_tumours"></a><b>Cystic Tumours.</b>&mdash;A great variety of cystic tumours is met with in the
+neck.</p>
+
+<p><a name="XXVI_branchial_cysts" id="XXVI_branchial_cysts"></a><b>Branchial cysts</b> 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 <i>dermoid cysts</i>, 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.</p>
+
+<p>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.</p>
+
+<p><a name="XXVI_cystic_lymphangioma" id="XXVI_cystic_lymphangioma"></a><a class="pagenum" name="Pg_599" id="Pg_599"></a>The <i>cystic lymphangioma</i>, <i>hygroma</i>, or <i>hydrocele of the neck</i> (<a href="#fig_274">Fig.&nbsp;274</a>),
+has been described with affections of lymphatics (Volume I., p.
+327); and <i>thyreo-glossal cysts in the neck</i> at <a href="#Pg_583">p.&nbsp;583</a>.</p>
+
+<div class="figcenter" style="width: 366px;">
+<a name="fig_274" id="fig_274"></a>
+<img src="images/fig274.jpg" width="366" height="400" alt="Fig. 274.&mdash;Hygroma of Neck." title="" />
+<span class="caption"><span class="smcap">Fig. 274.</span>&mdash;Hygroma of Neck.<br /><br />
+(Photograph lent by Mr. J. W. Dowden.)</span>
+</div>
+
+<p><a name="XXVI_blood_cysts" id="XXVI_blood_cysts"></a><i>Blood Cysts.</i>&mdash;These may originate in a diverticulum of a vein that
+has become isolated, or in a cavernous angioma; or they may be due to
+h&aelig;morrhage 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.</p>
+
+<p><a name="XXVI_bursal_cysts" id="XXVI_bursal_cysts"></a><i>Cystic Burs&aelig;.</i>&mdash;Cystic degeneration may occur in the supra-hyoid and
+thyreo-hyoid burs&aelig;, 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.</p>
+
+<p><a name="XXVI_solid_tumours" id="XXVI_solid_tumours"></a><b>Solid Tumours</b>, apart from the common enlargements of<a class="pagenum" name="Pg_600" id="Pg_600"></a> lymph glands,
+and the various forms of goitre, are not often met with in the neck.</p>
+
+<p><a name="XXVI_lipoma" id="XXVI_lipoma"></a>The <i>circumscribed lipoma</i> 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.</p>
+
+<p><i>Diffuse lipomatosis</i> 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.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_275" id="fig_275"></a>
+<img src="images/fig275.jpg" width="400" height="345" alt="Fig. 275.&mdash;Lympho-sarcoma of Neck." title="" />
+<span class="caption"><span class="smcap">Fig. 275.</span>&mdash;Lympho-sarcoma of Neck.<br /><br />
+(Mr. D. M. Greig&#39;s case.)</span>
+</div>
+
+<p><a name="XXVI_fibroma" id="XXVI_fibroma"></a><i>Fibroma</i> originating in the ligamentum nuch&aelig;, 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.</p>
+
+<p><i>Mixed tumours</i> 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.</p>
+
+<p><a name="XXVI_osteoma" id="XXVI_osteoma"></a><i>Osseous</i> and <i>cartilaginous tumours</i> occasionally grow in connection
+with the transverse processes of the lower cervical vertebr&aelig;.</p>
+
+<p><a name="XXVI_sarcoma" id="XXVI_sarcoma"></a><a class="pagenum" name="Pg_601" id="Pg_601"></a><i>Sarcoma</i> and <i>fibro-sarcoma</i> 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.</p>
+
+<p><a name="XXVI_carcinoma" id="XXVI_carcinoma"></a><i>Carcinoma.</i>&mdash;The commonest form of primary cancer is the <i>branchial
+carcinoma</i>, a squamous epithelioma which originates in connection with
+the second visceral cleft (<a href="#fig_276">Fig.&nbsp;276</a>). 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.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_276" id="fig_276"></a>
+<img src="images/fig276.jpg" width="400" height="301" alt="Fig. 276.&mdash;Branchial Carcinoma&mdash;subsequently removed by
+operation." title="" />
+<span class="caption"><span class="smcap">Fig. 276.</span>&mdash;Branchial Carcinoma&mdash;subsequently removed by
+operation.</span>
+</div>
+
+<p><a class="pagenum" name="Pg_602" id="Pg_602"></a>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.</p>
+
+<p>Unless completely removed at an early stage, recurrence inevitably
+takes place.</p>
+
+<p>Primary carcinoma may also occur in a supernumerary thyreoid, and in
+the para-thyreoid glands.</p>
+
+<p>We have met with a case of <i>paraffin epithelioma</i> on the neck, and a
+similar type of epithelioma may be met with in a lupus or a burn of
+long standing.</p>
+
+<p><a name="XXVI_thymus_gland" id="XXVI_thymus_gland"></a><b>The Thymus Gland.</b>&mdash;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&mdash;known as the <i>status lymphaticus</i>.</p>
+
+<p>The pressure effects may be entirely referable to the trachea&mdash;<i>thymus
+stenosis of the trachea</i>&mdash;giving rise to progressive dyspn&oelig;a
+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.</p>
+
+<p>The only way to afford relief is to expose the gland and withdraw it
+from behind the sternum by making traction on<a class="pagenum" name="Pg_603" id="Pg_603"></a> its capsule. If the
+breathing is not thereby improved, the capsule should be opened and
+the gland shelled out.</p>
+
+<p>The term <i>thymic asthma</i> 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&mdash;<i>thymus death</i>. 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 an&aelig;sthetic; in some instances the patient has suffered from
+the generalised status lymphaticus.</p>
+
+<p><a name="XXVI_carotid_gland" id="XXVI_carotid_gland"></a><b>Tumours of the Carotid Gland or Glomus Carotica</b> (<i>Potato-like tumour
+of the neck</i>).&mdash;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
+<i>endothelioma</i>. 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.</p>
+
+<p>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.</p>
+
+<p>The diagnosis has to be made from lymphoma, adenoma, tuberculous
+glands, sarcoma, and carcinoma.</p>
+
+<p>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.</p>
+
+
+
+
+<h2><a class="pagenum" name="Pg_604" id="Pg_604"></a><a name="CHAPTER_XXVII" id="CHAPTER_XXVII"></a>CHAPTER XXVII
+<br />
+THE THYREOID GLAND</h2>
+
+<ul class="chap">
+  <li><a href="#XXVII_anatomy">Surgical Anatomy</a></li>
+  <li>&mdash;<a href="#XXVII_physiological_hyperaemia">Physiological hyper&aelig;mia</a></li>
+  <li>&mdash;<a href="#XXVII_acute_thyreoiditis">Acute thyreoiditis</a></li>
+  <li>&mdash;<a href="#XXVII_goitre"><span class="smcap">Goitre</span></a></li>
+  <li>&mdash;<a href="#XXVII_parenchymatous">Varieties: <i>Parenchymatous</i></a>;</li>
+  <li><a href="#XXVII_adenomatous"><i>Adenomatous</i></a>;</li>
+  <li><a href="#XXVII_adenomatous"><i>Cystic</i></a>;</li>
+  <li><a href="#XXVII_malignant"><i>Malignant</i></a>;</li>
+  <li><a href="#XXVII_toxic"><i>Toxic</i></a>.</li>
+</ul>
+
+<p><a name="XXVII_anatomy" id="XXVII_anatomy"></a><b>Surgical Anatomy.</b>&mdash;The <i>thyreoid gland</i> 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&mdash;the <i>pyramidal
+lobe</i>&mdash;passes up in the middle line towards the hyoid bone.</p>
+
+<p>The gland lies under cover of the superficial muscles of the neck, and
+is surrounded by a process of the cervical fascia&mdash;the external
+thyreoid capsule of Kocher&mdash;which connects it with the larynx,
+trachea, and &oelig;sophagus, so that it moves with these structures on
+swallowing. In this capsule are numerous veins; and in the groove
+between the &oelig;sophagus 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&mdash;the
+superior and inferior thyreoids&mdash;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&mdash;<i>accessory thyreoids</i>&mdash;are sometimes met with in different
+parts of the neck; they are liable to the same diseases as the main
+gland.</p>
+
+<p>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&mdash;iodothyrin&mdash;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 myx&oelig;dema,
+cretinism, and goitre.</p>
+
+<p>The <i>para-thyreoid glands</i>&mdash;usually two on each side&mdash;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.</p>
+
+<p><a name="XXVII_physiological_hyperaemia" id="XXVII_physiological_hyperaemia"></a><b>Physiological Hyper&aelig;mia.</b>&mdash;The thyreoid varies greatly in size even
+within normal limits, and may become engorged and swollen from<a class="pagenum" name="Pg_605" id="Pg_605"></a>
+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.</p>
+
+<p><a name="XXVII_acute_thyreoiditis" id="XXVII_acute_thyreoiditis"></a><b>Acute Thyreoiditis</b> 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, py&aelig;mia, 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 &oelig;sophagus ulcerating through
+and perforating the gland.</p>
+
+<p>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.</p>
+
+<p><i>Clinical Features.</i>&mdash;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 dyspn&oelig;a.</p>
+
+<p>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 &oelig;sophagus.</p>
+
+<p><i>Treatment.</i>&mdash;In the non-suppurative stage the ordinary treatment of
+acute inflammatory conditions is employed; if pus forms, the abscess
+should be opened and drained.</p>
+
+<p><b>Tuberculous and syphilitic affections</b> of the thyreoid are very rare.</p>
+
+
+<h3><a name="XXVII_goitre" id="XXVII_goitre"></a><span class="smcap">Parenchymatous Goitre or Bronchocele</span></h3>
+
+<p>The term goitre is applied clinically to any non-inflammatory
+enlargement of the thyreoid gland.</p>
+
+<p><a name="XXVII_parenchymatous" id="XXVII_parenchymatous"></a><i>Etiology.</i>&mdash;Parenchymatous goitre, sometimes called also simple, or
+non-toxic goitre, is endemic in certain hilly districts in
+England&mdash;particularly Derbyshire and Gloucestershire&mdash;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<a class="pagenum" name="Pg_606" id="Pg_606"></a> been traced to certain mountain springs
+in goitrous districts; it has been observed that a patient with goitre
+may, through f&aelig;cal 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.</p>
+
+<div class="figcenter" style="width: 313px;">
+<a name="fig_277" id="fig_277"></a>
+<img src="images/fig277.jpg" width="313" height="400" alt="Fig. 277.&mdash;Parenchymatous Goitre in a girl &aelig;t. 15." title="" />
+<span class="caption"><span class="smcap">Fig. 277.</span>&mdash;Parenchymatous Goitre in a girl &aelig;t. 15.<br /><br />
+(Mr. D. M. Greig&#39;s case.)</span>
+</div>
+
+<p><i>Morbid Anatomy.</i>&mdash;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<a class="pagenum" name="Pg_607" id="Pg_607"></a> 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&mdash;<i>infra-thoracic</i> or
+<i>retro-sternal goitre</i>.</p>
+
+<div class="figcenter" style="width: 357px;">
+<a name="fig_278" id="fig_278"></a>
+<img src="images/fig278.jpg" width="357" height="400" alt="Fig. 278.&mdash;Larynx and Trachea surrounded by Goitre." title="" />
+<span class="caption"><span class="smcap">Fig. 278.</span>&mdash;Larynx and Trachea surrounded by Goitre.</span>
+</div>
+
+<p>&nbsp;</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_279" id="fig_279"></a>
+<img src="images/fig279.jpg" width="400" height="235" alt="Fig. 279.&mdash;Section of Goitre shown in Fig. 278, to
+illustrate compression of Trachea." title="" />
+<span class="caption"><span class="smcap">Fig. 279.</span>&mdash;Section of Goitre shown in <a href="#fig_278">Fig.&nbsp;278</a>, to
+illustrate compression of Trachea.</span>
+</div>
+
+<p>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&mdash;<i>colloid
+goitre</i>. The majority of these spaces are not larger than a pea, but
+one or more may enlarge and form cysts of considerable size&mdash;<i>cystic
+goitre</i>. These varieties, especially the cystic form, attain greater
+dimensions than any other form of goitre.</p>
+
+<p>When the fibrous stroma is greatly in excess&mdash;<i>fibrous goitre</i>&mdash;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, myx&oelig;dema may result.</p>
+
+<p>In some cases the hyperplasia affects chiefly the blood vessels<a class="pagenum" name="Pg_608" id="Pg_608"></a> of
+the thyreoid&mdash;<i>vascular goitre</i>. 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. H&aelig;morrhagic cysts
+may also develop in the substance of these goitres.</p>
+
+<hr style="width: 45%;" />
+
+<p><i>Effects on the Trachea.</i>&mdash;The trachea may be <i>displaced laterally</i>
+when the enlargement of the gland affects one lobe more than the
+other; or it may be <i>compressed and narrowed</i> from side to side&mdash;the
+<i>scabbard trachea</i>&mdash;when both lobes are about equally affected and the
+enlargement extends posteriorly so as almost to surround the
+air-passage (<a href="#fig_278">Figs.&nbsp;278</a>, <a href="#fig_279">279</a>). The third effect is that of <i>softening
+of the cartilaginous rings</i> 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.</p>
+
+<p>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.</p>
+
+<p><i>Pressure on other Structures.</i>&mdash;The <i>recurrent nerve</i> may be pressed
+upon intermittently causing spasms and choking, or continuously
+causing abductor paralysis and hoarseness.</p>
+
+<p>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 &oelig;sophagus. The
+carotid arteries are displaced laterally beneath the sterno-mastoids
+without detriment; the superficial veins&mdash;anterior and external
+jugular&mdash;are greatly distended in those cases in which the goitre
+grows downwards behind the sternum.</p>
+
+<p><i>Clinical Features.</i>&mdash;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 tox&aelig;mia varies in degree;
+in the milder cases it merely amounts to a nervousness or
+excita<a class="pagenum" name="Pg_609" id="Pg_609"></a>bility that may unfit the patient for occupation; it reaches
+its maximum in the condition of hyperthyreoidism characteristic of
+exophthalmic goitre or Graves' disease (<a href="#Pg_614">p.&nbsp;614</a>).</p>
+
+<p>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&mdash;a point of great diagnostic value. Of the mechanical
+symptoms dyspn&oelig;a is the most constant. It may only amount to
+shortness of breath on exertion, or the patient may suffer from sudden
+and severe dyspn&oelig;ic 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 dyspn&oelig;a, 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.</p>
+
+<p>The occurrence of h&aelig;morrhage into the substance of the goitre or into
+a cyst, produces a sudden aggravation of the symptoms.</p>
+
+<p>In <i>intra-thoracic</i> or <i>retro-sternal goitre</i> the tumour displaces and
+compresses the trachea and causes dyspn&oelig;a, 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.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p>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<a class="pagenum" name="Pg_610" id="Pg_610"></a> 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.</p>
+
+<p>The operation&mdash;<i>thyreoidectomy</i>&mdash;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).</p>
+
+<p>It is sometimes advisable to perform the operation under local
+an&aelig;sthesia. A general an&aelig;sthetic is, however, preferred in this
+country. The injection of <span class="frac_top">1</span>/<span class="frac_bottom">6</span>th grain of morphin and <span class="frac_top">1</span>/<span class="frac_bottom">120</span>th 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.</p>
+
+<p>There is reason to believe that the absorption of thyreoid secretion
+squeezed from the divided surfaces gives rise to a condition known as
+<i>acute thyreodism</i> during the first few hours after operation; its
+symptoms are elevation of temperature, increase in the pulse-rate
+(150&ndash;200), rapid respiration with dyspn&oelig;a, 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.</p>
+
+<p><i>Tetany</i>, 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
+myx&oelig;dema&mdash;<i>operative myx&oelig;dema</i> or <i>cachexia strumipriva</i>.</p>
+
+<p><i>Treatment of Sudden Dyspn&oelig;a.</i>&mdash;When dyspn&oelig;a 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.</p>
+
+<p><a name="XXVII_adenomatous" id="XXVII_adenomatous"></a><b>Adenoma of the Thyreoid.</b>&mdash;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.<a class="pagenum" name="Pg_611" id="Pg_611"></a> 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.</p>
+
+<p>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 (<a href="#fig_280">Fig.&nbsp;280</a>),
+and in these fluctuation may be<a class="pagenum" name="Pg_612" id="Pg_612"></a> detected. It is to be noted that
+there are no toxic symptoms in cystic adenoma.</p>
+
+<div class="figcenter" style="width: 364px;">
+<a name="fig_280" id="fig_280"></a>
+<img src="images/fig280.jpg" width="364" height="400" alt="Fig. 280.&mdash;Multiple Adenomata of Thyreoid in a woman
+&aelig;t. 50." title="" />
+<span class="caption"><span class="smcap">Fig. 280.</span>&mdash;Multiple Adenomata of Thyreoid in a woman
+&aelig;t. 50.<br /><br />
+(Mr. D. M. Greig&#39;s case.)</span>
+</div>
+
+<p>&nbsp;</p>
+
+<div class="figcenter" style="width: 256px;">
+<a name="fig_281" id="fig_281"></a>
+<img src="images/fig281.jpg" width="256" height="400" alt="Fig. 281.&mdash;Cyst of Left Lobe of Thyreoid." title="" />
+<span class="caption"><span class="smcap">Fig. 281.</span>&mdash;Cyst of Left Lobe of Thyreoid.<br /><br />
+(Mr. D. M. Greig&#39;s case.)</span>
+</div>
+
+<p>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.</p>
+
+<p><a name="XXVII_malignant" id="XXVII_malignant"></a><b>Malignant Disease of the Thyreoid.</b>&mdash;This, whether in the form of
+<i>carcinoma</i> or <i>sarcoma</i>, usually develops in a gland that has been
+the seat of goitre for several years, although it may begin in a
+previously healthy gland.</p>
+
+<p><i>Clinical Features.</i>&mdash;Both sexes, above the age of fifty, are affected
+in about equal proportion. The characteristic features<a class="pagenum" name="Pg_613" id="Pg_613"></a> 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&mdash;the <i>malignant form of
+retro-sternal goitre</i>&mdash;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.</p>
+
+<p><i>Treatment.</i>&mdash;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 &oelig;sophagus, and the operation is
+attended with grave risk to life.</p>
+
+<p>Operative interference is often called for, however, for the relief of
+respiratory embarrassment. <i>Tracheotomy</i> 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 dyspn&oelig;a 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<a class="pagenum" name="Pg_614" id="Pg_614"></a> the relief is
+only temporary, and the patient soon succumbs to a broncho-pneumonia,
+or to secondary h&aelig;morrhage from the trachea.</p>
+
+<p><a name="XXVII_toxic" id="XXVII_toxic"></a><b>Toxic Goitre</b>&mdash;<b>Exophthalmic Goitre</b>&mdash;<b>Graves'</b> or <b>Basedow's
+Disease</b>.&mdash;These terms are applied to a variety of goitre in which the
+symptoms due to absorption of thyreoid
+secretion&mdash;<i>thyreotoxicosis</i>&mdash;predominate. The name &ldquo;exophthalmic
+goitre&rdquo; 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
+<i>hyperthyreoidism</i>, suggested by C. H. Mayo, is preferable, as the
+manifestations of the disease depend upon excessive or abnormal action
+of the thyreoid tissue.</p>
+
+<div class="figcenter" style="width: 301px;">
+<a name="fig_282" id="fig_282"></a>
+<img src="images/fig282.jpg" width="301" height="400" alt="Fig. 282.&mdash;Exophthalmic Goitre." title="" />
+<span class="caption"><span class="smcap">Fig. 282.</span>&mdash;Exophthalmic Goitre.</span>
+</div>
+
+<p>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 eye<a class="pagenum" name="Pg_615" id="Pg_615"></a>balls, 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&mdash;von Graefe's symptom. There may be diarrh&oelig;a 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).</p>
+
+<p>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.</p>
+
+<p><i>Prognosis.</i>&mdash;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.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p><i>Operative measures</i> consist in the <i>ligation</i> of the vessels and
+nerves at one or other pole of the gland&mdash;usually the superior on one
+side&mdash;followed by, if necessary, a partial <i>thyreoidectomy</i>.</p>
+
+<p>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&mdash;what he calls &ldquo;stealing the
+goitre&rdquo;&mdash;the thorough preparation of the patient for the operation,
+the minimising the risk from the an&aelig;sthetic 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.</p>
+
+<p>Operations on the cervical sympathetic cord have been abandoned.</p>
+
+<p>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 an&aelig;sthesia.</p>
+
+
+
+
+<h2><a class="pagenum" name="Pg_616" id="Pg_616"></a><a name="CHAPTER_XXVIII" id="CHAPTER_XXVIII"></a>CHAPTER XXVIII
+<br />
+THE &OElig;SOPHAGUS</h2>
+
+<ul class="chap">
+  <li><a href="#XXVIII_anatomy">Surgical Anatomy</a></li>
+  <li>&mdash;<a href="#XXVIII_methods_examination">Methods of examination</a></li>
+  <li>&mdash;<a href="#XXVIII_wounds">Wounds</a></li>
+  <li>&mdash;<a href="#XXVIII_rupture">Rupture</a></li>
+  <li>&mdash;<a href="#XXVIII_swallowng_caustics">Swallowing of caustics</a></li>
+  <li>&mdash;<a href="#XXVIII_foreign_bodies">Impaction of foreign bodies</a></li>
+  <li>&mdash;<a href="#XXVIII_infective_conditions">Infective conditions</a>:</li>
+  <li><a href="#XXVIII_infective_conditions"><i>&OElig;sophagitis</i></a>;</li>
+  <li><a href="#XXVIII_infective_conditions"><i>Peri-&oelig;sophagitis</i></a>;</li>
+  <li><a href="#XXVIII_tuberculosis"><i>Tuberculosis</i></a>;</li>
+  <li><a href="#XXVIII_syphilis"><i>Syphilis</i></a></li>
+  <li>&mdash;<a href="#XXVIII_varix">Varix</a></li>
+  <li>&mdash;<a href="#XXVIII_difficulties_swallowing">Conditions causing difficulty in swallowing</a>:</li>
+  <li><a href="#XXVIII_swallowing_foreign_bodies"><i>Impaction of foreign bodies</i></a>;</li>
+  <li><a href="#XXVIII_compression_gullet"><i>Compression of the gullet from without</i></a>;</li>
+  <li><a href="#XXVIII_muscular_spasm"><i>Spasm of the muscular coat</i></a>;</li>
+  <li><a href="#XXVIII_cardiospasm"><i>Cardiospasm</i></a>;</li>
+  <li><a href="#XXVIII_paralysis_gullet"><i>Paralysis of the gullet</i></a>;</li>
+  <li><a href="#XXVIII_diverticula"><i>Diverticula</i> or <i>pouches of the gullet</i></a>;</li>
+  <li><a href="#XXVIII_innocent_stricture"><i>Innocent stricture</i></a>;</li>
+  <li><i><a href="#XXVIII_malignant_stricture">Malignant stricture</a>, including <a href="#XXVIII_cancer_cervical">cancer at the junction of pharynx and gullet</a> and <a href="#XXVIII_cancer_lower_end">cancer at the lower end of the gullet</a></i>.</li>
+</ul>
+
+<p><a name="XXVIII_anatomy" id="XXVIII_anatomy"></a><b>Surgical Anatomy.</b>&mdash;The &oelig;sophagus 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
+&oelig;sophagus is about 5 or 6 inches, and the &oelig;sophagus measures
+from 9 to 10 inches. The whole distance, therefore, from the teeth to
+the stomach is from 14 to 16 inches.</p>
+
+<p>The cervical portion of the &oelig;sophagus, 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 &oelig;sophagus throughout, while the right
+pleura passes behind it in its lower part. This accounts for the
+frequency with which growths in the &oelig;sophagus invade the pleura.
+The &oelig;sophagus passes through the diaphragm about an inch above the
+cardiac opening of the stomach.</p>
+
+<p>There are three points at which the &oelig;sophagus shows narrowing of
+the lumen: (1) at the lower border of the cricoid&mdash;the &ldquo;mouth of the
+&oelig;sophagus&rdquo;; (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
+&oelig;sophagus is insensitive to tactile and painful stimuli, but is
+sensitive to heat and cold and to exaggerated peristaltic
+contractions.</p>
+
+<p><a name="XXVIII_methods_examination" id="XXVIII_methods_examination"></a><b>Methods of Examination.</b>&mdash;It is sometimes possible to detect an
+impacted foreign body, a distended diverticulum, or a new growth in
+the cervical portion of the &oelig;sophagus by <i>palpation</i>.</p>
+
+<p><i>Auscultation</i> while the patient is drinking sometimes aids in the
+diagnosis of stricture; the stethoscope is placed at various points
+along<a class="pagenum" name="Pg_617" id="Pg_617"></a> the left side of the dorsal spine, and abnormal sounds may be
+heard as the fluid impinges against the stricture or trickles through
+it.</p>
+
+<p><i>Introduction of Bougies.</i>&mdash;&OElig;sophageal 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&mdash;which
+consists of a small round sponge fixed on a whalebone stem&mdash;is to be
+preferred.</p>
+
+<p>Before passing bougies, it is necessary to make certain that the
+symptoms are not due to the pressure of an aneurysm on the
+&oelig;sophagus, 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.</p>
+
+<p>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 &oelig;sophagus, the chin is brought down towards the
+chest, and if the patient is now directed to swallow, the instrument
+may be carried down the &oelig;sophagus, 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.</p>
+
+<p>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.</p>
+
+<p><i>Intubation</i>, or the passage of a cannula through a stricture, is
+referred to later.</p>
+
+<p><i>&OElig;sophagoscopy.</i>&mdash;The <i>&oelig;sophagoscope</i>&mdash;a form of speculum which
+enables the &oelig;sophagus to be illuminated by an electric lamp&mdash;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
+&oelig;sophagus having been cleansed and cocainised, the patient is
+placed in the recumbent or sitting posture, and the tube introduced.
+For prolonged examinations a general an&aelig;sthetic is preferred.</p>
+
+<p>The mouth of the &oelig;sophagus 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.</p>
+
+<p><i>Radiography.</i>&mdash;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.</p>
+
+<p><a name="XXVIII_wounds" id="XXVIII_wounds"></a><a class="pagenum" name="Pg_618" id="Pg_618"></a><b>Wounds</b> of the &oelig;sophagus 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 &oelig;sophagus. 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
+&oelig;sophagus. In more severe cases there is bleeding, followed by
+attacks of coughing and expectoration of blood-stained mucus. When the
+&oelig;sophagus 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 &oelig;sophagus rest by feeding the
+patient entirely by the rectum or through an opening made in the
+stomach&mdash;gastrostomy.</p>
+
+<p><a name="XXVIII_rupture" id="XXVIII_rupture"></a><b>Rupture</b> of the &oelig;sophagus 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.</p>
+
+<p><a name="XXVIII_swallowng_caustics" id="XXVIII_swallowng_caustics"></a><b>Swallowing of Corrosive Substances.</b>&mdash;The &oelig;sophagus 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 &oelig;sophagus, 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.</p>
+
+<p>If not rapidly fatal from shock and &oelig;dema 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 &oelig;sophagus, or
+peri-&oelig;sophageal abscess, may follow. Later, cicatricial contraction
+takes place at the injured portions, producing the most intractable
+form of fibrous stricture.</p>
+
+<p>The <i>treatment</i> 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<a class="pagenum" name="Pg_619" id="Pg_619"></a> 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 &oelig;sophageal 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.</p>
+
+<p>As soon as the &oelig;sophagus 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&mdash;it may
+be for the rest of the patient's life&mdash;a full-sized bougie should be
+passed at least once a month.</p>
+
+<p><a name="XXVIII_foreign_bodies" id="XXVIII_foreign_bodies"></a><b>Impaction of Foreign Bodies in the Pharynx and &OElig;sophagus.</b>&mdash;It is an
+interesting fact that foreign bodies, even as large as a dinner fork,
+when intentionally swallowed, can pass through the pharynx and
+&oelig;sophagus 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 an&aelig;sthesia
+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 &oelig;sophagus.</p>
+
+<p><i>In the Pharynx.</i>&mdash;If a large bolus of unmasticated food becomes
+impacted in the pharynx, it blocks the openings of both the
+&oelig;sophagus 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.</p>
+
+<p>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 &oelig;sophagus 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.</p>
+
+<p>In the case of small sharp bodies, such as fish, game, and mutton
+bones, there is not the same urgency, and a methodical<a class="pagenum" name="Pg_620" id="Pg_620"></a> 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.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p><a class="pagenum" name="Pg_621" id="Pg_621"></a><i>In the &OElig;sophagus.</i>&mdash;Smaller bodies, such as coins, bones, or pins,
+usually enter the &oelig;sophagus, 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.</p>
+
+<p>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&mdash;sometimes blood-stained&mdash;are
+regurgitated with retching soon after being swallowed. When the
+obstruction is incomplete, fluids may pass into the stomach while
+solids are regurgitated.</p>
+
+<p><a class="pagenum" name="Pg_622" id="Pg_622"></a>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.</p>
+
+<p>The <i>diagnosis</i> is made by the history, and by the use of the
+fluorescent screen, or X-ray photographs (<a href="#fig_283">Figs.&nbsp;283</a>, <a href="#fig_284">284</a>). The
+&oelig;sophagoscope 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 &oelig;sophagus,
+and the information obtained is often misleading.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_283" id="fig_283"></a>
+<img src="images/fig283.jpg" width="400" height="299" alt="Fig. 283.&mdash;Radiogram of Safety-pin impacted in the
+Gullet and perforating the Larynx." title="" />
+<span class="caption"><span class="smcap">Fig. 283.</span>&mdash;Radiogram of Safety-pin impacted in the
+Gullet and perforating the Larynx.<br /><br />
+(Professor Annandale&#39;s case. Radiogram by Dr. Dawson Turner.)</span>
+</div>
+
+<p>&nbsp;</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_284" id="fig_284"></a>
+<img src="images/fig284.jpg" width="400" height="336" alt="Fig. 284.&mdash;Denture impacted in &OElig;sophagus." title="" />
+<span class="caption"><span class="smcap">Fig. 284.</span>&mdash;Denture impacted in &OElig;sophagus.<br /><br />
+(Professor F. M. Caird&#39;s case.)</span>
+</div>
+
+<p>It should be borne in mind that drunkards may suffer from a form of
+spasm of the &oelig;sophagus, 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.</p>
+
+<p><i>Treatment.</i>&mdash;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 &oelig;sophagoscope. 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.</p>
+
+<p>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 &oelig;sophageal wall may predispose to rupture.</p>
+
+<p>Small, sharp, or irregular objects, such as fish bones, tacks, or
+pins, may be dislodged by the &ldquo;umbrella probang&rdquo;&mdash;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.</p>
+
+<p>Coins usually lodge edgewise in the &oelig;sophagus, and are best removed
+by means of an instrument known as a &ldquo;coin-catcher&rdquo;, 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.</p>
+
+<p><a class="pagenum" name="Pg_623" id="Pg_623"></a>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.</p>
+
+<p>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 &oelig;sophagus, these
+should be removed by the operation of <i>&oelig;sophagostomy</i> (<i>Operative
+Surgery</i>, p. 195).</p>
+
+<p>If the foreign body is lodged near the lower end of the gullet, it may
+be necessary to perform <i>gastrostomy</i> (<i>Operative Surgery</i>, 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.</p>
+
+<p>When the surgeon fails to remove the body by either of these routes,
+<i>gastrostomy</i> 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 h&aelig;morrhage or of cellulitis of the neck or mediastinum and
+empyema.</p>
+
+<p>Other complications include septic broncho-pneumonia from damage to
+the air-passage, and suppurative thyreoiditis.</p>
+
+<p><a name="XXVIII_infective_conditions" id="XXVIII_infective_conditions"></a><b>Infective conditions</b> due to pyogenic infection (<i>&oelig;sophagitis</i> and
+<i>peri-&oelig;sophagitis</i>) are rare.</p>
+
+<p>A <i>chronic form of &oelig;sophagitis</i> is occasionally met with in
+alcoholic subjects, giving rise to symptoms that simulate those of
+impacted foreign body, or of stricture.</p>
+
+<p><a name="XXVIII_tuberculosis" id="XXVIII_tuberculosis"></a>In <i>tuberculous</i> 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 &oelig;sophagus.</p>
+
+<p><a name="XXVIII_syphilis" id="XXVIII_syphilis"></a><i>Syphilitic affections</i> of the &oelig;sophagus are rare.</p>
+
+<p><a name="XXVIII_varix" id="XXVIII_varix"></a><b>Varix</b> at the lower end of the &oelig;sophagus may give rise to
+h&aelig;matemesis, and be mistaken for gastric ulcer. Bleeding from the
+dilated veins may follow the use of bougies or of the
+&oelig;sophagoscope.</p>
+
+
+<h3><a name="XXVIII_difficulties_swallowing" id="XXVIII_difficulties_swallowing"></a><span class="smcap">Conditions causing Difficulty in Swallowing</span></h3>
+
+<p>Difficulty in swallowing may arise from a wide variety of causes which
+it is convenient to consider together.</p>
+
+<p><a name="XXVIII_swallowing_foreign_bodies" id="XXVIII_swallowing_foreign_bodies"></a><b>Impaction of Foreign Bodies</b> has already been discussed,<a class="pagenum" name="Pg_624" id="Pg_624"></a> and attention
+has been drawn to the importance of the history given by the patient
+and to the various sources of fallacy or deception&mdash;in children it may
+be artful reticence or misrepresentation, in adults, the possibility
+of nightmare and of dreams.</p>
+
+<p><a name="XXVIII_compression_gullet" id="XXVIII_compression_gullet"></a><b>Compression of the Gullet from without.</b>&mdash;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.</p>
+
+<p><a name="XXVIII_muscular_spasm" id="XXVIII_muscular_spasm"></a><b>Spasm of the Muscular Coat.</b>&mdash;As in other tubular structures containing
+circular muscular fibres, sudden contraction or spasm may occur in the
+&oelig;sophagus and cause narrowing of the lumen, attended with
+difficulty in swallowing. This spasmodic dysphagia includes such
+widely varying conditions as the &ldquo;globus hystericus&rdquo; of neurasthenic
+women, the spasm of chronic alcoholics, and the affection known as
+<i>cardiospasm</i> or &ldquo;hiatal &oelig;sophagismus.&rdquo;</p>
+
+<p>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 &oelig;sophagus, and the
+influence of mental impressions, such as excitement, hurry in the
+presence of strangers, are exaggerated.</p>
+
+<p>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.</p>
+
+<p>Apart from the treatment of the neurosis underlying the dysphagia,
+reliance is placed upon dilatation of the portion of gullet affected.</p>
+
+<p><a name="XXVIII_cardiospasm" id="XXVIII_cardiospasm"></a><b>Cardiospasm</b> is the name given to &ldquo;a recurrent interference with
+deglutition by spasmodic contraction of the lower end of the
+&oelig;sophagus.&rdquo; As there is no muscular or nervous mechanism at the
+cardiac end of the &oelig;sophagus forming a true sphincter, the term
+&ldquo;&oelig;sophagospasm&rdquo; would be more accurate (D. M. Greig).</p>
+
+<p>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,<a class="pagenum" name="Pg_625" id="Pg_625"></a> 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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>The <i>treatment</i> 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
+&oelig;sophagus with the stomach.</p>
+
+<p><a name="XXVIII_paralysis_gullet" id="XXVIII_paralysis_gullet"></a><b>Paralysis of the Gullet.</b>&mdash;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.</p>
+
+<p><a name="XXVIII_diverticula" id="XXVIII_diverticula"></a><b>Diverticula or Pouches of the Gullet.</b>&mdash;A diverticulum consists in the
+protrusion of the mucous and submucous coats through a defect or weak
+part in the muscular tunic; it is<a class="pagenum" name="Pg_626" id="Pg_626"></a> 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 <i>pharyngeal dimple</i>, 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 <i>pressure or pulsion
+diverticulum</i> because the hernial protrusion is ascribed to<a class="pagenum" name="Pg_627" id="Pg_627"></a> 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.</p>
+
+<div class="figcenter" style="width: 346px;">
+<a name="fig_285" id="fig_285"></a>
+<img src="images/fig285.jpg" width="346" height="400" alt="Fig. 285.&mdash;Radiogram, after swallowing an opaque meal,
+in a man suffering from malignant stricture of lower end of Gullet." title="" />
+<span class="caption"><span class="smcap">Fig. 285.</span>&mdash;Radiogram, after swallowing an opaque meal,
+in a man suffering from malignant stricture of lower end of Gullet.</span>
+</div>
+
+<p>The <i>clinical features</i> 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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>In this, as in all cases of difficulty in swallowing, chief stress<a class="pagenum" name="Pg_628" id="Pg_628"></a>
+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.</p>
+
+<p><i>Treatment</i> is influenced by the manner in which the patient may have
+learned to overcome the difficulty of getting food into his
+stomach&mdash;Lord Jeffrey, who was the possessor of the pharyngeal pouch
+shown in <a href="#fig_286">Fig.&nbsp;286</a>, 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.</p>
+
+<div class="figcenter" style="width: 221px;">
+<a name="fig_286" id="fig_286"></a>
+<img src="images/fig286.jpg" width="221" height="400" alt="Fig. 286.&mdash;Diverticulum of the &OElig;sophagus at its
+junction with the Pharynx." title="" />
+<span class="caption"><span class="smcap">Fig. 286.</span>&mdash;Diverticulum of the &OElig;sophagus at its
+junction with the Pharynx.<br /><br />
+(Anatomical Museum, University of Edinburgh.)</span>
+</div>
+
+<p>If an <i>operation</i> 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 <i>infolded</i> into the lumen of the
+gullet, or the excision be carried out in two <i>stages</i>. 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.</p>
+
+<p>Should the diverticulum be inaccessible from the neck, and the
+difficulty of swallowing be attended with progressive emaciation,
+<i>gastrostomy</i> may be required to avert death by starvation.</p>
+
+<p><i>Traction diverticula</i> 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.</p>
+
+<p><a name="XXVIII_innocent_stricture" id="XXVIII_innocent_stricture"></a><b>Innocent Stricture or Cicatricial Stenosis of the Gullet.</b>&mdash;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 &ldquo;vomiting,&rdquo;
+but the material ejected shows no signs of gastric digestion. There is
+pain referred to<a class="pagenum" name="Pg_629" id="Pg_629"></a> the epigastrium or between the shoulder-blades, the
+patient suffers from hunger and thirst, and may present an extreme
+degree of emaciation.</p>
+
+<p>The <i>diagnosis</i> is suggested by the history, and is confirmed by the
+&oelig;sophagoscope 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.</p>
+
+<p><i>Treatment.</i>&mdash;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 &ldquo;threaded&rdquo; 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.</p>
+
+<p>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
+&ldquo;retrograde&rdquo; route. In aggravated cases, the gastrostomy opening must
+be retained in order to prevent death from starvation.</p>
+
+<p><a name="XXVIII_malignant_stricture" id="XXVIII_malignant_stricture"></a><b>Malignant Stricture&mdash;Carcinoma of the Gullet.</b>&mdash;This is met with in two
+forms which present widely different pathological and clinical
+features.</p>
+
+<p>Cancer of the <i>cervical</i> 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 <i>thoracic</i> portion affects the extreme lower end
+of the gullet, and is met with almost exclusively in men over fifty.</p>
+
+<p><a name="XXVIII_cancer_cervical" id="XXVIII_cancer_cervical"></a><a class="pagenum" name="Pg_630" id="Pg_630"></a><b>Cancer of the Cervical Portion.</b>&mdash;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.</p>
+
+<p>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-&oelig;sophageal junction.</p>
+
+<p>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
+&oelig;sophagoscope may be preferred. A portion of the growth may be
+removed for microscopical examination.</p>
+
+<p>The use of the &oelig;sophageal 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).</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p><i>&OElig;sophagectomy</i>, 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 <i>&oelig;sophagostomy</i><a class="pagenum" name="Pg_631" id="Pg_631"></a> or <i>gastrostomy</i> can be adopted.
+&OElig;sophagostomy 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. <i>Tracheotomy</i> may also become necessary
+because of the spread of the cancer to the interior of the larynx.</p>
+
+<p><a name="XXVIII_cancer_lower_end" id="XXVIII_cancer_lower_end"></a><b>Cancer of the Lower End of the Gullet.</b>&mdash;The remarkable preference of
+this location of &oelig;sophageal 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.</p>
+
+<p>The <i>clinical features</i> 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 &oelig;sophageal
+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.</p>
+
+<p>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.</p>
+
+<p>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
+<i>empyema</i> which may contain gas and food materials.</p>
+
+<p><a class="pagenum" name="Pg_632" id="Pg_632"></a><i>Diagnosis.</i>&mdash;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 (<a href="#fig_285">Fig.&nbsp;285</a>). A filiform, tortuous shadow of the
+bismuth may be continued downwards and show up the lumen of the
+stricture. The use of the &oelig;sophagoscope and of bougies is to be
+deprecated as not free from risk.</p>
+
+<p><i>Treatment.</i>&mdash;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.</p>
+
+<p>Among <i>palliative measures</i>, may be mentioned <i>intubation</i> 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 &oelig;sophagoscope. 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.</p>
+
+<p>The value of making a fistula in the stomach&mdash;<i>gastrostomy</i>&mdash;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 &ldquo;malignant stricture of the lower end of the
+gullet.&rdquo; 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.</p>
+
+<p><a class="pagenum" name="Pg_633" id="Pg_633"></a><i>Radiation.</i>&mdash;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.</p>
+
+<p><i>The Roux-operation.</i>&mdash;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&mdash;end to side&mdash;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.</p>
+
+
+
+
+<h2><a class="pagenum" name="Pg_634" id="Pg_634"></a><a name="CHAPTER_XXIX" id="CHAPTER_XXIX"></a>CHAPTER XXIX
+<br />
+THE LARYNX, TRACHEA, AND BRONCHI<a name="FNanchor_7_7" id="FNanchor_7_7"></a><a href="#Footnote_7_7" class="fnanchor">[7]</a></h2>
+
+<ul class="chap">
+  <li><a href="#XXIX_examination">Examination of the larynx</a></li>
+  <li>&mdash;<a href="#XXIX_cardinal_symptoms"><span class="smcap">Cardinal Symptoms of Laryngeal Affections</span></a>:</li>
+  <li><a href="#XXIX_hoarseness">(1) Interference with the voice</a>:</li>
+  <li><a href="#XXIX_hoarseness"><i>Hoarseness</i></a>;</li>
+  <li><a href="#XXIX_aphonia"><i>Aphonia</i></a></li>
+  <li>&mdash;<a href="#XXIX_dysphagia">(2) Dysphagia</a></li>
+  <li>&mdash;<a href="#XXIX_interference_respiration">(3) Interference with respiration</a>:</li>
+  <li><a href="#XXIX_diphtheria_larynx"><i>Diphtheritic laryngitis</i></a>;</li>
+  <li><a href="#XXIX_oedema_larynx"><i>Acute &oelig;dema of the larynx</i></a>;</li>
+  <li><a href="#XXIX_intubation"><i>Intubation of the larynx</i></a>;</li>
+  <li><a href="#XXIX_tracheotomy"><i>Tracheotomy</i></a>;</li>
+  <li><a href="#XXIX_bilateral_abductor_paralysis"><i>Bilateral abductor paralysis</i></a>;</li>
+  <li><a href="#XXIX_syphilitic_affections"><i>Syphilitic affections</i></a>;</li>
+  <li><a href="#XXIX_tuberculosis"><i>Tuberculosis</i></a></li>
+  <li>&mdash;<a href="#XXIX_tumours">Tumours</a>:</li>
+  <li><a href="#XXIX_tumours"><i>Papilloma</i></a>;</li>
+  <li><a href="#XXIX_epithelioma"><i>Epithelioma</i></a>;</li>
+  <li><a href="#XXIX_sarcoma"><i>Sarcoma</i></a></li>
+  <li>&mdash;<a href="#XXIX_foreign_bodies_pharynx">Foreign bodies in the air-passages</a>:</li>
+  <li><a href="#XXIX_foreign_bodies_pharynx"><i>In the pharynx</i></a>, <a href="#XXIX_foreign_bodies_larynx"><i>larynx</i></a>, <a href="#XXIX_foreign_bodies_trachea"><i>trachea</i></a>, <a href="#XXIX_foreign_bodies_bronchi"><i>bronchi</i></a>.</li>
+</ul>
+
+<p class="footnote"><a name="Footnote_7_7" id="Footnote_7_7"></a><a href="#FNanchor_7_7"><span class="label">[7]</span></a> Revised by Dr. Logan Turner.</p>
+
+<p><a name="XXIX_examination" id="XXIX_examination"></a><b>Examination of the Larynx.</b>&mdash;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 &ldquo;eh.&rdquo;</p>
+
+<p>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 vallecul&aelig;. 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<a class="pagenum" name="Pg_635" id="Pg_635"></a> 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.</p>
+
+<p><i>Direct Laryngoscopy.</i>&mdash;The larynx may also be examined by the direct
+method by means of Jackson's or Killian's spatul&aelig;. 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 an&aelig;sthetic is
+required, and the examination is made with the head hanging over the
+end of the table. Killian's &ldquo;suspension laryngoscopy&rdquo; affords the best
+method of examining the larynx in young children.</p>
+
+<p><i>Tracheoscopy and Bronchoscopy.</i>&mdash;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&mdash;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.</p>
+
+
+<h3><a name="XXIX_cardinal_symptoms" id="XXIX_cardinal_symptoms"></a><span class="smcap">Cardinal Symptoms of Laryngeal Affections</span></h3>
+
+<p>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. H&aelig;moptysis 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.</p>
+
+<p><a name="XXIX_hoarseness" id="XXIX_hoarseness"></a><b>Interference with the Voice.</b>&mdash;<i>Hoarseness</i> 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<a class="pagenum" name="Pg_636" id="Pg_636"></a> 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.</p>
+
+<p><a name="XXIX_aphonia" id="XXIX_aphonia"></a><i>Aphonia</i>, 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.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+<p>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.</p>
+
+<p><a name="XXIX_dysphagia" id="XXIX_dysphagia"></a><b>Dysphagia.</b>&mdash;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.</p>
+
+<p>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.</p>
+
+<p>The <i>treatment</i> 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 an&aelig;sthetic applications is orthoform
+powder, introduced by means of the ordinary laryngeal insufflator. Its
+action is more prolonged<a class="pagenum" name="Pg_637" id="Pg_637"></a> than that of any of the others, often
+lasting for from twenty-four to forty-eight hours.</p>
+
+<p>Injection of the superior laryngeal nerve with a 60 per cent. solution
+of alcohol has been found satisfactory where other means have failed.</p>
+
+<p><a name="XXIX_interference_respiration" id="XXIX_interference_respiration"></a><b>Interference with Respiration.</b>&mdash;It is only necessary here to refer to
+such causes of interference with respiration as may call for surgical
+treatment.</p>
+
+<p>The chief forms of <i>laryngitis</i> to be considered in connection with
+the production of dyspn&oelig;a, are membranous or diphtheritic
+laryngitis and acute inflammatory &oelig;dema.</p>
+
+<p><a name="XXIX_diphtheria_larynx" id="XXIX_diphtheria_larynx"></a><b>Diphtheria of the larynx</b> is described on p. 110, Volume I.</p>
+
+<p><a name="XXIX_oedema_larynx" id="XXIX_oedema_larynx"></a><b>Acute &OElig;dema of the Larynx.</b>&mdash;&OElig;dema 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.</p>
+
+<p>The &oelig;dema 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 foss&aelig; between the base of the tongue and the
+epiglottis, the ary-epiglottic folds (<a href="#fig_287">Fig.&nbsp;287</a>), and the false cords.
+If the infective process commences in front of the epiglottis this
+structure becomes swollen and rigid, and often<a class="pagenum" name="Pg_638" id="Pg_638"></a> livid in
+colour&mdash;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 &oelig;dema spread to the ary-epiglottic folds,
+either from the interior of the larynx or from the fauces and pharynx,
+dyspn&oelig;a 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.</p>
+
+<div class="figcenter" style="width: 319px;">
+<a name="fig_287" id="fig_287"></a>
+<img src="images/fig287.jpg" width="319" height="400" alt="Fig. 287.&mdash;Larynx from case of sudden death, due to
+&oelig;dema of ary-epiglottic folds, a, a." title="" />
+<span class="caption"><span class="smcap">Fig. 287.</span>&mdash;Larynx from case of sudden death, due to
+&oelig;dema of ary-epiglottic folds, a, a.<br /><br />
+(From drawing lent by Dr. Logan Turner.)</span>
+</div>
+
+<p><a name="XXIX_intubation" id="XXIX_intubation"></a><i>Treatment.</i>&mdash;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.</p>
+
+<p><a name="XXIX_tracheotomy" id="XXIX_tracheotomy"></a>In performing <b>tracheotomy</b>, 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
+(<i>laryngo-tracheotomy</i>). 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.<a class="pagenum" name="Pg_639" id="Pg_639"></a> The tube should be discarded as
+soon as the patient is able to breathe by the natural channel.</p>
+
+<p><i>Intubation of the Larynx.</i>&mdash;This procedure is employed as a
+substitute for tracheotomy, especially in children suffering from
+membranous and &oelig;dematous 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.</p>
+
+<p>In an emergency a gum-elastic catheter with a terminal aperture may be
+passed, as recommended by Macewen and Annandale.</p>
+
+<p><a name="XXIX_bilateral_abductor_paralysis" id="XXIX_bilateral_abductor_paralysis"></a><b>Bilateral Abductor Paralysis.</b>&mdash;Both recurrent nerves may be interfered
+with by such conditions as enlargement of the thyreoid, tumour of the
+&oelig;sophagus, or intra-thoracic tumour, or by injury in the course of
+operations for goitre. A gradually increasing inspiratory dyspn&oelig;a
+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.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+<p><a name="XXIX_syphilitic_affections" id="XXIX_syphilitic_affections"></a><b>Syphilitic Affections of the Larynx.</b>&mdash;<i>Secondary syphilitic</i>
+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.</p>
+
+<p>In <i>tertiary syphilis</i>, 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<a class="pagenum" name="Pg_640" id="Pg_640"></a> secretion, and the surrounding mucosa
+presents an angry red appearance. When the perichondrium becomes
+invaded, necrosis of cartilage is liable to occur.</p>
+
+<p>Hoarseness, dyspn&oelig;a, and, when the epiglottis is involved,
+dysphagia, are the most prominent symptoms.</p>
+
+<p>Cicatricial contraction leading to stenosis may ensue, and cause
+persistent dyspn&oelig;a.</p>
+
+<p>The usual <i>treatment</i> for tertiary syphilis is employed, but on
+account of the tendency of potassium iodide to increase the &oelig;dema
+of the larynx, this drug must at first be used with caution.
+Intubation or tracheotomy may be called for on account of sudden
+urgent dyspn&oelig;a 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.</p>
+
+<p><a name="XXIX_tuberculosis" id="XXIX_tuberculosis"></a><b>Tuberculosis.</b>&mdash;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
+&oelig;dematous 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.</p>
+
+<p>The voice becomes hoarse or may be lost, there is persistent and
+intractable cough, and in some cases dyspn&oelig;a supervenes. When the
+epiglottis is involved there is pain and difficulty in swallowing.</p>
+
+<p>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
+dyspn&oelig;a.</p>
+
+<p><a name="XXIX_tumours" id="XXIX_tumours"></a><b>Tumours.</b>&mdash;The commonest form of simple tumour met with in the larynx
+is the <i>papilloma</i>. 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,<a class="pagenum" name="Pg_641" id="Pg_641"></a> which may form a fringe hanging from
+the edge of the cord (<a href="#fig_288">Fig.&nbsp;288</a>), 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.</p>
+
+<div class="figcenter" style="width: 400px;">
+<a name="fig_288" id="fig_288"></a>
+<img src="images/fig288.jpg" width="400" height="294" alt="Fig. 288.&mdash;Papilloma of Larynx." title="" />
+<span class="caption"><span class="smcap">Fig. 288.</span>&mdash;Papilloma of Larynx.<br /><br />
+(From drawing lent by Dr. Logan Turner.)</span>
+</div>
+
+<p>The most prominent symptoms are hoarseness, aphonia, and dyspn&oelig;a,
+which in children may be paroxysmal.</p>
+
+<p>The <i>treatment</i> consists in removing the growth by means of laryngeal
+forceps or the snare, under cocain and adrenalin an&aelig;sthesia. 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.</p>
+
+<p><a name="XXIX_epithelioma" id="XXIX_epithelioma"></a><b>Cancer.</b>&mdash;<i>Epithelioma</i> 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&mdash;on the vocal cords, the
+ventricular bands, or in the sub-glottic cavity (<i>intrinsic
+cancer</i>)&mdash;and those in which it attacks the epiglottis, the
+ary-epiglottic folds, or the posterior surface of the cricoid
+cartilage (<i>extrinsic cancer</i>).</p>
+
+<p><i>Clinical Features.</i>&mdash;In the great majority of cases of <i>intrinsic</i>
+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 f&oelig;tor 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.</p>
+
+<p><a class="pagenum" name="Pg_642" id="Pg_642"></a>Intrinsic cancer may spread over the upper boundaries of the larynx
+and become <i>extrinsic</i>, or the disease may be extrinsic from the
+outset.</p>
+
+<p>In cases of <i>extrinsic</i> 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.</p>
+
+<p>When the growth spreads into the tissues of the neck the patient's
+sufferings are greatly increased. The &oelig;sophagus 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 h&aelig;morrhage. The duration of this form of
+the disease varies from one to three years.</p>
+
+<p>The <i>treatment</i> 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&mdash;<i>complete laryngectomy</i>&mdash;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.</p>
+
+<p>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.</p>
+
+<p><a name="XXIX_sarcoma" id="XXIX_sarcoma"></a><b>Sarcoma</b> of the larynx gives rise to the same symptoms as cancer, and
+can seldom be diagnosed from it before operation.</p>
+
+<p><a name="XXIX_foreign_bodies_pharynx" id="XXIX_foreign_bodies_pharynx"></a><b>Foreign Bodies in the Air-Passages.</b>&mdash;Foreign bodies impacted <i>in the
+pharynx</i> 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.</p>
+
+<p><a name="XXIX_foreign_bodies_larynx" id="XXIX_foreign_bodies_larynx"></a>The bodies most frequently impacted <i>in the larynx</i> 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<a class="pagenum" name="Pg_643" id="Pg_643"></a> 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.</p>
+
+<p>Small round bodies may lodge in the upper aperture or in one of the
+ventricles, and give rise to hoarseness and repeated attacks of
+dyspn&oelig;a 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 &oelig;dema. The position of the body may
+often be ascertained by the use of the X-rays.</p>
+
+<p><i>Treatment.</i>&mdash;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).</p>
+
+<p><a name="XXIX_foreign_bodies_trachea" id="XXIX_foreign_bodies_trachea"></a>The foreign bodies that are most likely to become impacted <i>in the
+trachea</i> 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
+dyspn&oelig;a.</p>
+
+<p>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<a class="pagenum" name="Pg_644" id="Pg_644"></a> tracheal tubes may be introduced
+through the tracheotomy wound and the body extracted by means of
+suitable forceps.</p>
+
+<p><a name="XXIX_foreign_bodies_bronchi" id="XXIX_foreign_bodies_bronchi"></a><i>Foreign Bodies in the Bronchi.</i>&mdash;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 dyspn&oelig;ic
+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.</p>
+
+<p>The <i>treatment</i> 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.</p>
+
+
+
+
+<h2><a class="pagenum" name="Pg_645" id="Pg_645"></a><a name="INDEX" id="INDEX"></a>INDEX</h2>
+
+<table class="az" border="1" summary="Alphabetic jump-table for the index">
+        <tr>
+            <td><a href="#IX_A">A</a></td>
+            <td><a href="#IX_B">B</a></td>
+            <td><a href="#IX_C">C</a></td>
+            <td><a href="#IX_D">D</a></td>
+            <td><a href="#IX_E">E</a></td>
+            <td><a href="#IX_F">F</a></td>
+            <td><a href="#IX_G">G</a></td>
+            <td><a href="#IX_H">H</a></td>
+            <td><a href="#IX_I">I</a></td>
+            <td><a href="#IX_J">J</a></td>
+            <td><a href="#IX_K">K</a></td>
+            <td><a href="#IX_L">L</a></td>
+            <td><a href="#IX_M">M</a></td>
+        </tr>
+        <tr>
+            <td><a href="#IX_N">N</a></td>
+            <td><a href="#IX_O">O</a></td>
+            <td><a href="#IX_P">P</a></td>
+            <td><a href="#IX_Q">Q</a></td>
+            <td><a href="#IX_R">R</a></td>
+            <td><a href="#IX_S">S</a></td>
+            <td><a href="#IX_T">T</a></td>
+            <td><a href="#IX_U">U</a></td>
+            <td><a href="#IX_V">V</a></td>
+            <td><a href="#IX_W">W</a></td>
+            <td><a href="#IX_X">X</a></td>
+            <td>Y</td>
+            <td><a href="#IX_Z">Z</a></td>
+        </tr>
+</table>
+
+<div class="index">
+<ul>
+<li><a name="IX_A" id="IX_A"></a>Abducens nerve, <a href="#Pg_400">400</a></li>
+
+<li>Abductor paralysis, <a href="#Pg_404">404</a>, <a href="#Pg_639">639</a>
+  <ul>
+  <li>splint, <a href="#Pg_221">221</a></li>
+  </ul></li>
+
+<li>Abscess. <i>See</i> Individual Organs and Regions</li>
+
+<li>Accessory nasal sinuses. <i>See</i> Individual Sinuses
+  <ul>
+  <li>nerve, <a href="#Pg_404">404</a></li>
+  </ul></li>
+
+<li>Acetabulum, fracture of, <a href="#Pg_125">125</a>
+  <ul>
+  <li>tuberculous disease of, <a href="#Pg_210">210</a></li>
+  <li>wandering, <a href="#Pg_210">210</a>, <a href="#Pg_227">227</a></li>
+  </ul></li>
+
+<li>Achillo-bursitis, <a href="#Pg_294">294</a></li>
+
+<li>Acoustic nerve, <a href="#Pg_579">579</a></li>
+
+<li>Acromion process, fracture of, <a href="#Pg_69">69</a></li>
+
+<li>Actinomycosis. <i>See</i> Individual Organs and Regions</li>
+
+<li>Adenoids, <a href="#Pg_578">578</a></li>
+
+<li>Alveolar abscess, <a href="#Pg_507">507</a>
+  <ul>
+  <li>process, fracture of, <a href="#Pg_519">519</a></li>
+  <li>tumours of, <a href="#Pg_513">513</a></li>
+  </ul></li>
+
+<li>Ambulant splint for ankle, <a href="#Pg_189">189</a>
+  <ul>
+  <li>treatment of hip disease, <a href="#Pg_222">222</a></li>
+  </ul></li>
+
+<li>Amputation in compound fracture, <a href="#Pg_26">26</a></li>
+
+<li>Anatomy. <i>See</i> Surgical Anatomy</li>
+
+<li>Angina Ludovici, <a href="#Pg_548">548</a>, <a href="#Pg_597">597</a></li>
+
+<li>Ankle, deformities of, <a href="#Pg_273">273</a>
+  <ul>
+  <li>diseases of, <a href="#Pg_238">238</a>, <a href="#Pg_240">240</a></li>
+  <li>dislocations of, <a href="#Pg_194">194</a></li>
+  <li>fractures in region of, <a href="#Pg_186">186</a>, <a href="#Pg_187">187</a></li>
+  <li>injuries in region of, <a href="#Pg_185">185</a></li>
+  <li>surgical anatomy of, <a href="#Pg_185">185</a></li>
+  <li>tuberculous disease of, <a href="#Pg_238">238</a></li>
+  </ul></li>
+
+<li>Ankylosis of joints. <i>See</i> Individual Joints</li>
+
+<li>Anosmia, <a href="#Pg_399">399</a>, <a href="#Pg_578">578</a></li>
+
+<li>Anterior poliomyelitis, <a href="#Pg_242">242</a></li>
+
+<li>Aphasia, <a href="#Pg_335">335</a></li>
+
+<li>Aphonia, <a href="#Pg_636">636</a></li>
+
+<li>Arm, upper, injuries of, <a href="#Pg_44">44</a></li>
+
+<li>Arthritis. <i>See also</i> Individual Joints</li>
+
+<li>Arthritis, septic, <a href="#Pg_34">34</a></li>
+
+<li>Arthrodesis, <a href="#Pg_246">246</a></li>
+
+<li>Astragalus. <i>See</i> Talus</li>
+
+<li>Athetosis, <a href="#Pg_247">247</a></li>
+
+<li>Atlo-axoid disease, <a href="#Pg_440">440</a>
+  <ul>
+  <li>joint, fracture-dislocation of, <a href="#Pg_430">430</a></li>
+  </ul></li>
+
+<li>Auditory nerve, <a href="#Pg_403">403</a></li>
+
+<li>Aural polypi, <a href="#Pg_558">558</a>
+  <ul>
+  <li>vertigo, <a href="#Pg_555">555</a></li>
+  </ul></li>
+
+<li>Auricular appendages, <a href="#Pg_560">560</a></li>
+
+<li>Avulsion of scalp, <a href="#Pg_322">322</a></li>
+</ul>
+
+<ul>
+<li><a name="IX_B" id="IX_B"></a>Balkan frame splint, <a href="#Pg_150">150</a></li>
+
+<li>Basedow's disease, <a href="#Pg_614">614</a></li>
+
+<li>Bell's paralysis, <a href="#Pg_401">401</a></li>
+
+<li>Bennett's fracture, <a href="#Pg_116">116</a></li>
+
+<li>Bezold's mastoiditis, <a href="#Pg_566">566</a></li>
+
+<li>Bier's constricting bandage, <a href="#Pg_12">12</a>, <a href="#Pg_26">26</a></li>
+
+<li>Black eye, <a href="#Pg_370">370</a>, <a href="#Pg_484">484</a></li>
+
+<li>Blepharospasm, <a href="#Pg_403">403</a></li>
+
+<li>Bones, atrophy of, <a href="#Pg_2">2</a>
+  <ul>
+  <li>contusion of, <a href="#Pg_1">1</a></li>
+  <li>fracture of, <a href="#Pg_1">1</a></li>
+  <li>gun-shot injuries of, <a href="#Pg_27">27</a></li>
+  <li>injuries of, <a href="#Pg_1">1</a></li>
+  <li>repair of, <a href="#Pg_8">8</a></li>
+  <li>wounds of, <a href="#Pg_1">1</a></li>
+  </ul></li>
+
+<li>Bow-knee, <a href="#Pg_271">271</a>
+  <ul>
+  <li>-leg, <a href="#Pg_271">271</a></li>
+  </ul></li>
+
+<li>Box splint, <a href="#Pg_182">182</a></li>
+
+<li>Brachial plexus, lesions of, <a href="#Pg_597">597</a></li>
+
+<li>Brachio-thoracic triangle, <a href="#Pg_470">470</a></li>
+
+<li>Bradford frame, <a href="#Pg_438">438</a></li>
+
+<li>Brain, abscess of, <a href="#Pg_360">360</a>, <a href="#Pg_374">374</a>, <a href="#Pg_376">376</a>, <a href="#Pg_378">378</a>, <a href="#Pg_382">382</a>
+  <ul>
+    <li><ul>
+    <li>localisation of, <a href="#Pg_380">380</a></li>
+    </ul></li>
+  <li>adhesions, <a href="#Pg_358">358</a></li>
+  <li>cerebral irritation, <a href="#Pg_342">342</a>, <a href="#Pg_346">346</a></li>
+  <li>compression of, <a href="#Pg_347">347</a>
+    <ul>
+    <li>differential diagnosis of, <a href="#Pg_350">350</a></li>
+    </ul></li>
+  <li>concussion of, <a href="#Pg_341">341</a>, <a href="#Pg_344">344</a></li>
+  <li>contusion of, <a href="#Pg_342">342</a></li>
+  <li>cyst of, h&aelig;morrhagic, <a href="#Pg_344">344</a></li>
+  <li>decompression operations on, <a href="#Pg_396">396</a></li>
+  <li>diseases of, <a href="#Pg_373">373</a>
+    <ul>
+    <li><a class="pagenum" name="Pg_646" id="Pg_646"></a>pyogenic, <a href="#Pg_373">373</a></li>
+    </ul></li>
+  <li>foreign bodies in, <a href="#Pg_350">350</a></li>
+  <li>functions of, <a href="#Pg_331">331</a></li>
+  <li>h&aelig;morrhage into, <a href="#Pg_352">352</a></li>
+  <li>hernia of, <a href="#Pg_397">397</a></li>
+  <li>injuries of, <a href="#Pg_341">341</a>
+    <ul>
+    <li>mechanism of, <a href="#Pg_343">343</a></li>
+    <li>repair of, <a href="#Pg_344">344</a></li>
+    </ul></li>
+  <li>irritation of, <a href="#Pg_342">342</a>, <a href="#Pg_346">346</a></li>
+  <li>laceration of, <a href="#Pg_342">342</a></li>
+  <li>lesions of, <a href="#Pg_341">341</a></li>
+  <li>localisation of centres in, <a href="#Pg_336">336</a></li>
+  <li>membranes of, <a href="#Pg_328">328</a>
+    <ul>
+    <li>diseases of, <a href="#Pg_372">372</a></li>
+    </ul></li>
+  <li>motor area of, <a href="#Pg_330">330</a></li>
+  <li>sclerosis of, <a href="#Pg_358">358</a></li>
+  <li>sensory mechanism of, <a href="#Pg_332">332</a></li>
+  <li>softening of, <a href="#Pg_342">342</a></li>
+  <li>surgical anatomy of, <a href="#Pg_328">328</a></li>
+  <li>syphilitic gumma, <a href="#Pg_395">395</a></li>
+  <li>traumatic &oelig;dema of, <a href="#Pg_343">343</a>, <a href="#Pg_352">352</a></li>
+  <li>tuberculosis of, <a href="#Pg_395">395</a></li>
+  <li>tumours of, <a href="#Pg_393">393</a>
+    <ul>
+    <li>localisation of, <a href="#Pg_394">394</a></li>
+    </ul></li>
+  <li>wounds of, <a href="#Pg_357">357</a></li>
+  </ul></li>
+
+<li>Branchial carcinoma, <a href="#Pg_601">601</a>
+  <ul>
+  <li>cysts, <a href="#Pg_598">598</a></li>
+  <li>fistul&aelig;, <a href="#Pg_585">585</a></li>
+  </ul></li>
+
+<li>Broken back, <a href="#Pg_427">427</a></li>
+
+<li>Bronchi, foreign bodies in, <a href="#Pg_644">644</a></li>
+
+<li>Bronchocele. <i>See</i> Goitre, <a href="#Pg_605">605</a></li>
+
+<li>Bronchoscopy, <a href="#Pg_635">635</a></li>
+
+<li>Bryant's triangle, <a href="#Pg_129">129</a></li>
+
+<li>Bunion, <a href="#Pg_296">296</a></li>
+</ul>
+
+<ul>
+<li><a name="IX_C" id="IX_C"></a>Cachexia strumipriva, <a href="#Pg_610">610</a></li>
+
+<li>Calcaneus, fracture of, <a href="#Pg_193">193</a>
+  <ul>
+  <li>separation of, tuberosity of, <a href="#Pg_193">193</a></li>
+  <li>spurs on, <a href="#Pg_294">294</a></li>
+  </ul></li>
+
+<li>Callipers, ice-tong, <a href="#Pg_165">165</a></li>
+
+<li>Callus, absorption of, <a href="#Pg_10">10</a>
+  <ul>
+  <li>excess of, <a href="#Pg_9">9</a></li>
+  <li>tumours of, <a href="#Pg_10">10</a></li>
+  <li>varieties of, <a href="#Pg_8">8</a></li>
+  </ul></li>
+
+<li>Cancrum oris, <a href="#Pg_497">497</a></li>
+
+<li>Capitate bone, dislocation of, <a href="#Pg_114">114</a></li>
+
+<li>Carcinoma. <i>See</i> Cancer</li>
+
+<li>Cardiospasm, <a href="#Pg_624">624</a></li>
+
+<li>Carotid artery, internal, injuries of, <a href="#Pg_356">356</a>
+  <ul>
+  <li>gland, tumours of, <a href="#Pg_603">603</a></li>
+  </ul></li>
+
+<li>Carpal bones, dislocation of, <a href="#Pg_113">113</a>
+  <ul>
+  <li>fracture of, <a href="#Pg_110">110</a></li>
+  </ul></li>
+
+<li>Carpo-metacarpal dislocations, <a href="#Pg_115">115</a></li>
+
+<li>Cauda equina, injuries of, <a href="#Pg_419">419</a></li>
+
+<li>Caudal appendage, <a href="#Pg_458">458</a>, <a href="#Pg_459">459</a></li>
+
+<li>Cavernous sinus, phlebitis of, <a href="#Pg_386">386</a></li>
+
+<li>Cellulitis. <i>See</i> Individual Regions</li>
+
+<li>Cephal-hydrocele, <a href="#Pg_321">321</a>
+  <ul>
+  <li>traumatic, <a href="#Pg_390">390</a></li>
+  </ul></li>
+
+<li>Cephaloceles, <a href="#Pg_387">387</a></li>
+
+<li>Cerebello-pontine angle, tumours of, <a href="#Pg_394">394</a></li>
+
+<li>Cerebellum, abscess of, <a href="#Pg_381">381</a>
+  <ul>
+  <li>tumours of, <a href="#Pg_394">394</a></li>
+  </ul></li>
+
+<li>Cerebral abscess, <a href="#Pg_360">360</a>
+  <ul>
+  <li>apoplexy, <a href="#Pg_351">351</a></li>
+  <li>centres, <a href="#Pg_334">334</a></li>
+  <li>embolism, <a href="#Pg_351">351</a></li>
+  <li>hyperpyrexia, <a href="#Pg_348">348</a></li>
+  <li>irritation, <a href="#Pg_342">342</a>, <a href="#Pg_346">346</a></li>
+  <li>localisation, <a href="#Pg_336">336</a></li>
+  <li>&oelig;dema, <a href="#Pg_352">352</a></li>
+  <li>palsies of childhood, <a href="#Pg_247">247</a></li>
+  <li>shock, <a href="#Pg_341">341</a>, <a href="#Pg_344">344</a></li>
+  <li>softening, <a href="#Pg_358">358</a></li>
+  <li>tumours, <a href="#Pg_393">393</a></li>
+  <li>vomiting, <a href="#Pg_377">377</a></li>
+  </ul></li>
+
+<li>Cerebro-spinal fluid, <a href="#Pg_329">329</a>, <a href="#Pg_339">339</a>
+  <ul>
+  <li>meningitis, <a href="#Pg_378">378</a></li>
+  </ul></li>
+
+<li>Cerebrum. <i>See</i> Brain</li>
+
+<li>Cerumen in ear, <a href="#Pg_561">561</a></li>
+
+<li>Cervical auricles, <a href="#Pg_583">583</a>
+  <ul>
+  <li>caries, <a href="#Pg_440">440</a></li>
+  <li>fascia, <a href="#Pg_583">583</a></li>
+  <li>ribs, <a href="#Pg_585">585</a></li>
+  <li>sympathetic, <a href="#Pg_405">405</a>, <a href="#Pg_615">615</a></li>
+  </ul></li>
+
+<li>Charcot's disease of hip, <a href="#Pg_228">228</a></li>
+
+<li>Chauffeur's fracture, <a href="#Pg_106">106</a></li>
+
+<li>Cheilotomy, <a href="#Pg_228">228</a></li>
+
+<li>Chiene's test, <a href="#Pg_129">129</a></li>
+
+<li>Cilio-spinal reflex, <a href="#Pg_405">405</a></li>
+
+<li>Cirsoid aneurysm of scalp, <a href="#Pg_326">326</a></li>
+
+<li>Clavicle, absence of, <a href="#Pg_303">303</a>
+  <ul>
+  <li>dislocations of, <a href="#Pg_49">49</a></li>
+  <li>fracture of, <a href="#Pg_45">45</a></li>
+  </ul></li>
+
+<li>Cleft palate, <a href="#Pg_475">475</a>, <a href="#Pg_477">477</a></li>
+
+<li>Club-foot, <a href="#Pg_273">273</a></li>
+
+<li>Club-hand, <a href="#Pg_311">311</a>, <a href="#Pg_312">312</a></li>
+
+<li>Coccydynia, <a href="#Pg_127">127</a>, <a href="#Pg_450">450</a></li>
+
+<li>Coccyx, fracture of, <a href="#Pg_127">127</a></li>
+
+<li>Cock-up splint, <a href="#Pg_77">77</a></li>
+
+<li>Coin-catcher, <a href="#Pg_622">622</a></li>
+
+<li>Colles' fracture, <a href="#Pg_102">102</a>
+  <ul>
+  <li>reversed, <a href="#Pg_106">106</a></li>
+  <li>unreduced, <a href="#Pg_106">106</a></li>
+  </ul></li>
+
+<li>Compound dislocation, <a href="#Pg_40">40</a></li>
+
+<li>Compression of brain, <a href="#Pg_347">347</a></li>
+
+<li><a class="pagenum" name="Pg_647" id="Pg_647"></a>Compression fracture of spine, <a href="#Pg_426">426</a></li>
+
+<li>Concussion of brain, <a href="#Pg_344">344</a>
+  <ul>
+  <li>of spinal cord, <a href="#Pg_413">413</a></li>
+  </ul></li>
+
+<li>Congenital deformities, <a href="#Pg_241">241</a>. <i>See</i> Individual Regions
+  <ul>
+  <li>dislocation, <a href="#Pg_43">43</a>. <i>See</i> Individual Joints</li>
+  </ul></li>
+
+<li>Conus medullaris, injuries of, <a href="#Pg_419">419</a></li>
+
+<li>Coracoid process, fracture of, <a href="#Pg_69">69</a>
+  <ul>
+  <li>separation of epiphysis of, <a href="#Pg_70">70</a></li>
+  </ul></li>
+
+<li>Coronoid process, fracture of, <a href="#Pg_87">87</a></li>
+
+<li>Coxa valga, <a href="#Pg_256">256</a>, <a href="#Pg_261">261</a>
+  <ul>
+  <li>vara, <a href="#Pg_136">136</a>, <a href="#Pg_256">256</a>, <a href="#Pg_257">257</a></li>
+  </ul></li>
+
+<li>Cranial nerves, affections of, <a href="#Pg_398">398</a>. <i>See</i> Individual Nerves</li>
+
+<li>Cranium. <i>See</i> Skull</li>
+
+<li>Crepitus in fracture, <a href="#Pg_15">15</a>, <a href="#Pg_30">30</a></li>
+
+<li>Cricoid cartilage, fracture of, <a href="#Pg_593">593</a></li>
+
+<li>Crossed-leg deformity, <a href="#Pg_224">224</a>, <a href="#Pg_257">257</a></li>
+
+<li>Cruciate ligaments, rupture of, <a href="#Pg_171">171</a></li>
+
+<li>Cubitus valgus, <a href="#Pg_84">84</a>, <a href="#Pg_308">308</a>
+  <ul>
+  <li>varus, <a href="#Pg_84">84</a>, <a href="#Pg_310">310</a></li>
+  </ul></li>
+
+<li>Cut-throat, <a href="#Pg_593">593</a></li>
+</ul>
+
+<ul>
+<li><a name="IX_D" id="IX_D"></a>Deafness, varieties of, <a href="#Pg_553">553</a></li>
+
+<li>Decompression of brain, <a href="#Pg_396">396</a></li>
+
+<li>Deep sensibility, <a href="#Pg_332">332</a></li>
+
+<li>Deformities of extremities, <a href="#Pg_241">241</a>. <i>See</i> Individual Regions</li>
+
+<li>Dental caries, <a href="#Pg_507">507</a>
+  <ul>
+  <li>ulcer of tongue, <a href="#Pg_529">529</a></li>
+  </ul></li>
+
+<li>Dentigerous cysts, <a href="#Pg_517">517</a></li>
+
+<li>Diplacusis, <a href="#Pg_554">554</a></li>
+
+<li>Dislocation. <i>See also</i> Individual Joints and Bones
+  <ul>
+  <li>compound, <a href="#Pg_40">40</a></li>
+  <li>congenital, <a href="#Pg_43">43</a></li>
+  <li>by elongation, <a href="#Pg_96">96</a></li>
+  <li>with fracture, <a href="#Pg_40">40</a></li>
+  <li>habitual, <a href="#Pg_43">43</a>, <a href="#Pg_65">65</a></li>
+  <li>old-standing, <a href="#Pg_40">40</a>, <a href="#Pg_65">65</a></li>
+  <li>pathological, <a href="#Pg_43">43</a></li>
+  <li>recurrent, <a href="#Pg_43">43</a></li>
+  <li>traumatic, <a href="#Pg_36">36</a></li>
+  <li>varieties of, <a href="#Pg_37">37</a></li>
+  </ul></li>
+
+<li>Displacement of semilunar menisci, <a href="#Pg_168">168</a></li>
+
+<li>Dorsal abscess, <a href="#Pg_444">444</a></li>
+
+<li>Drop-finger, <a href="#Pg_318">318</a>
+  <ul>
+  <li>wrist, <a href="#Pg_76">76</a>, <a href="#Pg_311">311</a></li>
+  </ul></li>
+
+<li>Dugas' symptom in dislocation of shoulder, <a href="#Pg_54">54</a>, <a href="#Pg_55">55</a></li>
+
+<li>Dupuytren's contraction, <a href="#Pg_314">314</a>
+  <ul>
+  <li>fracture, <a href="#Pg_187">187</a>, <a href="#Pg_188">188</a>, <a href="#Pg_196">196</a></li>
+  <li>splint, <a href="#Pg_190">190</a></li>
+  </ul></li>
+
+<li>Dysphagia, <a href="#Pg_623">623</a>, <a href="#Pg_636">636</a></li>
+</ul>
+
+<ul>
+<li><a name="IX_E" id="IX_E"></a>Ear, <a href="#Pg_553">553</a>. <i>See also</i> Tympanic membrane</li>
+
+<li>Ear, aspergillus in, <a href="#Pg_562">562</a>
+  <ul>
+  <li>boils, <a href="#Pg_562">562</a></li>
+  <li>cardinal symptoms of disease of, <a href="#Pg_554">554</a></li>
+  <li>deafness, <a href="#Pg_553">553</a>, <a href="#Pg_554">554</a></li>
+  <li>deformities of, <a href="#Pg_560">560</a></li>
+  <li>discharge from, <a href="#Pg_555">555</a></li>
+  <li>earache, <a href="#Pg_554">554</a></li>
+  <li>eczema of, <a href="#Pg_562">562</a></li>
+  <li>foreign bodies in, <a href="#Pg_563">563</a></li>
+  <li>furunculosis of, <a href="#Pg_562">562</a></li>
+  <li>hearing tests, <a href="#Pg_555">555</a></li>
+  <li>inspection of, <a href="#Pg_556">556</a></li>
+  <li>middle, acute infection of, <a href="#Pg_564">564</a>
+    <ul>
+    <li>chronic suppuration in, <a href="#Pg_565">565</a></li>
+    <li>inflation of, <a href="#Pg_558">558</a></li>
+    </ul></li>
+  <li>noises in, <a href="#Pg_554">554</a></li>
+  <li>otorrh&oelig;a, <a href="#Pg_555">555</a></li>
+  <li>outstanding, <a href="#Pg_560">560</a></li>
+  <li>pain in, <a href="#Pg_554">554</a></li>
+  <li>physiology of, <a href="#Pg_553">553</a></li>
+  <li>polypi, <a href="#Pg_558">558</a></li>
+  <li>rupture of membrane of, <a href="#Pg_563">563</a></li>
+  <li>syringing of, <a href="#Pg_561">561</a></li>
+  <li>surgical anatomy of, <a href="#Pg_553">553</a></li>
+  <li>tumours of, <a href="#Pg_560">560</a></li>
+  <li>vertigo, <a href="#Pg_555">555</a></li>
+  <li>wax in, <a href="#Pg_561">561</a></li>
+  </ul></li>
+
+<li>Earache, <a href="#Pg_554">554</a></li>
+
+<li>Ectropion, <a href="#Pg_483">483</a></li>
+
+<li>Elbow, ankylosis of, <a href="#Pg_208">208</a>
+  <ul>
+  <li>arthritis deformans of, <a href="#Pg_208">208</a></li>
+  <li>diseases of, <a href="#Pg_205">205</a></li>
+  <li>dislocations, congenital, <a href="#Pg_308">308</a>
+    <ul>
+    <li>paralytic, <a href="#Pg_308">308</a></li>
+    <li>traumatic, <a href="#Pg_88">88</a>, <a href="#Pg_92">92</a></li>
+    </ul></li>
+  <li>examination of, <a href="#Pg_80">80</a></li>
+  <li>injuries in region of, <a href="#Pg_79">79</a></li>
+  <li>neuro-arthropathies of, <a href="#Pg_208">208</a></li>
+  <li>pyogenic diseases of, <a href="#Pg_208">208</a></li>
+  <li>sprain of, <a href="#Pg_96">96</a></li>
+  <li>surgical anatomy of, <a href="#Pg_79">79</a></li>
+  <li>tennis player's, <a href="#Pg_97">97</a></li>
+  <li>tuberculous disease of, <a href="#Pg_206">206</a></li>
+  </ul></li>
+
+<li>Empyema of knee, <a href="#Pg_232">232</a></li>
+
+<li>Encephalitis, <a href="#Pg_376">376</a>, <a href="#Pg_377">377</a></li>
+
+<li>Encephalocele, <a href="#Pg_388">388</a>, <a href="#Pg_389">389</a></li>
+
+<li>Epicritic sensibility, <a href="#Pg_332">332</a></li>
+
+<li>Epilepsy, <a href="#Pg_397">397</a>
+  <ul>
+  <li><a class="pagenum" name="Pg_648" id="Pg_648"></a>Jacksonian, <a href="#Pg_359">359</a></li>
+  <li>traumatic, <a href="#Pg_358">358</a></li>
+  </ul></li>
+
+<li>Epiphyses, separation of. <i>See</i> Individual Bones</li>
+
+<li>Epistaxis, <a href="#Pg_575">575</a></li>
+
+<li>Epulis, <a href="#Pg_513">513</a></li>
+
+<li>Ethmoidal cells, suppuration in, <a href="#Pg_577">577</a>, <a href="#Pg_578">578</a></li>
+
+<li>Eustachian catheter, <a href="#Pg_558">558</a></li>
+
+<li>Extension by Hodgen's splint, <a href="#Pg_151">151</a>, <a href="#Pg_159">159</a>
+  <ul>
+  <li>by ice-tong callipers, <a href="#Pg_150">150</a>, <a href="#Pg_158">158</a></li>
+  <li>by perineal band, <a href="#Pg_152">152</a></li>
+  <li>by Steinmann's apparatus, <a href="#Pg_150">150</a></li>
+  <li>vertical, <a href="#Pg_154">154</a></li>
+  <li>by weight and pulley, <a href="#Pg_220">220</a></li>
+  </ul></li>
+
+<li>Extra-dural abscess, <a href="#Pg_374">374</a></li>
+
+<li>Eyeball, injuries of, <a href="#Pg_486">486</a></li>
+
+<li>Eyelids, wounds of, <a href="#Pg_484">484</a></li>
+</ul>
+
+<ul>
+<li><a name="IX_F" id="IX_F"></a>Face, cicatricial contraction of, <a href="#Pg_483">483</a>
+  <ul>
+  <li>congenital malformations of, <a href="#Pg_474">474</a>, <a href="#Pg_481">481</a></li>
+  <li>development of, <a href="#Pg_474">474</a></li>
+  <li>diseases of, <a href="#Pg_483">483</a></li>
+  <li>epithelioma of, <a href="#Pg_484">484</a></li>
+  <li>frog-, <a href="#Pg_581">581</a></li>
+  <li>injuries of, <a href="#Pg_482">482</a></li>
+  <li>rodent cancer of, <a href="#Pg_484">484</a></li>
+  <li>tumours of, <a href="#Pg_484">484</a></li>
+  </ul></li>
+
+<li>Facial cleft, <a href="#Pg_481">481</a>
+  <ul>
+  <li>nerve, <a href="#Pg_400">400</a></li>
+  <li>paralysis, <a href="#Pg_400">400</a></li>
+  <li>spasm, <a href="#Pg_403">403</a></li>
+  </ul></li>
+
+<li>Facio-hypoglossal anastomosis, <a href="#Pg_403">403</a></li>
+
+<li>False joint, <a href="#Pg_12">12</a></li>
+
+<li>Fat embolism in fractures, <a href="#Pg_19">19</a></li>
+
+<li>Femur, fracture of, in children, <a href="#Pg_135">135</a>, <a href="#Pg_154">154</a>
+  <ul>
+    <li><ul>
+    <li>of condyles of, <a href="#Pg_162">162</a></li>
+    <li>of greater trochanter of, <a href="#Pg_139">139</a></li>
+    <li>of head of, <a href="#Pg_129">129</a></li>
+    <li>just below lesser trochanter of, <a href="#Pg_139">139</a></li>
+    <li>of lower end of, <a href="#Pg_157">157</a></li>
+    <li>of neck of, <a href="#Pg_130">130</a></li>
+    <li>of shaft of, <a href="#Pg_148">148</a></li>
+    <li>of upper end of, <a href="#Pg_129">129</a></li>
+    </ul></li>
+  <li>incurvation of neck of, <a href="#Pg_257">257</a></li>
+  <li>separation of epiphyses of, <a href="#Pg_129">129</a>, <a href="#Pg_139">139</a>, <a href="#Pg_161">161</a></li>
+  </ul></li>
+
+<li>Fibula, absence of, <a href="#Pg_272">272</a>
+  <ul>
+  <li>dislocation of, total, <a href="#Pg_167">167</a></li>
+  <li>fracture of, <a href="#Pg_165">165</a>, <a href="#Pg_178">178</a>, <a href="#Pg_183">183</a></li>
+  </ul></li>
+
+<li>Fingers, congenital contraction of, <a href="#Pg_313">313</a>
+  <ul>
+  <li>deficiencies, <a href="#Pg_317">317</a></li>
+  <li>deformities of, <a href="#Pg_313">313</a></li>
+  <li>dislocation of, <a href="#Pg_121">121</a></li>
+  <li>drop-, <a href="#Pg_121">121</a>, <a href="#Pg_318">318</a></li>
+  <li>Dupuytren's contraction of, <a href="#Pg_314">314</a></li>
+  <li>fractures of, <a href="#Pg_115">115</a></li>
+  <li>hypertrophy of, <a href="#Pg_317">317</a></li>
+  <li>injuries of, <a href="#Pg_115">115</a></li>
+  <li>mallet, <a href="#Pg_121">121</a>, <a href="#Pg_318">318</a></li>
+  <li>supernumerary, <a href="#Pg_316">316</a></li>
+  <li>trigger, <a href="#Pg_318">318</a></li>
+  <li>webbed, <a href="#Pg_317">317</a></li>
+  </ul></li>
+
+<li>Flat-foot, <a href="#Pg_285">285</a>
+  <ul>
+  <li>adolescent, <a href="#Pg_287">287</a></li>
+  <li>degrees of, <a href="#Pg_291">291</a></li>
+  <li>exercises for, <a href="#Pg_291">291</a></li>
+  <li>paralytic, <a href="#Pg_292">292</a></li>
+  <li>spasmodic, <a href="#Pg_292">292</a></li>
+  <li>static, <a href="#Pg_287">287</a></li>
+  <li>traumatic, <a href="#Pg_293">293</a></li>
+  <li>varieties of, <a href="#Pg_287">287</a>, <a href="#Pg_294">294</a></li>
+  </ul></li>
+
+<li>Foerster's operation, <a href="#Pg_247">247</a></li>
+
+<li>Foot, club-, <a href="#Pg_273">273</a>
+  <ul>
+  <li>deformities of, <a href="#Pg_273">273</a></li>
+  <li>flat-, <a href="#Pg_285">285</a></li>
+  <li>hollow claw-, <a href="#Pg_284">284</a></li>
+  <li>injuries of, <a href="#Pg_185">185</a></li>
+  <li>movements of, <a href="#Pg_185">185</a></li>
+  <li>splay-, <a href="#Pg_285">285</a></li>
+  <li>surgical anatomy of, <a href="#Pg_185">185</a></li>
+  </ul></li>
+
+<li>Foot and mouth disease, <a href="#Pg_530">530</a></li>
+
+<li>Footballer's knee, <a href="#Pg_172">172</a></li>
+
+<li>Forearm, deformities of, <a href="#Pg_310">310</a>
+  <ul>
+  <li>fracture of both bones of, <a href="#Pg_97">97</a></li>
+  <li>injuries of, <a href="#Pg_79">79</a></li>
+  <li>intra-uterine amputation of, <a href="#Pg_311">311</a></li>
+  </ul></li>
+
+<li>Fracture, <a href="#Pg_1">1</a>. <i>See also</i> Individual Bones
+  <ul>
+  <li>amputation in, <a href="#Pg_26">26</a></li>
+  <li>badly united, <a href="#Pg_10">10</a></li>
+  <li>Bennett's, <a href="#Pg_116">116</a></li>
+  <li>during birth, <a href="#Pg_3">3</a></li>
+  <li>chauffeur's, <a href="#Pg_106">106</a></li>
+  <li>clinical varieties of, <a href="#Pg_4">4</a></li>
+  <li>Colles', <a href="#Pg_102">102</a></li>
+  <li>comminuted, <a href="#Pg_6">6</a></li>
+  <li>complications of, <a href="#Pg_18">18</a></li>
+  <li>compound, <a href="#Pg_5">5</a>, <a href="#Pg_24">24</a></li>
+  <li>crepitus in, <a href="#Pg_15">15</a></li>
+  <li>deformity in, <a href="#Pg_15">15</a></li>
+  <li>delayed union, <a href="#Pg_11">11</a></li>
+  <li><a class="pagenum" name="Pg_649" id="Pg_649"></a>depressed, <a href="#Pg_5">5</a>, <a href="#Pg_7">7</a></li>
+  <li>with dislocation, <a href="#Pg_40">40</a></li>
+  <li>displacement of fragments in, <a href="#Pg_7">7</a></li>
+  <li>Dupuytren's, <a href="#Pg_196">196</a></li>
+  <li>extension in, <a href="#Pg_26">26</a></li>
+  <li>fat embolism in, <a href="#Pg_19">19</a></li>
+  <li>fever in, <a href="#Pg_18">18</a></li>
+  <li>fibrous union of, <a href="#Pg_12">12</a></li>
+  <li>fissured, <a href="#Pg_5">5</a></li>
+  <li>greenstick, <a href="#Pg_5">5</a>, <a href="#Pg_98">98</a></li>
+  <li>gun-shot, <a href="#Pg_27">27</a></li>
+  <li>indentation, <a href="#Pg_5">5</a></li>
+  <li>intra-uterine, <a href="#Pg_3">3</a></li>
+  <li>Jones', <a href="#Pg_194">194</a></li>
+  <li>longitudinal, <a href="#Pg_6">6</a></li>
+  <li>mal-union of, <a href="#Pg_10">10</a>, <a href="#Pg_99">99</a>, <a href="#Pg_183">183</a></li>
+  <li>massage in, <a href="#Pg_21">21</a></li>
+  <li>mechanism of, <a href="#Pg_14">14</a></li>
+  <li>multiple, <a href="#Pg_6">6</a></li>
+  <li>non-union, <a href="#Pg_9">9</a>, <a href="#Pg_12">12</a></li>
+  <li>oblique, <a href="#Pg_6">6</a></li>
+  <li>old-standing, <a href="#Pg_87">87</a></li>
+  <li>open, <a href="#Pg_5">5</a></li>
+  <li>operation in, <a href="#Pg_24">24</a></li>
+  <li>pain in, <a href="#Pg_17">17</a></li>
+  <li>passive hyper&aelig;mia in, <a href="#Pg_12">12</a></li>
+  <li>pathological, <a href="#Pg_1">1</a></li>
+  <li>prognosis in, <a href="#Pg_19">19</a>, <a href="#Pg_25">25</a></li>
+  <li>radiography in, <a href="#Pg_16">16</a></li>
+  <li>reduction of, <a href="#Pg_20">20</a></li>
+  <li>repair of, <a href="#Pg_8">8</a></li>
+  <li>retention of, <a href="#Pg_21">21</a></li>
+  <li>setting of, <a href="#Pg_20">20</a></li>
+  <li>shock in, <a href="#Pg_18">18</a></li>
+  <li>simple, <a href="#Pg_4">4</a>, <a href="#Pg_8">8</a>, <a href="#Pg_14">14</a>, <a href="#Pg_19">19</a>, <a href="#Pg_24">24</a></li>
+  <li>Smith's, <a href="#Pg_106">106</a></li>
+  <li>spiral, <a href="#Pg_6">6</a></li>
+  <li>splints in, <a href="#Pg_22">22</a></li>
+  <li>sprain-, <a href="#Pg_35">35</a></li>
+  <li>subcutaneous, <a href="#Pg_4">4</a></li>
+  <li>sub-periosteal, <a href="#Pg_6">6</a></li>
+  <li>transverse, <a href="#Pg_6">6</a></li>
+  <li>traumatic, <a href="#Pg_3">3</a></li>
+  <li>treatment of, <a href="#Pg_20">20</a>, <a href="#Pg_25">25</a></li>
+  <li>un-united, <a href="#Pg_12">12</a>, <a href="#Pg_78">78</a>, <a href="#Pg_100">100</a>, <a href="#Pg_101">101</a>, <a href="#Pg_183">183</a></li>
+  <li>varieties of, <a href="#Pg_4">4</a></li>
+  <li>violence, forms of, causing, <a href="#Pg_3">3</a></li>
+  <li>X-rays in, <a href="#Pg_16">16</a></li>
+  </ul></li>
+
+<li>Frog-face, <a href="#Pg_581">581</a></li>
+
+<li>Frontal sinus, suppuration in, <a href="#Pg_577">577</a></li>
+</ul>
+
+<ul>
+<li><a name="IX_G" id="IX_G"></a>Gampsodactyly, <a href="#Pg_302">302</a></li>
+
+<li>Genu recurvatum, <a href="#Pg_263">263</a>
+  <ul>
+  <li>valgum, <a href="#Pg_264">264</a>, <a href="#Pg_265">265</a></li>
+  <li>varum, <a href="#Pg_264">264</a>, <a href="#Pg_271">271</a></li>
+  </ul></li>
+
+<li>Gingivitis, <a href="#Pg_508">508</a></li>
+
+<li>Girdle-pain, <a href="#Pg_419">419</a></li>
+
+<li>Glands, lymph. <i>See</i> Lymph Glands</li>
+
+<li>Globus hystericus, <a href="#Pg_624">624</a></li>
+
+<li>Glomus carotica, tumours of, <a href="#Pg_603">603</a></li>
+
+<li>Glossitis, <a href="#Pg_530">530</a>, <a href="#Pg_533">533</a></li>
+
+<li>Glosso-pharyngeal nerve, <a href="#Pg_403">403</a></li>
+
+<li>Goitre, <a href="#Pg_605">605</a>
+  <ul>
+  <li>adenomatous, <a href="#Pg_610">610</a></li>
+  <li>colloid, <a href="#Pg_607">607</a></li>
+  <li>cystic, <a href="#Pg_607">607</a></li>
+  <li>exophthalmic, <a href="#Pg_614">614</a></li>
+  <li>fibrous, <a href="#Pg_607">607</a></li>
+  <li>intra-thoracic, <a href="#Pg_607">607</a>, <a href="#Pg_609">609</a>, <a href="#Pg_613">613</a></li>
+  <li>malignant, <a href="#Pg_612">612</a></li>
+  <li>non-toxic, <a href="#Pg_605">605</a></li>
+  <li>parenchymatous, <a href="#Pg_605">605</a></li>
+  <li>retro-sternal, <a href="#Pg_607">607</a>, <a href="#Pg_609">609</a>, <a href="#Pg_613">613</a></li>
+  <li>sudden dyspn&oelig;a in, <a href="#Pg_608">608</a>&ndash;610</li>
+  <li>thyreoidectomy for, <a href="#Pg_610">610</a></li>
+  <li>toxic, <a href="#Pg_614">614</a></li>
+  <li>vascular, <a href="#Pg_607">607</a></li>
+  </ul></li>
+
+<li>Gooch's splinting, <a href="#Pg_22">22</a></li>
+
+<li>Graefe's symptom, <a href="#Pg_614">614</a></li>
+
+<li>Graves' disease, <a href="#Pg_614">614</a></li>
+
+<li>Gravitation paraplegia, <a href="#Pg_414">414</a></li>
+
+<li>Greenstick fracture, <a href="#Pg_5">5</a></li>
+
+<li>Gumboil, <a href="#Pg_507">507</a></li>
+
+<li>Gums, affections of, <a href="#Pg_508">508</a></li>
+
+<li>Gun-shot injuries. <i>See</i> Individual Structures</li>
+</ul>
+
+<ul>
+<li><a name="IX_H" id="IX_H"></a>Habitual dislocation, <a href="#Pg_43">43</a></li>
+
+<li>H&aelig;marthrosis, <a href="#Pg_33">33</a></li>
+
+<li>H&aelig;matoma auris, <a href="#Pg_560">560</a>
+  <ul>
+  <li>of periosteum, <a href="#Pg_1">1</a></li>
+  </ul></li>
+
+<li>H&aelig;matomyelia, <a href="#Pg_414">414</a></li>
+
+<li>H&aelig;matorrachis, <a href="#Pg_414">414</a></li>
+
+<li>Hallux dolorosus, <a href="#Pg_298">298</a>
+  <ul>
+  <li>flexus, <a href="#Pg_298">298</a></li>
+  <li>rigidus, <a href="#Pg_298">298</a></li>
+  <li>valgus, <a href="#Pg_296">296</a></li>
+  <li>varus, <a href="#Pg_298">298</a></li>
+  </ul></li>
+
+<li>Hammer nose, <a href="#Pg_570">570</a>
+  <ul>
+  <li>toe, <a href="#Pg_300">300</a></li>
+  </ul></li>
+
+<li><i>Hanche &agrave; ressort</i>, <a href="#Pg_254">254</a></li>
+
+<li>Hand, club-, <a href="#Pg_311">311</a>, <a href="#Pg_312">312</a>
+  <ul>
+  <li>deformities of, <a href="#Pg_310">310</a></li>
+  <li>injuries of, <a href="#Pg_102">102</a></li>
+  <li>surgical anatomy of, <a href="#Pg_102">102</a></li>
+  </ul></li>
+
+<li><a class="pagenum" name="Pg_650" id="Pg_650"></a>Hare-lip, <a href="#Pg_475">475</a></li>
+
+<li>Head injuries, <a href="#Pg_340">340</a>
+  <ul>
+    <li><ul>
+    <li>after-effects of, <a href="#Pg_358">358</a></li>
+    </ul></li>
+  </ul></li>
+
+<li>Hearing, impairment of, <a href="#Pg_554">554</a>
+  <ul>
+  <li>tests of, <a href="#Pg_555">555</a></li>
+  </ul></li>
+
+<li>Heel, painful affections of, <a href="#Pg_294">294</a></li>
+
+<li>Hemianopia, <a href="#Pg_335">335</a></li>
+
+<li>Hemi-glossitis, <a href="#Pg_530">530</a></li>
+
+<li>Hernia cerebri, <a href="#Pg_397">397</a></li>
+
+<li>Hiatal &oelig;sophagismus, <a href="#Pg_624">624</a></li>
+
+<li>Hip, ankylosis of, <a href="#Pg_256">256</a>
+  <ul>
+  <li>arthritis deformans of, <a href="#Pg_226">226</a></li>
+  <li>Charcot's disease of, <a href="#Pg_228">228</a></li>
+  <li>contractures of, <a href="#Pg_256">256</a></li>
+  <li>contusion of, <a href="#Pg_147">147</a></li>
+  <li>disease, <a href="#Pg_209">209</a></li>
+  <li>dislocations, congenital, <a href="#Pg_248">248</a>
+    <ul>
+    <li>old-standing, <a href="#Pg_147">147</a></li>
+    <li>varieties of, <a href="#Pg_126">126</a>, <a href="#Pg_142">142</a></li>
+    </ul></li>
+  <li>examination of, <a href="#Pg_128">128</a>, <a href="#Pg_211">211</a></li>
+  <li>hysterical, <a href="#Pg_229">229</a></li>
+  <li>injuries in region of, <a href="#Pg_127">127</a></li>
+  <li>loose bodies in, <a href="#Pg_229">229</a></li>
+  <li>neuro-arthropathies of, <a href="#Pg_228">228</a></li>
+  <li>osteo-chondritis deformans juvenilis, <a href="#Pg_228">228</a></li>
+  <li>paralytic deformities of, <a href="#Pg_255">255</a></li>
+  <li>Perthes' disease of, <a href="#Pg_228">228</a></li>
+  <li>pyogenic diseases of, <a href="#Pg_224">224</a></li>
+  <li>snapping, <a href="#Pg_254">254</a></li>
+  <li>sprain of, <a href="#Pg_147">147</a></li>
+  <li>surgical anatomy of, <a href="#Pg_128">128</a></li>
+  <li>Thomas' splint for, <a href="#Pg_222">222</a></li>
+  <li>tuberculous disease of, <a href="#Pg_210">210</a>
+    <ul>
+    <li>abscess formation in, <a href="#Pg_217">217</a></li>
+    <li>bilateral, <a href="#Pg_224">224</a></li>
+    <li>deformities following, <a href="#Pg_223">223</a></li>
+    <li>diagnosis of, <a href="#Pg_218">218</a></li>
+    <li>dislocation in, <a href="#Pg_218">218</a></li>
+    <li>stages of, <a href="#Pg_211">211</a></li>
+    <li>treatment of, <a href="#Pg_220">220</a></li>
+    </ul></li>
+  </ul></li>
+
+<li>Histrionic spasm, <a href="#Pg_403">403</a></li>
+
+<li>Hoarseness, <a href="#Pg_635">635</a></li>
+
+<li>Hodgen's splint, <a href="#Pg_151">151</a></li>
+
+<li>Hollow claw-foot, <a href="#Pg_284">284</a></li>
+
+<li>Homonymous hemianopia, <a href="#Pg_335">335</a></li>
+
+<li>Hospital throat, <a href="#Pg_500">500</a></li>
+
+<li>Humerus, fracture, of anatomical neck, <a href="#Pg_74">74</a>
+  <ul>
+  <li>of condyles, <a href="#Pg_80">80</a></li>
+  <li>with dislocation of shoulder, <a href="#Pg_63">63</a></li>
+  <li>of head, <a href="#Pg_70">70</a></li>
+  <li>of lower end, <a href="#Pg_84">84</a></li>
+  <li>of shaft, <a href="#Pg_75">75</a></li>
+  <li>of surgical neck, <a href="#Pg_70">70</a></li>
+  <li>of tuberosities, <a href="#Pg_74">74</a></li>
+  <li>un-united, <a href="#Pg_78">78</a></li>
+  <li>separation of lower epiphysis of, <a href="#Pg_82">82</a>, <a href="#Pg_84">84</a>
+    <ul>
+    <li>of upper epiphysis of, <a href="#Pg_73">73</a></li>
+    </ul></li>
+  </ul></li>
+
+<li>Hunch-back, <a href="#Pg_440">440</a>, <a href="#Pg_444">444</a></li>
+
+<li>Hydrencephalocele, <a href="#Pg_388">388</a>, <a href="#Pg_389">389</a></li>
+
+<li>Hydrocele of neck, <a href="#Pg_599">599</a></li>
+
+<li>Hydrocephalus, <a href="#Pg_391">391</a>
+  <ul>
+  <li>acute, <a href="#Pg_386">386</a>, <a href="#Pg_391">391</a></li>
+  <li>chronic, <a href="#Pg_391">391</a></li>
+  </ul></li>
+
+<li>Hygroma of neck, <a href="#Pg_599">599</a>
+  <ul>
+  <li>sacral, <a href="#Pg_459">459</a></li>
+  </ul></li>
+
+<li>Hyoid bone, fracture of, <a href="#Pg_593">593</a></li>
+
+<li>Hyper&aelig;sthesia acustica, <a href="#Pg_554">554</a></li>
+
+<li>Hyperpituitarism, <a href="#Pg_396">396</a></li>
+
+<li>Hyper-thyreoidism, <a href="#Pg_609">609</a>, <a href="#Pg_614">614</a></li>
+
+<li>Hypoglossal nerve, <a href="#Pg_404">404</a></li>
+
+<li>Hypophysis cerebri, tumours of, <a href="#Pg_396">396</a></li>
+
+<li>Hypopituitarism, <a href="#Pg_396">396</a></li>
+
+<li>Hysterical aphonia, <a href="#Pg_636">636</a>
+  <ul>
+  <li>spine, <a href="#Pg_448">448</a></li>
+  <li>wry-neck, <a href="#Pg_592">592</a></li>
+  </ul></li>
+</ul>
+
+<ul>
+<li><a name="IX_I" id="IX_I"></a>Ice-tong callipers, <a href="#Pg_150">150</a></li>
+
+<li>Iliac abscess, <a href="#Pg_445">445</a>, <a href="#Pg_446">446</a></li>
+
+<li>Ilium, fracture of, <a href="#Pg_126">126</a></li>
+
+<li>Infantile paralysis, <a href="#Pg_242">242</a></li>
+
+<li>Injuries. <i>See</i> Individual Regions</li>
+
+<li>Internal derangements of knee-joint, <a href="#Pg_168">168</a></li>
+
+<li>Inter-phalangeal dislocation, <a href="#Pg_200">200</a></li>
+
+<li>Intra-cranial h&aelig;morrhage, <a href="#Pg_352">352</a>
+  <ul>
+    <li><ul>
+    <li>in newly born, <a href="#Pg_356">356</a></li>
+    </ul></li>
+  <li>syphilis, <a href="#Pg_387">387</a>, <a href="#Pg_395">395</a></li>
+  <li>tuberculosis, <a href="#Pg_386">386</a></li>
+  <li>venous sinuses, injuries of, <a href="#Pg_356">356</a></li>
+  </ul></li>
+
+<li>Intra-uterine amputation, <a href="#Pg_311">311</a></li>
+
+<li>Intubation of larynx, <a href="#Pg_639">639</a>
+  <ul>
+  <li>of &oelig;sophagus, <a href="#Pg_632">632</a></li>
+  </ul></li>
+
+<li>Isch&aelig;mic contracture of muscles, <a href="#Pg_85">85</a>, <a href="#Pg_98">98</a>, <a href="#Pg_310">310</a></li>
+
+<li>Ischium, fracture of, <a href="#Pg_127">127</a></li>
+</ul>
+
+<ul>
+<li><a name="IX_J" id="IX_J"></a>Jacksonian epilepsy, <a href="#Pg_359">359</a>, <a href="#Pg_394">394</a></li>
+
+<li>Jaw, lower. <i>See</i> Mandible
+  <ul>
+  <li>upper. <i>See</i> Maxilla</li>
+  <li><i>See also</i> Temporo-mandibular Joint</li>
+  </ul></li>
+
+<li>Joints. <i>See also</i> Individual Joints
+  <ul>
+  <li>Charcot's disease of, <a href="#Pg_228">228</a>, <a href="#Pg_238">238</a></li>
+  <li><a class="pagenum" name="Pg_651" id="Pg_651"></a>contusions of, <a href="#Pg_33">33</a></li>
+  <li>dislocations of, <a href="#Pg_36">36</a></li>
+  <li>false, <a href="#Pg_12">12</a></li>
+  <li>gun-shot injuries of, <a href="#Pg_34">34</a></li>
+  <li>injuries of, <a href="#Pg_32">32</a></li>
+  <li>sources of strength of, <a href="#Pg_32">32</a></li>
+  <li>sprains of, <a href="#Pg_35">35</a></li>
+  <li>wounds of, <a href="#Pg_34">34</a></li>
+  </ul></li>
+
+<li>Jones' fracture of fifth metatarsal, <a href="#Pg_194">194</a></li>
+</ul>
+
+<ul>
+<li><a name="IX_K" id="IX_K"></a>Kernig's sign, <a href="#Pg_386">386</a></li>
+
+<li>Klapp's four-footed exercises for scoliosis, <a href="#Pg_472">472</a></li>
+
+<li>Knee, ankylosis of, <a href="#Pg_264">264</a>
+  <ul>
+  <li>arthritis deformans of, <a href="#Pg_237">237</a></li>
+  <li>bow-, <a href="#Pg_271">271</a></li>
+  <li>Charcot's disease of, <a href="#Pg_238">238</a></li>
+  <li>cold abscess of, <a href="#Pg_234">234</a></li>
+  <li>contracture of, <a href="#Pg_264">264</a></li>
+  <li>deformities of, <a href="#Pg_236">236</a>, <a href="#Pg_264">264</a></li>
+  <li>diseases of, <a href="#Pg_229">229</a>
+    <ul>
+    <li>pyogenic, <a href="#Pg_237">237</a></li>
+    <li>tuberculous, <a href="#Pg_231">231</a></li>
+    </ul></li>
+  <li>dislocations of, <a href="#Pg_165">165</a>
+    <ul>
+    <li>congenital, <a href="#Pg_262">262</a></li>
+    </ul></li>
+  <li>empyema of, <a href="#Pg_232">232</a></li>
+  <li>footballer's, <a href="#Pg_172">172</a></li>
+  <li>genu-recurvatum, <a href="#Pg_263">263</a>
+    <ul>
+    <li>valgum, <a href="#Pg_265">265</a></li>
+    <li>varum, <a href="#Pg_271">271</a></li>
+    </ul></li>
+  <li>hydrops of, <a href="#Pg_172">172</a></li>
+  <li>hysterical diseases of, <a href="#Pg_238">238</a></li>
+  <li>injuries in region of, <a href="#Pg_155">155</a></li>
+  <li>injuries of semilunar menisci, <a href="#Pg_167">167</a></li>
+  <li>internal derangement of, <a href="#Pg_168">168</a></li>
+  <li>knock-, <a href="#Pg_265">265</a></li>
+  <li>loose bodies in, <a href="#Pg_238">238</a></li>
+  <li>rugby, <a href="#Pg_165">165</a></li>
+  <li>rupture of cruciate ligaments of, <a href="#Pg_171">171</a></li>
+  <li>sprains of, <a href="#Pg_171">171</a></li>
+  <li>surgical anatomy of, <a href="#Pg_155">155</a></li>
+  <li>tuberculous disease of, <a href="#Pg_231">231</a>
+    <ul>
+    <li>clinical types of, <a href="#Pg_231">231</a></li>
+    <li>deformities following, <a href="#Pg_236">236</a></li>
+    <li>extra-articular abscess in, <a href="#Pg_234">234</a></li>
+    </ul></li>
+  <li>white swelling of, <a href="#Pg_233">233</a></li>
+  </ul></li>
+
+<li>Knock-knee, <a href="#Pg_265">265</a></li>
+
+<li>Kocher's method of reducing dislocation of shoulder, <a href="#Pg_58">58</a></li>
+
+<li>Kyphosis, <a href="#Pg_461">461</a>, <a href="#Pg_462">462</a></li>
+</ul>
+
+<ul>
+<li><a name="IX_L" id="IX_L"></a>Laryngitis, <a href="#Pg_637">637</a></li>
+
+<li>Laryngoscopy, <a href="#Pg_635">635</a></li>
+
+<li>Larynx, cancer of, <a href="#Pg_641">641</a>
+  <ul>
+  <li>cardinal symptoms of affections of, <a href="#Pg_635">635</a></li>
+  <li>diphtheria of, <a href="#Pg_637">637</a></li>
+  <li>examination of, <a href="#Pg_634">634</a></li>
+  <li>foreign bodies in, <a href="#Pg_642">642</a></li>
+  <li>fracture of, <a href="#Pg_593">593</a></li>
+  <li>inflammation of, <a href="#Pg_637">637</a></li>
+  <li>intubation of, <a href="#Pg_639">639</a></li>
+  <li>&oelig;dema of, <a href="#Pg_637">637</a></li>
+  <li>paralysis of, <a href="#Pg_639">639</a></li>
+  <li>surgical anatomy of, <a href="#Pg_634">634</a></li>
+  <li>syphilis of, <a href="#Pg_639">639</a></li>
+  <li>tuberculosis of, <a href="#Pg_640">640</a></li>
+  <li>tumours of, <a href="#Pg_640">640</a></li>
+  <li>wounds of, <a href="#Pg_594">594</a></li>
+  </ul></li>
+
+<li>Laryngo-tracheotomy, <a href="#Pg_638">638</a></li>
+
+<li>Lateral curvature of spine, <a href="#Pg_463">463</a>
+  <ul>
+  <li>sinus. <i>See</i> Transverse Sinus</li>
+  <li>ventricles, bursting of abscess into, <a href="#Pg_381">381</a>
+    <ul>
+    <li>h&aelig;morrhage into, <a href="#Pg_342">342</a></li>
+    </ul></li>
+  </ul></li>
+
+<li>Leg, bow-, <a href="#Pg_271">271</a>
+  <ul>
+  <li>fracture of bones of, <a href="#Pg_178">178</a></li>
+  <li>congenital deficiencies of, <a href="#Pg_272">272</a></li>
+  <li>injuries of, <a href="#Pg_155">155</a></li>
+  <li>rickety deformities of, <a href="#Pg_271">271</a></li>
+  </ul></li>
+
+<li>Lepto-meningitis, <a href="#Pg_376">376</a></li>
+
+<li>Leucokeratosis, <a href="#Pg_530">530</a></li>
+
+<li>Leucoplakia, <a href="#Pg_530">530</a></li>
+
+<li>Ligaments, cruciate, rupture of, <a href="#Pg_171">171</a></li>
+
+<li>Lingual dermoids, <a href="#Pg_537">537</a></li>
+
+<li>Lip, chancre of, <a href="#Pg_491">491</a>
+  <ul>
+  <li>chronic induration of, <a href="#Pg_491">491</a></li>
+  <li>cracks of, <a href="#Pg_491">491</a></li>
+  <li>cysts of, <a href="#Pg_493">493</a></li>
+  <li>double-lip, <a href="#Pg_491">491</a></li>
+  <li>epithelioma of, <a href="#Pg_493">493</a></li>
+  <li>fistul&aelig; of, <a href="#Pg_482">482</a></li>
+  <li>hare-lip, <a href="#Pg_475">475</a></li>
+  <li>herpes of, <a href="#Pg_490">490</a></li>
+  <li>lymphangioma of, <a href="#Pg_492">492</a></li>
+  <li>macrocheilia, <a href="#Pg_492">492</a></li>
+  <li>mucous cysts of, <a href="#Pg_493">493</a></li>
+  <li>strumous, <a href="#Pg_491">491</a></li>
+  <li>syphilis of, <a href="#Pg_491">491</a></li>
+  <li>tuberculosis of, <a href="#Pg_491">491</a></li>
+  <li>tumours of, <a href="#Pg_492">492</a></li>
+  <li>ulcers of, <a href="#Pg_491">491</a></li>
+  </ul></li>
+
+<li>Lipoma nasi, <a href="#Pg_570">570</a></li>
+
+<li>Liston's long splint, <a href="#Pg_152">152</a></li>
+
+<li><a class="pagenum" name="Pg_652" id="Pg_652"></a>Little's disease, <a href="#Pg_247">247</a>, <a href="#Pg_357">357</a></li>
+
+<li>Longitudinal sinus, phlebitis of, <a href="#Pg_385">385</a></li>
+
+<li>Lordosis, <a href="#Pg_461">461</a></li>
+
+<li>Ludwig's angina, <a href="#Pg_548">548</a>, <a href="#Pg_597">597</a></li>
+
+<li>Lumbar abscess, <a href="#Pg_445">445</a>
+  <ul>
+  <li>puncture, <a href="#Pg_338">338</a></li>
+  </ul></li>
+
+<li>Lunate bone, dislocation of, <a href="#Pg_114">114</a>
+  <ul>
+    <li><ul>
+    <li>fracture of, <a href="#Pg_110">110</a></li>
+    </ul></li>
+  </ul></li>
+
+<li>Luxation. <i>See</i> Dislocation</li>
+
+<li>Lymphangiomatous macroglossia, <a href="#Pg_540">540</a></li>
+</ul>
+
+<ul>
+<li><a name="IX_M" id="IX_M"></a>Macrocheilia, <a href="#Pg_492">492</a></li>
+
+<li>Macroglossia, <a href="#Pg_540">540</a></li>
+
+<li>Macrostoma, <a href="#Pg_481">481</a></li>
+
+<li>Madelung's deformity of wrist, <a href="#Pg_313">313</a></li>
+
+<li>Malar bone. <i>See</i> Zygomatic Bone</li>
+
+<li>Malformations. <i>See</i> Individual Regions</li>
+
+<li>Mallet finger, <a href="#Pg_318">318</a></li>
+
+<li>Mandible, actinomycosis of, <a href="#Pg_512">512</a>
+  <ul>
+  <li>cleft of, <a href="#Pg_481">481</a></li>
+  <li>dentigerous cyst of, <a href="#Pg_517">517</a></li>
+  <li>dislocation of, <a href="#Pg_523">523</a>
+    <ul>
+    <li>old-standing, <a href="#Pg_524">524</a></li>
+    </ul></li>
+  <li>fixation of, <a href="#Pg_526">526</a></li>
+  <li>tumours of, <a href="#Pg_517">517</a></li>
+  </ul></li>
+
+<li>Manus valga, <a href="#Pg_109">109</a>, <a href="#Pg_313">313</a>
+  <ul>
+  <li>vara, <a href="#Pg_313">313</a></li>
+  </ul></li>
+
+<li>Massage in fractures, <a href="#Pg_21">21</a></li>
+
+<li>Mastoid, suppuration in, <a href="#Pg_566">566</a></li>
+
+<li>Maxilla, affections of, <a href="#Pg_510">510</a>
+  <ul>
+  <li>fracture of, <a href="#Pg_519">519</a></li>
+  <li>tumours of, <a href="#Pg_514">514</a></li>
+  </ul></li>
+
+<li>Maxillary sinus, suppuration in, <a href="#Pg_577">577</a></li>
+
+<li>Meninges, surgical anatomy of, <a href="#Pg_328">328</a></li>
+
+<li>Meningitis, <a href="#Pg_360">360</a>, <a href="#Pg_374">374</a>
+  <ul>
+  <li>basal, <a href="#Pg_377">377</a></li>
+  <li>cerebro-spinal, <a href="#Pg_378">378</a></li>
+  <li>serous, <a href="#Pg_377">377</a></li>
+  <li>spinal, acute, <a href="#Pg_453">453</a>
+    <ul>
+    <li>chronic, <a href="#Pg_452">452</a></li>
+    <li>tuberculous, <a href="#Pg_433">433</a></li>
+    </ul></li>
+  <li>syphilitic, <a href="#Pg_387">387</a></li>
+  <li>tuberculous, <a href="#Pg_386">386</a></li>
+  </ul></li>
+
+<li>Meningocele, <a href="#Pg_388">388</a>
+  <ul>
+  <li>spinal, <a href="#Pg_454">454</a></li>
+  </ul></li>
+
+<li>Meningo-encephalitis, <a href="#Pg_376">376</a></li>
+
+<li>Meningo-myelocele, <a href="#Pg_454">454</a></li>
+
+<li>Mercurial gingivitis, <a href="#Pg_508">508</a>
+  <ul>
+  <li>glossitis, <a href="#Pg_530">530</a></li>
+  </ul></li>
+
+<li>Metacarpals, fracture of, <a href="#Pg_115">115</a>, <a href="#Pg_116">116</a></li>
+
+<li>Metatarsals, diseases of, <a href="#Pg_240">240</a>
+  <ul>
+  <li>fracture of, <a href="#Pg_194">194</a></li>
+  </ul></li>
+
+<li>Metatarsalgia, <a href="#Pg_295">295</a></li>
+
+<li>Micrencephaly, <a href="#Pg_393">393</a></li>
+
+<li>Microstoma, <a href="#Pg_481">481</a></li>
+
+<li>Middeldorpf's splint, <a href="#Pg_72">72</a></li>
+
+<li>Middle-ear disease, cerebral abscess due to, <a href="#Pg_378">378</a></li>
+
+<li>Middle meningeal h&aelig;morrhage, <a href="#Pg_352">352</a></li>
+
+<li>Mid-tarsal dislocation, <a href="#Pg_199">199</a></li>
+
+<li>Miller's method of reducing dislocation of shoulder, <a href="#Pg_60">60</a></li>
+
+<li>Mobile semilunar meniscus, <a href="#Pg_168">168</a></li>
+
+<li>Morbus cox&aelig;, <a href="#Pg_210">210</a></li>
+
+<li>Morton's disease, <a href="#Pg_295">295</a></li>
+
+<li>Motor areas, <a href="#Pg_330">330</a>
+  <ul>
+  <li>tracts, <a href="#Pg_331">331</a></li>
+  </ul></li>
+
+<li>Mouth, affections of, <a href="#Pg_496">496</a>
+  <ul>
+  <li>floor of, <a href="#Pg_499">499</a></li>
+  <li>roof of, <a href="#Pg_498">498</a></li>
+  </ul></li>
+
+<li>Mumps, <a href="#Pg_546">546</a></li>
+
+<li>Musculo-spiral nerve. <i>See</i> Radial Nerve</li>
+
+<li>Myelitis, compression, <a href="#Pg_453">453</a>
+  <ul>
+  <li>h&aelig;morrhagic, <a href="#Pg_453">453</a></li>
+  <li>spinal, <a href="#Pg_453">453</a></li>
+  <li>syphilitic, <a href="#Pg_453">453</a></li>
+  <li>tuberculous, <a href="#Pg_433">433</a></li>
+  </ul></li>
+
+<li>Myelocele, <a href="#Pg_455">455</a></li>
+
+<li>Myx&oelig;dema, post-operative, <a href="#Pg_610">610</a></li>
+</ul>
+
+<ul>
+<li><a name="IX_N" id="IX_N"></a>Nasal affections. <i>See</i> Nose
+  <ul>
+  <li>bones, fracture of, <a href="#Pg_567">567</a></li>
+  <li>ducts, injuries of, <a href="#Pg_567">567</a></li>
+  </ul></li>
+
+<li>Naso-pharynx, affections of, <a href="#Pg_567">567</a>
+  <ul>
+  <li>tumours of, <a href="#Pg_580">580</a></li>
+  </ul></li>
+
+<li>Navicular bone, dislocation of, <a href="#Pg_115">115</a>
+  <ul>
+  <li>fracture of, <a href="#Pg_110">110</a>, <a href="#Pg_194">194</a></li>
+  </ul></li>
+
+<li>Neck, actinomycosis of, <a href="#Pg_598">598</a>
+  <ul>
+  <li>boils of, <a href="#Pg_598">598</a></li>
+  <li>branchial carcinoma, <a href="#Pg_160">160</a></li>
+  <li>bursal swellings in, <a href="#Pg_599">599</a></li>
+  <li>carbuncles of, <a href="#Pg_598">598</a></li>
+  <li>cellulitis of, <a href="#Pg_597">597</a></li>
+  <li>cervical auricles, <a href="#Pg_583">583</a>
+    <ul>
+    <li>fascia, <a href="#Pg_583">583</a></li>
+    <li>ribs, <a href="#Pg_585">585</a></li>
+    </ul></li>
+  <li>cicatricial contraction of, <a href="#Pg_592">592</a></li>
+  <li>contusion of, <a href="#Pg_592">592</a></li>
+  <li>cystic lymphangioma of, <a href="#Pg_599">599</a></li>
+  <li>cysts of, <a href="#Pg_598">598</a>
+    <ul>
+    <li>blood, <a href="#Pg_599">599</a></li>
+    <li>branchial, <a href="#Pg_598">598</a></li>
+    <li>bursal, <a href="#Pg_599">599</a></li>
+    <li>dermoid, <a href="#Pg_598">598</a></li>
+    </ul></li>
+  <li><a class="pagenum" name="Pg_653" id="Pg_653"></a>fistul&aelig; of, <a href="#Pg_584">584</a>, <a href="#Pg_585">585</a></li>
+  <li>hydrocele of, <a href="#Pg_599">599</a></li>
+  <li>hygroma of, <a href="#Pg_599">599</a></li>
+  <li>injuries of, <a href="#Pg_592">592</a></li>
+  <li>malformations of, <a href="#Pg_583">583</a></li>
+  <li>paraffin epithelioma of, <a href="#Pg_602">602</a></li>
+  <li>potato-like tumour of, <a href="#Pg_603">603</a></li>
+  <li>stiff, <a href="#Pg_587">587</a></li>
+  <li>surgical anatomy of, <a href="#Pg_582">582</a></li>
+  <li>thyreo-glossal cysts in, <a href="#Pg_538">538</a></li>
+  <li>tumours of, <a href="#Pg_598">598</a>, <a href="#Pg_599">599</a></li>
+  <li>wounds of, <a href="#Pg_593">593</a></li>
+  <li>wry-, <a href="#Pg_587">587</a></li>
+  </ul></li>
+
+<li>N&eacute;laton's line, <a href="#Pg_129">129</a></li>
+
+<li>Nerve anastomosis, <a href="#Pg_246">246</a></li>
+
+<li>Nerve roots, injuries of, <a href="#Pg_420">420</a></li>
+
+<li>Neuralgia, trigeminal, <a href="#Pg_400">400</a></li>
+
+<li>Neuro-arthropathies. <i>See</i> Individual Joints</li>
+
+<li>Neurone lesions, <a href="#Pg_334">334</a></li>
+
+<li>Node, traumatic, <a href="#Pg_1">1</a></li>
+
+<li>Nose, adenoids, <a href="#Pg_578">578</a>
+  <ul>
+  <li>anomalies of smell, <a href="#Pg_578">578</a></li>
+  <li>artificial, <a href="#Pg_570">570</a></li>
+  <li>asthma, reflex, <a href="#Pg_578">578</a></li>
+  <li>bleeding from, <a href="#Pg_575">575</a></li>
+  <li>carcinoma of, <a href="#Pg_573">573</a></li>
+  <li>cardinal symptoms of nasal affections, <a href="#Pg_571">571</a></li>
+  <li>concretions in, <a href="#Pg_575">575</a></li>
+  <li>deformities of, <a href="#Pg_568">568</a></li>
+  <li>discharge from, <a href="#Pg_574">574</a></li>
+  <li>displacement of cartilages of, <a href="#Pg_567">567</a></li>
+  <li>emphysema of, <a href="#Pg_568">568</a></li>
+  <li>erectile swelling of, <a href="#Pg_572">572</a></li>
+  <li>examination of, <a href="#Pg_570">570</a></li>
+  <li>foreign bodies in, <a href="#Pg_574">574</a>, <a href="#Pg_576">576</a></li>
+  <li>fracture of, <a href="#Pg_567">567</a></li>
+  <li>hammer, <a href="#Pg_570">570</a></li>
+  <li>lipoma nasi, <a href="#Pg_570">570</a></li>
+  <li>obstruction of, <a href="#Pg_572">572</a></li>
+  <li>oz&aelig;na, <a href="#Pg_575">575</a></li>
+  <li>polypi of, <a href="#Pg_573">573</a></li>
+  <li>potato, <a href="#Pg_570">570</a></li>
+  <li>reflex symptoms, <a href="#Pg_578">578</a></li>
+  <li>rhinitis, <a href="#Pg_575">575</a></li>
+  <li>rhinoliths, <a href="#Pg_575">575</a></li>
+  <li>rhinophyma, <a href="#Pg_570">570</a></li>
+  <li>saddle, <a href="#Pg_567">567</a>, <a href="#Pg_568">568</a></li>
+  <li>sarcoma of, <a href="#Pg_580">580</a></li>
+  <li>septum of, deviations, <a href="#Pg_573">573</a>
+    <ul>
+    <li>h&aelig;matoma, <a href="#Pg_573">573</a></li>
+    <li>ridges, <a href="#Pg_573">573</a></li>
+    <li>spines, <a href="#Pg_573">573</a></li>
+    </ul></li>
+  <li>sunken-bridge, <a href="#Pg_568">568</a></li>
+  <li>suppuration in accessory sinuses, <a href="#Pg_576">576</a></li>
+  <li>swelling of turbinated bones, <a href="#Pg_572">572</a></li>
+  <li>traumatic saddle, <a href="#Pg_567">567</a></li>
+  </ul></li>
+
+<li>Nystagmus, labyrinthine, <a href="#Pg_555">555</a></li>
+</ul>
+
+<ul>
+<li><a name="IX_O" id="IX_O"></a>Oculo-motor nerve, <a href="#Pg_399">399</a></li>
+
+<li>Odontoid process, fracture of, <a href="#Pg_430">430</a></li>
+
+<li>Odontoma, <a href="#Pg_517">517</a></li>
+
+<li>&OElig;dema glottidis, <a href="#Pg_637">637</a></li>
+
+<li>&OElig;sophagismus, hiatal, <a href="#Pg_624">624</a></li>
+
+<li>&OElig;sophagitis, <a href="#Pg_623">623</a></li>
+
+<li>&OElig;sophagoscopy, <a href="#Pg_617">617</a></li>
+
+<li>&OElig;sophagospasm, <a href="#Pg_624">624</a></li>
+
+<li>&OElig;sophagus, carcinoma of, <a href="#Pg_629">629</a>, <a href="#Pg_631">631</a>
+  <ul>
+  <li>cicatricial contraction of, <a href="#Pg_628">628</a></li>
+  <li>compression of, <a href="#Pg_624">624</a></li>
+  <li>dilatation of, <a href="#Pg_625">625</a></li>
+  <li>diverticula of, <a href="#Pg_625">625</a></li>
+  <li>examination of, <a href="#Pg_616">616</a></li>
+  <li>foreign bodies in, <a href="#Pg_619">619</a>, <a href="#Pg_621">621</a>, <a href="#Pg_623">623</a></li>
+  <li>inflammation of, <a href="#Pg_623">623</a></li>
+  <li>intubation of, <a href="#Pg_632">632</a></li>
+  <li>paralysis of, <a href="#Pg_625">625</a></li>
+  <li>rupture of, <a href="#Pg_618">618</a></li>
+  <li>spasm of, <a href="#Pg_624">624</a></li>
+  <li>stricture of, cicatricial, <a href="#Pg_628">628</a>
+    <ul>
+    <li>malignant, <a href="#Pg_629">629</a></li>
+    <li>spasmodic, <a href="#Pg_624">624</a></li>
+    </ul></li>
+  <li>surgical anatomy of, <a href="#Pg_616">616</a></li>
+  <li>swallowing of corrosive substances, <a href="#Pg_618">618</a></li>
+  <li>syphilis of, <a href="#Pg_623">623</a></li>
+  <li>tuberculosis of, <a href="#Pg_623">623</a></li>
+  <li>tumours of, <a href="#Pg_629">629</a></li>
+  <li>varix of, <a href="#Pg_623">623</a></li>
+  <li>wounds of, <a href="#Pg_618">618</a></li>
+  <li>X-ray examination of, <a href="#Pg_617">617</a></li>
+  </ul></li>
+
+<li>Old-standing dislocations, <a href="#Pg_40">40</a>. <i>See also</i> Individual Joints</li>
+
+<li>Olecranon, fracture of, <a href="#Pg_85">85</a>
+  <ul>
+  <li>separation of epiphysis of, <a href="#Pg_87">87</a></li>
+  </ul></li>
+
+<li>Olfactory nerve, <a href="#Pg_399">399</a></li>
+
+<li>Ophthalmia, sympathetic, <a href="#Pg_487">487</a></li>
+
+<li>Ophthalmoplegia externa, <a href="#Pg_400">400</a></li>
+
+<li>Optic nerve, <a href="#Pg_399">399</a></li>
+
+<li>Orbit, aneurysms of, <a href="#Pg_490">490</a>
+  <ul>
+  <li>cellulitis of, <a href="#Pg_487">487</a></li>
+  <li>contusions of, <a href="#Pg_484">484</a></li>
+  <li>emphysema of, <a href="#Pg_486">486</a></li>
+  <li>eyeball, injuries of, <a href="#Pg_486">486</a></li>
+  <li><a class="pagenum" name="Pg_654" id="Pg_654"></a>foreign bodies in, <a href="#Pg_485">485</a></li>
+  <li>fractures of, <a href="#Pg_485">485</a></li>
+  <li>injuries of, <a href="#Pg_484">484</a></li>
+  <li>tumours of, <a href="#Pg_487">487</a></li>
+  <li>wounds of, <a href="#Pg_485">485</a></li>
+  </ul></li>
+
+<li>Os magnum. <i>See</i> Capitate Bone</li>
+
+<li>Osteo-chondritis deformans juvenilis, <a href="#Pg_228">228</a></li>
+
+<li>Os trigonum tarsi, <a href="#Pg_193">193</a></li>
+
+<li>Otitis media, <a href="#Pg_564">564</a></li>
+
+<li>Otorrh&oelig;a, <a href="#Pg_555">555</a></li>
+
+<li>Oz&aelig;na, <a href="#Pg_575">575</a></li>
+</ul>
+
+<ul>
+<li><a name="IX_P" id="IX_P"></a>Pachymeningitis, <a href="#Pg_374">374</a>, <a href="#Pg_433">433</a></li>
+
+<li>Palate, affections of, <a href="#Pg_498">498</a>
+  <ul>
+  <li>cleft, <a href="#Pg_477">477</a></li>
+  </ul></li>
+
+<li>Palmar fascia, Dupuytren's contraction of, <a href="#Pg_314">314</a></li>
+
+<li>Panophthalmitis, <a href="#Pg_487">487</a></li>
+
+<li>Paracusis of Willis, <a href="#Pg_554">554</a></li>
+
+<li>Paralysis, abductor, <a href="#Pg_404">404</a>, <a href="#Pg_639">639</a>
+  <ul>
+  <li>Bell's, <a href="#Pg_401">401</a></li>
+  <li>conjugate, <a href="#Pg_335">335</a></li>
+  <li>crossed, <a href="#Pg_334">334</a></li>
+  <li>facial, <a href="#Pg_400">400</a></li>
+  <li>infantile, <a href="#Pg_242">242</a></li>
+  <li>spastic, <a href="#Pg_247">247</a></li>
+  <li>of sterno-mastoid, <a href="#Pg_404">404</a></li>
+  <li>of tongue, <a href="#Pg_542">542</a></li>
+  <li>of trapezius, <a href="#Pg_404">404</a></li>
+  </ul></li>
+
+<li>Paraplegia dolorosa, <a href="#Pg_448">448</a>
+  <ul>
+  <li>gravitation, <a href="#Pg_414">414</a></li>
+  <li>spastic, <a href="#Pg_451">451</a></li>
+  </ul></li>
+
+<li>Para-thyreoid glands, <a href="#Pg_604">604</a></li>
+
+<li>Parosmia, <a href="#Pg_578">578</a></li>
+
+<li>Parotid, carcinoma of, <a href="#Pg_552">552</a>
+  <ul>
+  <li>duct, affections of, <a href="#Pg_544">544</a></li>
+  <li>fistula, <a href="#Pg_544">544</a></li>
+  <li>inflammation of, <a href="#Pg_545">545</a></li>
+  <li>injuries of, <a href="#Pg_543">543</a></li>
+  <li>mixed tumours of, <a href="#Pg_549">549</a></li>
+  <li>recurrent enlargement of, <a href="#Pg_547">547</a></li>
+  <li>sarcoma of, <a href="#Pg_552">552</a></li>
+  <li>surgical anatomy of, <a href="#Pg_543">543</a></li>
+  <li>tuberculosis of, <a href="#Pg_549">549</a></li>
+  <li>tumours of, <a href="#Pg_549">549</a></li>
+  </ul></li>
+
+<li>Parotitis, <a href="#Pg_545">545</a>, <a href="#Pg_547">547</a></li>
+
+<li>Patella, absence of, <a href="#Pg_262">262</a>
+  <ul>
+  <li>dislocation of, <a href="#Pg_177">177</a>
+    <ul>
+    <li>congenital, <a href="#Pg_262">262</a></li>
+    </ul></li>
+  <li>floating, <a href="#Pg_171">171</a>, <a href="#Pg_229">229</a></li>
+  <li>fracture of, <a href="#Pg_173">173</a></li>
+  <li>injuries of, <a href="#Pg_173">173</a></li>
+  </ul></li>
+
+<li>Patheticus nerve, <a href="#Pg_400">400</a></li>
+
+<li>Pathological dislocation, <a href="#Pg_43">43</a>
+  <ul>
+  <li>fracture, <a href="#Pg_1">1</a></li>
+  </ul></li>
+
+<li>Pelvis, fractures of, <a href="#Pg_122">122</a>
+  <ul>
+  <li>injuries of, <a href="#Pg_122">122</a></li>
+  </ul></li>
+
+<li>Periodontitis, <a href="#Pg_507">507</a></li>
+
+<li>Peri-&oelig;sophagitis, <a href="#Pg_623">623</a></li>
+
+<li>Periosteum, h&aelig;matoma of, <a href="#Pg_1">1</a></li>
+
+<li>Peri-tonsillitis, <a href="#Pg_501">501</a></li>
+
+<li>Perthes' disease, <a href="#Pg_228">228</a></li>
+
+<li>Pes arcuatus, <a href="#Pg_273">273</a>, <a href="#Pg_284">284</a>
+  <ul>
+  <li>calcaneo-valgus, <a href="#Pg_273">273</a>, <a href="#Pg_282">282</a>, <a href="#Pg_284">284</a></li>
+  <li>calcaneo-varus, <a href="#Pg_273">273</a>, <a href="#Pg_282">282</a>, <a href="#Pg_284">284</a></li>
+  <li>calcaneus, <a href="#Pg_273">273</a>, <a href="#Pg_282">282</a></li>
+  <li>cavus, <a href="#Pg_273">273</a>, <a href="#Pg_282">282</a>, <a href="#Pg_283">283</a>, <a href="#Pg_284">284</a></li>
+  <li>equinus, <a href="#Pg_273">273</a>, <a href="#Pg_280">280</a></li>
+  <li>excavatus, <a href="#Pg_284">284</a></li>
+  <li>planus, <a href="#Pg_285">285</a>, <a href="#Pg_287">287</a></li>
+  <li>transverso-planus, <a href="#Pg_294">294</a></li>
+  <li>valgus, <a href="#Pg_273">273</a>, <a href="#Pg_285">285</a>, <a href="#Pg_287">287</a></li>
+  <li>varus, <a href="#Pg_280">280</a></li>
+  </ul></li>
+
+<li>Phalanges of fingers, injuries of, <a href="#Pg_119">119</a>, <a href="#Pg_121">121</a>
+  <ul>
+  <li>of toes, injuries of, <a href="#Pg_194">194</a>, <a href="#Pg_200">200</a></li>
+  </ul></li>
+
+<li>Pharyngeal dimple, <a href="#Pg_626">626</a></li>
+
+<li>Pharyngitis, varieties of, <a href="#Pg_500">500</a></li>
+
+<li>Pharynx, affections of, <a href="#Pg_500">500</a>, <a href="#Pg_619">619</a>
+  <ul>
+  <li>foreign bodies in, <a href="#Pg_619">619</a>, <a href="#Pg_642">642</a></li>
+  <li>tumours of, <a href="#Pg_504">504</a></li>
+  </ul></li>
+
+<li>Phlebitis. <i>See</i> Individual Vessels</li>
+
+<li>Phosphorus necrosis of jaw, <a href="#Pg_510">510</a></li>
+
+<li>Pigeon-toe, <a href="#Pg_298">298</a></li>
+
+<li>Pituitary body, tumours of, <a href="#Pg_396">396</a></li>
+
+<li>Plaster-of-Paris splints, <a href="#Pg_23">23</a></li>
+
+<li>Pneumatocele capitis, <a href="#Pg_326">326</a></li>
+
+<li>Pneumogastric nerve, <a href="#Pg_403">403</a></li>
+
+<li>Poliomyelitis, anterior, <a href="#Pg_242">242</a></li>
+
+<li>Politzer's inflation of middle ear, <a href="#Pg_558">558</a></li>
+
+<li>Polydactylism, <a href="#Pg_303">303</a>, <a href="#Pg_316">316</a></li>
+
+<li>Polypi. <i>See</i> Individual Organs</li>
+
+<li>Poroplastic felt, <a href="#Pg_23">23</a></li>
+
+<li>Post-anal dimple, <a href="#Pg_459">459</a></li>
+
+<li>Posterior nerve roots, resection of, <a href="#Pg_247">247</a></li>
+
+<li>Post-nasal obstruction, <a href="#Pg_578">578</a></li>
+
+<li>Pott's disease of spine, <a href="#Pg_431">431</a>
+  <ul>
+  <li>fracture, <a href="#Pg_186">186</a>
+    <ul>
+    <li>with inversion, <a href="#Pg_191">191</a></li>
+    </ul></li>
+  <li>puffy tumour, <a href="#Pg_375">375</a>, <a href="#Pg_406">406</a></li>
+  </ul></li>
+
+<li>Premaxillary bone, <a href="#Pg_474">474</a></li>
+
+<li>Protopathic sensibility, <a href="#Pg_332">332</a></li>
+
+<li>Pseudarthrosis, <a href="#Pg_12">12</a></li>
+
+<li>Psoas abscess, <a href="#Pg_445">445</a></li>
+
+<li><a class="pagenum" name="Pg_655" id="Pg_655"></a>Pubes, fracture of, <a href="#Pg_123">123</a></li>
+
+<li>Pulpitis, <a href="#Pg_507">507</a></li>
+
+<li>Pyorrh&oelig;a alveolaris, <a href="#Pg_509">509</a></li>
+</ul>
+
+<ul>
+<li><a name="IX_Q" id="IX_Q"></a>Quinsy, <a href="#Pg_501">501</a></li>
+</ul>
+
+<ul>
+<li><a name="IX_R" id="IX_R"></a>Radial nerve, implicated in fracture of humerus, <a href="#Pg_76">76</a></li>
+
+<li>Radio-carpal joint, dislocation of, <a href="#Pg_112">112</a></li>
+
+<li>Radio-ulnar joint, inferior, dislocation of, <a href="#Pg_112">112</a>
+  <ul>
+    <li><ul>
+    <li>superior, synostosis of, <a href="#Pg_310">310</a></li>
+    </ul></li>
+  </ul></li>
+
+<li>Radius, absence of, <a href="#Pg_310">310</a>
+  <ul>
+  <li>avulsion of tubercle of, <a href="#Pg_88">88</a></li>
+  <li>dislocation of, <a href="#Pg_94">94</a></li>
+  <li>fracture of lower end, <a href="#Pg_102">102</a>
+    <ul>
+    <li>of shaft, <a href="#Pg_100">100</a></li>
+    <li>of tubercle, <a href="#Pg_88">88</a></li>
+    <li>of upper end, <a href="#Pg_88">88</a></li>
+    </ul></li>
+  <li>separation of epiphyses, <a href="#Pg_88">88</a>, <a href="#Pg_109">109</a>, <a href="#Pg_110">110</a></li>
+  <li>subluxation of, <a href="#Pg_96">96</a></li>
+  </ul></li>
+
+<li>Railway spine, <a href="#Pg_422">422</a></li>
+
+<li>Ranula, <a href="#Pg_549">549</a></li>
+
+<li>Recurrent dislocation, <a href="#Pg_43">43</a></li>
+
+<li>Reduction of dislocations. <i>See</i> Individual Joints</li>
+
+<li>Retro-pharyngeal abscess, <a href="#Pg_441">441</a>, <a href="#Pg_442">442</a>, <a href="#Pg_505">505</a></li>
+
+<li>Rhinitis, <a href="#Pg_575">575</a></li>
+
+<li>Rhinoliths, <a href="#Pg_575">575</a></li>
+
+<li>Rhinophyma, <a href="#Pg_570">570</a></li>
+
+<li>Rhinoscopy, <a href="#Pg_570">570</a>, <a href="#Pg_571">571</a></li>
+
+<li>Rib hump, <a href="#Pg_466">466</a></li>
+
+<li>Ribs, cervical, <a href="#Pg_585">585</a></li>
+
+<li>Round shoulders, <a href="#Pg_462">462</a></li>
+
+<li>Rugby knee, <a href="#Pg_165">165</a></li>
+</ul>
+
+<ul>
+<li><a name="IX_S" id="IX_S"></a>Sacral hygroma, <a href="#Pg_459">459</a></li>
+
+<li>Sacro-coccygeal fistul&aelig;, <a href="#Pg_459">459</a>
+  <ul>
+  <li>sinuses, <a href="#Pg_459">459</a></li>
+  <li>tumours, <a href="#Pg_459">459</a></li>
+  </ul></li>
+
+<li>Sacro-iliac joint, tuberculosis of, <a href="#Pg_446">446</a></li>
+
+<li>Sacrum, fracture of, <a href="#Pg_127">127</a></li>
+
+<li>Saddle nose, <a href="#Pg_567">567</a>, <a href="#Pg_568">568</a></li>
+
+<li>Salivary calculi, <a href="#Pg_545">545</a>
+  <ul>
+  <li>fistul&aelig;, <a href="#Pg_544">544</a></li>
+  <li>glands. <i>See</i> Parotid, Submaxillary, Sublingual
+    <ul>
+    <li>Mikulicz's disease of, <a href="#Pg_547">547</a></li>
+    <li>recurrent enlargement of, <a href="#Pg_547">547</a></li>
+    <li>surgical anatomy of, <a href="#Pg_543">543</a></li>
+    <li>tuberculosis of, <a href="#Pg_548">548</a></li>
+    <li>tumours of, <a href="#Pg_549">549</a></li>
+    </ul></li>
+  </ul></li>
+
+<li>Scalp, abscess of, <a href="#Pg_323">323</a>
+  <ul>
+  <li>air-containing swellings of, <a href="#Pg_326">326</a></li>
+  <li>aneurysms of, <a href="#Pg_326">326</a></li>
+  <li>avulsion of, <a href="#Pg_322">322</a></li>
+  <li>cellulitis of, <a href="#Pg_322">322</a>, <a href="#Pg_406">406</a></li>
+  <li>cirsoid aneurysm of, <a href="#Pg_326">326</a></li>
+  <li>contusion of, <a href="#Pg_320">320</a></li>
+  <li>cysts of, <a href="#Pg_323">323</a></li>
+  <li>dangerous area of, <a href="#Pg_321">321</a></li>
+  <li>diseases of, <a href="#Pg_323">323</a></li>
+  <li>emphysema of, <a href="#Pg_326">326</a></li>
+  <li>erysipelas of, <a href="#Pg_323">323</a></li>
+  <li>h&aelig;matoma of, <a href="#Pg_320">320</a>, <a href="#Pg_366">366</a></li>
+  <li>infective conditions of, <a href="#Pg_323">323</a></li>
+  <li>injuries of, <a href="#Pg_320">320</a></li>
+  <li>lupus of, <a href="#Pg_323">323</a></li>
+  <li>pneumatocele of, <a href="#Pg_326">326</a></li>
+  <li>surgical anatomy of, <a href="#Pg_319">319</a></li>
+  <li>tumours of, <a href="#Pg_324">324</a></li>
+  <li>wounds of, <a href="#Pg_321">321</a>
+    <ul>
+    <li>complications of, <a href="#Pg_322">322</a></li>
+    </ul></li>
+  </ul></li>
+
+<li>Scaphoid. <i>See</i> Navicular</li>
+
+<li>Scapula, congenital elevation of, <a href="#Pg_303">303</a>
+  <ul>
+  <li>displacements of, <a href="#Pg_303">303</a>, <a href="#Pg_306">306</a></li>
+  <li>fracture of, <a href="#Pg_67">67</a></li>
+  <li>separation of epiphyses of, <a href="#Pg_69">69</a>, <a href="#Pg_70">70</a></li>
+  <li>winged, <a href="#Pg_306">306</a></li>
+  </ul></li>
+
+<li>Schlatter's disease, <a href="#Pg_165">165</a></li>
+
+<li>Scissors-leg deformity, <a href="#Pg_224">224</a>, <a href="#Pg_257">257</a></li>
+
+<li>Scoliosis, of adolescents, <a href="#Pg_465">465</a>
+  <ul>
+  <li>congenital, <a href="#Pg_465">465</a></li>
+  <li>exercises for, <a href="#Pg_472">472</a></li>
+  <li>habitual, <a href="#Pg_465">465</a></li>
+  <li>paralytic, <a href="#Pg_464">464</a></li>
+  <li>postural, <a href="#Pg_465">465</a></li>
+  <li>rickety, <a href="#Pg_464">464</a></li>
+  <li>static, <a href="#Pg_463">463</a></li>
+  </ul></li>
+
+<li>Sculler's sprain, <a href="#Pg_97">97</a></li>
+
+<li>Semilunar menisci of knee, injuries of, <a href="#Pg_167">167</a></li>
+
+<li>Sensation, varieties of, <a href="#Pg_332">332</a></li>
+
+<li>Separation of bony processes, <a href="#Pg_6">6</a>
+  <ul>
+  <li>of epiphyses. <i>See</i> Individual Bones</li>
+  </ul></li>
+
+<li>Shock, cerebral, <a href="#Pg_341">341</a>, <a href="#Pg_344">344</a></li>
+
+<li>Shoulder, ankylosis of, <a href="#Pg_204">204</a>
+  <ul>
+  <li>arthritis deformans of, <a href="#Pg_203">203</a></li>
+  <li>contusion of, <a href="#Pg_66">66</a></li>
+  <li>diseases of, <a href="#Pg_201">201</a></li>
+  <li><a class="pagenum" name="Pg_656" id="Pg_656"></a>deformities of, paralytic, <a href="#Pg_308">308</a></li>
+  <li>dislocation of, with fracture of humerus, <a href="#Pg_63">63</a></li>
+  <li>dislocation of, <a href="#Pg_52">52</a>
+    <ul>
+    <li>congenital, <a href="#Pg_306">306</a></li>
+    <li>old-standing, <a href="#Pg_65">65</a></li>
+    <li>paralytic, <a href="#Pg_308">308</a></li>
+    <li>recurrent or habitual, <a href="#Pg_65">65</a></li>
+    <li>varieties, <a href="#Pg_53">53</a></li>
+    </ul></li>
+  <li>examination of, <a href="#Pg_44">44</a></li>
+  <li>injuries of, <a href="#Pg_44">44</a></li>
+  <li>loose bodies in, <a href="#Pg_204">204</a></li>
+  <li>neuro-arthropathies of, <a href="#Pg_203">203</a></li>
+  <li>pyogenic diseases of, <a href="#Pg_203">203</a></li>
+  <li>sprain of, <a href="#Pg_66">66</a></li>
+  <li>Sprengel's, <a href="#Pg_303">303</a></li>
+  <li>surgical anatomy of, <a href="#Pg_44">44</a></li>
+  <li>tuberculosis of, <a href="#Pg_201">201</a></li>
+  </ul></li>
+
+<li>Sigmoid sinus, phlebitis of, <a href="#Pg_384">384</a></li>
+
+<li>Sinus phlebitis, <a href="#Pg_383">383</a>
+  <ul>
+  <li>thrombosis, <a href="#Pg_360">360</a></li>
+  </ul></li>
+
+<li>Skull, contusion of, <a href="#Pg_361">361</a>
+  <ul>
+  <li>diseases of, <a href="#Pg_406">406</a></li>
+  <li>fracture of, <a href="#Pg_361">361</a>
+    <ul>
+    <li>base, <a href="#Pg_367">367</a>
+      <ul>
+      <li>anterior fossa, <a href="#Pg_369">369</a></li>
+      <li>middle fossa, <a href="#Pg_370">370</a></li>
+      <li>posterior fossa, <a href="#Pg_371">371</a></li>
+      </ul></li>
+    <li>comminuted, <a href="#Pg_364">364</a></li>
+    <li>compound infected, <a href="#Pg_382">382</a></li>
+    <li>by <i>contre-coup</i>, <a href="#Pg_362">362</a></li>
+    <li>depressed, <a href="#Pg_364">364</a></li>
+    <li>fissured, <a href="#Pg_363">363</a></li>
+    <li>gutter, <a href="#Pg_364">364</a></li>
+    <li>indentation, <a href="#Pg_364">364</a></li>
+    <li>pond, <a href="#Pg_364">364</a></li>
+    <li>punctured, <a href="#Pg_364">364</a></li>
+    <li>vault, <a href="#Pg_361">361</a></li>
+    </ul></li>
+  <li>injuries of, <a href="#Pg_360">360</a></li>
+  <li>necrosis of, <a href="#Pg_406">406</a>, <a href="#Pg_407">407</a></li>
+  <li>osteomyelitis of, <a href="#Pg_406">406</a></li>
+  <li>periostitis of, <a href="#Pg_406">406</a></li>
+  <li>surgical anatomy of, <a href="#Pg_328">328</a></li>
+  <li>syphilis of, <a href="#Pg_407">407</a></li>
+  <li>tuberculosis of, <a href="#Pg_407">407</a></li>
+  <li>tumours of, <a href="#Pg_407">407</a></li>
+  </ul></li>
+
+<li>Smell, anomalies of, <a href="#Pg_399">399</a>, <a href="#Pg_578">578</a></li>
+
+<li>Smith's fracture of radius, <a href="#Pg_106">106</a></li>
+
+<li>Smoker's patch on tongue, <a href="#Pg_532">532</a></li>
+
+<li>Snapping hip, <a href="#Pg_254">254</a></li>
+
+<li>Sore throat, varieties of, <a href="#Pg_500">500</a></li>
+
+<li>Spastic paralysis, <a href="#Pg_247">247</a>
+  <ul>
+  <li>paraplegia, <a href="#Pg_451">451</a></li>
+  </ul></li>
+
+<li>Speech centres, <a href="#Pg_335">335</a></li>
+
+<li>Sphenoidal cells, suppuration in, <a href="#Pg_578">578</a></li>
+
+<li>Spina bifida, <a href="#Pg_453">453</a>
+  <ul>
+  <li>occulta, <a href="#Pg_457">457</a></li>
+  </ul></li>
+
+<li>Spinal accessory nerve, <a href="#Pg_404">404</a></li>
+
+<li>Spinal cord, concussion of, <a href="#Pg_413">413</a>
+  <ul>
+  <li>diseases of, <a href="#Pg_431">431</a></li>
+  <li>functions of, <a href="#Pg_331">331</a>, <a href="#Pg_412">412</a></li>
+  <li>h&aelig;morrhage into, <a href="#Pg_413">413</a></li>
+  <li>injuries of, <a href="#Pg_413">413</a>
+    <ul>
+    <li>at different levels, <a href="#Pg_416">416</a></li>
+    </ul></li>
+  <li>localisation of, lesions in, <a href="#Pg_410">410</a>, <a href="#Pg_412">412</a></li>
+  <li>membranes of, <a href="#Pg_412">412</a></li>
+  <li>partial lesions of, <a href="#Pg_420">420</a></li>
+  <li>in Pott's disease, <a href="#Pg_433">433</a></li>
+  <li>reflex centres in, <a href="#Pg_412">412</a></li>
+  <li>segments of, <a href="#Pg_412">412</a></li>
+  <li>surgical anatomy of, <a href="#Pg_411">411</a></li>
+  <li>total transverse lesions of, <a href="#Pg_415">415</a></li>
+  <li>tuberculosis of, <a href="#Pg_433">433</a></li>
+  <li>tumours of, <a href="#Pg_450">450</a></li>
+  <li>h&aelig;morrhage, <a href="#Pg_413">413</a></li>
+  </ul></li>
+
+<li>Spine, railway, <a href="#Pg_422">422</a></li>
+
+<li>Splay-foot, <a href="#Pg_285">285</a></li>
+
+<li>Splints, <a href="#Pg_22">22</a>
+  <ul>
+  <li>abduction; for hip, <a href="#Pg_221">221</a>
+    <ul>
+    <li>frame, for arm, <a href="#Pg_72">72</a></li>
+    </ul></li>
+  <li>ambulant, for ankle, <a href="#Pg_189">189</a></li>
+  <li>Balkan frame, <a href="#Pg_150">150</a></li>
+  <li>box, <a href="#Pg_182">182</a></li>
+  <li>Bradford frame, <a href="#Pg_438">438</a></li>
+  <li>&ldquo;cock-up,&rdquo; <a href="#Pg_77">77</a></li>
+  <li>for Colles' fracture, <a href="#Pg_106">106</a></li>
+  <li>Dupuytren's, <a href="#Pg_190">190</a></li>
+  <li>Hodgen's, <a href="#Pg_151">151</a></li>
+  <li>Liston's long, <a href="#Pg_152">152</a></li>
+  <li>Middeldorpf's, <a href="#Pg_72">72</a></li>
+  <li>Syme's stirrup, <a href="#Pg_190">190</a></li>
+  <li>Taylor's, for hip, <a href="#Pg_222">222</a></li>
+  <li>Thomas', arm, <a href="#Pg_72">72</a>
+    <ul>
+    <li>double, <a href="#Pg_439">439</a></li>
+    <li>hip, <a href="#Pg_222">222</a></li>
+    <li>knee, <a href="#Pg_149">149</a>, <a href="#Pg_159">159</a>, <a href="#Pg_235">235</a></li>
+    </ul></li>
+  <li>wheel-barrow, <a href="#Pg_439">439</a></li>
+  </ul></li>
+
+<li>Spondylitis, traumatic, <a href="#Pg_427">427</a></li>
+
+<li>Sprains of joints, <a href="#Pg_35">35</a>
+  <ul>
+  <li>fracture, <a href="#Pg_35">35</a>, <a href="#Pg_171">171</a></li>
+  <li>sculler's, <a href="#Pg_97">97</a></li>
+  </ul></li>
+
+<li>Sprengel's shoulder, <a href="#Pg_303">303</a></li>
+
+<li>Status lymphaticus, <a href="#Pg_602">602</a></li>
+
+<li>Steinmann's apparatus, <a href="#Pg_150">150</a></li>
+
+<li>Stenson's duct, <a href="#Pg_543">543</a></li>
+
+<li><a class="pagenum" name="Pg_657" id="Pg_657"></a>Sterno-mastoid, h&aelig;matoma of, <a href="#Pg_588">588</a></li>
+
+<li>Stomatitis, varieties of, <a href="#Pg_496">496</a></li>
+
+<li>Subclavicular dislocation of shoulder, <a href="#Pg_62">62</a></li>
+
+<li>Sub-conjunctival ecchymosis, <a href="#Pg_369">369</a></li>
+
+<li>Sub-coracoid dislocation of shoulder, <a href="#Pg_54">54</a></li>
+
+<li>Subdural abscess, <a href="#Pg_376">376</a></li>
+
+<li>Sub-glenoid dislocation of shoulder, <a href="#Pg_62">62</a></li>
+
+<li>Subgluteal abscess, <a href="#Pg_446">446</a></li>
+
+<li>Sublingual gland, inflammation of, <a href="#Pg_548">548</a>
+  <ul>
+  <li>ranula of, <a href="#Pg_549">549</a></li>
+  <li>surgical anatomy of, <a href="#Pg_543">543</a></li>
+  <li>tumours of, <a href="#Pg_552">552</a></li>
+  </ul></li>
+
+<li>Submaxillary gland, calculi of, <a href="#Pg_545">545</a>
+  <ul>
+  <li>inflammation of, <a href="#Pg_548">548</a></li>
+  <li>peri-adenitis of, <a href="#Pg_548">548</a></li>
+  <li>recurrent enlargement of, <a href="#Pg_547">547</a></li>
+  <li>surgical anatomy of, <a href="#Pg_543">543</a></li>
+  <li>tuberculosis of, <a href="#Pg_549">549</a></li>
+  <li>tumours of, <a href="#Pg_552">552</a></li>
+  </ul></li>
+
+<li>Subspinous dislocation of shoulder, <a href="#Pg_62">62</a></li>
+
+<li>Sub-taloid dislocation, <a href="#Pg_198">198</a></li>
+
+<li>Superior sagittal sinus, phlebitis of, <a href="#Pg_385">385</a></li>
+
+<li>Supernumerary fingers, <a href="#Pg_316">316</a>
+  <ul>
+  <li>toes, <a href="#Pg_303">303</a></li>
+  </ul></li>
+
+<li>Surgical anatomy, of ankle, <a href="#Pg_185">185</a>
+  <ul>
+  <li>of brain, <a href="#Pg_328">328</a></li>
+  <li>of ear, <a href="#Pg_553">553</a></li>
+  <li>of elbow, <a href="#Pg_79">79</a></li>
+  <li>of forearm, <a href="#Pg_79">79</a></li>
+  <li>of foot, <a href="#Pg_185">185</a></li>
+  <li>of hip, <a href="#Pg_128">128</a></li>
+  <li>of knee, <a href="#Pg_155">155</a></li>
+  <li>of meninges, <a href="#Pg_328">328</a></li>
+  <li>of neck, <a href="#Pg_582">582</a></li>
+  <li>of &oelig;sophagus, <a href="#Pg_616">616</a></li>
+  <li>of parotid gland, <a href="#Pg_543">543</a></li>
+  <li>of salivary glands, <a href="#Pg_543">543</a></li>
+  <li>of scalp, <a href="#Pg_319">319</a>, <a href="#Pg_328">328</a></li>
+  <li>of shoulder, <a href="#Pg_44">44</a></li>
+  <li>of sublingual gland, <a href="#Pg_543">543</a></li>
+  <li>of submaxillary gland, <a href="#Pg_543">543</a></li>
+  <li>of thymus gland, <a href="#Pg_582">582</a></li>
+  <li>of thyreoid gland, <a href="#Pg_604">604</a></li>
+  <li>of tongue, <a href="#Pg_528">528</a></li>
+  <li>of tympanic membrane, <a href="#Pg_557">557</a></li>
+  <li>of vertebral column, <a href="#Pg_411">411</a></li>
+  <li>of wrist, <a href="#Pg_102">102</a></li>
+  </ul></li>
+
+<li>Swallowing, difficulty in, <a href="#Pg_623">623</a>, <a href="#Pg_636">636</a>
+  <ul>
+  <li>pain in, <a href="#Pg_623">623</a>, <a href="#Pg_636">636</a></li>
+  </ul></li>
+
+<li>Syme's stirrup splint, <a href="#Pg_190">190</a></li>
+
+<li>Symonds' tube, <a href="#Pg_632">632</a></li>
+
+<li>Symphysis pubis, separation of, <a href="#Pg_122">122</a></li>
+
+<li>Syndactylism, <a href="#Pg_303">303</a>, <a href="#Pg_317">317</a></li>
+
+<li>Synovitis, septic, <a href="#Pg_34">34</a></li>
+
+<li>Syphilis. <i>See</i> Individual Organs</li>
+
+<li>Syringo-myelocele, <a href="#Pg_455">455</a></li>
+</ul>
+
+<ul>
+<li><a name="IX_T" id="IX_T"></a>Tail-like appendage, <a href="#Pg_458">458</a>, <a href="#Pg_459">459</a></li>
+
+<li>Talipes equino-varus. <i>See also</i> Pes
+  <ul>
+  <li>acquired, <a href="#Pg_279">279</a></li>
+  <li>congenital, <a href="#Pg_274">274</a></li>
+  </ul></li>
+
+<li>Talus, dislocation of, <a href="#Pg_196">196</a>
+  <ul>
+  <li>fracture of, <a href="#Pg_192">192</a></li>
+  </ul></li>
+
+<li>Tarso-metatarsal dislocation, <a href="#Pg_200">200</a></li>
+
+<li>Tarsus, diseases of, <a href="#Pg_240">240</a>
+  <ul>
+  <li>dislocations of, <a href="#Pg_196">196</a></li>
+  <li>fractures of, <a href="#Pg_192">192</a></li>
+  <li>tuberculosis of, <a href="#Pg_240">240</a></li>
+  </ul></li>
+
+<li>Taste, anomalies of, <a href="#Pg_578">578</a></li>
+
+<li>Taylor's splint for hip, <a href="#Pg_222">222</a></li>
+
+<li>Temporal abscess, <a href="#Pg_380">380</a></li>
+
+<li>Temporo-mandibular joint,
+  <ul>
+  <li>arthritis of, <a href="#Pg_525">525</a></li>
+  <li>arthritis deformans of, <a href="#Pg_525">525</a></li>
+  <li>dislocation of, <a href="#Pg_523">523</a></li>
+  <li>fixation of, <a href="#Pg_525">525</a></li>
+  <li>internal derangements of, <a href="#Pg_524">524</a></li>
+  <li>suppuration in, <a href="#Pg_525">525</a></li>
+  <li>tuberculosis of, <a href="#Pg_525">525</a></li>
+  </ul></li>
+
+<li>Tendons, lengthening of, <a href="#Pg_248">248</a>
+  <ul>
+  <li>transplantation of, <a href="#Pg_245">245</a></li>
+  </ul></li>
+
+<li>Tennis elbow, <a href="#Pg_97">97</a></li>
+
+<li>Tetany, <a href="#Pg_610">610</a></li>
+
+<li>Thomas' flexion test for hip disease, <a href="#Pg_215">215</a>
+  <ul>
+  <li>splints, <a href="#Pg_72">72</a>, <a href="#Pg_149">149</a>, <a href="#Pg_159">159</a>, <a href="#Pg_222">222</a>, <a href="#Pg_235">235</a>, <a href="#Pg_439">439</a></li>
+  </ul></li>
+
+<li>Thoracic duct, <a href="#Pg_597">597</a></li>
+
+<li>Throat, hospital, <a href="#Pg_500">500</a></li>
+
+<li>Thrush, <a href="#Pg_496">496</a></li>
+
+<li>Thumb, dislocation of, <a href="#Pg_119">119</a>
+  <ul>
+  <li>fracture of, <a href="#Pg_116">116</a></li>
+  <li>stave of, <a href="#Pg_116">116</a></li>
+  </ul></li>
+
+<li>Thymic asthma, <a href="#Pg_603">603</a></li>
+
+<li>Thymus death, <a href="#Pg_603">603</a>
+  <ul>
+  <li>gland, affections of, <a href="#Pg_602">602</a>
+    <ul>
+    <li>surgical anatomy of, <a href="#Pg_582">582</a></li>
+    </ul></li>
+  <li>stenosis, <a href="#Pg_602">602</a></li>
+  </ul></li>
+
+<li>Thyreo-glossal cysts, <a href="#Pg_538">538</a>, <a href="#Pg_583">583</a>, <a href="#Pg_599">599</a>
+  <ul>
+  <li>fistul&aelig;, <a href="#Pg_538">538</a>, <a href="#Pg_583">583</a></li>
+  <li><a class="pagenum" name="Pg_658" id="Pg_658"></a>tumours, <a href="#Pg_538">538</a></li>
+  </ul></li>
+
+<li>Thyreoid cartilage, fracture of, <a href="#Pg_593">593</a>
+  <ul>
+  <li>gland. <i>See also</i> Goitre
+    <ul>
+    <li>accessory, <a href="#Pg_604">604</a></li>
+    <li>adenoma of, <a href="#Pg_610">610</a></li>
+    <li>carcinoma of, <a href="#Pg_281">281</a></li>
+    <li>goitre, <a href="#Pg_605">605</a>. <i>See also</i> Goitre</li>
+    <li>inflammation of, <a href="#Pg_605">605</a></li>
+    <li>malignant, <a href="#Pg_612">612</a></li>
+    <li>physiological hyper&aelig;mia of, <a href="#Pg_604">604</a></li>
+    <li>sarcoma of, <a href="#Pg_281">281</a></li>
+    <li>surgical anatomy of, <a href="#Pg_604">604</a></li>
+    <li>syphilis of, <a href="#Pg_605">605</a></li>
+    <li>tuberculosis of, <a href="#Pg_605">605</a></li>
+    </ul></li>
+  </ul></li>
+
+<li>Thyreoidectomy, <a href="#Pg_610">610</a></li>
+
+<li>Thyreoidism, acute, <a href="#Pg_610">610</a></li>
+
+<li>Thyreoiditis, <a href="#Pg_605">605</a></li>
+
+<li>Thyreotoxicosis, <a href="#Pg_614">614</a></li>
+
+<li>Tibia, absence of, <a href="#Pg_272">272</a>
+  <ul>
+  <li>fracture of, <a href="#Pg_183">183</a>
+    <ul>
+    <li>upper end of, <a href="#Pg_162">162</a></li>
+    <li>head of, <a href="#Pg_162">162</a></li>
+    </ul></li>
+  <li>separation of lower epiphysis of, <a href="#Pg_192">192</a>
+    <ul>
+    <li>upper epiphysis of, <a href="#Pg_165">165</a></li>
+    </ul></li>
+  <li>tuberosity, avulsion of, <a href="#Pg_165">165</a></li>
+  <li>and fibula, fracture of, <a href="#Pg_178">178</a></li>
+  </ul></li>
+
+<li>Tibio-fibular articulation, inferior, dislocation of, <a href="#Pg_196">196</a>
+  <ul>
+  <li>superior, dislocation of, <a href="#Pg_167">167</a></li>
+  </ul></li>
+
+<li>Tinnitus aurium, <a href="#Pg_554">554</a></li>
+
+<li>Toes, clawing of, <a href="#Pg_280">280</a>
+  <ul>
+  <li>deformities of, <a href="#Pg_296">296</a></li>
+  <li>dislocation of, <a href="#Pg_200">200</a></li>
+  <li>fracture of phalanges of, <a href="#Pg_194">194</a></li>
+  <li>hammer-, <a href="#Pg_300">300</a></li>
+  <li>hypertrophy of, <a href="#Pg_302">302</a></li>
+  <li>pigeon-, <a href="#Pg_298">298</a></li>
+  <li>supernumerary, <a href="#Pg_303">303</a></li>
+  <li>webbing of, <a href="#Pg_303">303</a></li>
+  </ul></li>
+
+<li>Tongue,
+  <ul>
+  <li>absence of, <a href="#Pg_540">540</a></li>
+  <li>atrophy of, <a href="#Pg_540">540</a></li>
+  <li>bifid, <a href="#Pg_540">540</a></li>
+  <li>cancer of, <a href="#Pg_534">534</a>
+    <ul>
+    <li>inoperable, <a href="#Pg_537">537</a></li>
+    </ul></li>
+  <li>cysts, <a href="#Pg_537">537</a></li>
+  <li>dental ulcer of, <a href="#Pg_529">529</a></li>
+  <li>foot and mouth disease, <a href="#Pg_530">530</a></li>
+  <li>foreign bodies in, <a href="#Pg_529">529</a></li>
+  <li>glossitis, <a href="#Pg_530">530</a></li>
+  <li>gumma of, <a href="#Pg_533">533</a></li>
+  <li>hemi-glossitis, <a href="#Pg_530">530</a></li>
+  <li>inflammatory affections of, <a href="#Pg_530">530</a></li>
+  <li>leucokeratosis, <a href="#Pg_530">530</a></li>
+  <li>leucoplakia, <a href="#Pg_530">530</a></li>
+  <li>macroglossia, <a href="#Pg_540">540</a></li>
+  <li>malformations of, <a href="#Pg_540">540</a></li>
+  <li>mucous patches on, <a href="#Pg_533">533</a></li>
+  <li>nervous affections of, <a href="#Pg_540">540</a></li>
+  <li>neuralgia of, <a href="#Pg_540">540</a></li>
+  <li>paralysis of, <a href="#Pg_542">542</a></li>
+  <li>sarcoma of, <a href="#Pg_536">536</a></li>
+  <li>sclerosing glossitis, <a href="#Pg_533">533</a></li>
+  <li>smoker's parch, <a href="#Pg_532">532</a></li>
+  <li>spasm of, <a href="#Pg_542">542</a></li>
+  <li>surgical anatomy of, <a href="#Pg_528">528</a></li>
+  <li>syphilis of, <a href="#Pg_533">533</a></li>
+  <li>-tie, <a href="#Pg_540">540</a></li>
+  <li>tuberculosis of, <a href="#Pg_532">532</a></li>
+  <li>tumours of, <a href="#Pg_534">534</a>, <a href="#Pg_537">537</a></li>
+  <li>ulcers of, <a href="#Pg_532">532</a>, <a href="#Pg_536">536</a></li>
+  <li>wounds of, <a href="#Pg_529">529</a></li>
+  </ul></li>
+
+<li>Tonsil, calculi of, <a href="#Pg_503">503</a>
+  <ul>
+  <li>hypertrophy of, <a href="#Pg_502">502</a></li>
+  <li>infective conditions of, <a href="#Pg_500">500</a></li>
+  <li>inflammation of, <a href="#Pg_500">500</a></li>
+  <li>Luschka's, <a href="#Pg_579">579</a></li>
+  <li>naso-pharyngeal, <a href="#Pg_579">579</a></li>
+  <li>quinsy, <a href="#Pg_501">501</a></li>
+  <li>syphilis of, <a href="#Pg_503">503</a></li>
+  <li>tuberculosis of, <a href="#Pg_503">503</a></li>
+  <li>tumours of, <a href="#Pg_504">504</a></li>
+  </ul></li>
+
+<li>Tonsillitis, varieties of, <a href="#Pg_500">500</a></li>
+
+<li>Tooth, wisdom, impaction of, <a href="#Pg_508">508</a></li>
+
+<li>Torn semilunar meniscus, <a href="#Pg_170">170</a></li>
+
+<li>Torticollis, <a href="#Pg_587">587</a>. <i>See</i> Wry-neck</li>
+
+<li>Trachea, foreign bodies in, <a href="#Pg_643">643</a>
+  <ul>
+  <li>fracture of, <a href="#Pg_593">593</a></li>
+  <li>scabbard, <a href="#Pg_608">608</a></li>
+  <li>thymus stenosis of, <a href="#Pg_602">602</a></li>
+  <li>wounds of, <a href="#Pg_595">595</a></li>
+  </ul></li>
+
+<li>Tracheoscopy, <a href="#Pg_635">635</a></li>
+
+<li>Tracheotomy, <a href="#Pg_638">638</a></li>
+
+<li>Transplantation of tendons, <a href="#Pg_245">245</a></li>
+
+<li>Transverse sinus, phlebitis of, <a href="#Pg_384">384</a>
+  <ul>
+  <li>tarsal dislocation, <a href="#Pg_199">199</a></li>
+  </ul></li>
+
+<li>Trapezius, paralysis of, <a href="#Pg_404">404</a></li>
+
+<li>Traumatic apoplexy, <a href="#Pg_355">355</a>
+  <ul>
+  <li>cephal-hydrocele, <a href="#Pg_321">321</a>, <a href="#Pg_390">390</a></li>
+  <li>epilepsy, <a href="#Pg_358">358</a></li>
+  <li>insanity, <a href="#Pg_360">360</a></li>
+  <li>neurasthenia, <a href="#Pg_345">345</a>, <a href="#Pg_358">358</a></li>
+  <li>node, <a href="#Pg_1">1</a></li>
+  <li>&oelig;dema of brain, <a href="#Pg_352">352</a></li>
+  <li>spondylitis, <a href="#Pg_427">427</a></li>
+  </ul></li>
+
+<li>Trendelenburg's test, <a href="#Pg_252">252</a></li>
+
+<li><a class="pagenum" name="Pg_659" id="Pg_659"></a>Trigeminal nerve, <a href="#Pg_400">400</a>
+  <ul>
+  <li>neuralgia, <a href="#Pg_400">400</a></li>
+  </ul></li>
+
+<li>Trigger finger, <a href="#Pg_318">318</a></li>
+
+<li>Trochlear nerve, <a href="#Pg_400">400</a></li>
+
+<li>Tuberculosis. <i>See</i> Individual Organs</li>
+
+<li>Tumours. <i>See</i> Individual Organs</li>
+
+<li>Tympanic antrum, suppuration in, <a href="#Pg_566">566</a>
+  <ul>
+  <li>membrane, lesions of, <a href="#Pg_557">557</a>
+    <ul>
+    <li>perforation of, <a href="#Pg_557">557</a></li>
+    <li>rupture of, <a href="#Pg_557">557</a>, <a href="#Pg_563">563</a></li>
+    <li>surgical anatomy of, <a href="#Pg_557">557</a></li>
+    </ul></li>
+  </ul></li>
+
+<li>Typhoid spine, <a href="#Pg_448">448</a></li>
+</ul>
+
+<ul>
+<li><a name="IX_U" id="IX_U"></a>Ulna, deficiency of, <a href="#Pg_311">311</a>
+  <ul>
+  <li>dislocation of, <a href="#Pg_94">94</a></li>
+  <li>fracture of upper end, <a href="#Pg_85">85</a>
+    <ul>
+    <li>lower end, <a href="#Pg_110">110</a></li>
+    <li>shaft, <a href="#Pg_100">100</a></li>
+    </ul></li>
+  <li>separation of epiphysis of, <a href="#Pg_87">87</a>, <a href="#Pg_110">110</a></li>
+  </ul></li>
+
+<li>Uvula, bifid, <a href="#Pg_477">477</a>
+  <ul>
+  <li>elongation of, <a href="#Pg_499">499</a></li>
+  </ul></li>
+</ul>
+
+<ul>
+<li><a name="IX_V" id="IX_V"></a>Vagus nerve, <a href="#Pg_403">403</a></li>
+
+<li>Valsalva's method of inflating ear, <a href="#Pg_558">558</a></li>
+
+<li>Venous sinuses, intra-cranial injuries of, <a href="#Pg_356">356</a></li>
+
+<li>Ventricles, lateral, bursting of abscess into, <a href="#Pg_381">381</a>
+  <ul>
+  <li>h&aelig;morrhage into, <a href="#Pg_342">342</a></li>
+  </ul></li>
+
+<li>Vertebral column, actinomycosis of, <a href="#Pg_448">448</a>
+  <ul>
+  <li>arthritis deformans of, <a href="#Pg_449">449</a></li>
+  <li>blastomycosis of, <a href="#Pg_448">448</a></li>
+  <li>compression fracture of, <a href="#Pg_426">426</a></li>
+  <li>congenital deformities of, <a href="#Pg_458">458</a></li>
+  <li>deviations of, <a href="#Pg_461">461</a></li>
+  <li>diseases of, <a href="#Pg_431">431</a></li>
+  <li>dislocations of, <a href="#Pg_424">424</a>, <a href="#Pg_427">427</a>, <a href="#Pg_428">428</a></li>
+  <li>fracture-dislocation of, <a href="#Pg_427">427</a></li>
+  <li>fractures of, <a href="#Pg_425">425</a>, <a href="#Pg_426">426</a>, <a href="#Pg_427">427</a></li>
+  <li>hydatid cysts of, <a href="#Pg_448">448</a></li>
+  <li>hysterical affections of, <a href="#Pg_448">448</a></li>
+  <li>injuries of, <a href="#Pg_423">423</a></li>
+  <li>kyphosis, <a href="#Pg_461">461</a>, <a href="#Pg_462">462</a></li>
+  <li>lateral curvature of, <a href="#Pg_463">463</a></li>
+  <li>lordosis, <a href="#Pg_461">461</a></li>
+  <li>malignant disease of, <a href="#Pg_447">447</a></li>
+  <li>osteomyelitis of, <a href="#Pg_431">431</a>, <a href="#Pg_448">448</a></li>
+  <li>Pott's disease of, <a href="#Pg_431">431</a></li>
+  <li>scoliosis, <a href="#Pg_463">463</a></li>
+  <li>sprains of, <a href="#Pg_423">423</a></li>
+  <li>surgical anatomy of, <a href="#Pg_411">411</a></li>
+  <li>syphilis of, <a href="#Pg_447">447</a></li>
+  <li>tuberculous disease of, <a href="#Pg_431">431</a></li>
+  <li>tumours of, <a href="#Pg_447">447</a></li>
+  <li>twists of, <a href="#Pg_423">423</a></li>
+  <li>typhoid, <a href="#Pg_448">448</a></li>
+  <li>wounds of, <a href="#Pg_430">430</a></li>
+  </ul></li>
+
+<li>Vertigo, <a href="#Pg_555">555</a></li>
+
+<li>Visual centres, <a href="#Pg_335">335</a></li>
+
+<li>Volkmann's isch&aelig;mic contracture, <a href="#Pg_85">85</a>, <a href="#Pg_98">98</a>, <a href="#Pg_310">310</a>
+  <ul>
+  <li>supra-malleolar deformity, <a href="#Pg_273">273</a></li>
+  </ul></li>
+</ul>
+
+<ul>
+<li><a name="IX_W" id="IX_W"></a>Wandering acetabulum, <a href="#Pg_210">210</a>, <a href="#Pg_227">227</a></li>
+
+<li>Wax in ear, <a href="#Pg_561">561</a></li>
+
+<li>Webbed fingers, <a href="#Pg_317">317</a>
+  <ul>
+  <li>toes, <a href="#Pg_303">303</a></li>
+  </ul></li>
+
+<li>Wens, <a href="#Pg_324">324</a></li>
+
+<li>White swelling of knee, <a href="#Pg_233">233</a></li>
+
+<li>Winged scapula, <a href="#Pg_306">306</a></li>
+
+<li>Wisdom tooth, impaction of, <a href="#Pg_508">508</a></li>
+
+<li>Wounds. <i>See</i> Individual Regions and Organs</li>
+
+<li>Wrist, diseases of, <a href="#Pg_208">208</a>
+  <ul>
+  <li>dislocation of, <a href="#Pg_111">111</a>, <a href="#Pg_112">112</a>
+    <ul>
+    <li>congenital, <a href="#Pg_313">313</a></li>
+    </ul></li>
+  <li>drop-, <a href="#Pg_311">311</a></li>
+  <li>injuries of, <a href="#Pg_102">102</a></li>
+  <li>Madelung's deformity of, <a href="#Pg_313">313</a></li>
+  <li>sprain of, <a href="#Pg_115">115</a></li>
+  <li>surgical anatomy of, <a href="#Pg_102">102</a></li>
+  <li>tuberculous disease of, <a href="#Pg_208">208</a>, <a href="#Pg_209">209</a></li>
+  </ul></li>
+
+<li>Wry-neck, <a href="#Pg_587">587</a>
+  <ul>
+  <li>acute, <a href="#Pg_587">587</a></li>
+  <li>hysterical, <a href="#Pg_592">592</a></li>
+  <li>permanent, <a href="#Pg_588">588</a></li>
+  <li>rheumatic, <a href="#Pg_587">587</a></li>
+  <li>spasmodic, <a href="#Pg_591">591</a></li>
+  <li>transient, <a href="#Pg_587">587</a></li>
+  </ul></li>
+</ul>
+
+<ul>
+<li><a name="IX_X" id="IX_X"></a>Xerostomia, <a href="#Pg_547">547</a></li>
+
+<li>X-rays in fracture, <a href="#Pg_16">16</a></li>
+</ul>
+
+<ul>
+<li><a name="IX_Z" id="IX_Z"></a>Zygomatic bone, fracture of, <a href="#Pg_519">519</a></li>
+</ul>
+</div>
+
+
+
+
+
+
+
+
+
+<pre>
+
+
+
+
+
+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 ***
+
+***** This file should be named 28428-h.htm or 28428-h.zip *****
+This and all associated files of various formats will be found in:
+        http://www.gutenberg.org/2/8/4/2/28428/
+
+Produced by Jonathan Ingram, Chris Logan and the Online
+Distributed Proofreading Team at http://www.pgdp.net
+
+
+Updated editions will replace the previous one--the old editions
+will be renamed.
+
+Creating the works from public domain print editions means that no
+one owns a United States copyright in these works, so the Foundation
+(and you!) can copy and distribute it in the United States without
+permission and without paying copyright royalties.  Special rules,
+set forth in the General Terms of Use part of this license, apply to
+copying and distributing Project Gutenberg-tm electronic works to
+protect the PROJECT GUTENBERG-tm concept and trademark.  Project
+Gutenberg is a registered trademark, and may not be used if you
+charge for the eBooks, unless you receive specific permission.  If you
+do not charge anything for copies of this eBook, complying with the
+rules is very easy.  You may use this eBook for nearly any purpose
+such as creation of derivative works, reports, performances and
+research.  They may be modified and printed and given away--you may do
+practically ANYTHING with public domain eBooks.  Redistribution is
+subject to the trademark license, especially commercial
+redistribution.
+
+
+
+*** START: FULL LICENSE ***
+
+THE FULL PROJECT GUTENBERG LICENSE
+PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK
+
+To protect the Project Gutenberg-tm mission of promoting the free
+distribution of electronic works, by using or distributing this work
+(or any other work associated in any way with the phrase "Project
+Gutenberg"), you agree to comply with all the terms of the Full Project
+Gutenberg-tm License (available with this file or online at
+http://gutenberg.org/license).
+
+
+Section 1.  General Terms of Use and Redistributing Project Gutenberg-tm
+electronic works
+
+1.A.  By reading or using any part of this Project Gutenberg-tm
+electronic work, you indicate that you have read, understand, agree to
+and accept all the terms of this license and intellectual property
+(trademark/copyright) agreement.  If you do not agree to abide by all
+the terms of this agreement, you must cease using and return or destroy
+all copies of Project Gutenberg-tm electronic works in your possession.
+If you paid a fee for obtaining a copy of or access to a Project
+Gutenberg-tm electronic work and you do not agree to be bound by the
+terms of this agreement, you may obtain a refund from the person or
+entity to whom you paid the fee as set forth in paragraph 1.E.8.
+
+1.B.  "Project Gutenberg" is a registered trademark.  It may only be
+used on or associated in any way with an electronic work by people who
+agree to be bound by the terms of this agreement.  There are a few
+things that you can do with most Project Gutenberg-tm electronic works
+even without complying with the full terms of this agreement.  See
+paragraph 1.C below.  There are a lot of things you can do with Project
+Gutenberg-tm electronic works if you follow the terms of this agreement
+and help preserve free future access to Project Gutenberg-tm electronic
+works.  See paragraph 1.E below.
+
+1.C.  The Project Gutenberg Literary Archive Foundation ("the Foundation"
+or PGLAF), owns a compilation copyright in the collection of Project
+Gutenberg-tm electronic works.  Nearly all the individual works in the
+collection are in the public domain in the United States.  If an
+individual work is in the public domain in the United States and you are
+located in the United States, we do not claim a right to prevent you from
+copying, distributing, performing, displaying or creating derivative
+works based on the work as long as all references to Project Gutenberg
+are removed.  Of course, we hope that you will support the Project
+Gutenberg-tm mission of promoting free access to electronic works by
+freely sharing Project Gutenberg-tm works in compliance with the terms of
+this agreement for keeping the Project Gutenberg-tm name associated with
+the work.  You can easily comply with the terms of this agreement by
+keeping this work in the same format with its attached full Project
+Gutenberg-tm License when you share it without charge with others.
+
+1.D.  The copyright laws of the place where you are located also govern
+what you can do with this work.  Copyright laws in most countries are in
+a constant state of change.  If you are outside the United States, check
+the laws of your country in addition to the terms of this agreement
+before downloading, copying, displaying, performing, distributing or
+creating derivative works based on this work or any other Project
+Gutenberg-tm work.  The Foundation makes no representations concerning
+the copyright status of any work in any country outside the United
+States.
+
+1.E.  Unless you have removed all references to Project Gutenberg:
+
+1.E.1.  The following sentence, with active links to, or other immediate
+access to, the full Project Gutenberg-tm License must appear prominently
+whenever any copy of a Project Gutenberg-tm work (any work on which the
+phrase "Project Gutenberg" appears, or with which the phrase "Project
+Gutenberg" is associated) is accessed, displayed, performed, viewed,
+copied or distributed:
+
+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
+
+1.E.2.  If an individual Project Gutenberg-tm electronic work is derived
+from the public domain (does not contain a notice indicating that it is
+posted with permission of the copyright holder), the work can be copied
+and distributed to anyone in the United States without paying any fees
+or charges.  If you are redistributing or providing access to a work
+with the phrase "Project Gutenberg" associated with or appearing on the
+work, you must comply either with the requirements of paragraphs 1.E.1
+through 1.E.7 or obtain permission for the use of the work and the
+Project Gutenberg-tm trademark as set forth in paragraphs 1.E.8 or
+1.E.9.
+
+1.E.3.  If an individual Project Gutenberg-tm electronic work is posted
+with the permission of the copyright holder, your use and distribution
+must comply with both paragraphs 1.E.1 through 1.E.7 and any additional
+terms imposed by the copyright holder.  Additional terms will be linked
+to the Project Gutenberg-tm License for all works posted with the
+permission of the copyright holder found at the beginning of this work.
+
+1.E.4.  Do not unlink or detach or remove the full Project Gutenberg-tm
+License terms from this work, or any files containing a part of this
+work or any other work associated with Project Gutenberg-tm.
+
+1.E.5.  Do not copy, display, perform, distribute or redistribute this
+electronic work, or any part of this electronic work, without
+prominently displaying the sentence set forth in paragraph 1.E.1 with
+active links or immediate access to the full terms of the Project
+Gutenberg-tm License.
+
+1.E.6.  You may convert to and distribute this work in any binary,
+compressed, marked up, nonproprietary or proprietary form, including any
+word processing or hypertext form.  However, if you provide access to or
+distribute copies of a Project Gutenberg-tm work in a format other than
+"Plain Vanilla ASCII" or other format used in the official version
+posted on the official Project Gutenberg-tm web site (www.gutenberg.org),
+you must, at no additional cost, fee or expense to the user, provide a
+copy, a means of exporting a copy, or a means of obtaining a copy upon
+request, of the work in its original "Plain Vanilla ASCII" or other
+form.  Any alternate format must include the full Project Gutenberg-tm
+License as specified in paragraph 1.E.1.
+
+1.E.7.  Do not charge a fee for access to, viewing, displaying,
+performing, copying or distributing any Project Gutenberg-tm works
+unless you comply with paragraph 1.E.8 or 1.E.9.
+
+1.E.8.  You may charge a reasonable fee for copies of or providing
+access to or distributing Project Gutenberg-tm electronic works provided
+that
+
+- You pay a royalty fee of 20% of the gross profits you derive from
+     the use of Project Gutenberg-tm works calculated using the method
+     you already use to calculate your applicable taxes.  The fee is
+     owed to the owner of the Project Gutenberg-tm trademark, but he
+     has agreed to donate royalties under this paragraph to the
+     Project Gutenberg Literary Archive Foundation.  Royalty payments
+     must be paid within 60 days following each date on which you
+     prepare (or are legally required to prepare) your periodic tax
+     returns.  Royalty payments should be clearly marked as such and
+     sent to the Project Gutenberg Literary Archive Foundation at the
+     address specified in Section 4, "Information about donations to
+     the Project Gutenberg Literary Archive Foundation."
+
+- You provide a full refund of any money paid by a user who notifies
+     you in writing (or by e-mail) within 30 days of receipt that s/he
+     does not agree to the terms of the full Project Gutenberg-tm
+     License.  You must require such a user to return or
+     destroy all copies of the works possessed in a physical medium
+     and discontinue all use of and all access to other copies of
+     Project Gutenberg-tm works.
+
+- You provide, in accordance with paragraph 1.F.3, a full refund of any
+     money paid for a work or a replacement copy, if a defect in the
+     electronic work is discovered and reported to you within 90 days
+     of receipt of the work.
+
+- You comply with all other terms of this agreement for free
+     distribution of Project Gutenberg-tm works.
+
+1.E.9.  If you wish to charge a fee or distribute a Project Gutenberg-tm
+electronic work or group of works on different terms than are set
+forth in this agreement, you must obtain permission in writing from
+both the Project Gutenberg Literary Archive Foundation and Michael
+Hart, the owner of the Project Gutenberg-tm trademark.  Contact the
+Foundation as set forth in Section 3 below.
+
+1.F.
+
+1.F.1.  Project Gutenberg volunteers and employees expend considerable
+effort to identify, do copyright research on, transcribe and proofread
+public domain works in creating the Project Gutenberg-tm
+collection.  Despite these efforts, Project Gutenberg-tm electronic
+works, and the medium on which they may be stored, may contain
+"Defects," such as, but not limited to, incomplete, inaccurate or
+corrupt data, transcription errors, a copyright or other intellectual
+property infringement, a defective or damaged disk or other medium, a
+computer virus, or computer codes that damage or cannot be read by
+your equipment.
+
+1.F.2.  LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except for the "Right
+of Replacement or Refund" described in paragraph 1.F.3, the Project
+Gutenberg Literary Archive Foundation, the owner of the Project
+Gutenberg-tm trademark, and any other party distributing a Project
+Gutenberg-tm electronic work under this agreement, disclaim all
+liability to you for damages, costs and expenses, including legal
+fees.  YOU AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT
+LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT EXCEPT THOSE
+PROVIDED IN PARAGRAPH F3.  YOU AGREE THAT THE FOUNDATION, THE
+TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE
+LIABLE TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE OR
+INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF THE POSSIBILITY OF SUCH
+DAMAGE.
+
+1.F.3.  LIMITED RIGHT OF REPLACEMENT OR REFUND - If you discover a
+defect in this electronic work within 90 days of receiving it, you can
+receive a refund of the money (if any) you paid for it by sending a
+written explanation to the person you received the work from.  If you
+received the work on a physical medium, you must return the medium with
+your written explanation.  The person or entity that provided you with
+the defective work may elect to provide a replacement copy in lieu of a
+refund.  If you received the work electronically, the person or entity
+providing it to you may choose to give you a second opportunity to
+receive the work electronically in lieu of a refund.  If the second copy
+is also defective, you may demand a refund in writing without further
+opportunities to fix the problem.
+
+1.F.4.  Except for the limited right of replacement or refund set forth
+in paragraph 1.F.3, this work is provided to you 'AS-IS' WITH NO OTHER
+WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO
+WARRANTIES OF MERCHANTIBILITY OR FITNESS FOR ANY PURPOSE.
+
+1.F.5.  Some states do not allow disclaimers of certain implied
+warranties or the exclusion or limitation of certain types of damages.
+If any disclaimer or limitation set forth in this agreement violates the
+law of the state applicable to this agreement, the agreement shall be
+interpreted to make the maximum disclaimer or limitation permitted by
+the applicable state law.  The invalidity or unenforceability of any
+provision of this agreement shall not void the remaining provisions.
+
+1.F.6.  INDEMNITY - You agree to indemnify and hold the Foundation, the
+trademark owner, any agent or employee of the Foundation, anyone
+providing copies of Project Gutenberg-tm electronic works in accordance
+with this agreement, and any volunteers associated with the production,
+promotion and distribution of Project Gutenberg-tm electronic works,
+harmless from all liability, costs and expenses, including legal fees,
+that arise directly or indirectly from any of the following which you do
+or cause to occur: (a) distribution of this or any Project Gutenberg-tm
+work, (b) alteration, modification, or additions or deletions to any
+Project Gutenberg-tm work, and (c) any Defect you cause.
+
+
+Section  2.  Information about the Mission of Project Gutenberg-tm
+
+Project Gutenberg-tm is synonymous with the free distribution of
+electronic works in formats readable by the widest variety of computers
+including obsolete, old, middle-aged and new computers.  It exists
+because of the efforts of hundreds of volunteers and donations from
+people in all walks of life.
+
+Volunteers and financial support to provide volunteers with the
+assistance they need, are critical to reaching Project Gutenberg-tm's
+goals and ensuring that the Project Gutenberg-tm collection will
+remain freely available for generations to come.  In 2001, the Project
+Gutenberg Literary Archive Foundation was created to provide a secure
+and permanent future for Project Gutenberg-tm and future generations.
+To learn more about the Project Gutenberg Literary Archive Foundation
+and how your efforts and donations can help, see Sections 3 and 4
+and the Foundation web page at http://www.pglaf.org.
+
+
+Section 3.  Information about the Project Gutenberg Literary Archive
+Foundation
+
+The Project Gutenberg Literary Archive Foundation is a non profit
+501(c)(3) educational corporation organized under the laws of the
+state of Mississippi and granted tax exempt status by the Internal
+Revenue Service.  The Foundation's EIN or federal tax identification
+number is 64-6221541.  Its 501(c)(3) letter is posted at
+http://pglaf.org/fundraising.  Contributions to the Project Gutenberg
+Literary Archive Foundation are tax deductible to the full extent
+permitted by U.S. federal laws and your state's laws.
+
+The Foundation's principal office is located at 4557 Melan Dr. S.
+Fairbanks, AK, 99712., but its volunteers and employees are scattered
+throughout numerous locations.  Its business office is located at
+809 North 1500 West, Salt Lake City, UT 84116, (801) 596-1887, email
+business@pglaf.org.  Email contact links and up to date contact
+information can be found at the Foundation's web site and official
+page at http://pglaf.org
+
+For additional contact information:
+     Dr. Gregory B. Newby
+     Chief Executive and Director
+     gbnewby@pglaf.org
+
+
+Section 4.  Information about Donations to the Project Gutenberg
+Literary Archive Foundation
+
+Project Gutenberg-tm depends upon and cannot survive without wide
+spread public support and donations to carry out its mission of
+increasing the number of public domain and licensed works that can be
+freely distributed in machine readable form accessible by the widest
+array of equipment including outdated equipment.  Many small donations
+($1 to $5,000) are particularly important to maintaining tax exempt
+status with the IRS.
+
+The Foundation is committed to complying with the laws regulating
+charities and charitable donations in all 50 states of the United
+States.  Compliance requirements are not uniform and it takes a
+considerable effort, much paperwork and many fees to meet and keep up
+with these requirements.  We do not solicit donations in locations
+where we have not received written confirmation of compliance.  To
+SEND DONATIONS or determine the status of compliance for any
+particular state visit http://pglaf.org
+
+While we cannot and do not solicit contributions from states where we
+have not met the solicitation requirements, we know of no prohibition
+against accepting unsolicited donations from donors in such states who
+approach us with offers to donate.
+
+International donations are gratefully accepted, but we cannot make
+any statements concerning tax treatment of donations received from
+outside the United States.  U.S. laws alone swamp our small staff.
+
+Please check the Project Gutenberg Web pages for current donation
+methods and addresses.  Donations are accepted in a number of other
+ways including checks, online payments and credit card donations.
+To donate, please visit: http://pglaf.org/donate
+
+
+Section 5.  General Information About Project Gutenberg-tm electronic
+works.
+
+Professor Michael S. Hart is the originator of the Project Gutenberg-tm
+concept of a library of electronic works that could be freely shared
+with anyone.  For thirty years, he produced and distributed Project
+Gutenberg-tm eBooks with only a loose network of volunteer support.
+
+
+Project Gutenberg-tm eBooks are often created from several printed
+editions, all of which are confirmed as Public Domain in the U.S.
+unless a copyright notice is included.  Thus, we do not necessarily
+keep eBooks in compliance with any particular paper edition.
+
+
+Most people start at our Web site which has the main PG search facility:
+
+     http://www.gutenberg.org
+
+This Web site includes information about Project Gutenberg-tm,
+including how to make donations to the Project Gutenberg Literary
+Archive Foundation, how to help produce our new eBooks, and how to
+subscribe to our email newsletter to hear about new eBooks.
+
+
+</pre>
+
+</body>
+</html>
diff --git a/28428-h/images/fig001.jpg b/28428-h/images/fig001.jpg
new file mode 100644
index 0000000..dc1a66f
--- /dev/null
+++ b/28428-h/images/fig001.jpg
diff --git a/28428-h/images/fig002.jpg b/28428-h/images/fig002.jpg
new file mode 100644
index 0000000..3e0d58c
--- /dev/null
+++ b/28428-h/images/fig002.jpg
diff --git a/28428-h/images/fig003.jpg b/28428-h/images/fig003.jpg
new file mode 100644
index 0000000..91a0b01
--- /dev/null
+++ b/28428-h/images/fig003.jpg
diff --git a/28428-h/images/fig004.jpg b/28428-h/images/fig004.jpg
new file mode 100644
index 0000000..79386cd
--- /dev/null
+++ b/28428-h/images/fig004.jpg
diff --git a/28428-h/images/fig005.jpg b/28428-h/images/fig005.jpg
new file mode 100644
index 0000000..1f04d99
--- /dev/null
+++ b/28428-h/images/fig005.jpg
diff --git a/28428-h/images/fig006.jpg b/28428-h/images/fig006.jpg
new file mode 100644
index 0000000..35936b5
--- /dev/null
+++ b/28428-h/images/fig006.jpg
diff --git a/28428-h/images/fig007.jpg b/28428-h/images/fig007.jpg
new file mode 100644
index 0000000..d2ba2ec
--- /dev/null
+++ b/28428-h/images/fig007.jpg
diff --git a/28428-h/images/fig008.jpg b/28428-h/images/fig008.jpg
new file mode 100644
index 0000000..d9ab79a
--- /dev/null
+++ b/28428-h/images/fig008.jpg
diff --git a/28428-h/images/fig009.jpg b/28428-h/images/fig009.jpg
new file mode 100644
index 0000000..adefbf1
--- /dev/null
+++ b/28428-h/images/fig009.jpg
diff --git a/28428-h/images/fig010.jpg b/28428-h/images/fig010.jpg
new file mode 100644
index 0000000..e377f67
--- /dev/null
+++ b/28428-h/images/fig010.jpg
diff --git a/28428-h/images/fig011.jpg b/28428-h/images/fig011.jpg
new file mode 100644
index 0000000..d409033
--- /dev/null
+++ b/28428-h/images/fig011.jpg
diff --git a/28428-h/images/fig012.jpg b/28428-h/images/fig012.jpg
new file mode 100644
index 0000000..b0589a3
--- /dev/null
+++ b/28428-h/images/fig012.jpg
diff --git a/28428-h/images/fig013.jpg b/28428-h/images/fig013.jpg
new file mode 100644
index 0000000..72c1988
--- /dev/null
+++ b/28428-h/images/fig013.jpg
diff --git a/28428-h/images/fig014.jpg b/28428-h/images/fig014.jpg
new file mode 100644
index 0000000..b8799f0
--- /dev/null
+++ b/28428-h/images/fig014.jpg
diff --git a/28428-h/images/fig015.jpg b/28428-h/images/fig015.jpg
new file mode 100644
index 0000000..662c6ae
--- /dev/null
+++ b/28428-h/images/fig015.jpg
diff --git a/28428-h/images/fig016.jpg b/28428-h/images/fig016.jpg
new file mode 100644
index 0000000..eb02622
--- /dev/null
+++ b/28428-h/images/fig016.jpg
diff --git a/28428-h/images/fig017.png b/28428-h/images/fig017.png
new file mode 100644
index 0000000..2c11fe8
--- /dev/null
+++ b/28428-h/images/fig017.png
diff --git a/28428-h/images/fig018.jpg b/28428-h/images/fig018.jpg
new file mode 100644
index 0000000..eb728d3
--- /dev/null
+++ b/28428-h/images/fig018.jpg
diff --git a/28428-h/images/fig019.jpg b/28428-h/images/fig019.jpg
new file mode 100644
index 0000000..51454fd
--- /dev/null
+++ b/28428-h/images/fig019.jpg
diff --git a/28428-h/images/fig020.jpg b/28428-h/images/fig020.jpg
new file mode 100644
index 0000000..5958a2c
--- /dev/null
+++ b/28428-h/images/fig020.jpg
diff --git a/28428-h/images/fig021.jpg b/28428-h/images/fig021.jpg
new file mode 100644
index 0000000..33b7cce
--- /dev/null
+++ b/28428-h/images/fig021.jpg
diff --git a/28428-h/images/fig022.jpg b/28428-h/images/fig022.jpg
new file mode 100644
index 0000000..ea5b6da
--- /dev/null
+++ b/28428-h/images/fig022.jpg
diff --git a/28428-h/images/fig023.jpg b/28428-h/images/fig023.jpg
new file mode 100644
index 0000000..2fd66ba
--- /dev/null
+++ b/28428-h/images/fig023.jpg
diff --git a/28428-h/images/fig024.jpg b/28428-h/images/fig024.jpg
new file mode 100644
index 0000000..679e67c
--- /dev/null
+++ b/28428-h/images/fig024.jpg
diff --git a/28428-h/images/fig025.jpg b/28428-h/images/fig025.jpg
new file mode 100644
index 0000000..0b656e6
--- /dev/null
+++ b/28428-h/images/fig025.jpg
diff --git a/28428-h/images/fig026.jpg b/28428-h/images/fig026.jpg
new file mode 100644
index 0000000..6c75282
--- /dev/null
+++ b/28428-h/images/fig026.jpg
diff --git a/28428-h/images/fig027.jpg b/28428-h/images/fig027.jpg
new file mode 100644
index 0000000..94b8f84
--- /dev/null
+++ b/28428-h/images/fig027.jpg
diff --git a/28428-h/images/fig028.jpg b/28428-h/images/fig028.jpg
new file mode 100644
index 0000000..ea22f65
--- /dev/null
+++ b/28428-h/images/fig028.jpg
diff --git a/28428-h/images/fig029.jpg b/28428-h/images/fig029.jpg
new file mode 100644
index 0000000..c00bec6
--- /dev/null
+++ b/28428-h/images/fig029.jpg
diff --git a/28428-h/images/fig030.jpg b/28428-h/images/fig030.jpg
new file mode 100644
index 0000000..d8db152
--- /dev/null
+++ b/28428-h/images/fig030.jpg
diff --git a/28428-h/images/fig031.jpg b/28428-h/images/fig031.jpg
new file mode 100644
index 0000000..336e191
--- /dev/null
+++ b/28428-h/images/fig031.jpg
diff --git a/28428-h/images/fig032.jpg b/28428-h/images/fig032.jpg
new file mode 100644
index 0000000..75a3842
--- /dev/null
+++ b/28428-h/images/fig032.jpg
diff --git a/28428-h/images/fig033.jpg b/28428-h/images/fig033.jpg
new file mode 100644
index 0000000..1a40048
--- /dev/null
+++ b/28428-h/images/fig033.jpg
diff --git a/28428-h/images/fig034.jpg b/28428-h/images/fig034.jpg
new file mode 100644
index 0000000..67b9acb
--- /dev/null
+++ b/28428-h/images/fig034.jpg
diff --git a/28428-h/images/fig035.jpg b/28428-h/images/fig035.jpg
new file mode 100644
index 0000000..7a47e28
--- /dev/null
+++ b/28428-h/images/fig035.jpg
diff --git a/28428-h/images/fig036.jpg b/28428-h/images/fig036.jpg
new file mode 100644
index 0000000..134511d
--- /dev/null
+++ b/28428-h/images/fig036.jpg
diff --git a/28428-h/images/fig037.jpg b/28428-h/images/fig037.jpg
new file mode 100644
index 0000000..901fa11
--- /dev/null
+++ b/28428-h/images/fig037.jpg
diff --git a/28428-h/images/fig038.jpg b/28428-h/images/fig038.jpg
new file mode 100644
index 0000000..bf34d0a
--- /dev/null
+++ b/28428-h/images/fig038.jpg
diff --git a/28428-h/images/fig039.jpg b/28428-h/images/fig039.jpg
new file mode 100644
index 0000000..8c244e3
--- /dev/null
+++ b/28428-h/images/fig039.jpg
diff --git a/28428-h/images/fig040.jpg b/28428-h/images/fig040.jpg
new file mode 100644
index 0000000..51b3fef
--- /dev/null
+++ b/28428-h/images/fig040.jpg
diff --git a/28428-h/images/fig041.jpg b/28428-h/images/fig041.jpg
new file mode 100644
index 0000000..4db95ab
--- /dev/null
+++ b/28428-h/images/fig041.jpg
diff --git a/28428-h/images/fig042.jpg b/28428-h/images/fig042.jpg
new file mode 100644
index 0000000..b1a206c
--- /dev/null
+++ b/28428-h/images/fig042.jpg
diff --git a/28428-h/images/fig043.jpg b/28428-h/images/fig043.jpg
new file mode 100644
index 0000000..7e5b5cf
--- /dev/null
+++ b/28428-h/images/fig043.jpg
diff --git a/28428-h/images/fig044.jpg b/28428-h/images/fig044.jpg
new file mode 100644
index 0000000..2cec7b9
--- /dev/null
+++ b/28428-h/images/fig044.jpg
diff --git a/28428-h/images/fig045.jpg b/28428-h/images/fig045.jpg
new file mode 100644
index 0000000..700cb78
--- /dev/null
+++ b/28428-h/images/fig045.jpg
diff --git a/28428-h/images/fig046.jpg b/28428-h/images/fig046.jpg
new file mode 100644
index 0000000..489b785
--- /dev/null
+++ b/28428-h/images/fig046.jpg
diff --git a/28428-h/images/fig047.jpg b/28428-h/images/fig047.jpg
new file mode 100644
index 0000000..965edf2
--- /dev/null
+++ b/28428-h/images/fig047.jpg
diff --git a/28428-h/images/fig048.jpg b/28428-h/images/fig048.jpg
new file mode 100644
index 0000000..d5df4a5
--- /dev/null
+++ b/28428-h/images/fig048.jpg
diff --git a/28428-h/images/fig049.jpg b/28428-h/images/fig049.jpg
new file mode 100644
index 0000000..b67f01c
--- /dev/null
+++ b/28428-h/images/fig049.jpg
diff --git a/28428-h/images/fig050.jpg b/28428-h/images/fig050.jpg
new file mode 100644
index 0000000..bcdaa09
--- /dev/null
+++ b/28428-h/images/fig050.jpg
diff --git a/28428-h/images/fig051.jpg b/28428-h/images/fig051.jpg
new file mode 100644
index 0000000..72ce2ac
--- /dev/null
+++ b/28428-h/images/fig051.jpg
diff --git a/28428-h/images/fig052.jpg b/28428-h/images/fig052.jpg
new file mode 100644
index 0000000..ccc38d5
--- /dev/null
+++ b/28428-h/images/fig052.jpg
diff --git a/28428-h/images/fig053.jpg b/28428-h/images/fig053.jpg
new file mode 100644
index 0000000..859de49
--- /dev/null
+++ b/28428-h/images/fig053.jpg
diff --git a/28428-h/images/fig054.jpg b/28428-h/images/fig054.jpg
new file mode 100644
index 0000000..cb946ac
--- /dev/null
+++ b/28428-h/images/fig054.jpg
diff --git a/28428-h/images/fig055.jpg b/28428-h/images/fig055.jpg
new file mode 100644
index 0000000..1d43654
--- /dev/null
+++ b/28428-h/images/fig055.jpg
diff --git a/28428-h/images/fig056.jpg b/28428-h/images/fig056.jpg
new file mode 100644
index 0000000..6b34506
--- /dev/null
+++ b/28428-h/images/fig056.jpg
diff --git a/28428-h/images/fig057.png b/28428-h/images/fig057.png
new file mode 100644
index 0000000..64f8cc8
--- /dev/null
+++ b/28428-h/images/fig057.png
diff --git a/28428-h/images/fig058.png b/28428-h/images/fig058.png
new file mode 100644
index 0000000..a810839
--- /dev/null
+++ b/28428-h/images/fig058.png
diff --git a/28428-h/images/fig059.png b/28428-h/images/fig059.png
new file mode 100644
index 0000000..575c067
--- /dev/null
+++ b/28428-h/images/fig059.png
diff --git a/28428-h/images/fig060.png b/28428-h/images/fig060.png
new file mode 100644
index 0000000..1e23e78
--- /dev/null
+++ b/28428-h/images/fig060.png
diff --git a/28428-h/images/fig061.jpg b/28428-h/images/fig061.jpg
new file mode 100644
index 0000000..0f9a4ae
--- /dev/null
+++ b/28428-h/images/fig061.jpg
diff --git a/28428-h/images/fig062.jpg b/28428-h/images/fig062.jpg
new file mode 100644
index 0000000..37bbfbb
--- /dev/null
+++ b/28428-h/images/fig062.jpg
diff --git a/28428-h/images/fig063.jpg b/28428-h/images/fig063.jpg
new file mode 100644
index 0000000..6d455ff
--- /dev/null
+++ b/28428-h/images/fig063.jpg
diff --git a/28428-h/images/fig064.jpg b/28428-h/images/fig064.jpg
new file mode 100644
index 0000000..5ff0e17
--- /dev/null
+++ b/28428-h/images/fig064.jpg
diff --git a/28428-h/images/fig065.jpg b/28428-h/images/fig065.jpg
new file mode 100644
index 0000000..598c2a1
--- /dev/null
+++ b/28428-h/images/fig065.jpg
diff --git a/28428-h/images/fig066.jpg b/28428-h/images/fig066.jpg
new file mode 100644
index 0000000..31fff0a
--- /dev/null
+++ b/28428-h/images/fig066.jpg
diff --git a/28428-h/images/fig067.jpg b/28428-h/images/fig067.jpg
new file mode 100644
index 0000000..2596a09
--- /dev/null
+++ b/28428-h/images/fig067.jpg
diff --git a/28428-h/images/fig068.jpg b/28428-h/images/fig068.jpg
new file mode 100644
index 0000000..517ec69
--- /dev/null
+++ b/28428-h/images/fig068.jpg
diff --git a/28428-h/images/fig069.jpg b/28428-h/images/fig069.jpg
new file mode 100644
index 0000000..ba760dc
--- /dev/null
+++ b/28428-h/images/fig069.jpg
diff --git a/28428-h/images/fig070.jpg b/28428-h/images/fig070.jpg
new file mode 100644
index 0000000..8124e46
--- /dev/null
+++ b/28428-h/images/fig070.jpg
diff --git a/28428-h/images/fig071.png b/28428-h/images/fig071.png
new file mode 100644
index 0000000..0193518
--- /dev/null
+++ b/28428-h/images/fig071.png
diff --git a/28428-h/images/fig072.jpg b/28428-h/images/fig072.jpg
new file mode 100644
index 0000000..7075b3c
--- /dev/null
+++ b/28428-h/images/fig072.jpg
diff --git a/28428-h/images/fig073.jpg b/28428-h/images/fig073.jpg
new file mode 100644
index 0000000..1d7e932
--- /dev/null
+++ b/28428-h/images/fig073.jpg
diff --git a/28428-h/images/fig074.jpg b/28428-h/images/fig074.jpg
new file mode 100644
index 0000000..be5a7c8
--- /dev/null
+++ b/28428-h/images/fig074.jpg
diff --git a/28428-h/images/fig075.jpg b/28428-h/images/fig075.jpg
new file mode 100644
index 0000000..40768ef
--- /dev/null
+++ b/28428-h/images/fig075.jpg
diff --git a/28428-h/images/fig076.jpg b/28428-h/images/fig076.jpg
new file mode 100644
index 0000000..3da761c
--- /dev/null
+++ b/28428-h/images/fig076.jpg
diff --git a/28428-h/images/fig077.png b/28428-h/images/fig077.png
new file mode 100644
index 0000000..c017754
--- /dev/null
+++ b/28428-h/images/fig077.png
diff --git a/28428-h/images/fig078.jpg b/28428-h/images/fig078.jpg
new file mode 100644
index 0000000..e2f833d
--- /dev/null
+++ b/28428-h/images/fig078.jpg
diff --git a/28428-h/images/fig079.jpg b/28428-h/images/fig079.jpg
new file mode 100644
index 0000000..7ae2baa
--- /dev/null
+++ b/28428-h/images/fig079.jpg
diff --git a/28428-h/images/fig080.png b/28428-h/images/fig080.png
new file mode 100644
index 0000000..2810596
--- /dev/null
+++ b/28428-h/images/fig080.png
diff --git a/28428-h/images/fig081.jpg b/28428-h/images/fig081.jpg
new file mode 100644
index 0000000..3bdf6a7
--- /dev/null
+++ b/28428-h/images/fig081.jpg
diff --git a/28428-h/images/fig082.jpg b/28428-h/images/fig082.jpg
new file mode 100644
index 0000000..c854b40
--- /dev/null
+++ b/28428-h/images/fig082.jpg
diff --git a/28428-h/images/fig083.jpg b/28428-h/images/fig083.jpg
new file mode 100644
index 0000000..c46e733
--- /dev/null
+++ b/28428-h/images/fig083.jpg
diff --git a/28428-h/images/fig084.jpg b/28428-h/images/fig084.jpg
new file mode 100644
index 0000000..ff11b09
--- /dev/null
+++ b/28428-h/images/fig084.jpg
diff --git a/28428-h/images/fig085.jpg b/28428-h/images/fig085.jpg
new file mode 100644
index 0000000..a81bba2
--- /dev/null
+++ b/28428-h/images/fig085.jpg
diff --git a/28428-h/images/fig086.jpg b/28428-h/images/fig086.jpg
new file mode 100644
index 0000000..8bd3cb1
--- /dev/null
+++ b/28428-h/images/fig086.jpg
diff --git a/28428-h/images/fig087.jpg b/28428-h/images/fig087.jpg
new file mode 100644
index 0000000..6903b7e
--- /dev/null
+++ b/28428-h/images/fig087.jpg
diff --git a/28428-h/images/fig088.jpg b/28428-h/images/fig088.jpg
new file mode 100644
index 0000000..9ded199
--- /dev/null
+++ b/28428-h/images/fig088.jpg
diff --git a/28428-h/images/fig089.jpg b/28428-h/images/fig089.jpg
new file mode 100644
index 0000000..20694ed
--- /dev/null
+++ b/28428-h/images/fig089.jpg
diff --git a/28428-h/images/fig090.jpg b/28428-h/images/fig090.jpg
new file mode 100644
index 0000000..fbe503c
--- /dev/null
+++ b/28428-h/images/fig090.jpg
diff --git a/28428-h/images/fig091.jpg b/28428-h/images/fig091.jpg
new file mode 100644
index 0000000..f6ecc65
--- /dev/null
+++ b/28428-h/images/fig091.jpg
diff --git a/28428-h/images/fig092.jpg b/28428-h/images/fig092.jpg
new file mode 100644
index 0000000..a2ca3c7
--- /dev/null
+++ b/28428-h/images/fig092.jpg
diff --git a/28428-h/images/fig093.png b/28428-h/images/fig093.png
new file mode 100644
index 0000000..b4b4969
--- /dev/null
+++ b/28428-h/images/fig093.png
diff --git a/28428-h/images/fig094.jpg b/28428-h/images/fig094.jpg
new file mode 100644
index 0000000..be38a8d
--- /dev/null
+++ b/28428-h/images/fig094.jpg
diff --git a/28428-h/images/fig095.png b/28428-h/images/fig095.png
new file mode 100644
index 0000000..177b111
--- /dev/null
+++ b/28428-h/images/fig095.png
diff --git a/28428-h/images/fig096.jpg b/28428-h/images/fig096.jpg
new file mode 100644
index 0000000..c71c42e
--- /dev/null
+++ b/28428-h/images/fig096.jpg
diff --git a/28428-h/images/fig097.png b/28428-h/images/fig097.png
new file mode 100644
index 0000000..3f481c4
--- /dev/null
+++ b/28428-h/images/fig097.png
diff --git a/28428-h/images/fig098.jpg b/28428-h/images/fig098.jpg
new file mode 100644
index 0000000..3669d85
--- /dev/null
+++ b/28428-h/images/fig098.jpg
diff --git a/28428-h/images/fig099.jpg b/28428-h/images/fig099.jpg
new file mode 100644
index 0000000..335ed9c
--- /dev/null
+++ b/28428-h/images/fig099.jpg
diff --git a/28428-h/images/fig100.jpg b/28428-h/images/fig100.jpg
new file mode 100644
index 0000000..a874d38
--- /dev/null
+++ b/28428-h/images/fig100.jpg
diff --git a/28428-h/images/fig101.jpg b/28428-h/images/fig101.jpg
new file mode 100644
index 0000000..44925f8
--- /dev/null
+++ b/28428-h/images/fig101.jpg
diff --git a/28428-h/images/fig102.jpg b/28428-h/images/fig102.jpg
new file mode 100644
index 0000000..bf8e34b
--- /dev/null
+++ b/28428-h/images/fig102.jpg
diff --git a/28428-h/images/fig103.jpg b/28428-h/images/fig103.jpg
new file mode 100644
index 0000000..f8d85cd
--- /dev/null
+++ b/28428-h/images/fig103.jpg
diff --git a/28428-h/images/fig104.jpg b/28428-h/images/fig104.jpg
new file mode 100644
index 0000000..89c00db
--- /dev/null
+++ b/28428-h/images/fig104.jpg
diff --git a/28428-h/images/fig105.jpg b/28428-h/images/fig105.jpg
new file mode 100644
index 0000000..3daee48
--- /dev/null
+++ b/28428-h/images/fig105.jpg
diff --git a/28428-h/images/fig106.jpg b/28428-h/images/fig106.jpg
new file mode 100644
index 0000000..f6a91c9
--- /dev/null
+++ b/28428-h/images/fig106.jpg
diff --git a/28428-h/images/fig107.jpg b/28428-h/images/fig107.jpg
new file mode 100644
index 0000000..effb94b
--- /dev/null
+++ b/28428-h/images/fig107.jpg
diff --git a/28428-h/images/fig108.png b/28428-h/images/fig108.png
new file mode 100644
index 0000000..41ad1ab
--- /dev/null
+++ b/28428-h/images/fig108.png
diff --git a/28428-h/images/fig109.jpg b/28428-h/images/fig109.jpg
new file mode 100644
index 0000000..7afc53b
--- /dev/null
+++ b/28428-h/images/fig109.jpg
diff --git a/28428-h/images/fig110.jpg b/28428-h/images/fig110.jpg
new file mode 100644
index 0000000..018de32
--- /dev/null
+++ b/28428-h/images/fig110.jpg
diff --git a/28428-h/images/fig111.jpg b/28428-h/images/fig111.jpg
new file mode 100644
index 0000000..85c3017
--- /dev/null
+++ b/28428-h/images/fig111.jpg
diff --git a/28428-h/images/fig112.jpg b/28428-h/images/fig112.jpg
new file mode 100644
index 0000000..b9c4929
--- /dev/null
+++ b/28428-h/images/fig112.jpg
diff --git a/28428-h/images/fig113.jpg b/28428-h/images/fig113.jpg
new file mode 100644
index 0000000..fc4f022
--- /dev/null
+++ b/28428-h/images/fig113.jpg
diff --git a/28428-h/images/fig114.jpg b/28428-h/images/fig114.jpg
new file mode 100644
index 0000000..f35cdb1
--- /dev/null
+++ b/28428-h/images/fig114.jpg
diff --git a/28428-h/images/fig115.jpg b/28428-h/images/fig115.jpg
new file mode 100644
index 0000000..2ef44d9
--- /dev/null
+++ b/28428-h/images/fig115.jpg
diff --git a/28428-h/images/fig116.jpg b/28428-h/images/fig116.jpg
new file mode 100644
index 0000000..2317bb5
--- /dev/null
+++ b/28428-h/images/fig116.jpg
diff --git a/28428-h/images/fig117.jpg b/28428-h/images/fig117.jpg
new file mode 100644
index 0000000..f824280
--- /dev/null
+++ b/28428-h/images/fig117.jpg
diff --git a/28428-h/images/fig118.jpg b/28428-h/images/fig118.jpg
new file mode 100644
index 0000000..9b98e41
--- /dev/null
+++ b/28428-h/images/fig118.jpg
diff --git a/28428-h/images/fig119.jpg b/28428-h/images/fig119.jpg
new file mode 100644
index 0000000..6aace91
--- /dev/null
+++ b/28428-h/images/fig119.jpg
diff --git a/28428-h/images/fig120.jpg b/28428-h/images/fig120.jpg
new file mode 100644
index 0000000..f9b4e37
--- /dev/null
+++ b/28428-h/images/fig120.jpg
diff --git a/28428-h/images/fig121.jpg b/28428-h/images/fig121.jpg
new file mode 100644
index 0000000..56d2786
--- /dev/null
+++ b/28428-h/images/fig121.jpg
diff --git a/28428-h/images/fig122.jpg b/28428-h/images/fig122.jpg
new file mode 100644
index 0000000..04de15b
--- /dev/null
+++ b/28428-h/images/fig122.jpg
diff --git a/28428-h/images/fig123.jpg b/28428-h/images/fig123.jpg
new file mode 100644
index 0000000..a35606a
--- /dev/null
+++ b/28428-h/images/fig123.jpg
diff --git a/28428-h/images/fig124.jpg b/28428-h/images/fig124.jpg
new file mode 100644
index 0000000..29817b5
--- /dev/null
+++ b/28428-h/images/fig124.jpg
diff --git a/28428-h/images/fig125.jpg b/28428-h/images/fig125.jpg
new file mode 100644
index 0000000..d6e0560
--- /dev/null
+++ b/28428-h/images/fig125.jpg
diff --git a/28428-h/images/fig126.jpg b/28428-h/images/fig126.jpg
new file mode 100644
index 0000000..45a47fc
--- /dev/null
+++ b/28428-h/images/fig126.jpg
diff --git a/28428-h/images/fig127.jpg b/28428-h/images/fig127.jpg
new file mode 100644
index 0000000..2661790
--- /dev/null
+++ b/28428-h/images/fig127.jpg
diff --git a/28428-h/images/fig128.jpg b/28428-h/images/fig128.jpg
new file mode 100644
index 0000000..ca98cd9
--- /dev/null
+++ b/28428-h/images/fig128.jpg
diff --git a/28428-h/images/fig129.jpg b/28428-h/images/fig129.jpg
new file mode 100644
index 0000000..cf74704
--- /dev/null
+++ b/28428-h/images/fig129.jpg
diff --git a/28428-h/images/fig130.jpg b/28428-h/images/fig130.jpg
new file mode 100644
index 0000000..be5573a
--- /dev/null
+++ b/28428-h/images/fig130.jpg
diff --git a/28428-h/images/fig131.jpg b/28428-h/images/fig131.jpg
new file mode 100644
index 0000000..a777e3b
--- /dev/null
+++ b/28428-h/images/fig131.jpg
diff --git a/28428-h/images/fig132.jpg b/28428-h/images/fig132.jpg
new file mode 100644
index 0000000..d859108
--- /dev/null
+++ b/28428-h/images/fig132.jpg
diff --git a/28428-h/images/fig133.jpg b/28428-h/images/fig133.jpg
new file mode 100644
index 0000000..7987c8a
--- /dev/null
+++ b/28428-h/images/fig133.jpg
diff --git a/28428-h/images/fig134.jpg b/28428-h/images/fig134.jpg
new file mode 100644
index 0000000..e2b7ec4
--- /dev/null
+++ b/28428-h/images/fig134.jpg
diff --git a/28428-h/images/fig135.png b/28428-h/images/fig135.png
new file mode 100644
index 0000000..4ecbb2a
--- /dev/null
+++ b/28428-h/images/fig135.png
diff --git a/28428-h/images/fig136.jpg b/28428-h/images/fig136.jpg
new file mode 100644
index 0000000..8755926
--- /dev/null
+++ b/28428-h/images/fig136.jpg
diff --git a/28428-h/images/fig137.jpg b/28428-h/images/fig137.jpg
new file mode 100644
index 0000000..b8748a8
--- /dev/null
+++ b/28428-h/images/fig137.jpg
diff --git a/28428-h/images/fig138.jpg b/28428-h/images/fig138.jpg
new file mode 100644
index 0000000..d9aa0d8
--- /dev/null
+++ b/28428-h/images/fig138.jpg
diff --git a/28428-h/images/fig139.jpg b/28428-h/images/fig139.jpg
new file mode 100644
index 0000000..91b6a5c
--- /dev/null
+++ b/28428-h/images/fig139.jpg
diff --git a/28428-h/images/fig140.jpg b/28428-h/images/fig140.jpg
new file mode 100644
index 0000000..25360d3
--- /dev/null
+++ b/28428-h/images/fig140.jpg
diff --git a/28428-h/images/fig141.jpg b/28428-h/images/fig141.jpg
new file mode 100644
index 0000000..b142e11
--- /dev/null
+++ b/28428-h/images/fig141.jpg
diff --git a/28428-h/images/fig142.jpg b/28428-h/images/fig142.jpg
new file mode 100644
index 0000000..be91e86
--- /dev/null
+++ b/28428-h/images/fig142.jpg
diff --git a/28428-h/images/fig143.jpg b/28428-h/images/fig143.jpg
new file mode 100644
index 0000000..8ad45ee
--- /dev/null
+++ b/28428-h/images/fig143.jpg
diff --git a/28428-h/images/fig144.jpg b/28428-h/images/fig144.jpg
new file mode 100644
index 0000000..a3a0376
--- /dev/null
+++ b/28428-h/images/fig144.jpg
diff --git a/28428-h/images/fig145.jpg b/28428-h/images/fig145.jpg
new file mode 100644
index 0000000..46ecbf1
--- /dev/null
+++ b/28428-h/images/fig145.jpg
diff --git a/28428-h/images/fig146.jpg b/28428-h/images/fig146.jpg
new file mode 100644
index 0000000..608223b
--- /dev/null
+++ b/28428-h/images/fig146.jpg
diff --git a/28428-h/images/fig147.jpg b/28428-h/images/fig147.jpg
new file mode 100644
index 0000000..64096e7
--- /dev/null
+++ b/28428-h/images/fig147.jpg
diff --git a/28428-h/images/fig148.png b/28428-h/images/fig148.png
new file mode 100644
index 0000000..e7cccb6
--- /dev/null
+++ b/28428-h/images/fig148.png
diff --git a/28428-h/images/fig149.jpg b/28428-h/images/fig149.jpg
new file mode 100644
index 0000000..020fe28
--- /dev/null
+++ b/28428-h/images/fig149.jpg
diff --git a/28428-h/images/fig150.jpg b/28428-h/images/fig150.jpg
new file mode 100644
index 0000000..6e1ad7d
--- /dev/null
+++ b/28428-h/images/fig150.jpg
diff --git a/28428-h/images/fig151.jpg b/28428-h/images/fig151.jpg
new file mode 100644
index 0000000..a774031
--- /dev/null
+++ b/28428-h/images/fig151.jpg
diff --git a/28428-h/images/fig152.jpg b/28428-h/images/fig152.jpg
new file mode 100644
index 0000000..5575305
--- /dev/null
+++ b/28428-h/images/fig152.jpg
diff --git a/28428-h/images/fig153.jpg b/28428-h/images/fig153.jpg
new file mode 100644
index 0000000..7a031b4
--- /dev/null
+++ b/28428-h/images/fig153.jpg
diff --git a/28428-h/images/fig154.png b/28428-h/images/fig154.png
new file mode 100644
index 0000000..870505b
--- /dev/null
+++ b/28428-h/images/fig154.png
diff --git a/28428-h/images/fig155.jpg b/28428-h/images/fig155.jpg
new file mode 100644
index 0000000..fb2818f
--- /dev/null
+++ b/28428-h/images/fig155.jpg
diff --git a/28428-h/images/fig156.jpg b/28428-h/images/fig156.jpg
new file mode 100644
index 0000000..9e80965
--- /dev/null
+++ b/28428-h/images/fig156.jpg
diff --git a/28428-h/images/fig157.jpg b/28428-h/images/fig157.jpg
new file mode 100644
index 0000000..ce0ea03
--- /dev/null
+++ b/28428-h/images/fig157.jpg
diff --git a/28428-h/images/fig158.jpg b/28428-h/images/fig158.jpg
new file mode 100644
index 0000000..75bbf66
--- /dev/null
+++ b/28428-h/images/fig158.jpg
diff --git a/28428-h/images/fig159.jpg b/28428-h/images/fig159.jpg
new file mode 100644
index 0000000..118c4e3
--- /dev/null
+++ b/28428-h/images/fig159.jpg
diff --git a/28428-h/images/fig160.jpg b/28428-h/images/fig160.jpg
new file mode 100644
index 0000000..18947ac
--- /dev/null
+++ b/28428-h/images/fig160.jpg
diff --git a/28428-h/images/fig161.png b/28428-h/images/fig161.png
new file mode 100644
index 0000000..b3fabfa
--- /dev/null
+++ b/28428-h/images/fig161.png
diff --git a/28428-h/images/fig162.jpg b/28428-h/images/fig162.jpg
new file mode 100644
index 0000000..7a9db34
--- /dev/null
+++ b/28428-h/images/fig162.jpg
diff --git a/28428-h/images/fig163.jpg b/28428-h/images/fig163.jpg
new file mode 100644
index 0000000..d6d4882
--- /dev/null
+++ b/28428-h/images/fig163.jpg
diff --git a/28428-h/images/fig164.jpg b/28428-h/images/fig164.jpg
new file mode 100644
index 0000000..ae5e319
--- /dev/null
+++ b/28428-h/images/fig164.jpg
diff --git a/28428-h/images/fig165.jpg b/28428-h/images/fig165.jpg
new file mode 100644
index 0000000..d3e6b97
--- /dev/null
+++ b/28428-h/images/fig165.jpg
diff --git a/28428-h/images/fig166.jpg b/28428-h/images/fig166.jpg
new file mode 100644
index 0000000..d24da21
--- /dev/null
+++ b/28428-h/images/fig166.jpg
diff --git a/28428-h/images/fig167.jpg b/28428-h/images/fig167.jpg
new file mode 100644
index 0000000..69b28b7
--- /dev/null
+++ b/28428-h/images/fig167.jpg
diff --git a/28428-h/images/fig168.jpg b/28428-h/images/fig168.jpg
new file mode 100644
index 0000000..b54a91f
--- /dev/null
+++ b/28428-h/images/fig168.jpg
diff --git a/28428-h/images/fig169.jpg b/28428-h/images/fig169.jpg
new file mode 100644
index 0000000..cc38390
--- /dev/null
+++ b/28428-h/images/fig169.jpg
diff --git a/28428-h/images/fig170.jpg b/28428-h/images/fig170.jpg
new file mode 100644
index 0000000..d754df6
--- /dev/null
+++ b/28428-h/images/fig170.jpg
diff --git a/28428-h/images/fig171.jpg b/28428-h/images/fig171.jpg
new file mode 100644
index 0000000..7e00bf7
--- /dev/null
+++ b/28428-h/images/fig171.jpg
diff --git a/28428-h/images/fig172.jpg b/28428-h/images/fig172.jpg
new file mode 100644
index 0000000..fa31ff4
--- /dev/null
+++ b/28428-h/images/fig172.jpg
diff --git a/28428-h/images/fig173.jpg b/28428-h/images/fig173.jpg
new file mode 100644
index 0000000..3f996c1
--- /dev/null
+++ b/28428-h/images/fig173.jpg
diff --git a/28428-h/images/fig174.jpg b/28428-h/images/fig174.jpg
new file mode 100644
index 0000000..c546de8
--- /dev/null
+++ b/28428-h/images/fig174.jpg
diff --git a/28428-h/images/fig175.jpg b/28428-h/images/fig175.jpg
new file mode 100644
index 0000000..dd2880e
--- /dev/null
+++ b/28428-h/images/fig175.jpg
diff --git a/28428-h/images/fig176.jpg b/28428-h/images/fig176.jpg
new file mode 100644
index 0000000..153990b
--- /dev/null
+++ b/28428-h/images/fig176.jpg
diff --git a/28428-h/images/fig177.jpg b/28428-h/images/fig177.jpg
new file mode 100644
index 0000000..c2aae5f
--- /dev/null
+++ b/28428-h/images/fig177.jpg
diff --git a/28428-h/images/fig178.jpg b/28428-h/images/fig178.jpg
new file mode 100644
index 0000000..e6c1632
--- /dev/null
+++ b/28428-h/images/fig178.jpg
diff --git a/28428-h/images/fig179-large.jpg b/28428-h/images/fig179-large.jpg
new file mode 100644
index 0000000..a5d1e52
--- /dev/null
+++ b/28428-h/images/fig179-large.jpg
diff --git a/28428-h/images/fig179.jpg b/28428-h/images/fig179.jpg
new file mode 100644
index 0000000..f49d59d
--- /dev/null
+++ b/28428-h/images/fig179.jpg
diff --git a/28428-h/images/fig180-large.png b/28428-h/images/fig180-large.png
new file mode 100644
index 0000000..6fc2f7f
--- /dev/null
+++ b/28428-h/images/fig180-large.png
diff --git a/28428-h/images/fig180.png b/28428-h/images/fig180.png
new file mode 100644
index 0000000..f70ccc9
--- /dev/null
+++ b/28428-h/images/fig180.png
diff --git a/28428-h/images/fig181.jpg b/28428-h/images/fig181.jpg
new file mode 100644
index 0000000..b89e7c8
--- /dev/null
+++ b/28428-h/images/fig181.jpg
diff --git a/28428-h/images/fig182-large.jpg b/28428-h/images/fig182-large.jpg
new file mode 100644
index 0000000..cd1ae3b
--- /dev/null
+++ b/28428-h/images/fig182-large.jpg
diff --git a/28428-h/images/fig182.jpg b/28428-h/images/fig182.jpg
new file mode 100644
index 0000000..bc0e85a
--- /dev/null
+++ b/28428-h/images/fig182.jpg
diff --git a/28428-h/images/fig183.jpg b/28428-h/images/fig183.jpg
new file mode 100644
index 0000000..6e3b9bf
--- /dev/null
+++ b/28428-h/images/fig183.jpg
diff --git a/28428-h/images/fig184.jpg b/28428-h/images/fig184.jpg
new file mode 100644
index 0000000..e221105
--- /dev/null
+++ b/28428-h/images/fig184.jpg
diff --git a/28428-h/images/fig185.jpg b/28428-h/images/fig185.jpg
new file mode 100644
index 0000000..bf6cb45
--- /dev/null
+++ b/28428-h/images/fig185.jpg
diff --git a/28428-h/images/fig186-large.jpg b/28428-h/images/fig186-large.jpg
new file mode 100644
index 0000000..00b330d
--- /dev/null
+++ b/28428-h/images/fig186-large.jpg
diff --git a/28428-h/images/fig186.jpg b/28428-h/images/fig186.jpg
new file mode 100644
index 0000000..5e951ea
--- /dev/null
+++ b/28428-h/images/fig186.jpg
diff --git a/28428-h/images/fig187.jpg b/28428-h/images/fig187.jpg
new file mode 100644
index 0000000..e25e576
--- /dev/null
+++ b/28428-h/images/fig187.jpg
diff --git a/28428-h/images/fig188.jpg b/28428-h/images/fig188.jpg
new file mode 100644
index 0000000..b446eab
--- /dev/null
+++ b/28428-h/images/fig188.jpg
diff --git a/28428-h/images/fig189.jpg b/28428-h/images/fig189.jpg
new file mode 100644
index 0000000..a715412
--- /dev/null
+++ b/28428-h/images/fig189.jpg
diff --git a/28428-h/images/fig190.jpg b/28428-h/images/fig190.jpg
new file mode 100644
index 0000000..5c01ef2
--- /dev/null
+++ b/28428-h/images/fig190.jpg
diff --git a/28428-h/images/fig191.jpg b/28428-h/images/fig191.jpg
new file mode 100644
index 0000000..aa9db5e
--- /dev/null
+++ b/28428-h/images/fig191.jpg
diff --git a/28428-h/images/fig192.jpg b/28428-h/images/fig192.jpg
new file mode 100644
index 0000000..632c8f2
--- /dev/null
+++ b/28428-h/images/fig192.jpg
diff --git a/28428-h/images/fig193.jpg b/28428-h/images/fig193.jpg
new file mode 100644
index 0000000..3c4dbb9
--- /dev/null
+++ b/28428-h/images/fig193.jpg
diff --git a/28428-h/images/fig194.jpg b/28428-h/images/fig194.jpg
new file mode 100644
index 0000000..31765d5
--- /dev/null
+++ b/28428-h/images/fig194.jpg
diff --git a/28428-h/images/fig195.jpg b/28428-h/images/fig195.jpg
new file mode 100644
index 0000000..5a6b84e
--- /dev/null
+++ b/28428-h/images/fig195.jpg
diff --git a/28428-h/images/fig196.jpg b/28428-h/images/fig196.jpg
new file mode 100644
index 0000000..f2c0c9a
--- /dev/null
+++ b/28428-h/images/fig196.jpg
diff --git a/28428-h/images/fig197.jpg b/28428-h/images/fig197.jpg
new file mode 100644
index 0000000..4e0d334
--- /dev/null
+++ b/28428-h/images/fig197.jpg
diff --git a/28428-h/images/fig198.jpg b/28428-h/images/fig198.jpg
new file mode 100644
index 0000000..d1fadfb
--- /dev/null
+++ b/28428-h/images/fig198.jpg
diff --git a/28428-h/images/fig199.jpg b/28428-h/images/fig199.jpg
new file mode 100644
index 0000000..c725c9c
--- /dev/null
+++ b/28428-h/images/fig199.jpg
diff --git a/28428-h/images/fig200.jpg b/28428-h/images/fig200.jpg
new file mode 100644
index 0000000..e4607a3
--- /dev/null
+++ b/28428-h/images/fig200.jpg
diff --git a/28428-h/images/fig201.jpg b/28428-h/images/fig201.jpg
new file mode 100644
index 0000000..08907c8
--- /dev/null
+++ b/28428-h/images/fig201.jpg
diff --git a/28428-h/images/fig202.jpg b/28428-h/images/fig202.jpg
new file mode 100644
index 0000000..99e791c
--- /dev/null
+++ b/28428-h/images/fig202.jpg
diff --git a/28428-h/images/fig203.jpg b/28428-h/images/fig203.jpg
new file mode 100644
index 0000000..a9b8988
--- /dev/null
+++ b/28428-h/images/fig203.jpg
diff --git a/28428-h/images/fig204.jpg b/28428-h/images/fig204.jpg
new file mode 100644
index 0000000..8a0254d
--- /dev/null
+++ b/28428-h/images/fig204.jpg
diff --git a/28428-h/images/fig205-large.jpg b/28428-h/images/fig205-large.jpg
new file mode 100644
index 0000000..29966ed
--- /dev/null
+++ b/28428-h/images/fig205-large.jpg
diff --git a/28428-h/images/fig205.jpg b/28428-h/images/fig205.jpg
new file mode 100644
index 0000000..32a6556
--- /dev/null
+++ b/28428-h/images/fig205.jpg
diff --git a/28428-h/images/fig206.jpg b/28428-h/images/fig206.jpg
new file mode 100644
index 0000000..ec8a8d5
--- /dev/null
+++ b/28428-h/images/fig206.jpg
diff --git a/28428-h/images/fig207.jpg b/28428-h/images/fig207.jpg
new file mode 100644
index 0000000..c5af2e1
--- /dev/null
+++ b/28428-h/images/fig207.jpg
diff --git a/28428-h/images/fig208.jpg b/28428-h/images/fig208.jpg
new file mode 100644
index 0000000..bb79b5e
--- /dev/null
+++ b/28428-h/images/fig208.jpg
diff --git a/28428-h/images/fig209.jpg b/28428-h/images/fig209.jpg
new file mode 100644
index 0000000..03ec041
--- /dev/null
+++ b/28428-h/images/fig209.jpg
diff --git a/28428-h/images/fig210.jpg b/28428-h/images/fig210.jpg
new file mode 100644
index 0000000..48efaa0
--- /dev/null
+++ b/28428-h/images/fig210.jpg
diff --git a/28428-h/images/fig211.jpg b/28428-h/images/fig211.jpg
new file mode 100644
index 0000000..81c7808
--- /dev/null
+++ b/28428-h/images/fig211.jpg
diff --git a/28428-h/images/fig212.jpg b/28428-h/images/fig212.jpg
new file mode 100644
index 0000000..1f031a1
--- /dev/null
+++ b/28428-h/images/fig212.jpg
diff --git a/28428-h/images/fig213.jpg b/28428-h/images/fig213.jpg
new file mode 100644
index 0000000..7f47eb9
--- /dev/null
+++ b/28428-h/images/fig213.jpg
diff --git a/28428-h/images/fig214.jpg b/28428-h/images/fig214.jpg
new file mode 100644
index 0000000..e8abaa6
--- /dev/null
+++ b/28428-h/images/fig214.jpg
diff --git a/28428-h/images/fig215.jpg b/28428-h/images/fig215.jpg
new file mode 100644
index 0000000..ff331cb
--- /dev/null
+++ b/28428-h/images/fig215.jpg
diff --git a/28428-h/images/fig216.jpg b/28428-h/images/fig216.jpg
new file mode 100644
index 0000000..d25a249
--- /dev/null
+++ b/28428-h/images/fig216.jpg
diff --git a/28428-h/images/fig217.png b/28428-h/images/fig217.png
new file mode 100644
index 0000000..2b6adf7
--- /dev/null
+++ b/28428-h/images/fig217.png
diff --git a/28428-h/images/fig218.jpg b/28428-h/images/fig218.jpg
new file mode 100644
index 0000000..7e7e50e
--- /dev/null
+++ b/28428-h/images/fig218.jpg
diff --git a/28428-h/images/fig219.jpg b/28428-h/images/fig219.jpg
new file mode 100644
index 0000000..ce953b1
--- /dev/null
+++ b/28428-h/images/fig219.jpg
diff --git a/28428-h/images/fig220.jpg b/28428-h/images/fig220.jpg
new file mode 100644
index 0000000..a6a6b70
--- /dev/null
+++ b/28428-h/images/fig220.jpg
diff --git a/28428-h/images/fig221.jpg b/28428-h/images/fig221.jpg
new file mode 100644
index 0000000..68d2f01
--- /dev/null
+++ b/28428-h/images/fig221.jpg
diff --git a/28428-h/images/fig222.jpg b/28428-h/images/fig222.jpg
new file mode 100644
index 0000000..69215d4
--- /dev/null
+++ b/28428-h/images/fig222.jpg
diff --git a/28428-h/images/fig223.jpg b/28428-h/images/fig223.jpg
new file mode 100644
index 0000000..9bf0e46
--- /dev/null
+++ b/28428-h/images/fig223.jpg
diff --git a/28428-h/images/fig224.jpg b/28428-h/images/fig224.jpg
new file mode 100644
index 0000000..e91291f
--- /dev/null
+++ b/28428-h/images/fig224.jpg
diff --git a/28428-h/images/fig225.jpg b/28428-h/images/fig225.jpg
new file mode 100644
index 0000000..a33cf9f
--- /dev/null
+++ b/28428-h/images/fig225.jpg
diff --git a/28428-h/images/fig226.jpg b/28428-h/images/fig226.jpg
new file mode 100644
index 0000000..0ffd071
--- /dev/null
+++ b/28428-h/images/fig226.jpg
diff --git a/28428-h/images/fig227.jpg b/28428-h/images/fig227.jpg
new file mode 100644
index 0000000..e3b99d6
--- /dev/null
+++ b/28428-h/images/fig227.jpg
diff --git a/28428-h/images/fig228.jpg b/28428-h/images/fig228.jpg
new file mode 100644
index 0000000..a4597de
--- /dev/null
+++ b/28428-h/images/fig228.jpg
diff --git a/28428-h/images/fig229.jpg b/28428-h/images/fig229.jpg
new file mode 100644
index 0000000..dcd8e2d
--- /dev/null
+++ b/28428-h/images/fig229.jpg
diff --git a/28428-h/images/fig230.png b/28428-h/images/fig230.png
new file mode 100644
index 0000000..90d1852
--- /dev/null
+++ b/28428-h/images/fig230.png
diff --git a/28428-h/images/fig231.jpg b/28428-h/images/fig231.jpg
new file mode 100644
index 0000000..f33983b
--- /dev/null
+++ b/28428-h/images/fig231.jpg
diff --git a/28428-h/images/fig232.jpg b/28428-h/images/fig232.jpg
new file mode 100644
index 0000000..96b12a6
--- /dev/null
+++ b/28428-h/images/fig232.jpg
diff --git a/28428-h/images/fig233.jpg b/28428-h/images/fig233.jpg
new file mode 100644
index 0000000..3995af0
--- /dev/null
+++ b/28428-h/images/fig233.jpg
diff --git a/28428-h/images/fig234.jpg b/28428-h/images/fig234.jpg
new file mode 100644
index 0000000..c0656f6
--- /dev/null
+++ b/28428-h/images/fig234.jpg
diff --git a/28428-h/images/fig235.jpg b/28428-h/images/fig235.jpg
new file mode 100644
index 0000000..6388eae
--- /dev/null
+++ b/28428-h/images/fig235.jpg
diff --git a/28428-h/images/fig236.jpg b/28428-h/images/fig236.jpg
new file mode 100644
index 0000000..db2436f
--- /dev/null
+++ b/28428-h/images/fig236.jpg
diff --git a/28428-h/images/fig237.jpg b/28428-h/images/fig237.jpg
new file mode 100644
index 0000000..636cf23
--- /dev/null
+++ b/28428-h/images/fig237.jpg
diff --git a/28428-h/images/fig238.jpg b/28428-h/images/fig238.jpg
new file mode 100644
index 0000000..1fa68f3
--- /dev/null
+++ b/28428-h/images/fig238.jpg
diff --git a/28428-h/images/fig239.jpg b/28428-h/images/fig239.jpg
new file mode 100644
index 0000000..9518d7b
--- /dev/null
+++ b/28428-h/images/fig239.jpg
diff --git a/28428-h/images/fig240.jpg b/28428-h/images/fig240.jpg
new file mode 100644
index 0000000..107ae80
--- /dev/null
+++ b/28428-h/images/fig240.jpg
diff --git a/28428-h/images/fig241.jpg b/28428-h/images/fig241.jpg
new file mode 100644
index 0000000..7c30bf1
--- /dev/null
+++ b/28428-h/images/fig241.jpg
diff --git a/28428-h/images/fig242.jpg b/28428-h/images/fig242.jpg
new file mode 100644
index 0000000..c52add0
--- /dev/null
+++ b/28428-h/images/fig242.jpg
diff --git a/28428-h/images/fig243.jpg b/28428-h/images/fig243.jpg
new file mode 100644
index 0000000..382255c
--- /dev/null
+++ b/28428-h/images/fig243.jpg
diff --git a/28428-h/images/fig244.jpg b/28428-h/images/fig244.jpg
new file mode 100644
index 0000000..be131a2
--- /dev/null
+++ b/28428-h/images/fig244.jpg
diff --git a/28428-h/images/fig245.jpg b/28428-h/images/fig245.jpg
new file mode 100644
index 0000000..310a4d6
--- /dev/null
+++ b/28428-h/images/fig245.jpg
diff --git a/28428-h/images/fig246.jpg b/28428-h/images/fig246.jpg
new file mode 100644
index 0000000..304e8cb
--- /dev/null
+++ b/28428-h/images/fig246.jpg
diff --git a/28428-h/images/fig247.jpg b/28428-h/images/fig247.jpg
new file mode 100644
index 0000000..60f1073
--- /dev/null
+++ b/28428-h/images/fig247.jpg
diff --git a/28428-h/images/fig248.jpg b/28428-h/images/fig248.jpg
new file mode 100644
index 0000000..5c40273
--- /dev/null
+++ b/28428-h/images/fig248.jpg
diff --git a/28428-h/images/fig249.jpg b/28428-h/images/fig249.jpg
new file mode 100644
index 0000000..e331bb7
--- /dev/null
+++ b/28428-h/images/fig249.jpg
diff --git a/28428-h/images/fig250.jpg b/28428-h/images/fig250.jpg
new file mode 100644
index 0000000..f38b887
--- /dev/null
+++ b/28428-h/images/fig250.jpg
diff --git a/28428-h/images/fig251.jpg b/28428-h/images/fig251.jpg
new file mode 100644
index 0000000..bf7e12e
--- /dev/null
+++ b/28428-h/images/fig251.jpg
diff --git a/28428-h/images/fig252.jpg b/28428-h/images/fig252.jpg
new file mode 100644
index 0000000..8aeccb1
--- /dev/null
+++ b/28428-h/images/fig252.jpg
diff --git a/28428-h/images/fig253.jpg b/28428-h/images/fig253.jpg
new file mode 100644
index 0000000..cdaf4c5
--- /dev/null
+++ b/28428-h/images/fig253.jpg
diff --git a/28428-h/images/fig254.jpg b/28428-h/images/fig254.jpg
new file mode 100644
index 0000000..acbef70
--- /dev/null
+++ b/28428-h/images/fig254.jpg
diff --git a/28428-h/images/fig255.jpg b/28428-h/images/fig255.jpg
new file mode 100644
index 0000000..bf37630
--- /dev/null
+++ b/28428-h/images/fig255.jpg
diff --git a/28428-h/images/fig256.jpg b/28428-h/images/fig256.jpg
new file mode 100644
index 0000000..5d93a53
--- /dev/null
+++ b/28428-h/images/fig256.jpg
diff --git a/28428-h/images/fig257.jpg b/28428-h/images/fig257.jpg
new file mode 100644
index 0000000..9de3d3b
--- /dev/null
+++ b/28428-h/images/fig257.jpg
diff --git a/28428-h/images/fig258.jpg b/28428-h/images/fig258.jpg
new file mode 100644
index 0000000..55cd15a
--- /dev/null
+++ b/28428-h/images/fig258.jpg
diff --git a/28428-h/images/fig259.jpg b/28428-h/images/fig259.jpg
new file mode 100644
index 0000000..d75da2d
--- /dev/null
+++ b/28428-h/images/fig259.jpg
diff --git a/28428-h/images/fig260.jpg b/28428-h/images/fig260.jpg
new file mode 100644
index 0000000..7c12bc1
--- /dev/null
+++ b/28428-h/images/fig260.jpg
diff --git a/28428-h/images/fig261.jpg b/28428-h/images/fig261.jpg
new file mode 100644
index 0000000..714a11f
--- /dev/null
+++ b/28428-h/images/fig261.jpg
diff --git a/28428-h/images/fig262.jpg b/28428-h/images/fig262.jpg
new file mode 100644
index 0000000..15a1e34
--- /dev/null
+++ b/28428-h/images/fig262.jpg
diff --git a/28428-h/images/fig263.jpg b/28428-h/images/fig263.jpg
new file mode 100644
index 0000000..dcc2224
--- /dev/null
+++ b/28428-h/images/fig263.jpg
diff --git a/28428-h/images/fig264.jpg b/28428-h/images/fig264.jpg
new file mode 100644
index 0000000..678d880
--- /dev/null
+++ b/28428-h/images/fig264.jpg
diff --git a/28428-h/images/fig265.jpg b/28428-h/images/fig265.jpg
new file mode 100644
index 0000000..46e3de5
--- /dev/null
+++ b/28428-h/images/fig265.jpg
diff --git a/28428-h/images/fig266.jpg b/28428-h/images/fig266.jpg
new file mode 100644
index 0000000..3924799
--- /dev/null
+++ b/28428-h/images/fig266.jpg
diff --git a/28428-h/images/fig267.jpg b/28428-h/images/fig267.jpg
new file mode 100644
index 0000000..7a8d6b6
--- /dev/null
+++ b/28428-h/images/fig267.jpg
diff --git a/28428-h/images/fig268.jpg b/28428-h/images/fig268.jpg
new file mode 100644
index 0000000..ec978ac
--- /dev/null
+++ b/28428-h/images/fig268.jpg
diff --git a/28428-h/images/fig269.jpg b/28428-h/images/fig269.jpg
new file mode 100644
index 0000000..db30659
--- /dev/null
+++ b/28428-h/images/fig269.jpg
diff --git a/28428-h/images/fig270.jpg b/28428-h/images/fig270.jpg
new file mode 100644
index 0000000..8fe83eb
--- /dev/null
+++ b/28428-h/images/fig270.jpg
diff --git a/28428-h/images/fig271.jpg b/28428-h/images/fig271.jpg
new file mode 100644
index 0000000..7fcb02f
--- /dev/null
+++ b/28428-h/images/fig271.jpg
diff --git a/28428-h/images/fig272.jpg b/28428-h/images/fig272.jpg
new file mode 100644
index 0000000..8a2572d
--- /dev/null
+++ b/28428-h/images/fig272.jpg
diff --git a/28428-h/images/fig273.jpg b/28428-h/images/fig273.jpg
new file mode 100644
index 0000000..1b070c5
--- /dev/null
+++ b/28428-h/images/fig273.jpg
diff --git a/28428-h/images/fig274.jpg b/28428-h/images/fig274.jpg
new file mode 100644
index 0000000..2e5d841
--- /dev/null
+++ b/28428-h/images/fig274.jpg
diff --git a/28428-h/images/fig275.jpg b/28428-h/images/fig275.jpg
new file mode 100644
index 0000000..dcf034d
--- /dev/null
+++ b/28428-h/images/fig275.jpg
diff --git a/28428-h/images/fig276.jpg b/28428-h/images/fig276.jpg
new file mode 100644
index 0000000..548b072
--- /dev/null
+++ b/28428-h/images/fig276.jpg
diff --git a/28428-h/images/fig277.jpg b/28428-h/images/fig277.jpg
new file mode 100644
index 0000000..ea28c59
--- /dev/null
+++ b/28428-h/images/fig277.jpg
diff --git a/28428-h/images/fig278.jpg b/28428-h/images/fig278.jpg
new file mode 100644
index 0000000..42ba070
--- /dev/null
+++ b/28428-h/images/fig278.jpg
diff --git a/28428-h/images/fig279.jpg b/28428-h/images/fig279.jpg
new file mode 100644
index 0000000..706de3a
--- /dev/null
+++ b/28428-h/images/fig279.jpg
diff --git a/28428-h/images/fig280.jpg b/28428-h/images/fig280.jpg
new file mode 100644
index 0000000..187a36c
--- /dev/null
+++ b/28428-h/images/fig280.jpg
diff --git a/28428-h/images/fig281.jpg b/28428-h/images/fig281.jpg
new file mode 100644
index 0000000..58243e1
--- /dev/null
+++ b/28428-h/images/fig281.jpg
diff --git a/28428-h/images/fig282.jpg b/28428-h/images/fig282.jpg
new file mode 100644
index 0000000..ff2ffd4
--- /dev/null
+++ b/28428-h/images/fig282.jpg
diff --git a/28428-h/images/fig283.jpg b/28428-h/images/fig283.jpg
new file mode 100644
index 0000000..dbab067
--- /dev/null
+++ b/28428-h/images/fig283.jpg
diff --git a/28428-h/images/fig284.jpg b/28428-h/images/fig284.jpg
new file mode 100644
index 0000000..8da4d04
--- /dev/null
+++ b/28428-h/images/fig284.jpg
diff --git a/28428-h/images/fig285.jpg b/28428-h/images/fig285.jpg
new file mode 100644
index 0000000..197afd7
--- /dev/null
+++ b/28428-h/images/fig285.jpg
diff --git a/28428-h/images/fig286.jpg b/28428-h/images/fig286.jpg
new file mode 100644
index 0000000..6fc6695
--- /dev/null
+++ b/28428-h/images/fig286.jpg
diff --git a/28428-h/images/fig287.jpg b/28428-h/images/fig287.jpg
new file mode 100644
index 0000000..cf42f35
--- /dev/null
+++ b/28428-h/images/fig287.jpg
diff --git a/28428-h/images/fig288.jpg b/28428-h/images/fig288.jpg
new file mode 100644
index 0000000..bf4b3cb
--- /dev/null
+++ b/28428-h/images/fig288.jpg