+--------------------------------------------------------------------+| || Transcriber's note: The inverted 'Y' symbol used in this book has || been transcribed as [inverted Y]. || |+--------------------------------------------------------------------+ OXFORD MEDICAL PUBLICATIONS MANUAL OF SURGERY BY ALEXIS THOMSON, F. R. C. S. Ed. AND Eng. _PROFESSOR OF SURGERY, UNIVERSITY OF EDINBURGH_ SURGEON EDINBURGH ROYAL INFIRMARY AND ALEXANDER MILES, F. R. C. S. Ed. SURGEON EDINBURGH ROYAL INFIRMARY VOLUME SECOND EXTREMITIES--HEAD--NECK _SIXTH EDITION REVISED AND ENLARGED_ _WITH 288 ILLUSTRATIONS_ LONDON HENRY FROWDE and HODDER & STOUGHTON THE _LANCET_ BUILDING 1 & 2 BEDFORD STREET, STRAND, W. C. 2 First Edition 1904 Second Edition 1907 Third Edition 1909 Fourth Edition 1912 " " Second Impression 1913 Fifth Edition 1915 " " Second Impression 1919 Sixth Edition 1921 PRINTED IN GREAT BRITAIN BY MORRISON AND GIBB LTD. , EDINBURGH CONTENTS PAGE CHAPTER I INJURIES OF BONES 1 CHAPTER II INJURIES OF JOINTS 32 CHAPTER III INJURIES IN THE REGION OF THE SHOULDER AND UPPER ARM 44 CHAPTER IV INJURIES IN THE REGION OF THE ELBOW AND FOREARM 79 CHAPTER V INJURIES IN THE REGION OF THE WRIST AND HAND 102 CHAPTER VI INJURIES IN THE REGION OF THE PELVIS, HIP-JOINT, AND THIGH 122 CHAPTER VII INJURIES IN THE REGION OF THE KNEE AND LEG 155 CHAPTER VIII INJURIES IN REGION OF ANKLE AND FOOT 185 CHAPTER IX DISEASES OF INDIVIDUAL JOINTS 201 CHAPTER X DEFORMITIES OF THE EXTREMITIES 241 CHAPTER XI THE SCALP 319 CHAPTER XII THE CRANIUM AND ITS CONTENTS 328 CHAPTER XIII INJURIES OF THE SKULL 361 CHAPTER XIV DISEASES OF THE BRAIN AND MEMBRANES 373 CHAPTER XV DISEASES OF THE CRANIAL BONES 406 CHAPTER XVI THE VERTEBRAL COLUMN AND SPINAL CORD 411 CHAPTER XVII DISEASES OF THE VERTEBRAL COLUMN AND SPINAL CORD 431 CHAPTER XVIII DEVIATIONS OF THE VERTEBRAL COLUMN 461 CHAPTER XIX THE FACE, ORBIT, AND LIPS 474 CHAPTER XX THE MOUTH, FAUCES, AND PHARYNX 496 CHAPTER XXI THE JAWS, INCLUDING THE TEETH AND GUMS 507 CHAPTER XXII THE TONGUE 528 CHAPTER XXIII THE SALIVARY GLANDS 543 CHAPTER XXIV THE EAR 553 CHAPTER XXV THE NOSE AND NASO-PHARYNX 567 CHAPTER XXVI THE NECK 582 CHAPTER XXVII THE THYREOID GLAND 604 CHAPTER XXVIII THE ŒSOPHAGUS 616 CHAPTER XXIX THE LARYNX, TRACHEA, AND BRONCHI 634 INDEX 645 LIST OF ILLUSTRATIONS FIG. PAGE 1. Multiple Fracture of both Bones of Leg 4 2. Radiogram showing Comminuted Fracture of both Bones of 5 Forearm 3. Oblique Fracture of Tibia; with partial Separation of 6 Epiphysis of Upper End of Fibula; and Incomplete Fracture of Fibula in Upper Third 4. Excess of Callus after Compound Fracture of Bones of 9 Forearm 5. Multiple Fractures of both Bones of Forearm showing 11 Mal-union 6. Radiogram of Un-united Fracture of Shaft of Ulna 13 7. Excessive Callus Formation after Infected Compound 27 Fracture of both Bones of Forearm 8. Partial Separation of Epiphysis, with Fracture running 29 into Diaphysis 9. Complete Separation of Epiphysis 29 10. Partial Separation with Fracture of Epiphysis 29 11. Complete Separation with Fracture of Epiphysis 29 12. Os Innominatum showing new Socket formed after 41 Old-standing Dislocation 13. Oblique Fracture of Right Clavicle in Middle Third, 45 united 14. Fracture of Acromial End of Clavicle 46 15. Adhesive Plaster applied for Fracture of Clavicle 49 16. Forward Dislocation of Sternal End of Right Clavicle 51 17. Diagram of most common varieties of Dislocation of the 53 Shoulder 18. Sub-coracoid Dislocation of Right Shoulder 55 19. Sub-coracoid Dislocation of Humerus 56 20. Kocher's Method of reducing Sub-coracoid 57 Dislocation--First Movement 21. Kocher's Method--Second Movement 58 22. Kocher's Method--Third Movement 59 23. Miller's Method of reducing Sub-coracoid 60 Dislocation--First Movement 24. Miller's Method--Second Movement 61 25. Dislocation of Shoulder with Fracture of Neck of Humerus 64 26. Transverse Fracture of Scapula 68 27. Fracture of Surgical Neck of Humerus, united with 70 Angular Displacement 28. Impacted Fracture of Neck of Humerus 71 29. Ambulatory Abduction Splint for Fracture of Humerus 72 30. Radiogram of Separation of Upper Epiphysis of Humerus 73 31. "Cock-up" Splint 77 32. Gooch Splints for Fracture of Shaft of Humerus; and Rectangular Splint to secure Elbow 77 33. Radiogram of Supra-condylar Fracture of Humerus in a 81 Child 34. Radiogram of T-shaped Fracture of Lower End of Humerus 83 35. Radiogram of Fracture of Olecranon Process 86 36. Backward Dislocation of Elbow in a Boy 89 37. Bony Outgrowth in relation to insertion of Brachialis 90 Muscle 38. Radiogram of Incomplete Backward Dislocation of Elbow 91 39. Forward Dislocation of Elbow, with Fracture of Olecranon 93 40. Radiogram of Forward Dislocation of Head of Radius, with 95 Fracture of Shaft of Ulna 41. Greenstick Fracture of both Bones of the Forearm 98 42. Gooch Splints for Fracture of both Bones of Forearm 99 43. Colles' Fracture showing Radial Deviation of Hand 103 44. Colles' Fracture showing undue prominence of Ulnar 103 Styloid 45. Radiogram showing the Line of Fracture and Upward 104 Displacement of the Radial Styloid in Colles' Fracture 46. Radiogram of Chauffeur's Fracture 107 47. Radiogram of Smith's Fracture 108 48. Manus Valga following Separation of Lower Radial 109 Epiphysis in Childhood 49. Radiogram showing Fracture of Navicular (Scaphoid) Bone 111 50. Dorsal Dislocation of Wrist at Radio-carpal Articulation 113 51. Radiogram showing Forward Dislocation of Navicular Bone 114 52. Extension Apparatus for Oblique Fracture of Metacarpals 117 53. Radiogram of Bennett's Fracture of Base of Metacarpal 118 of Right Thumb 54. Splints for Bennett's Fracture 119 55. Multiple Fracture of Pelvis through Horizontal and 123 Descending Rami of both Pubes, and Longitudinal Fracture of left side of Sacrum 56. Fracture of Left Iliac Bone; and of both Pubic Arches 124 57. Many-tailed Bandage and Binder for Fracture of Pelvic 125 Girdle 58. Nélaton's Line 128 59. Bryant's Line 129 60. Section through Hip-Joint to show Epiphyses at Upper 130 End of Femur, and their relation to the Joint 61. Fracture through Narrow Part of Neck of Femur on Section 131 62. Impacted Fracture through Narrow Part of Neck of Femur 132 63. Fracture of Neck of Right Femur, showing Shortening, 133 Abduction, and Eversion of Limb 64. Fracture of Narrow Part of Neck of Femur 134 65. Coxa Vara following Fracture of Neck of Femur in a Child 136 66. Non-impacted Fracture through Base of Neck 137 67. Fracture through Base of Neck of Femur with Impaction 137 into the Trochanters 68. Non-impacted Fracture through Base of Neck 138 69. Fracture of the Femur just below the small Trochanter, 140 united, showing Flexion and Lateral Rotation of Upper Fragment 70. Adjustable Double-inclined Plane 141 71. Diagram of the most Common Dislocations of the Hip 142 72. Dislocation of Right Femur on to Dorsum Ilii 143 73. Dislocation on to Dorsum Ilii 144 74. Dislocation into the Vicinity of the Ischiatic Notch 145 75. Longitudinal Section of Femur showing Fracture of Shaft 148 with Overriding of Fragments 76. Radiogram of Steinmann's Apparatus applied for Direct 150 Extension to the Femur 77. Hodgen's Splint 151 78. Long Splint with Perineal Band 152 79. Fracture of Thigh treated by Vertical Extension 153 80. Section of Knee-joint showing Extent of Synovial Cavity 156 81. Extension applied by means of Ice-tong Callipers for Fracture of Femur 158 82. Radiogram of Separation of Lower Epiphysis of Femur, 160 with Backward Displacement of the Diaphysis 83. Separation of Lower Epiphysis of Femur, with Fracture 161 of Lower End of Diaphysis 84. Radiogram of Fracture of Head of Tibia and upper Third 163 of Fibula 85. Radiogram illustrating Schlatter's Disease 164 86. Diagram of Longitudinal Tear of Posterior End of Right 171 Medial Semilunar Meniscus 87. Radiogram of Fracture of Patella 173 88. Fracture of Patella, showing wide Separation of Fragments 175 89. Radiogram of Transverse Fracture of both Bones of Leg 178 by Direct Violence 90. Radiogram of Oblique Fracture of both Bones of Leg by 178 Indirect Violence 91. Box Splint for Fractures of Leg 180 92. Box Splint applied 181 93. Section through Ankle-joint showing relation of 186 Epiphyses to Synovial Cavity 94. Radiogram of Pott's Fracture, with Lateral Displacement 187 of Foot 95. Ambulant Splint of Plaster of Paris 189 96. Dupuytren's Splint applied to Correct Eversion of Foot 190 97. Syme's Horse-shoe Splint applied to Correct Backward 191 Displacement of Foot 98. Radiogram of Fracture of Lower End of Fibula, with 192 Separation of Lower Epiphysis of Tibia 99. Radiogram of Backward Dislocation of Ankle 195 100. Compound Dislocation of Talus 197 101. Radiogram of Fracture-Dislocation of Talus 198 102. Radiogram of Dislocation of Toes 199 103. Arthropathy of Shoulder in Syringomyelia 203 104. Radiogram of Specimen of Arthropathy of Shoulder in 204 Syringomyelia 105. Radiogram showing Multiple partially Ossified 205 Cartilaginous Loose Bodies in Shoulder-joint 106. Diffuse Tuberculous Thickening of Synovial Membrane of 206 Elbow 107. Contracture of Elbow and Wrist following a Burn in 207 Childhood 108. Advanced Tuberculous Disease of Acetabulum with Caries 210 and Perforation into Pelvis 109. Early Tuberculous Disease of Right Hip-joint in a Boy 212 110. Disease of Left Hip; showing Moderate Flexion and 213 Lordosis 111. Disease of Left Hip; Disappearance of Lordosis on 213 further Flexion of the Hip 112. Disease of Left Hip; Exaggeration of Lordosis 214 113. Thomas' Flexion Test, showing Angle of Flexion at 214 Diseased Hip 114. Tuberculous Disease of Left Hip: Third Stage 215 115. Advanced Tuberculous Disease of Left Hip-joint in a Girl 216 116. Extension by Adhesive Plaster and Weight and Pulley 220 117. Stiles' Double Long Splint to admit of Abduction of 221 Diseased Limb 118. Thomas' Hip-splint applied for Disease of Right Hip 222 119. Arthritis Deformans, showing erosion of Cartilage and 225 lipping of Articular Edge of Head of Femur 120. Upper End of Femur in advanced Arthritis Deformans 226 of Hip 121. Femur in advanced Arthritis Deformans of Hip and Knee 227 Joints 122. Tuberculous Synovial Membrane of Knee 230 123. Lower End of Femur from an Advanced Case of Tuberculous 231 Arthritis of the Knee 124. Advanced Tuberculous Disease of Knee, with Backward 233 Displacement of Tibia 125. Thomas' Knee-splint applied 236 126. Tuberculous Disease of Right Ankle 239 127. Female Child showing the results of Poliomyelitis 243 affecting the Left Lower Extremity 128. Radiogram of Double Congenital Dislocation of Hip in 249 a Girl 129. Innominate Bone and Upper End of Femur from a case of 250 Congenital Dislocation of Hip 130. Congenital Dislocation of Left Hip in a Girl 251 131. Contracture Deformities of Upper and Lower Limbs 255 resulting from Spastic Cerebral Palsy in Infancy 132. Rachitic Coxa Vara 258 133. Coxa Vara, showing Adduction Curvature of Neck of Femur 260 associated with Arthritis of the Hip and Knee 134. Bilateral Coxa Vara, showing Scissors-leg Deformity 260 135. Genu Valgum and Genu Varum 265 136. Female Child with Right-sided Genu Valgum, the result of 266 Rickets 137. Double Genu Valgum; and Rickety Deformities of Arms 267 138. Radiogram of Case of Double Genu Valgum in a Child 268 139. Genu Valgum in a Child. Patient standing 269 140. Genu Valgum. Same Patient as Fig. 139, sitting 270 141. Bow-knee in Rickety Child 271 142. Bilateral Congenital Club-foot in an Infant 274 143. Radiogram of Bilateral Congenital Club-foot in an Infant 275 144. Congenital Talipes Equino-varus in a Man 277 145. Bilateral Pes Equinus in a Boy 280 146. Extreme form of Pes Equinus in a Girl 281 147. Skeleton of Foot from case of Pes Equinus due to 282 Poliomyelitis 148. Pes Calcaneo-valgus with excessive arching of Foot 284 149. Pes Calcaneo-valgus, the result of Poliomyelitis 285 150. Pes Cavus in Association with Pes Equinus, the Result 286 of Poliomyelitis 151. Radiogram of Foot of Adult, showing Changes in the 286 Bones in Pes Cavus 152. Adolescent Flat-Foot 287 153. Flat-Foot, showing Loss of Arch 288 154. Imprint of Normal and of Flat Foot 290 155. Bilateral Pes Valgus and Hallux Valgus in a Girl 293 156. Radiogram of Spur on Under Aspect of Calcaneus 295 157. Radiogram of Hallux Valgus 296 158. Radiogram of Hallux Varus or Pigeon-Toe 298 159. Hallux Rigidus and Flexus in a Boy 299 160. Hammer-Toe 300 161. Section of Hammer-Toe 301 162. Congenital Hypertrophy of Left Lower Extremity in a Boy 302 163. Supernumerary Great Toe 303 164. Congenital Elevation of Left Scapula in a Girl: also 304 shows Hairy Mole over Sacrum 165. Winged Scapula 305 166. Arrested Growth and Wasting of Tissues of Right Upper 307 Extremity 167. Lower End of Humerus from case of Cubitus Varus 309 168. Intra-Uterine Amputation of Forearm 310 169. Radiogram of Arm of Patient shown in Fig. 168 310 170. Congenital Absence of Left Radius and Tibia in a Child 311 171. Club-Hand, the Result of Imperfect Development of Radius 312 172. Congenital Contraction of Ring and Little Fingers 314 173. Dupuytren's Contraction 315 174. Splint used after Operation for Dupuytren's Contraction 316 175. Supernumerary Thumb 317 176. Trigger Finger 318 177. Multiple Wens 324 178. Adenoma of Scalp 325 179. Relations of the Motor and Sensory Areas to the 330 Convolutions and to Chiene's Lines 180. Diagram of the Course of Motor and Sensory Nerve Fibres 333 181. Chiene's Method of Cerebral Localisation 336 182. To illustrate the Site of Various Operations on the Skull 337 183. Localisation of Site for Introduction of Needle in Lumbar 338 Puncture 184. Contusion and Laceration of Brain 343 185. Charts of Pyrexia in Head Injuries 348 186. Relations of the Middle Meningeal Artery and Lateral 353 Sinus to the Surface as indicated by Chiene's Lines 187. Extra-Dural Clot resulting from Hæmorrhage from the 354 Middle Meningeal Artery 188. Depressed Fracture of Frontal Bones with Fissured 365 Fracture 189. Depressed and Comminuted Fracture of Right Parietal 365 Bone: Pond Fracture 190. Pond Fracture of Left Frontal Bone, produced during 366 Delivery 191. Transverse Fracture through Middle Fossa of Base of Skull 368 192. Diagram of Extra-Dural Abscess 374 193. Pott's Puffy Tumour in case of Extra-Dural Abscess 375 following Compound Fracture of Orbital Margin 194. Diagram of Sub-Dural Abscess 376 195. Diagram illustrating sequence of Paralysis, caused by 380 Abscess in Temporal Lobe 196. Chart of case of Sinus Phlebitis following Middle Ear 384 Disease 197. Occipital Meningocele 388 198. Frontal Hydrencephalocele 389 199. Nævus at Root of Nose, simulating Cephalocele 390 200. Hydrocephalus in a Child 391 201. Patient suffering from Left Facial Paralysis 402 202. Skull of Woman illustrating the appearances of Tertiary 408 Syphilis of Frontal Bone--Corona Veneris--in the Healed Condition 203. Sarcoma of Orbital Plate of Frontal Bone in a Child at 409 Age of 11 months and 18 months 204. Destruction of Bones of Left Orbit, caused by Rodent 410 Cancer 205. Distribution of the Segments of the Spinal Cord 417 206. Attitude of Upper Extremities in Traumatic Lesions of 418 the Sixth Cervical Segment 207. Compression Fracture of Bodies of Third and Fourth 426 Lumbar Vertebræ 208. Fracture-Dislocation of Ninth Thoracic Vertebra 428 209. Fracture of Odontoid Process of Axis Vertebra 429 210. Tuberculous Osteomyelitis affecting several Vertebræ at 432 Thoracico-Lumbar Junction 211. Osseous Ankylosis of Bodies (_a_) of Dorsal Vertebræ, 434 (_b_) of Lumbar Vertebræ following Pott's Disease 212. Radiogram of Museum Specimen of Pott's Disease in a Child 435 213. Radiogram of Child's Thorax showing Spindle-shaped 437 Shadow at Site of Pott's Disease of Fourth, Fifth, and Sixth Thoracic Vertebræ 214. Attitude of Patient suffering from Tuberculous Disease 441 of the Cervical Spine 215. Thomas' Double Splint for Tuberculous Disease of the 442 Spine 216. Hunch-back Deformity following Pott's Disease of Thoracic 443 Vertebræ 217. Attitude in Pott's Disease of Thoracico-Lumbar Region of 444 Spine 218. Arthritis Deformans of Spine 449 219. Meningo-Myelocele of Thoracico-Lumbar Region 454 220. Meningo-Myelocele of Cervical Spine 454 221. Meningo-Myelocele in Thoracic Region 456 222. Tail-like Appendage over Spina Bifida Occulta in a Boy 457 223. Congenital Sacro-Coccygeal Tumour 458 224. Scoliosis following upon Poliomyelitis affecting Right 463 Arm and Leg 225. Rickety Scoliosis in a Child 464 226. Vertebræ from case of Scoliosis showing Alteration in 466 Shape of Bones 227. Adolescent Scoliosis in a Girl 467 228. Scoliosis with Primary Curve in Thoracic Region 468 229. Scoliosis showing Rotation of Bodies of Vertebræ, and 469 widening of Intercostal Spaces on side of Convexity 230. Diagram of Attitudes in Klapp's Four-Footed Exercises for 473 Scoliosis 231. Head of Human Embryo about 29 days old 475 232. Simple Hare-Lip 476 233. Unilateral Hare-Lip with Cleft Alveolus 477 234. Double Hare-Lip in a Girl 478 235. Double Hare-Lip with Projection of the Os Incisivum 479 236. Asymmetrical Cleft Palate extending through Alveolar 480 Process on Left Side 237. Illustrating the Deformities caused by Lupus Vulgaris 483 238. Sarcoma of Orbit causing Exophthalmos and Downward 488 Displacement of the Eye, and Projecting in Temporal Region 239. Sarcoma of Eyelid in Child 489 240. Dermoid Cyst at Outer Angle of Orbital Margin 490 241. Macrocheilia 492 242. Squamous Epithelioma of Lower Lip in a Man 493 243. Advanced Epithelioma of Lower Lip 494 244. Recurrent Epithelioma in Glands of Neck adherent to 495 Mandible 245. Cancrum Oris 497 246. Perforation of Palate, the Result of Syphilis, and Gumma 498 of Right Frontal Bone 247. Cario-necrosis of Mandible 510 248. Diffuse Syphilitic Disease of Mandible 512 249. Epulis of Mandible 513 250. Sarcoma of the Maxilla 515 251. Malignant Disease of Left Maxilla 516 252. Dentigerous Cyst of Mandible containing Rudimentary Tooth 517 253. Osseous Shell of Myeloma of Mandible 518 254. Multiple Fracture of Mandible 520 255. Four-Tailed Bandage applied for Fracture of Mandible 522 256. Defective Development of Mandible from Fixation of Jaw 526 due to Tuberculous Osteomyelitis in Infancy 257. Leucoplakia of the Tongue 531 258. Papillomatous Angioma of Left Side of Tongue in a Woman 538 259. Dermoid Cyst in Middle Line of Neck 539 260. Temporary Unilateral Paralysis of Tongue 541 261. Series of Salivary Calculi 545 262. Acute Suppurative Parotitis 546 263. Mixed Tumour of Parotid 550 264. Mixed Tumour of the Parotid of over twenty years' 551 duration 265. Acute Mastoid Disease showing Œdema and Projection of 565 Auricle 266. Rhinophyma or Lipoma Nasi 569 267. The Outer Wall of Left Nasal Chamber after removal of 571 the Middle Turbinated Body 268. Congenital Branchial Cyst in a Woman 584 269. Bilateral Cervical Ribs 586 270. Transient Wry-Neck 587 271. Congenital Wry-Neck in a Boy 589 272. Congenital Wry-Neck seen from behind to show Scoliosis 590 273. Recovery from Suicidal Cut-Throat after Low Tracheotomy 596 and Gastrostomy 274. Hygroma of Neck 599 275. Lympho-Sarcoma of Neck 600 276. Branchial Carcinoma 601 277. Parenchymatous Goitre in a Girl 606 278. Larynx and Trachea surrounded by Goitre 607 279. Section of Goitre shown in Fig. 278 to illustrate 607 Compression of Trachea 280. Multiple Adenomata of Thyreoid in a Woman 611 281. Cyst of Left Lobe of Thyreoid 612 282. Exophthalmic Goitre 614 283. Radiogram of Safety-Pin impacted in the Gullet and 620 Perforating the Larynx 284. Denture Impacted in Œsophagus 621 285. Radiogram, after swallowing an Opaque Meal, in a Man 626 suffering from Malignant Stricture of Lower End of Gullet 286. Diverticulum of the Œsophagus at its Junction with the 627 Pharynx 287. Larynx from case of Sudden Death due to Œdema of 637 Ary-Epiglottic Folds 288. Papilloma of Larynx 641 MANUAL OF SURGERY CHAPTER I INJURIES OF BONES Contusions--Wounds--FRACTURES: _Pathological_; _Traumatic_; _Varieties_--Simple fractures--Compound fractures--Repair of fractures--Interference with repair--Gun-shot fractures--SEPARATION OF EPIPHYSES. The injuries to which a bone is liable are Contusions, Open Wounds, and Fractures. #Contusions of Bone# are almost of necessity associated with a similarinjury of the overlying soft parts. The mildest degree consists in abruising of the periosteum, which is raised from the bone by aneffusion of blood, constituting a _hæmatoma of the periosteum_. Thismay be absorbed, or it may give place to a persistent thickening ofthe bone--_traumatic node_. #Open Wounds of Bone# of the incised and contused varieties areusually produced by sabres, axes, butcher's knives, scythes, orcircular saws. Punctured wounds are caused by bayonets, arrows, orother pointed instruments. They are all equivalent to compound, incomplete fractures. FRACTURES A fracture may be defined as a sudden solution in the continuity of abone. PATHOLOGICAL FRACTURES A pathological fracture has as its primary cause some diseased stateof the bone, which permits of its giving way on the application of aforce which would be insufficient to break a healthy bone. It cannotbe too strongly emphasised that when a bone is found to have beenbroken by a slight degree of violence, the presence of somepathological condition should be suspected, and a careful examinationmade with the X-rays and by other means, before arriving at aconclusion as to the cause of the fracture. Many cases are on recordin which such an accident has first drawn attention to the presence ofa new-growth, or other serious lesion in the bone. The followingconditions, which are more fully described with diseases of bone, maybe mentioned as the causes of pathological fractures. _Atrophy_ of bone may proceed to such an extent in old people, or inthose who for long periods have been bed-ridden, that slight violencesuffices to determine a fracture. This most frequently occurs in theneck of the femur in old women, the mere catching of the foot in thebedclothes while the patient is turning in bed being sometimessufficient to cause the bone to give way. Atrophy from the pressure ofan aneurysm or of a simple tumour may erode the whole thickness of abone, or may thin it out to such an extent that slight force issufficient to break it. In general paralysis, and in the advancedstages of locomotor ataxia and other chronic diseases of the nervoussystem, an atrophy of all the bones sometimes takes place, and mayproceed so far that multiple fractures are induced by comparativelyslight causes. They occur most frequently in the ribs or long bones ofthe limbs, are not attended with pain, and usually unitesatisfactorily, although with an excessive amount of callus. Attendants and nurses, especially in asylums, must be warned againstusing force in handling such patients, as otherwise they may beunfairly blamed for causing these fractures. Among diseases which affect the skeleton as a whole and render thebones abnormally fragile, the most important are rickets, osteomalacia, and fibrous osteomyelitis. In these conditions multiplepathological fractures may occur, and they are prone to heal withconsiderable deformity. In osteomalacia, the bones are profoundlyaltered, but they are more liable to bend than to break; in ricketsthe liability is towards greenstick fractures. Of the diseases affecting individual bones and predisposing them tofracture 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 thesudden breaking of the bone to be the first intimation of the presenceof a new-growth. In adolescents, fibrous osteomyelitis affecting asingle bone, and in adults, secondary cancer, are the commonest localcauses of pathological fracture. _Intra-uterine fractures_ and fractures occurring _during birth_ areusually associated with some form of violence, but in the majority ofcases the fœtus is the subject of constitutional disease which rendersthe bones unduly fragile. TRAUMATIC FRACTURES Traumatic fractures are usually the result of a severe force actingfrom without, although sometimes they are produced by muscularcontraction. When the bone gives way at the point of impact of the force, theviolence is said to be _direct_, and a "fracture by compression"results, the line of fracture being as a rule transverse. The softparts overlying the fracture are more or less damaged according to theweight and shape of the impinging body. Fracture of both bones of theleg from the passage of a wheel over the limb, fracture of the shaftof the ulna in warding off a stroke aimed at the head, and fracture ofa rib from a kick, are illustrative examples of fractures by directviolence. When the force is transmitted to the seat of fracture from a distance, the violence is said to be _indirect_, and the bone is broken by"torsion" or by "bending. " In such cases the bone gives way at itsweakest point, and the line of fracture tends to be oblique. Thus bothbones of the leg are frequently broken by a person jumping from aheight and landing on the feet, the tibia breaking in its lower third, and the fibula at a higher level. Fracture of the clavicle in itsmiddle third, or of the radius at its lower end, from a fall on theoutstretched hand, are common accidents produced by indirect violence. The ribs also may be broken by indirect violence, as when the chest iscrushed antero-posteriorly and the bones give way near their angles. In fractures by indirect violence the soft parts do not suffer by theviolence causing the fracture, but they may be injured by displacementof the fragments. In fractures by _muscular action_ the bone is broken by "traction" or"tearing. " The sudden and violent contraction of a muscle may tear offan epiphysis, such as the head of the fibula, the anterior superioriliac spine, or the coronoid process of the ulna; or a bony processmay be separated, as, for example, the tuberosity of the calcaneus, the coracoid process of the scapula, or the larger tubercle (greattuberosity) of the humerus. Long bones also may be broken by muscularaction. The clavicle has snapped across during the act of swinging astick, the humerus in throwing a stone, and the femur when a kick hasmissed its object. Fractures of ribs have occurred during fits ofcoughing and in the violent efforts of parturition. Before concluding that a given fracture is the result of muscularaction, it is necessary to exclude the presence of any of the diseasedconditions that lead to pathological fracture. Although the force acting upon the bone is the primary factor in theproduction of fractures, there are certain subsidiary factors to beconsidered. Thus the age of the patient is of importance. Duringinfancy and early childhood, fractures are less common than at anyother period of life, and are usually transverse, incomplete, and ofthe nature of bends. During adult life, especially between the ages ofthirty and forty, the frequency of fractures reaches its maximum. Inaged persons, although the bones become more brittle by the marrowspaces in their interior becoming larger and filled with fat, fractures are less frequent, doubtless because the old are lessexposed to such violence as is likely to produce fracture. Males, from the nature of their occupations and recreations, sustainfractures more frequently than do females; in old age, however, fractures are more common in women than in men, partly because theirbones are more liable to be the seat of fatty atrophy from senilityand disease, and partly because of their clothing--a long skirt--theyare more exposed to unexpected or sudden falls. [Illustration: FIG. 1. --Multiple Fracture of both Bones of Leg. ] #Clinical Varieties of Fractures. #--The most important subdivision offractures is that into simple and compound. In a _simple_ or subcutaneous fracture there is no communication, directly or indirectly, between the broken ends of the bone and thesurface of the skin. In a _compound_ or open fracture, on the otherhand, such a communication exists, and, by furnishing a means ofentrance for bacteria, may add materially to the gravity of theinjury. A simple fracture may be complicated by the existence of a wound ofthe soft parts, which, however, does not communicate with the brokenbone. Fractures, whether simple or compound, fall into other clinicalgroups, according to (1) the degree of damage done to the bone, (2)the direction of the break, and (3) the relative position of thefragments. (1) _According to the Degree of Damage done to the Bone. _--A fracturemay be incomplete, for example in _greenstick fractures_, which occuronly in young persons--usually below the age of twelve--while thebones are still soft and flexible. They result from forcible bendingof the bone, the osseous tissue on the convexity of the curve givingway, while that on the concavity is compressed. The clavicle and thebones of the forearm are those most frequently the seat of greenstickfracture (Fig. 41). _Fissures_ occur on the flat bones of the skull, the pelvic bones, and the scapula; or in association with otherfractures in long bones, when they often run into joint surfaces. _Depressions_ or indentations are most common in the bones of theskull. The bone at the seat of fracture may be broken into several pieces, constituting a _comminuted_ fracture. This usually results from severedegrees of direct violence, such as are sustained in railway ormachinery accidents, and in gun-shot injuries (Fig. 2). [Illustration: FIG. 2. --Radiogram of Comminuted Fracture of both Bonesof Forearm. ] _Sub-periosteal_ fractures are those in which, although the bone iscompletely broken across, the periosteum remains intact. These arecommon in children, and as the thick periosteum prevents displacement, the existence of a fracture may be overlooked, even in such a largebone as the femur. A bone may be broken at several places, constituting a _multiple_fracture (Fig. 1). _Separation of bony processes_, such as the coracoid process, theepicondyle of the humerus, or the tuberosity of the calcaneus, mayresult from muscular action or from direct violence. _Separation ofepiphyses_ will be considered later. (2) _According to the Direction of the Break. _--_Transverse_ fracturesare those in which the bone gives way more or less exactly at rightangles to its long axis. These usually result from direct violence orfrom end-to-end pressure. _Longitudinal_ fractures extending thegreater part of the length of a long bone are exceedingly rare. _Oblique_ fractures are common, and result usually from indirectviolence, bending, or torsion (Fig. 3). _Spiral_ fractures result fromforcible torsion of a long bone, and are met with most frequently inthe tibia, femur, and humerus. [Illustration: FIG. 3. --Showing (1) Oblique fracture of Tibia; (2)Oblique fracture with partial separation of Epiphysis of upper end ofFibula; (3) Incomplete fracture of Fibula in upper third. Result ofrailway accident. Boy æt. 16. ] (3) _According to the Relative Position of the Fragments. _--The bonemay be completely broken across, yet its ends remain in apposition, in which case there is said to be _no displacement_. There may be an_angular_ displacement--for example, in greenstick fracture. Intransverse fractures of the patella or of the olecranon there is often_distraction_ or pulling apart of the fragments (Fig. 35). The brokenends, especially in oblique fractures, may _override_ one another, andso give rise to shortening of the limb (Fig. 2). Where one fragment isacted upon by powerful muscles, a _rotatory_ displacement may takeplace, as in fracture of the radius above the insertion of thepronator teres, or of the femur just below the small trochanter. Thefragments may be _depressed_, as in the flat bones of the skull or thenasal bones. At the cancellated ends of the long bones, particularlythe upper end of the femur and humerus, and the lower end of theradius, it is not uncommon for one fragment to be _impacted_ or wedgedinto the substance of the other (Fig. 28). _Causes of Displacement. _--The factors which influence displacementare chiefly mechanical in their action. Thus the direction and natureof the fracture play an important part. Transverse fractures withroughly serrated ends are less liable to displacement than those whichare oblique with smooth surfaces. The direction of the causative forcealso is a dominant factor in determining the direction in which one orboth of the fragments will be displaced. Gravity, acting chiefly uponthe distal fragment, also plays a part in determining thedisplacement--for example, in fractures of the thigh or of the leg, where the lower segment of the limb rolls outwards, and in fracturesof the shaft of the clavicle, where the weight of the arm carries theshoulder downwards, forwards, and medially. After the break has takenplace and the force has ceased to act, displacement may be produced byrough handling on the part of those who render first aid, the carelessor improper application of splints or bandages, or by the weight ofthe bedclothes. In certain situations the contraction of unopposed, or of unequallyopposed, groups of muscles plays a part in determining displacement. For example, in fracture immediately below the lesser trochanter ofthe femur, the ilio-psoas tends to tilt the upper fragment forward andlaterally; in supra-condylar fracture of the femur, the muscles of thecalf pull the lower fragment back towards the popliteal space; and infracture of the humerus above the deltoid insertion, the musclesinserted into the inter-tubercular (bicipital) groove adduct the upperfragment. REPAIR OF INJURIES OF BONE In a _simple fracture_ the vessels of the periosteum and the marrowbeing torn at the same time as the bone is broken, blood is pouredout, and clots around and between the fragments. This clot is soonpermeated by newly formed blood vessels, and by leucocytes andfibroblasts, the latter being derived from proliferation of the cellsof the marrow and periosteum. The granulation tissue thus formedresembles in every particular that described in the repair of othertissues, except that the fibroblasts, being the offspring of cellswhich normally form bone, assume the functions of _osteoblasts_, andproceed to the formation of bone. The new bone may be formed either bya direct conversion of the fibrous tissue into osseous tissue, theosteoblasts arranging themselves concentrically in the recesses of thecapillary loops, and secreting a homogeneous matrix in which limesalts are speedily deposited; or there may be an intermediate stage ofcartilage formation, especially in young subjects, and in cases wherethe fragments are incompletely immobilised. The newly formed bone isat first arranged in little masses or in the form of rods which unitewith each other to form a network of spongy bone, the meshes of whichcontain marrow. The reparative material, consisting of granulation tissue in theprocess of conversion into bone, is called _callus_, on account of itshard and unyielding character. In a fracture of a long bone, thatwhich surrounds the fragments is called the _external_ or _ensheathingcallus_, and may be likened to the mass of solder which surrounds thejunction of pipes in plumber-work; that which occupies the position ofthe medullary canal is called the _internal_ or _medullary callus_;and that which intervenes between the fragments and maintains thecontinuity of the cortical compact tissue of the shaft is called the_intermediate callus_. This intermediate callus is the only permanentportion of the reparative material, the external and internal callusbeing only temporary, and being largely re-absorbed through the agencyof giant cells. Detached fragments or splinters of bone are usually included in thecallus and ultimately become incorporated in the new bone that bridgesthe gap. In time all surplus bone is removed, the medullary canal is re-formed, the young spongy bone of the intermediate callus becomes more and morecompact, and thus the original architectural arrangement of the bonemay be faithfully reproduced. If, however, apposition is not perfect, some of the new bone is permanently required and some of the old boneis absorbed in order to meet the altered physiological strain upon thebone resulting from the alteration in its architectural form. Inoverriding displacement, even the dense cortical bone interveningbetween the medullary canal of the two fragments is ultimatelyabsorbed and the continuity of the medullary canal is reproduced. The amount of callus produced in the repair of a given fracture isgreater when movement is permitted between the broken ends. It is alsoinfluenced by the character of the bone involved, being less in bonesentirely ossified in membrane, such as the flat bones of the skull, than in those primarily ossified in cartilage. If the fragments are widely separated from one another, or if sometissue, such as muscle, intervenes between them, callus may not beable to bring about a bony union between the fragments, and_non-union_ results. Bones divided in the course of an operation, for example in osteotomyfor knock-knee, or wedge-shaped resection for bow-leg, are repaired bythe same process as fractures. #Excess of Callus. #--In comminuted fractures, and in fractures inwhich there is much displacement, the amount of callus is in excess, but this is necessary to ensure stability. In fractures in thevicinity of large joints, such as the hip or elbow, the formation ofcallus is sometimes excessive, and the projecting masses of new bonerestrict the movements of the joint. When exuberant callus formsbetween the bones in fractures of the forearm, pronation andsupination may be interfered with (Fig. 4). Certain nerve-trunks, suchas the radial (musculo-spiral) in the middle of the arm, or the ulnarat the elbow-joint, may become included in or pressed upon by callus. [Illustration: FIG. 4. --Excess of Callus after compound fracture ofBones of Forearm. ] #Absorption of Callus. #--It sometimes happens that when an acuteinfective disease, especially one of the exanthemata, supervenes whilea fracture is undergoing repair, the callus which has formed becomessoftened and is absorbed. This may occur weeks or even months afterthe bone has united, with the result that the fragments again becomemovable, and it may be a considerable time before union finally takesplace. #Tumours of Callus. #--Tumours, such as chondroma and sarcoma, andcysts which are probably of the same nature as those met with inosteomyelitis fibrosa, are liable to occur in callus, or at the seatof old fractures, but the evidence so far is inconclusive as to thecausative relationship of the injury to the new-growth. They aretreated on the same lines as tumours occurring independently offracture. #Badly United Fracture--Mal-Union. #--Union with marked displacement ofthe fragments is most common in fractures that have not been properlytreated--as, for example, those occurring in sailors at sea; and incases in which the comminution was so great that accurate appositionwas 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, deliriumtremens, or mania, is the cause of mal-union in some cases; sometimesit has resulted because the patient was expected to die from someother lesion and the fracture was left untreated. Whether or not any attempt should be made to improve matters dependslargely on the degree of deformity and the amount of interference withfunction. When interference is called for, if the callus is not yet firmlyconsolidated, it may be possible, under an anæsthetic, to bend thebone into position or to re-break it, either with the hands or bymeans of a strong mechanical contrivance known as an osteoclast. Inthe majority of cases, however, an open operation yields results whichare more certain and satisfactory. When the deformity is comparativelyslight, the bone is divided with an osteotome and straightened; whenthere is marked bending or angling, a wedge is taken from theconvexity, as in the operation for bow-leg. To maintain the fragmentsin apposition it may be necessary to employ pegs, plates, bone-grafts, or other mechanical means. Splints and extension are then applied, andthe condition is treated on the same lines as a compound fracture. [Illustration: FIG. 5. --Multiple Fractures of both Bones of Forearmshowing mal-union. ] #Delayed Union. #--At the time when union should be firm and solid, itmay be found that the fragments are only united by a softcartilaginous callus, which for a prolonged period may undergo nofurther change, so that the limb remains incapable of bearing weightor otherwise performing its functions. The normal period required forunion may be extended from various causes. The most important of theseis general debility, but the presence of rickets or tuberculosis, oran intercurrent acute infectious disease, may delay the reparativeprocess. The influence of syphilis, except in its gummatous form, ininterfering with union is doubtful. The influence of old age as afactor in delaying union has been overestimated; in the great majorityof cases, fractures in old people unite as rapidly and as firmly asthose occurring at other periods of life. _Treatment. _--The general condition of the patient should be improved, by dieting and tonics. One of the most reliable methods of hasteningunion in these cases is by inducing passive hyperæmia of the limbafter the method advocated by Bier, and this plan should always betried in the first instance. An elastic bandage is applied above theseat of fracture, sufficiently tightly to congest the limb beyond, and, to concentrate the congestion in the vicinity of the fracture, anordinary bandage should be applied from the distal extremity to withina few inches of the break. The hyperæmia should be maintained forseveral hours (six to twelve) daily. An apparatus should be adjustedto enable the patient to get into the open air, and in fractures ofthe lower extremity the patient should move about with crutches in theintervals, putting weight on the fractured bone. This method oftreatment should be persevered with for three or four weeks, and thelimb should be massaged daily while the constricting bandage is off. Among the other methods which have been recommended are the injectionbetween the fragments of oil of turpentine (Mikulicz), a quantity ofthe patient's own blood (Schmieden), or alcohol and iodine; theforcible rubbing of the ends together, under an anæsthetic ifnecessary; and the administration of thyreoid extract. If thesemethods fail, the case should be treated as one of un-united fracture. As a rule, satisfactory union is ultimately obtained, although muchpatience is required. #Non-Union. #--Sometimes the fragments become united by a dense band offibrous tissue, and the reparative process goes no further--_fibrousunion_. This is frequently the case in fractures of the patella, theolecranon, and the narrow part of the neck of the femur. _False Joint--Pseudarthrosis. _--In rare cases the ends of thefragments become rounded and are covered with a layer of cartilage. Around their ends a capsule of fibrous tissues forms, on the inneraspect of which a layer of endothelium develops and secretes asynovia-like fluid. This is met with chiefly in the humerus and in theclavicle. _Failure of Union--"Un-united Fracture. "_--As the time taken for unionvaries widely in different bones, and ossification may ultimatelyensue after being delayed for several months, a fracture cannot besaid to have failed to unite until the average period has been longoverpassed and still there is no evidence of fusion of the fragments. Under these conditions failure of union is a rare complication offractures. In adults it is most frequently met with in the humerus, the radius and ulna (Fig. 6), and the femur; in children in the bonesof the leg and in the forearm. [Illustration: FIG. 6. --Radiogram of Un-united Fracture of Shaft ofUlna of fifteen years' duration. ] In a radiogram the bones in the vicinity of the fracture, particularlythe distal fragment, cast a comparatively faint shadow, and there mayeven be a clear space between the fragments. When the parts areexposed by operation, the bone is found to be soft and spongy and theends of the fragments are rarefied and atrophied; sometimes they arepointed, and occasionally absorption has taken place to such an extentthat a gap exists between the fragments. The bone is easily penetratedby a bradawl, and if an attempt is made to apply plates, the screwsfail to bite. These changes are most marked in the distal fragment. The want of union is evidently due to defective activity of thebone-forming cells in the vicinity of the fracture. This may resultfrom constitutional dyscrasia, or may be associated with a defectiveblood supply, as when the nutrient artery is injured. Interferencewith the trophic nerve supply may play a part, as cases are recordedby Bognaud in which union of fractures of the leg failed to take placeafter injuries of the spinal medulla causing paraplegia. The conditionhas been attributed to local causes, such as the interposition ofmuscle or other soft tissue between the fragments, or to the presenceof a separated fragment of bone or of a sequestrum followingsuppuration. In our experience such factors are seldom present. If the treatment recommended for delayed union fails, recourse must behad to operation, the most satisfactory procedure being to insert abone graft in the form of an intra-medullary splint. In certain casesmet with in the bones of the leg in children, the degree of atrophy ofthe bones is such that it has been found necessary to amputate afterrepeated attempts to obtain union by operative measures have failed. In the tibia we have found that with the double electric saw a rod ofbone can be rapidly and accurately cut, extending well above as wellas below the site of fracture but unequally in the two directions; therod is then reinserted into the trough from which it was taken _withthe ends reversed_, so that a strong bridge of bone is provided at theseat of non-union. CLINICAL FEATURES OF SIMPLE FRACTURES In the first place, the _history of the accident_ should beinvestigated, attention being paid to the nature of theviolence--whether a blow, a twist, a wrench, or a crush, and whetherthe violence was directly or indirectly applied. The degree of theviolence may often be judged approximately from the instrumentinflicting it--whether, for example, a fist, a stick, a cart wheel, ora piece of heavy machinery. The position of the limb at the time ofthe injury; whether the muscles were braced to meet the blow or werelax and taken unawares; and the patient's sensations at the moment, such as his feeling something snap or tear, may all furnishinformation useful for purposes of diagnosis. _Signs of Fracture. _--The most characteristic signs of fracture areunnatural mobility, deformity, and crepitus. _Unnatural mobility_--that is, movement between two segments of a limbat a place where movement does not normally occur--may be evident whenthe patient makes attempts to use his limb, or may only be elicitedwhen the fragments are seized and moved in opposite directions. _Deformity_, or the part being "out of drawing" in comparison with thenormal side, varies with the site and direction of the break, anddepends upon the degree of displacement of the fragments. _Crepitus_is the name applied to the peculiar grating or clicking which may beheard or felt when the fractured surfaces are brought into contactwith one another. The presence of these three signs in association is sufficient toprove the existence of a fracture, but the absence of one or more ofthem does not negative this diagnosis. There are certain fallacies tobe guarded against. For example, a fracture may exist and yetunnatural mobility may not be present, because the bones are impactedinto one another, or because the fracture is an incomplete one. Again, the extreme tension of the swollen tissues overlying the fracture mayprevent the recognition of movement between the fragments. Deformityalso may be absent--as, for instance, when there is no displacement ofthe fragments, or when only one of two parallel bones is broken, as inthe leg or forearm. Similarly, crepitus may be absent when impactionexists, when the fragments completely override one another, or areseparated by an interval, or when soft tissues, such as tornperiosteum or muscle, are interposed between them. A sensationsimulating crepitus may be felt on palpating a part into which bloodhas been extravasated, or which is the seat of subcutaneous emphysema. The creaking which accompanies movements in certain forms ofteno-synovitis and chronic joint disease, and the rubbing of thedislocated end of a bone against the tissues amongst which it lies, may also be mistaken for the crepitus of fracture. It is not advisable to be too diligent in eliciting these signs, because of the pain caused by the manipulations, and also becausevigorous handling may do harm by undoing impaction, causing damage tosoft parts or producing displacement which does not already exist, orby converting a simple into a compound fracture. It is often necessary for purposes of diagnosis to administer ageneral anæsthetic, particularly in injuries of deeply placed bonesand in the vicinity of joints. Before doing so, the appliancesnecessary for the treatment of the injury should be made ready, inorder that the fracture may be reduced and set before the patientregains consciousness. _Radiography in the Diagnosis of Fractures. _--While radiography is ofinestimable value in the diagnosis of many fractures and otherinjuries, particularly in the vicinity of joints, the student iswarned against relying too implicitly on the evidence it seems toafford. A radiogram is not a photograph of the object exposed to the X-raysbut merely a picture of its shadow, or rather of a series of shadowsof the different structures, which vary in opacity. As the raysemanate from a single point in the vacuum tube, and as they are not, like the sun's rays, approximately parallel, the shadows they cast arenecessarily distorted. Hence, in interpreting a radiogram, it isnecessary to know the relative positions of the point from which therays proceed, the object exposed, and the plate on which the shadow isregistered. The least distortion takes place when the object is incontact with the plate, and the shadow of that part of the objectwhich lies perpendicularly under the light is less distorted than thatof the parts lying outside the perpendicular. The light and the plateremaining constant, the amount of distortion varies directly with thedistance between the object and the plate. To ensure accuracy in the diagnosis of fracture by the X-rays, it isnecessary to take two views of the limb--one in the sagittal and theother in the coronal plane. By the use of the fluorescent screen, thebest positions from which to obtain a clear impression of the fracturemay be determined before the radiograms are taken. Stereoscopicradiograms may be of special value in demonstrating the details of afracture that is otherwise doubtful. Imperfect technique and faulty interpretation of the pictures obtainedlead to certain fallacies. In young subjects, for example, epiphysiallines may be mistaken for fractures, or the ossifying centres ofepiphyses for separated fragments of bone. The os trigonum tarsi hasbeen mistaken for a fracture of the talus. In the vicinity of jointsthe bones may be crossed by pale bands, due to the rays traversing thecavity of the joint. In this way fracture of the olecranon or of theclavicle may be simulated. The neck of the femur may appear to befractured if a foreshortened view is taken. It is possible, on the other hand, to overlook a fracture--forexample, if there is no displacement, or if the line of fracture iscrossed by the shadow of an adjacent bone. In deeply placed bones suchas those about the hip, or in bones related to dense, solidviscera--for example, ribs, sternum, or dorsal vertebræ--it issometimes difficult to obtain conclusive evidence of fracture in aradiogram. It is to be borne in mind also, and especially from the medico-legalpoint of view, that, as early callus does not cast a deep shadow in aradiogram, the appearance of fracture may persist after union hastaken place. The earliest shadow of callus appears in from fourteen totwenty-one days, and can hardly be relied upon till the fourth orsixth week. The disturbed perspective produced by divergence of therays may cause the fragments of a fracture to appear displaced, although in reality they are in good position. If the limb and theplate are not parallel, the bones may appear to be distorted, anderrors in diagnosis may in this way arise. In this relation it shouldbe mentioned that perfect apposition of the fragments and anatomicallyaccurate restoration of the outline of the bones are not alwaysessential to a good functional result. * * * * * As most of the remaining signs are common to all the lesions fromwhich fractures have to be distinguished, their diagnostic value mustbe carefully weighed. _Interference with Function. _--As a rule, a broken bone is incapableof performing its normal function as a lever or weight-bearer; butwhen a fracture is incomplete, when the fragments are impacted, orwhen only one of two parallel bones is broken, this does notnecessarily follow. It is no uncommon experience to find a patientwalk into hospital with an impacted fracture of the neck of the femuror a fracture of the fibula; or to be able to pronate and supinate theforearm with a greenstick fracture of the radius or a fracture of theulna. _Pain. _--Three forms of pain may be present in fractures: painindependent of movement or pressure; pain induced by movement of thelimb; and pain elicited on pressure or "tenderness. " In injuries bydirect violence, pain independent of movement and pressure is neverdiagnostic of fracture, as it may be due to bruising of soft tissues. In injuries resulting from indirect violence, however, pain localisedto a spot at some distance from the point of impact is stronglysuggestive of fracture--as, for example, when a patient complains ofpain over the clavicle after a fall on the hand, or over the upper endof the fibula after a twist of the ankle. Pain elicited by attempts tomove the damaged part, or by applying pressure over the seat ofinjury, is more significant of fracture. Pain elicited at a particularpoint on pressing the bone at a distance, "pain on distalpressure, "--for example, pain at the lower end of the fibula onpressing near its neck, or at the angle of a rib on pressing near thesternum, --is a valuable diagnostic sign of fracture. When nerve-trunksare implicated in the vicinity of a fracture, pain is often referredalong the course of their distribution. _Localised swelling_ comes on rapidly, and is due to displacement ofthe fragments and to hæmorrhage from the torn vessels of the marrowand periosteum. _Discoloration_ accompanies the swelling, and is often widespread, especially in fracture of bones near the surface and when the tensionis great. It is not uncommon to find over the ecchymosed area, especially over the shin-bone, large blebs containing blood-stainedserum. In fractures of deep-seated bones, discoloration may only showon the surface after some days, and at a distance from the break. Alterations in the relative position of _bony landmarks_ are valuablediagnostic guides. Alteration in the _length_ of the limb, usually inthe direction of shortening, is also an important sign. Before drawingdeductions, care must be taken to place both limbs in the sameposition and to determine accurately the fixed points for measurement, and also to ascertain if the limbs were previously normal. _Shock_ is seldom a prominent symptom in uncomplicated fractures, although in old and enfeebled patients it may be serious and evenfatal. During the first two or three days after a fracture there isalmost invariably some degree of traumatic _fever_, indicated by arise of temperature to 99° or 100° F. #Complications. #--_Injuries to large arteries_ are not common insimple fractures. The popliteal artery, however, is liable to becompressed or torn across in fractures of the lower end of the femur;extravasation of blood from the ruptured artery and gangrene of thelimb may result. If large _veins_ are injured, thrombosis may occur, and be followed by pulmonary embolism. _Injuries to nerve-trunks_ are comparatively common, especially infractures of the arm, where the radial (musculo-spiral) nerve isliable to suffer. The nerve may be implicated at the time of the injury, beingcompressed, bruised, lacerated, or completely torn across by brokenfragments, or it may be involved later by the pressure of callus. Thesymptoms depend upon the degree of damage sustained by the nerve, andvary from partial and temporary interference with sensation and motionto complete and permanent abrogation of function. In rare instances _fat embolism_ is said to occur, and fat globulesare alleged to have been found in the urine. In persons addicted toexcess of alcohol, _delirium tremens_ is a not infrequentaccompaniment of a fracture which confines the patient to bed. #Prognosis in Simple Fractures. #--_Danger to life_ in simple fracturesdepends chiefly on the occurrence of complications. In old people, afracture of the neck of the femur usually necessitates long andcontinuous lying on the back, and bronchitis, hypostatic pneumonia, and bed-sores are prone to occur and endanger life. Fracturescomplicated with injury to internal organs, and fractures in whichgangrene of the limb threatens, are, of course, of grave import. The prognosis as regards the _function of the limb_ should always beguarded, even in simple fractures. Incidental complications are liableto arise, delaying recovery and preventing a satisfactory result, andthese not only lead to disappointment, but may even form a ground foractions for malpraxis. The chief and most frequent cause of permanent disability afterfracture is angular displacement. A comparatively small degree ofangularity may lead to serious loss of function, especially in thelower limb; the joints above and below the fracture are placed at adisadvantage, arthritic changes result from the abnormal strain towhich they are subjected, and rarefaction of the bone may also ensue. Fibrous union is a common result in fractures of the neck of the femurin old people and in certain other fractures, such as fracture of thepatella, of the olecranon, coronoid and coracoid processes, andalthough this does not necessarily involve interference with function, the patient should always be warned of the possibility. Impairment of growth and eventual shortening of the limb may resultfrom involvement of an epiphysial junction. Stiffness of joints is liable to follow fractures implicatingarticular surfaces, or it may result from arthritic changes followingupon the injury. Osseous ankylosis is not a common sequel of simple fractures, butlocking of joints from the mechanical impediment produced by theunion of imperfectly reduced fragments, or from masses of callus, isnot uncommon, especially in the region of the elbow. Wasting of the muscles and œdema of the limb often delay the completerestoration of function. Delayed union, want of union, and theformation of a false joint have already been referred to. #Treatment. #--The treatment of a fracture should be commenced as soonafter the accident as possible, before the muscles become contractedand hold the fragments in abnormal positions, and before the blood andserum effused into the tissues undergo organisation. Care must be taken during the transport of the patient that no furtherdamage is done to the injured limb. To this end the part must besecured in some form of extemporised splint, the apparatus being sodesigned as to control not only the broken fragments, but also thejoints above and below the fracture. When the ordinary method of removing the clothes involves any risk ofunduly moving the injured part, they should be slit open along theseams. The patient should be placed on a firm straw, horse-hair, or springmattress, stiffened in the case of fractures of the pelvis or lowerlimbs by fracture-boards inserted beneath the mattress. Specialmattresses constructed in four pieces, to facilitate the nursing ofthe patient, are sometimes used. In many cases, particularly in muscular subjects, in restlessalcoholic patients, and in those who do not bear pain well, a generalanæsthetic is a valuable aid to the accurate setting of a fracture, aswell as a means of rendering the diagnosis more certain. The procedure popularly known as "setting a fracture" consists inrestoring the displaced parts to their normal position as nearly aspossible, and is spoken of technically as the _reduction_ of thefracture. _The Reduction of Fractures. _--In some cases the displacement may beovercome by relaxing the muscles acting upon the fragments, and thismay be accomplished by the stroking movements of massage. In mostcases, however, it is necessary, after relaxing the muscles, to employ_extension_, by making forcible but steady traction on the distalfragment, while _counter-extension_ is exerted on the proximal one, either by an assistant pulling upon that portion of the limb, or bythe weight of the patient's body. The fragments having been freed, andany shortening of the limb corrected in this way, the broken ends aremoulded into position--a process termed _coaptation_. The reduction of a recent greenstick fracture consists in forciblystraightening the bend in the bone, and in some cases it is necessaryto render the fracture complete before this can be accomplished. In selecting a means of retaining the fragments in position afterreduction, the various factors which tend to bring aboutre-displacement must be taken into consideration, and appropriatemeasures adopted to counteract each of these. In addition to retaining the broken ends of the bone in apposition, the after-treatment of a fracture involves the taking of steps topromote the absorption of effused blood and serum, to maintain thecirculation through the injured parts, and to favour the repair ofdamaged muscles and other soft tissues. Means must also be taken tomaintain the functional activity of the muscles of the damaged area, to prevent the formation of adhesions in joints and tendon sheaths, and generally to restore the function of the injured part. _Practical Means of Effecting Retention--By Position. _--It is oftenfound that only in one particular position can the fragments be madeto meet and remain in apposition--for example, the completely supineposition of the forearm in fracture of the radius just above theinsertion of the pronator teres. Again, in certain cases it is only byrelaxing particular groups of muscles that the displacement can beundone--as, for instance, in fracture of the bones of the leg, or ofthe femur immediately above the condyles, where flexion of the knee, by relaxing the calf muscles, permits of reduction. _Massage and Movement in the Treatment ofFractures. _--Lucas-Championnière, in 1886, first pointed out that acertain amount of movement between the ends of a fractured bonefavours their union by promoting the formation of callus, andadvocated the treatment of fractures by massage and movement, discarding almost entirely the use of splints and otherretentive appliances. We were early convinced by the teaching ofLucas-Championnière, and have adopted his principles in fractures. In the majority of cases the massage and movement are commenced atonce, but circumstances may necessitate their being deferred for a fewdays. The measures adopted vary according to the seat and nature ofthe fracture, but in general terms it may be stated that after thefracture has been reduced, the ends of the broken bone are retained inposition, and gentle massage is applied by the surgeon or by a trainedmasseur. The lubricant may either be a powder composed of equal partsof talc and boracic acid, or an oily substance such as olive oil orlanolin. The rubbing should never cause pain, but, on the contrary, should relieve any pain that exists, as well as the muscular spasmwhich is one of the most important causes of pain and of displacementin recent fractures. The parts on the proximal side of the injuredarea are first gently stroked upwards to empty the veins andlymphatics, and to disperse the effused blood and serum. The processis then applied to the swollen area, and gradually extended down overthe seat of the fracture and into the parts beyond. In this way thecirculation through the damaged segment of the limb is improved, theveins are emptied of blood, the removal of effused fluid isstimulated, and the muscular irritability allayed. The joints of thelimb are gently moved, care being taken that the broken ends of thebone are not displaced. After the rubbing has been continued for fromfifteen to twenty minutes, the limb is placed in a comfortableposition, and retained there by pillows, sand-bags, or, if found moreconvenient, by a light form of splint. The massage is repeated once each day; the sittings last from ten tofifteen minutes. The sequence should be, first, massage; second, passive movement; and third, active movement. At first massagepredominates, and more passive than active movement; gradually massageis lessened and movements are increased, active movements ultimatelypreponderating. _Splints and other Appliances. _--The appropriate splints forindividual fractures and the method of applying them will be describedlater; but it may here be said that the general principle is that whendealing with a part where there is a single bone, as the thigh orupper arm, the splint should be applied in the form of a _ferrule_ tosurround the break; while in situations where there are two parallelbones, as in the forearm and leg, the splint should take the form of a_box_. _Simple wooden splints_ of plain deal board or yellow pine, sawn tothe appropriate length and width; or _Gooch's splinting_, whichconsists of long strips of soft wood, glued to a backing ofwash-leather, are the most useful materials. Gooch's splinting has theadvantage that when applied with the leather side next the limb itencircles the part as a ferrule; while it remains rigid when thewooden side is turned towards the skin. Perforated sheet lead or tin, stiff wire netting, and hoop iron also form useful splints. When it is desirable that the splint should take the shape of the partaccurately, a plastic material may be employed. Perhaps the mostconvenient is _poroplastic felt_, which consists of strong feltsaturated with resin. When heated before a fire or placed in boilingwater, it becomes quite plastic and may be accurately moulded to anypart, and on cooling it again becomes rigid. The splint should be cutfrom a carefully fitted paper pattern. Millboard, leather, orgutta-percha softened in hot water, and moulded to the part, may alsobe employed. In conditions where treatment by massage and movement isimpracticable, and where movable splints are inconvenient, splints of_plaster of Paris_, _starch_, or _water-glass_ are sometimes used, especially in the treatment of fractures of the leg. When employed inthe form of an immovable case, they are open to certainobjections--for example, if applied immediately after the accidentthey are apt to become too tight if swelling occurs; and if appliedwhile swelling is still present, they become slack when this subsides, so that displacement is liable to occur. When it is desired to enclose the limb in a plaster case, coarsemuslin bandages, 3 yards long, and charged with the finest quality ofthoroughly dried plaster of Paris, are employed. The "acetic plasterbandages" sold in the shops set most quickly and firmly. Boracic lintor a loose stocking is applied next the skin, and the bony prominencesare specially padded. The plaster bandage is then placed in cold watertill air-bubbles cease to escape, by which time it is thoroughlysaturated, and, after the excess of water is squeezed out, is appliedin the usual way from below upward. From two to four plies of thebandage are required. In the course of half an hour the plaster shouldbe thoroughly set. To facilitate the removal of a plaster case thelimb should be immersed for a short time in tepid water. A convenient and efficient splint is made by moulding two pieces ofporoplastic felt to the sides of the limb, and fixing them in positionwith an elastic webbing bandage; this apparatus can be easily removedfor the daily massage. _Padding_ is an essential adjunct to all forms of splints. The wholepart enclosed in the splint must be covered with a thick layer of softand elastic material, such as wool from which the fat has not beenremoved. All hollows should be filled up, and all bony projectionsspecially protected by rings of wadding so arranged as to take thepressure off the prominent point and distribute it on the surroundingparts. Opposing skin surfaces must always be separated by a layer ofwool or boracic lint. A bandage should never be applied to the limbunderneath the splints and pads, as congestion or even gangrene may beinduced thereby. #Operative Treatment of Simple Fractures. #--Operation in simplefracture is specially called for (1) in fracture into or near a jointwhere a permanently displaced fragment will cause locking of thejoint; (2) when fragments are drawn apart, as in fractures of thepatella 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 tobe feared, as in certain cases of fracture of the neck of the femur inold people. Under such circumstances it is necessary to expose thefracture by operation, and to place the fragments in accurateapposition, if necessary, fixing them in position by wires, pegs, plates, or screws (_Op. Surg. _, p. 52). Operative interference isusually delayed till about five to seven days after the injury, bywhich time the effect of other measures will have been estimated, accurate information obtained by means of the X-rays regarding thenature of the lesion and the position of the fragments, and thetissues recovered their normal powers of resistance. Such operations, however, are not to be undertaken lightly, as they are oftendifficult, and if infection takes place the results may be disastrous. Arbuthnot Lane and Lambotte advocate a more general resort tooperative measures, even in simple and uncomplicated fractures, and itmust be conceded that in many fractures an open operation affords theonly means of securing accurate apposition and alignment of thefragments. Both before and after operation, massage and movement are to becarried out, as in fractures treated by other methods. COMPOUND FRACTURES The essential feature of a compound fracture is the existence of anopen wound leading down to the break in the bone. The wound may varyin size from a mere puncture to an extensive tearing and bruising ofall the soft parts. A fracture may be rendered compound _from without_, the soft partsbeing damaged by the object which breaks the bone--as, for example, acart wheel, a piece of machinery, or a bullet. Sloughing of soft partsresulting from the pressure of improperly applied splints, also, mayconvert a simple into a compound fracture. On the other hand, a simplefracture may be rendered compound _from within_--for example, a sharpfragment of bone may penetrate the skin; this is the least seriousvariety of compound fracture. As a rule, it is easy to recognise that the fracture is compound, asthe bone can either be seen or felt. The _prognosis_ depends on the success which attends the efforts tomake and to keep the wound aseptic, as well as on the extent of damageto the tissues. When asepsis is secured, repair takes place as insimple fracture, only it usually takes a little longer; sometimes thereason for the delay is obvious, as when the compound fracture is theresult of a more severe form of violence and where there iscomminution and loss of one or more portions of bone that would havecontributed 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 inrepair. If sepsis gains the upper hand in a compound fracture there is, firstly, the risk of infection of the marrow--osteomyelitis--which informer times was liable to result in pyæmia; in the second place, notonly 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 deadbone is slow in being separated, and until it is separated and thrownoff, no actual repair can take place. The sepsis stimulates thebone-forming tissues and new bone is formed in considerable amount, especially on the surface of the shaft in the vicinity of thefracture; in macerated specimens it presents a porous, crumblingtexture. Sometimes the new bone--which corresponds to the involucrumof an osteomyelitis--imprisons a sequestrum and prevents itsextrusion, in which case one or more sinuses may persist indefinitely. Cases are met with where such sinuses have existed for the best partof a long life and have ultimately become the seat of epithelioma. It should be noted that all the above changes can be followed inskiagrams. _Treatment. _--The leading indication is to ensure asepsis. Even in thecase of a small punctured wound caused by a pointed fragment comingthrough the skin it is never wise to assume that the wound is notinfected. It is much safer to enlarge such a wound, pare away thebruised edges, and disinfect the raw surfaces. In cases of extensive laceration of the soft parts, all soiled, bruised, or torn portions of tissue should be clipped away withscissors, blood-clots removed, and the bleeding arrested byforci-pressure or ligature. If there is any reason to believe thatthe wound is infected, any fragments of bone completely separated fromthe periosteum should be removed. In comminuted fractures, extensionapplied by strips of plaster or by means of ice-tong callipers orSteinmann's apparatus (p. 150) often facilitates replacement of thefragments and their retention in position. Plates and screws are notrecommended for comminuted fractures, owing to the mechanicaldifficulty of fixing a number of small fragments and the risks ofinfection. The wound should be purified with eusol, and thesurrounding parts painted with iodine. On the whole, it is safer notto attempt to obtain primary union by completely closing such wounds, but rather to drain or pack them. To increase the local leucocytosisand so check the spread of infection, a Bier's constricting bandagemay be applied. In other respects the treatment is carried out on the same lines as insimple fractures, provision being made for dressing the wound withoutdisturbance of the fracture. Massage and movement should be commencedafter the wound is healed and the condition has become analogous to asimple fracture. #Question of Amputation in Compound Fractures. #--Before deciding toperform primary amputation of a limb for compound fracture, thesurgeon must satisfy himself (1) that the attainment of asepsis isimpossible; (2) that the soft parts are so widely and so grosslydamaged that their recovery is improbable; (3) that the vascular andnervous supply of the parts beyond has been rendered insufficient bydestruction of the main blood vessels and nerve-trunks; (4) that thebones have been so shattered as to be beyond repair; and (5) that thelimb, even if healing takes place, will be less useful than anartificial one. In attempting to save the limb of a young subject, it is justifiableto run risks which would not be permissible in the case of an olderperson. To save an upper limb, also, risks may be run which would notbe justifiable in the case of a lower limb, because, while aserviceable artificial leg can readily be procured, any portion of thenatural hand or arm is infinitely more useful than the best substitutewhich the instrument-maker can contrive. The risk involved inattempting to save a limb should always be explained to the patient orhis guardian, in order that he may share the responsibility in case offailure. Whether or not the amputation should be performed at once, dependsupon the general condition of the patient. If the injury is a severeone, and attended with a profound degree of shock, it is better towait for twenty-four or forty-eight hours. Meanwhile the wound ispurified, and the limb wrapped in a sterile dressing. Means are takento counteract shock and to maintain the patient's strength, andevidence of infection or of hæmorrhage is carefully watched for. Whenthe shock has passed off, the operation is then performed under morefavourable auspices. Clinical experience has proved that by this meansthe mortality of primary amputations may be materially diminished, especially in injuries necessitating removal of an entire limb. Having decided to amputate, it is important to avoid having bruised, torn, or separated tissues in the flaps, as these are liable to sloughor to become the seat of infection. In this connection it should beborne in mind that the damage to soft tissues is always wider inextent than appears from external examination. The attempt to save a limb may fail and amputation may be called forlater because of spreading infective processes, osteomyelitis, organgrene; to prevent exhaustion from prolonged suppuration and toxinabsorption; or on account of secondary hæmorrhage. #Gun-shot Injuries of Bone. #--Fractures resulting from the impact ofbullet or fragments of shell are of necessity compound, and areusually infected from the outset by organisms carried in by themissile or by portions of clothing or other foreign material. Notinfrequently the missile lodges in the bone. [Illustration: FIG. 7. --Excessive Callus Formation after infectedCompound Fracture of both Bones of Forearm--result of gun-shot wound. Fusion of Bones across Interosseous Space. ] The extent of the injury to the bone varies infinitely, from a merechip or gutter-shaped wound to complete pulverisation of the portionstruck. The fracture is of the comminuted and fissured variety, thecracks radiating from the point of impact and extending for aconsiderable distance, sometimes even implicating the articularsurface of the bone some inches away. In comminuted fractures of theshafts of long bones there is often a large wedge-shaped fragmentcompletely isolated from the rest, and in the presence of infectionthis may form a sequestrum. Healing is often delayed by the separationof sequestra, which takes place slowly, and union is attended withexcessive formation of callus. When a considerable section of theshaft has been lost, want of union, fibrous union, or the formation ofa false joint may result. The treatment is carried out on the same lines as in other forms ofcompound fracture, except that mention should be made of theirrigation method of Carrel, found to be the most potent means ofovercoming the associated infection. SEPARATION OF EPIPHYSES[1] [1] We do not employ the term "diastasis, " which has been used indifferent senses by different writers. In young subjects before the bones are fully developed the epiphysesmay be separated from the diaphyses. The use of the X-rays has addedgreatly to our knowledge of these lesions. It is useful to remember that in the upper extremity the epiphyses inthe 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 itis in these situations that growth in length of the bone goes onlongest and most actively (twenty to twenty-one years). Injuries ofthese epiphyses, therefore, are most liable to interfere with thegrowth of the limb. An epiphysis is nourished from the articular arteries and through thevessels of the periosteum. _Pathological Separation of Epiphyses. _--There are certainpathological conditions, such as rickets, scurvy, congenital syphilis, tubercle, suppurative conditions, and tumour growths, which renderseparation of the epiphyses liable to occur from injuries altogetherinsufficient to produce such lesions under normal conditions. #Traumatic Separations. #[2]--Speaking generally, it may be said thatinjuries which in an adult would be liable to produce dislocation, arein a young person more apt to cause separation of an epiphysis. Indirect violence, especially when exerted in such a way as to combinetraction with torsion, --for example, when the foot is caught in thespokes of a carriage wheel, --is the commonest cause of epiphysialseparation. Direct violence is a much less frequent cause. Muscularaction occasionally produces separation of the epiphyses--for example, the anterior superior iliac spine, the small trochanter of the femur, or the upper end of the fibula. [2] We desire here to acknowledge our indebtedness to Mr. JohnPoland's work on _Traumatic Separation of the Epiphyses_. [Illustration: FIG. 8. --Partial Separation of Epiphysis, with Fracturerunning into Diaphysis. ] [Illustration: FIG. 9. --Complete Separation of Epiphysis. ] [Illustration: FIG. 10. --Partial Separation with Fracture ofEpiphysis. ] [Illustration: FIG. 11. --Complete Separation with Fracture ofEpiphysis. ] The majority of separations take place between the eleventh and theeighteenth years, chiefly because during this period the injuriesliable to produce such lesions are most common. They do not occurafter twenty-five, because by that time all the epiphyses have united. In females this form of injury is rare, and almost invariably occursbefore puberty. The following are the most common seats of separation in the order oftheir frequency: (1) the lower end of the femur; (2) the lower end ofthe radius; (3) the upper end of the humerus; (4) the lower end of thehumerus; (5) the lower end of the tibia; and (6) the upper end of thetibia. _Morbid Anatomy. _--In a true separation the epiphysial cartilageremains attached to the epiphysis. As a rule the epiphysis is notcompletely separated from the diaphysis, the common lesion being aseparation along part of the epiphysial line, with a fracture runninginto the diaphysis (Fig. 8). It is not uncommon for more than oneepiphysis to be separated by the same accident--for example, the lowerend of the femur and the upper ends of the tibia and fibula. Epiphysial separations, like fractures, may be _simple_ or _compound_. Incomplete separations are liable to be overlooked at the time of theaccident, but there is reason to believe that they may form thestarting-point of disease. Strain of the epiphysial junction--the_juxta-epiphysial strain_ of Ollier--is a common injury in youngchildren. _Clinical Features. _--The symptoms simulate those of dislocationrather than of fracture. Thus, _unnatural mobility_ at an epiphysialjunction may closely resemble movement at the adjacent joint, especially when the epiphysis is an intra-capsular one. Therelationship of the bony points, however, serves to indicate thenature of the lesion. The degree of _deformity_ is often slight, because the transverse direction of the lesion, the breadth of theseparated surfaces, and the firmness of the periosteal attachmentalong the epiphysial line often prevent displacement. In many cases adistinct, rounded, smooth, and regular ridge, caused by the projectionof the diaphysis, can be felt. The peculiar "muffled" nature of the_crepitus_ is one of the most characteristic signs. The older thepatient, and the further ossification has progressed, the more doesthe crepitus resemble that of fracture. Of the subsidiary signs, _loss of power_ in the limb is one of themost constant; indeed, in young children it is sometimes the first, and may be the only, sign that attracts attention. _Pain_ and_tenderness_ along the epiphysial line are valuable signs, particularly when the lesion is due to indirect or muscular violenceand there is no bruising of soft parts. Localised _swelling_, accompanied by _ecchymosis_, is often marked; and the adjacent jointmay be distended with fluid. As distinguishing this injury from a dislocation, it may be noted thatin epiphysial separation there is no snap felt when the deformity isreduced, the tendency to re-displacement is greater, and the amount ofrelief given by reduction less than in dislocation. The use of theRöntgen rays at once establishes the diagnosis. _Prognosis and Results. _--In the majority of cases union takes placesatisfactorily by the formation of callus in the spongy tissue of thediaphysis and on the deep surface of the periosteum. In spite of thefavourable nature of the prognosis in general, however, the friends ofthe patient should be warned that a completely satisfactory resultcannot always be relied upon. Deformity, with stiffness and locking at the adjacent joint, especially at the elbow, may result from imperfect reduction, or fromexuberant callus. Arrest of growth of the bone in length is a raresequel, and when it occurs, it is due, not to premature union of theepiphysis with the shaft, but to diminished action at the ossifyingjunction. When the growth of one of the bones of the leg or forearm is arrestedafter separation of its epiphysis while the other bone continues togrow, the foot or hand is deviated towards the side of the shorterone. Partial separations may be overlooked at the time of the accident andcause trouble later from bending of the bone, as in one variety ofcoxa vara. The epiphysis at the lower end of the femur may bedisplaced into the ham and press on the popliteal vessels. _Treatment. _--The general principles which govern the treatment offractures apply equally to epiphysial separations, the essential beingthe accurate replacement of the epiphysis. In _compound separations of epiphysis_, the end of the diaphysis maybe pushed through the skin. The entrance of sepsis may prove anobstacle to any operative measure that would otherwise be indicated. CHAPTER II INJURIES OF JOINTS SURGICAL ANATOMY--INJURIES: _Contusions_; _Wounds_; _Sprains_; _Dislocations_--TRAUMATIC DISLOCATIONS: _Causes_: _Varieties_; _Clinical features_; _Treatment_--Compound dislocations--Old-standing dislocations. #Surgical Anatomy. #--The function of a joint is to permit of themovement of one bone upon another. The articular surfaces are coveredwith a thin layer of hyaline cartilage, and are retained in appositionby the tension of ligaments and of the muscles surrounding the joint. The articular capsule (capsular ligament) is directly continuous withthe periosteum, and is lined by a synovial layer, which at the line ofattachment of the capsule is reflected on to the bone as far as thearticular cartilage. The synovial layer invests intra-articularligaments, and is projected into the interior of the joint in the formof loose folds wherever the articulating surfaces are not in immediatecontact. The surface of the synovial layer is covered with minuteprocesses or villi, which in diseased conditions may becomehypertrophied. The synovia owes its lubricating property to mucin, derived from the solution of the endothelial cells on the free surfaceof the synovial layer. The opposing surfaces of a joint being alwaysin accurate contact, the so-called cavity is only a potential one. Iffluid is poured out into the joint, the synovial layer and the capsuleare put upon the stretch, causing discomfort or actual pain, which ispartly relieved by slightly flexing the joint. If the distensionpersists, the ligaments become elongated and the joint unstable. The common origin of bone, cartilage, periosteum, and synovial layerfrom one parent tissue of the embryo, accords with the readiness withwhich any one of these tissues may be converted into another undertraumatic or pathological influences; and how in ligaments and insynovial membrane foci of hyaline cartilage may form and, afterincreasing in size, undergo ossification. Joints derive an abundant blood supply through the articular arteries. The lymphatics, which take origin in the synovial layer, pass toefferent vessels which run in the intermuscular and otherconnective-tissue planes of the limb. The nerve supply is derivedchiefly from the nerves distributed to the muscles acting on the jointand to the skin over it. #Sources of Joint Strength. #--The capacity of a joint to resistdislocation depends upon (1) the shape of its osseous elements; (2)the strength and arrangement of its ligaments; (3) the support itreceives from muscles or tendons placed in relation to it; and (4) therelative stability of adjacent structures. While all these factorscontribute to the strength of a given joint, one or other of themusually predominates, so that certain joints are osseously strong, others are ligamentously strong, while a few depend chiefly uponadjacent muscles for their stability. The hip and elbows are the best examples of joints deriving theirstrength mainly from the architectural arrangement of the constituentbones. These joints are dislocated only by extreme degrees ofviolence, and not infrequently--especially in the elbow--portions ofthe bones are fractured before the articular surfaces are separated. The knee, the wrist, the carpal, the tarsal, and the clavicular jointsdepend for their stability almost entirely on the strength of theirligaments. These joints are rarely dislocated, but as the mainincidence of the violence falls on the ligaments they are frequentlysprained. The shoulder is the typical example of a joint depending for itssecurity chiefly upon the muscles and tendons passing over it, andhence the frequency with which it is dislocated when the muscles aretaken unawares. At the same time the great mobility of the scapula andclavicle materially increases the stability of the shoulder-joint. Thetendons passing in relation to the knee, ankle, and wrist add to thestability of these joints. The proximity of an easily fractured bone also contributes to preventdislocation of certain joints--for example, fracture of the clavicleprevents an impinging force expending itself on the shoulder-joint;and the frequency of Colles' fracture of the radius, and of Pott'sfracture of the fibula, doubtless accounts to some extent for therarity of dislocation of the wrist and ankle-joints respectively. Theimmunity from dislocation which the joints of young subjects enjoy ispartly due to the ease with which an adjacent epiphysis is separated. The mechanical axiom that "what is gained in movement is lost instability" applies to joints, those which have the widest range ofmovement being the most frequently dislocated. * * * * * The injuries to which a joint is liable are Contusions, Wounds, Sprains, and Dislocations. #Contusions of Joints. #--Contusion is the mildest form of injury to ajoint. Whether the violence is transmitted from a distance, as incontusion 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 drivenagainst one another, and the force expends itself on their articularsurfaces. The articular cartilages and the underlying spongy bone, aswell as the synovial lining, are bruised, and there is an effusion ofblood and serous fluid into the joint and surrounding tissues. The most prominent _clinical features_ are swelling and discoloration. The swelling, especially in superficially placed joints, is an earlyand marked symptom, and is mainly due to the effusion of blood intothe joint (_hæmarthrosis_). In deeply placed joints, discoloration maynot appear on the surface for some days, especially if the violencehas been indirect. The joint is kept in the flexed position, and ispainful only when moved. In hæmophilic subjects, considerable effusionof blood into a joint may follow the most trivial injury. A slight degree of serous effusion into the joint (_hydrarthrosis_)often persists for some time, and tuberculous affections of joints notinfrequently date from a contusion. The _treatment_ is the same as for sprains (p. 36). #Wounds of Joints. #--The importance of accidental wounds ofjoints--such, for example, as result from a stab with a penknife orthe spike of a railing--lies in the fact that they are liable to befollowed by infection of the synovial cavity. The infection mayinvolve only the synovial layer (_septic synovitis_), or may spread toall the elements of the joint (_septic arthritis_). These conditionsare described with diseases of joints. Penetration of the joint may sometimes be recognised by the escape ofsynovia from the wound, or the synovial layer or articular cartilagemay be exposed. When doubt exists, the wound should be enlarged. Theuse of the probe is to be avoided, on account of the risk of carryinginfective material from the track of the wound into the joint. Penetrating wounds of joints are treated on the same lines as compoundfractures. If the penetrating instrument is to be regarded asinfected, --as, for example, when the spoke of a motor bicycle isdriven through the upper pouch of the knee, --the injury is to belooked upon as serious and capable of endangering the function of thejoint, loss of the limb, or even life itself. Reliance is chiefly laidon primary excision of the edges and track of the wound, and othermeasures employed in the treatment of gun-shot wounds. While the woundin the synovialis and capsule is sutured, that in the soft parts isleft open. If drainage is employed, the tube extends down to theopening in the synovialis, but not into the joint itself. If sepsissupervenes, the joint is opened and irrigated by Carrel's method. Someform of splint and a Bier's bandage are valuable adjuncts. The finalrecourse is to amputation. #Gun-shot injuries# of joints vary in severity from a mere puncture ofthe synovial layer by a chip of shell to complete shattering of thearticular surfaces. Between these extremes are cases in which thecapsular and synovial layer are extensively lacerated withoutinvolvement of the bones, and others in which the bones are implicatedwithout serious damage being done to ligaments or synovial layer--forexample, by a bullet passing through and through the cancellated partof one of the constituent bones, or by a fissure extending into thearticular surface. In all degrees the great risk is from septic infection, which may beassumed to be present in all but the last-named variety. The _treatment_ consists in immediately cleansing the wound byexcising grossly damaged tissue and removing any foreign body that mayhave lodged; disinfecting the exposed part of the joint cavity witheusol, "bipp, " or other antiseptic, and closing the wound orestablishing drainage, according to circumstances. The joint is thenimmobilised till the wound has healed, after which massage andmovement are commenced. When the bones are shattered or when sepsisgets the upper hand and disorganises the joint, amputation is calledfor. #Sprains. #--A sprain results from a stretching or twisting form ofviolence which causes the joint to move beyond its physiologicallimits, or in some direction for which it is not structurally adapted. The main incidence of the force therefore falls upon the ligaments, which are suddenly stretched or torn. The synovial layer also is torn, and the joint becomes filled with blood and synovial fluid. Muscles and tendons passing over the joint are stretched or torn, andtheir sheaths filled with serous effusion. It is not uncommon forportions of bone to be torn off at the site of attachment of strongligamentous bands or tendons, constituting a "sprain fracture"; or forintra-articular cartilages to be torn and displaced, as in the knee. _Clinical Features. _--The injury is accompanied by intense sickeningpain, and this may persist for a considerable time. At first it isaggravated by moving the joint, but if the movement is continued ittends to pass off. The particular ligaments involved may be recognisedby the tenderness which is elicited on making pressure over them, orby putting them on the stretch. In this way a sprain may often bediagnosed from a fracture in which the maximum tenderness is over theinjury to the bone. The effusion of blood and synovia into the joint and into the tissuesaround gives rise to swelling and discoloration, and the fluid effusedinto tendon sheaths often produces a peculiar creaking sensation, which may be mistaken for the crepitus of fracture. In sprains, thebony points about the joint retain their normal relations to oneanother, and this usually enables these injuries to be diagnosed fromdislocations. When the swelling is great, it is often necessary tohave recourse to the Röntgen rays to make certain that there is nofracture or dislocation. The special features and complications ofsprains of the knee are discussed with other injuries of that joint. _Repair of Sprains. _--Blood and synovia are absorbed and tornstructures become reunited, but in this process adhesions may forminside the joint and in the surrounding tendon sheaths and interferewith the movement of the joint. _Prognosis. _--Stiffness, lasting for a longer or shorter time, followsmost sprains, but may be largely prevented by proper treatment. In oldand rheumatic persons, changes of the nature of arthritis deformansare liable to supervene, interfering greatly with movement. Whilesuppuration is rare, tuberculous disease is alleged to have resultedfrom a sprain. _Treatment. _--If seen immediately after the accident, firm pressureshould be applied by means of an elastic bandage over a thick layer ofcotton wool, to prevent bleeding and effusion of synovia. Later thebest treatment is by massage and movement. In the ankle, for example, massage should be commenced at once, the part being gently strokedupwards. If the massage is light enough there is no pain, it isactually soothing. The rubbing is continued for from fifteen to twentyminutes, and the patient is encouraged to move the toes and ankle; amoderately firm elastic bandage is then applied. The massage isrepeated once or twice a day, the sittings lasting for about fifteenminutes. The patient should be encouraged to move the joint from thefirst, beginning with the movements that put least strain upon thedamaged ligaments, and gradually increasing the range. In the courseof a few days he is encouraged to walk or cycle, or otherwise to usethe joint without subjecting it to strain, or to a repetition of themovement that caused the accident. Alternate hot and cold douching, orhot-air baths, followed by massage, are also useful. Complete rest andprolonged immobilisation are to be condemned. TRAUMATIC DISLOCATIONS A dislocation or luxation is a persistent displacement of the opposingends of the bones forming a joint. We are here concerned only withsuch dislocations as immediately follow upon injury. Those that arecongenital or that result from disease will be studied later. _Causes. _--The majority of dislocations are the result of _indirect_violence, the more movable bone acting as a lever, on a fulcrumfurnished by the natural check to movement in the form of ligament, bone, or muscle. It is in this way that most dislocations of theshoulder, hip, and elbow are produced. At the moment the violence is applied, the muscles are relaxed orotherwise taken at a disadvantage, so that the joint is for the timebeing deprived of their support. The joint is moved beyond itsphysiological range, and the end of one of the bones being brought tobear upon the capsule, tears it, and passes through the rent thusmade. The muscles then contract reflexly, and pull the head of thebone into an unnatural position outside the capsule. The positionassumed will depend upon such factors as the direction of the force, the structure of the joint, the position of the limb at the time ofthe accident, and the relative strength of the different groups ofmuscles acting upon the bone which is displaced. Violence applied _directly_ to the joint is a much less frequent causeof dislocation. In this way, however, the knee-joint may bedislocated, one bone being driven past the other--for example, by akick from a horse; or the acromio-clavicular joint by a blow on theshoulder. _Muscular contraction_ is not often the sole cause of dislocation, although, as has been mentioned, it plays an important rôle in theproduction of the majority of these injuries. The shoulder, mandible, and patella are, however, not infrequently displaced by muscularaction alone. Acrobats sometimes acquire the power of dislocatingcertain joints by voluntary contraction of their muscles. _Age and Sex. _--Dislocations occur most frequently in adult males, doubtless on account of the nature of their occupations andrecreations. In children the epiphyses are separated, and in oldpeople the bones are broken by such forms of violence as causedislocation in the middle-aged. Muscular debility and undue laxness of ligaments resulting fromdisease or previous dislocation are also predisposing factors. _Clinical Varieties. _--The separation between the bones may be_complete_ or _partial_. When partial, portions of the articularsurfaces remain in apposition, and the injury is known as a_sub-luxation_. Like fractures, dislocations may be _simple_ or_compound_, the latter being specially dangerous on account of therisk of infection. When seen within a few days of its occurrence, adislocation is looked upon as _recent_; but when several weeks ormonths have elapsed, it is spoken of as an _old-standing_ dislocation. The latter will be described later. Dislocations, like fractures, may be _complicated_ by injuries tolarge blood vessels or nerve-trunks, by injuries to internal organs, or by a wound of the soft tissues which does not communicate with thejoint. Further, a fracture may coexist with a dislocation--a mostimportant complication. _Clinical Features. _--The most characteristic signs of dislocation are_preternatural rigidity_, or want of movement where movement shouldnaturally take place; _mobility in abnormal directions_; and_deformity_, the part being "out of drawing" as compared with theuninjured side (Fig. 18). The bony landmarks lose their normalrelationship to one another; and the deformity is characteristic, andis common to all examples of the same dislocation. Although any of the subsidiary signs may occur in lesions other thandislocations, due weight must be given to them in making a diagnosis. _Loss of function_ is complete as a rule. _Pain_ is much more intensethan in fracture, usually because the displaced bone presses uponnerve-trunks, and from the same cause there is often numbness andpartial paralysis of the limb beyond. _Swelling_ of the soft parts dueto effused blood is usually less marked in dislocation than infracture, but is often sufficiently great to interfere with diagnosticmanipulations. The displaced bone, and sometimes the empty socket, maybe palpable. _Discoloration_ is usually later of appearing than infractures. _Alteration in the length_ of the injured limb--usually inthe direction of shortening--is a common feature; while girthmeasurements usually show an increase. A peculiar soft _grating_ or_creaking sensation_ is often felt on attempting to move the joint;this is due to cartilaginous or ligamentous structures rubbing on oneanother, and must not be mistaken for the crepitus of fracture. In themajority of cases, although not in all, after reduction has beeneffected, the bones retain their proper relations without externalsupport, a point in which a dislocation differs from a fracture. Acareful investigation of the kind of force which produced the injury, particularly as regards its intensity and direction of action, may aidin the diagnosis. The diagnosis can always be verified by the use ofthe Röntgen rays, and this should be had recourse to wheneverpossible, as a fracture may be shown that otherwise would escaperecognition. _Prognosis. _--After having once been dislocated, a joint is seldom asstrong as it was formerly, although for all practical purposes thelimb may be as useful as ever. Some degree of stiffness, of limitedmovement, or of muscular weakness, and occasional arthritic changesand a liability to re-dislocation, are the commonest sequelæ. Prolonged immobilisation is liable to lead to stiffness by permittingof the formation of adhesions; while too early movement tends toproduce a laxity of the ligaments which favours re-displacement fromslight causes. _Treatment. _--Reduction should be attempted at the earliest possiblemoment. Every hour of delay increases the difficulty. The guidingprinciple is to cause the displaced bone to re-enter its socket bythe same route as that by which it left it--that is, through theexisting rent in the capsule. This is done by carrying out certainmanipulations which depend upon the anatomical arrangement of theparts, and which vary, not only with different joints, but also withdifferent varieties of dislocation of the same joint. In general termsit may be said that the main impediments to reduction are: thecontraction of the muscles acting upon the displaced bone; theentanglement of the bone among tendons or ligamentous bands which fixit in its abnormal position; and the rent in the capsule being smallor valvular, so that it forms an obstacle to the bone reentering thesocket. Muscular contraction is best overcome by the administration of ageneral anæsthetic, and in all but the simplest cases this should begiven to ensure accurate and painless reduction. Failing this, however, the muscles may be wearied out by the surgeon making steadyand prolonged traction on the limb, while an assistant makescounter-extension on the proximal segment of the joint. Advantage mayalso be taken of such muscular relaxation as occurs when the patientis already faint, or when his attention is diverted from the injuredpart, to carry out the manipulations necessary to restore the bone toits normal position. The appropriate manœuvres for disengaging the head of the bone fromtendons, ligaments, or bony processes with which it may be entangled, will be suggested by a consideration of the anatomy of the particularjoint involved, and will be described with individual dislocations. In reducing a dislocation, no amount of physical force will compensatefor a want of anatomical knowledge. All tugging, twisting, orwrenching movements are to be avoided, as they are liable to causedamage to blood vessels, nerves, or other soft parts, or even--andespecially in old people--to fracture one of the bones concerned. After reduction, great benefit is gained by the systematic use of_massage_ and movement. Before any restraining apparatus is appliedthe whole region should be gently stroked in a centrifugal directionfor fifteen or twenty minutes; and this is to be repeated daily, eachsitting lasting for about twenty minutes. From the first day onward, movement of the joint is carried out in every direction, except thatwhich tends to bring the head of the bone against the injured part ofthe capsule; and the patient is encouraged to move the joint as earlyas possible. The appropriate apparatus and the period during which itshould be worn will be considered with the individual dislocations. _Operation in Simple Dislocations. _--In a limited number of cases, even with the aid of an anæsthetic, reduction by manipulation is foundto be impossible. Resort must then be had to operation, which is acomparatively safe and satisfactory proceeding, although oftendifficult. It may happen in rare instances that the undoing of thedisplacement is only possible after the removal of a portion of one orother of the bones. #Compound Dislocations. #--Compound dislocations are usually the resultof extreme violence produced by machinery or railway accidents, or bya fall from a height. In the majority of cases they are complicated byfracture of one or more of the constituent bones of the joint, as wellas by laceration of muscles, tendons, and blood vessels. In the regionof the ankle, wrist, and joints of the thumb, however, compounddislocation is sometimes met with uncomplicated by other lesions. Thegreat risk is infection, which may result in serious impairment of theusefulness of the joint or even in its complete destruction, resultstowards which the concomitant injuries materially contribute. In manyinstances where infection has occurred, ankylosis is the best resultthat can be hoped for. _Treatment. _--As a rule, the first question that arises is whetheramputation is necessary or not, and the considerations that determinethis point are the same as in compound fractures (p. 26). If anattempt is to be made to save the limb, the treatment is the same asin compound fracture (p. 25). #Dislocation complicated by Fracture. #--In certain dislocations theseparation of small portions of bones or of epiphyses is of commonoccurrence--for example, fracture of the tip of the coronoid processin dislocation of the elbow backwards, and chipping off of a portionof the edge of the acetabulum in dislocation of the hip. The most important example of a fracture complicating a dislocation isfracture of the surgical neck of the humerus coexisting withdislocation of the shoulder. Here the difficulty of diagnosis isgreatly increased, and the treatment of both injuries requires to bemodified. The dislocation must be reduced--by operation ifnecessary--before the fracture is treated, and in many cases it isadvisable to secure the fragments of the broken bone by pegs, orplates, to admit of movement being commenced early, and so to preventstiffness of the joint. #Old-standing Dislocations. #--When, from want of recognition--and, curiously enough, a dislocation is much more liable to be overlookedthan would have been thought possible--or from unsuccessful treatment, a dislocation is left unreduced, changes take place in and around thejoint which render reduction increasingly difficult or impossible. Therent in the capsule closes upon the neck of the bone, and fibrousadhesions form between muscles, tendons, and other structures thathave been torn. The articular cartilage of the head, being no longerin contact with an opposing cartilage, tends in time to be convertedinto fibrous tissue, and may become adherent to other fibrousstructures in its vicinity. By pressing on adjacent structures it mayform for itself a new socket of dense fibrous tissue which in timebecomes lined with a secreting membrane. When the displaced head liesagainst a bone, the continuous pressure produces a new osseous socket, from the margins of which osteophytic outgrowths may spring, and asthe surrounding fibrous tissue becomes condensed and forms a strongcapsule, a new joint results. The occurrence of these changes in thedirection of a new ball-and-socket joint is largely dependent on thebehaviour of the patient: a vigorous man, anxious to recover the useof the limb, will employ it with a degree of determination andindifference to pain that could not be expected in a sensitive elderlyfemale. The most perfect example of a new ball-and-socket joint, following upon an unreduced dislocation at the hip, that has comeunder our observation, was in a hunting dog, given one of us by anAustralian pupil, who testified that the animal was as fleet with thenew joint as it had been with the original one. Meanwhile thecartilage of the original socket is converted into fibrous tissue, which may come to fill up the cavity. Changes resembling those ofarthritis deformans may occur. The large blood vessels and nerves inthe vicinity may be pressed upon or stretched by the displaced bone, or may be implicated in fibrous adhesions. In course of time theybecome lengthened or shortened in accordance with the altered attitudeof the limb. [Illustration: FIG. 12. --Os Innominatum showing new socket formedafter old-standing dislocation. The acetabulum is almost obliterated. ] In many cases the new joint is remarkably mobile and useful; but inothers, pain, limited movement, and atrophy of muscles render itcomparatively useless, and surgical intervention is called for. _Treatment. _--It is always a difficult problem to determine the dateafter which it is inadvisable to attempt reduction by manipulation inan old dislocation and no rules can be laid down which will cover allcases. Rather must each case be decided on its own merits, dueconsideration being had to the risks that attend this line oftreatment. The chief of these are: rupture of a large blood vessel ornerve that has formed adhesions with the displaced bone, or has becomeshortened in adaptation to the altered shape or length of the limb;tearing of muscles or tendons, or even of skin; fracture of the bone, especially in old people; and separation of epiphyses in the young. Before carrying out the manipulations appropriate to the particulardislocation, all adhesions must first be broken down; and during theproceedings no undue force is to be employed. The first attempt atreduction may fail, and yet subsequent efforts, at intervals of a fewdays, may ultimately prove successful; the vigorous traction andtwisting of the soft parts, matted together as they are byscar-tissue, causes reactive changes in the vessels and tissues whichrender them more liable to yield on subsequent attempts at reduction. In old people, and where there is an absence of suffering frompressure on nerves or vessels, it may be wiser to leave thedislocation unreduced, and strive rather by massage and movement toobtain a useful variety of false joint. If the conditions areotherwise, it may be better to improve the function of the limb by an_open operation_. Tight ligaments and other structures are divided, and the socket is cleared out. If reduction is still impossible, apartial excision may be performed and a flap of fascia lata introducedto prevent ankylosis (arthroplasty). In the case of the hip, thedislocation may be left alone and the femur divided below thetrochanter, especially if there is pronounced flexion. #Habitual or recurrent dislocation# is almost exclusively met with inthe shoulder, and will be described with the injuries of that joint. #Pathological Dislocations. #--Joints may become dislocated in thecourse of certain diseases. These pathological dislocations fall intodifferent groups: (1) those due to gradual stretching of the capsularand other ligaments weakened by inflammatory and suppurativeprocesses, such as sometimes follow on typhoid, scarlet fever, ordiphtheria, and in pyæmia; (2) those due to destructive changes in theligaments and bones--typically seen in tuberculous arthritis, inarthritis deformans, in Charcot's disease, and in nerve lesions, _e. G. _ dislocation of the hip in spastic conditions, such as Little'sdisease; (3) those associated with deformed attitudes of the limb; (4)those due to changes in the articular surfaces, _e. G. _ the phalangesin arthritis deformans. These will be considered with the conditionswhich give rise to them. #Congenital Dislocations. #--Congenital dislocations are believed to bethe result of abnormal or arrested development _in utero_, and are tobe distinguished from dislocations occurring during birth, which areessentially traumatic in origin. They will be described along with theDeformities of the Extremities. CHAPTER III INJURIES IN THE REGION OF THE SHOULDER AND UPPER ARM Surgical Anatomy--FRACTURES OF CLAVICLE: _Varieties_--DISLOCATION OF CLAVICLE: _Varieties_--DISLOCATION OF SHOULDER: _Varieties_--Sprains and contusions of shoulder--FRACTURE OF SCAPULA: Sites--FRACTURE OF UPPER END OF HUMERUS: _Surgical neck_; _Separation of epiphysis_; _Fracture of head, anatomical neck, or tuberosities_--FRACTURES OF SHAFT OF HUMERUS. The injuries met with in the region of the shoulder include fracturesand dislocations of the clavicle, fractures of the scapula, dislocations and sprains of the shoulder-joint, and fractures of theupper end of the humerus. #Surgical Anatomy. #--For the examination of an injury in the region ofthe shoulder the patient should be seated on a low stool or chair. After inspecting the parts from the front, the surgeon stands behindthe patient and systematically examines by palpation the shouldergirdle and upper end of the humerus. The uninjured side should beexamined along with the other for purposes of comparison. Immediately lateral to the supra-sternal notch, the sterno-claviculararticulation may be felt, the large end of the clavicle projecting toa varying degree beyond the margins of the small and shallow articularsurface on the sternum. Any dislocation of this joint is at oncerecognised. The clavicle being subcutaneous throughout its wholelength, any irregularity in its outline can be easily detected. Asmall tubercle (deltoid tubercle) which frequently exists near theacromial end is liable to suggest the presence of a fracture. Thelateral end forms with the acromion the acromio-clavicular joint, which, however, is not always readily identified. The fingers are nowcarried over the acromion, which often exhibits in the situation ofits epiphysial cartilage a prominent ridge, which must not be mistakenfor a fracture. The tip of the acromion is usually employed as a fixedpoint in measuring the length of the upper arm. The outline of the spine of the scapula can be traced back to thevertebral border; and the body of the bone may be manipulated, and itsmovements tested by moving the arm. The coracoid process can be recognised in the upper and lateral angleof the triangular depression bounded by the pectoralis major, thedeltoid, and the clavicle. The head and surgical neck of the humerus may now be felt from theaxilla, if the axillary fascia is relaxed by bringing the arm to theside. The great tuberosity can be indistinctly felt on the lateralaspect of the shoulder through the fibres of the deltoid. It liesvertically above the lateral epicondyle, and may be felt to rotatewith the shaft. The inter-tubercular (bicipital) groove looks forward, and lies in a line drawn vertically through the biceps muscle. The subclavian artery, with its vein to the median side and the cordsof the brachial plexus to the lateral side, passes under the middle ofthe clavicle, and may be compressed against the first rib immediatelyabove this bone. FRACTURE OF THE CLAVICLE Fracture of the clavicle is one of the commonest injuries met with inpractice. As about one-third of the cases occur in children, thefracture is often of the greenstick variety. The fractures are seldomcompound or complicated, unless as a result of gun-shot injuries; butoccasionally one of the fragments pierces the skin, or comes to pressupon the subclavian vessels or the cords of the brachial plexus, arresting the pulsation in the vessels of the limb, and causing severepain in the arm. [Illustration: FIG. 13. --Oblique Fracture of Right Clavicle in MiddleThird, united. ] The most common site of fracture is in the _middle third_ (Fig. 13), and this usually results from indirect violence, such as a fall on theoutstretched hand, the elbow, or the outer aspect of the shoulder, theforce being transmitted through the glenoid cavity to the scapula, andthence by the coraco-clavicular ligaments to the clavicle. Theviolence is therefore of a twisting character, and the bone gives waynear the junction of the lateral and middle thirds, just where the twonatural curves of the bone meet, and where the supporting muscular andligamentous attachments are weakest. The fracture so produced is usually oblique from above, downwards andinwards. The sternal fragment may be slightly drawn upwards by theclavicular fibres of the sterno-mastoid, while the acromial fragmentfalls by the weight of the arm, and the fragments usually overlap tothe extent of about half an inch. The shoulder, having lost thebuttressing support of the clavicle, falls in towards the chest wall, narrowing the axillary space, while the weight of the arm pulls itdownward, and the muscles inserted in the region of the bicipitalgroove pull it forward. Fracture of the middle third may result also from a direct stroke, such as the recoil of a gun, or from violent muscular contraction, thefracture as a rule being transverse, and the displacement less markedthan in fracture by indirect violence. _Clinical Features. _--The attitude of the patient is characteristic:the elbow is flexed and is supported by the opposite hand, while thehead is inclined towards the affected shoulder to relax the muscles ofthe neck. Crepitus is elicited on bracing back the shoulders, or onattempting to raise the arm beyond the horizontal, and these movementscause pain. Tenderness is elicited on making pressure over the seat offracture, and also on distal pressure. The sternal fragment almostinvariably overrides the acromial, and can usually be palpated throughthe skin; on measurement, the clavicle is found to be shortened. Whenthe fracture is incomplete (greenstick) or transverse, the symptomsare less marked. [Illustration: FIG. 14. --Fracture of Acromial End of Clavicle. Showsforward rotation of lateral fragment, and line of fracture united bybone. ] Fracture of the _lateral_ or _acromial third_ of the clavicle is acommon form of accident at football matches, and usually results fromdirect violence, the bone being driven down against the coracoidprocess, and broken as one breaks a stick over the knee. The fracturemay take place through the attachment of the conoid and trapezoidligaments, in which case the only symptoms are pain and tenderness atthe seat of fracture, with impaired movement of the limb. Displacementand crepitus are prevented by the splinting action of the ligaments. When the break is lateral to the attachment of the trapezoid ligament, the fracture is usually transverse, and is almost always due to a fallon the back of the shoulder--the angle between the spine and theacromion process striking the ground. The acromial fragment rotatesforward (Fig. 14), sometimes even to a right angle, causing the tip ofthe shoulder to pass forwards, and so to lie slightly nearer themiddle line. The integrity of the coraco-clavicular ligaments preventsany marked drooping of the shoulder. It is noteworthy that thedisplacement is not always evident at first. Fractures of the _medial_ or _sternal third_ are rare, are usuallyoblique, and result either from an indirect force acting in the lineof the clavicle, or, less frequently, from direct violence or muscularaction. As a rule, the deformity is insignificant, except when thecosto-clavicular ligament is torn, in which case the medial end of thedistal fragment is tilted up by the weight of the arm. The shoulderpasses downwards, forwards, and medially. When close to the sternalend, this fracture may simulate a dislocation of the sterno-clavicularjoint or a _separation of the clavicular epiphysis_. This last is arare accident, which may occur between the seventeenth and thetwenty-fifth years, and is usually the result of violent muscularaction. It differs from the other injuries in this region in beingmore easily reduced and retained in position, the epiphysis lyingentirely within the limits of the articular capsule of thesterno-clavicular joint. _Simultaneous fracture of both clavicles_ usually results from asevere transverse crush of the upper part of the thorax or from a fallon the outstretched hands--for example, in hunting. The middle thirdof the bone is implicated, and there is marked displacement andoverriding. The patient is rendered helpless, and from the extrinsicmuscles of respiration being thrown out of action and the weight ofthe powerless limbs pressing on the chest, there is considerabledifficulty in breathing, and this is often increased by the fracturebeing complicated by injuries of the lung or pleura. The _prognosis_ as to union in all these injuries is good. Firm bonyunion 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 beborne in mind that, in spite of all precautions, some deformity andshortening may result, without, however, interfering with theusefulness of the limb. _Treatment. _--The displacement in complete fractures of the clavicleis readily reduced by supporting the elbow, bracing back theshoulders, and levering out the tip of the affected shoulder. In a fewcases the interposition of some fibres of the subclavius musclebetween the fragments has prevented perfect reduction. In the greenstick variety the bone may be bent back into its normalposition, but no great force should be employed, as, in spite ofimperfect reduction, the clavicle usually straightens as it grows, andalthough some deformity may persist, the function of the limb is notinterfered with. _Recumbent Position. _--There is little doubt that the most perfectæsthetic results are obtained by treating the patient in the recumbentposition. In girls, therefore, in whom it is desired that theshoulders should be perfectly symmetrical, the best results areobtained from placing the patient on a firm mattress, with a narrow, firm cushion between the shoulder-blades, so that the weight of theshoulder may carry the acromial fragment laterally and backwards. Apad is inserted in the axilla, the elbow raised, and the arm placed bythe side on a pillow and steadied with sand-bags. Massage is applieddaily. As this position must be maintained uninterruptedly for two orthree weeks, it proves too irksome for most patients. When bothclavicles are fractured, however, it is, short of operation, the onlyavailable method of treatment. In ordinary cases the arm should be placed in that position whichgives the best alignment of the fragments and least deformity. A thinlayer of wool is placed in the axilla to separate the skin surfaces. Asling, supporting the _elbow_, is now applied, maintaining the arm inposition, and a body bandage fixes the arm to the side. Massage andmovement should be commenced at once. A simple method, which yields satisfactory results, is that suggestedby Wharton Hood. The fracture having been reduced, three strips ofadhesive plaster, each an inch and a half wide, are applied from apoint immediately above the nipple to a point 2 inches below the angleof the scapula (Fig. 15). The middle strap covers the seat offracture, and is applied first: the others, slightly overlapping it, extend about half an inch on either side. The elbow is supported in asling. This plan has the advantage that it permits of movement of theshoulder being carried out from the first, but the plaster ratherinterferes with massage. _The Handkerchief Method. _--In cases of emergency, one of the bestmethods applicable to all fractures of the clavicle is to brace backthe shoulders by means of two padded handkerchiefs, folded _encravate_, placed well over the tips of the shoulders and tied, orinterlaced, between the scapulæ. The forearm is then supported by athird handkerchief applied as a sling, the base of which is placedunder the elbow, the ends passing over the sound shoulder. _Operative treatment_ may be called for in compound or comminutedfractures when the fragments have injured, or are likely to injure, the subclavian vessels or the cords of the brachial plexus, or when itis otherwise impossible to reduce the fracture or to retain thefragments in apposition. It is also indicated in some cases offracture of both clavicles. These various methods of treatment are not equally applicable to allcases. In our experience, in the circumstances indicated, thefollowing methods have proved the most satisfactory: (1) As atemporary means of retention in emergency cases, --for example, accidents occurring on the football field, --the handkerchief method. (2) In uncomplicated fractures of average severity in any part of thebone, the method of sling and body bandage. (3) In cases where, foræsthetic reasons, the chief consideration is the avoidance ofdeformity and the maintenance of the symmetry of the shoulders, as ingirls, the treatment by recumbency. (4) When retentive apparatusfails, or when the fragments are exerting injurious pressure, operative treatment. [Illustration: FIG. 15. --Adhesive Plaster applied for Fracture ofClavicle. ] In quite a number of cases, there is an excessive amount of pain, preventing sleep; where this is due to cramp-like contractions of themuscles and movements of the fragments, it is relieved by moreaccurate fixation, as by strips of plaster; otherwise a hypodermicinjection of heroin or morphin is indicated. DISLOCATION OF THE CLAVICLE Dislocation of the #acromial end#--sometimes, and perhaps morecorrectly, spoken of as dislocation of the scapula--is more frequentthan that at the sternal end, and it usually results from a blow frombehind, or from a fall on the tip of the shoulder, driving down thescapula, so that the clavicle projects _upwards_ and overrides theacromion process. _Downward_ displacement of the acromial end of the clavicle is muchrarer, 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 withthe capsule of the shoulder-joint, and the acromion stands outprominently. The _clinical features_ are so well marked that the diagnosis isunmistakable. The head inclines towards the affected side, and the tipof the shoulder tends to pass slightly downward, forward, andmedially. The displaced end of the bone can be seen and felt as aprominence under the skin, or the empty socket can be palpated, whilethe muscles attached to the displaced clavicle stand out in relief. The movements at the shoulder are restricted, particularly in thedirection of abduction above the level of the shoulder. These injuriesare sometimes associated with fracture of the ribs, a complicationwhich adds materially to the difficulties of treatment. _Treatment. _--Reduction is easily effected by bracing back theshoulders and replacing the bone in its socket by manipulation; butretention is invariably difficult, and in many cases impossible; evenwhen the displacement is permanent, however, the usefulness of the armis not necessarily impaired. Treatment is similar to that for fracture of the clavicle by sling andbody bandage. Another plan is to place a pad over the acromial end ofthe clavicle, and fix it in this position by a few turns of elasticbandage carried over the shoulder and under the elbow. The forearm isplaced in a sling with the elbow well supported, and the arm is boundto the side by a circular bandage. When the bone cannot be kept inposition and the usefulness of the limb is impaired, the jointsurfaces may be rawed and the bones wired, with a view to obtainingankylosis. #The sternal end# may be dislocated forwards, backwards, or upwards. _Forward_ dislocation is the most common; the end of the clavicle lieson the front of the sternum, somewhat below the level of thesterno-clavicular joint, and its articular surface can be distinctlypalpated (Fig. 16). The inter-articular cartilage sometimes remainsattached to one bone, sometimes to the other; the rhomboid ligament isusually intact. In the _backward_ dislocation the end of the clavicle lies behind themanubrium sterni and the muscles attached to it; there is a markedhollow in the position of the joint, and the facet on the sternum canbe felt. In a comparatively small number of cases the bone exertspressure upon the trachea and œsophagus, producing difficulty inbreathing and swallowing. It has also been known to press upon thesubclavian artery and on other important structures at the root of theneck. [Illustration: FIG. 16. --Forward Dislocation of Sternal End of RightClavicle. From a fall on a polished floor, in a man æt. 40. ] In rare cases the rhomboid ligament is torn, and the end of theclavicle passes _upwards_, and rests in the episternal notch behindthe sterno-mastoid muscle. The bone may be retained in position by keeping the shoulders bracedback by a figure-of-eight bandage, or by padded handkerchiefs, andmaking pressure over the displaced end of the bone with a pad. Theforearm is supported by a sling, and the arm fixed to the side. Massage is employed from the first, and the patient is allowed to movethe arm by the end of a week. Imperfect reduction interferes so littlewith the functions of the limb that operative measures are seldomrequired except for æsthetic reasons. Dislocation of #both ends# of the clavicle has occasionally occurredfrom a severe crush. The ultimate result has been satisfactory, as oneor other end has always healed in normal position, and the function ofthe arm has thus been maintained. DISLOCATION OF THE SHOULDER The shoulder is more frequently dislocated than all the other jointsin the body taken together. This is explained by its exposed position, the wide range of movement of which it is capable, the length of thelever afforded by the humerus, and the anatomical construction of thejoint--the large, round humeral head imperfectly fitting the small andshallow glenoid cavity, and the ligaments being comparatively lax andthin. The capsule of the joint is materially strengthened in its upperand back parts by the tendons of the supra- and infra-spinatus andteres minor muscles; while it is weakest below and in front, betweenthe subscapularis and teres major tendons. It is here that it mostfrequently gives way and allows of the escape of the head of the bone. The determining factor is probably that when the arm is abducted theneck of the humerus comes in contact with the tip of the acromion, andfurther abduction forces the head against the lower, weak portion ofthe capsule, which gives way. The violence is usually transmitted from the hand or elbow, lessfrequently from the lateral aspect of the shoulder, the limb beingusually abducted and the muscles relaxed and taken unawares. The headof the humerus, thus brought to bear on the weakest part of thecapsule, ruptures it and passes out through the rent. Dislocation isreadily produced in an unconscious person--as, for example, inconducting artificial respiration in a patient suffering from opiumpoisoning, the arms being hyper-abducted to exert traction on thechest. _Varieties. _--Several varieties of dislocation are recognised, according to the position in which the head of the humerus finallyrests (Fig. 17). The simplest of these is the _sub-glenoid_ variety, in which the head rests on the long tendon of the triceps, where itarises from the axillary border of the scapula just below the glenoidcavity. In almost all dislocations of the shoulder the head of thebone is at least momentarily in this position, but the sharp edge ofthe scapula and the rounded head are ill adapted to one another, andthe position is not long maintained. The subsequent course taken bythe humerus depends upon the nature and direction of the force, theposition of the limb at the moment of injury, and the relativestrength and capacity for effective action of the different groups ofmuscles acting upon the bone. [Illustration: FIG. 17. --Diagram of most common varieties ofDislocation of the Shoulder. ] In the great majority of cases it passes forward and medially, andcomes to lie against the anterior surface of the neck of thescapula, under cover of the tendons of origin of the biceps andcoraco-brachialis muscles, constituting the _sub-coracoiddislocation_. Much less frequently it passes under cover of thepectoralis minor and against the edge of the clavicle--the_sub-clavicular_ variety. In rare cases the head passes backward andlies against the spine on the dorsum of the scapula, beneath theinfra-spinatus muscle--the _sub-spinous_ variety. Other varieties areso rare that they do not call for mention. _Clinical Features common to all Varieties. _--Dislocation of theshoulder is commonest in adult males; in advanced life the proportionof female sufferers increases. It is usually attended with great pain, and there is often numbness of the limb due to pressure of the head ofthe bone upon the large nerve-trunks. There is sometimes considerableshock. The patient inclines his head towards the injured side, and, while standing, the forearm is supported by the hand of the oppositeside. The acromion process stands out prominently, the roundness ofthe shoulder giving place to a flattening or depression immediatelybelow it, so that a straight-edge applied to the lateral aspect of thelimb touches both the acromion and the lateral epicondyle. Thevertical circumference of the shoulder is markedly increased; thistest is easily made with a piece of tape or bandage and is comparedwith a similar measurement on the normal side--we lay great stress onthis simple measure, as it is a most reliable aid in diagnosis. Thehead of the bone can usually be felt in its new position, and the axisof the humerus is correspondingly altered, the elbow being carriedfrom the side--forward or backward according to the position of thehead. The empty glenoid may sometimes be palpated from the axilla. Inmost cases, although not in all, the patient is unable at one and thesame time to bring his elbow to the side and to place his hand uponthe opposite shoulder (Dugas' symptom). Measurements of the length ofthe limb from acromion to lateral epicondyle are rarely of anydiagnostic value. The #sub-coracoid dislocation# (Fig. 18) is that most frequently metwith. It usually results from hyper-abduction of the arm while thescapula is fixed, as in a fall on the medial side of the elbow whenthe arm is abducted from the side. The surgical neck of the humerus isthen brought to bear upon the under aspect of the acromion, whichforms a fulcrum, and the head of the bone is pressed against themedial and lower part of the capsule. In some cases muscular actionproduces this dislocation; it may also result from force applieddirectly to the upper end of the humerus. [Illustration: FIG. 18. --Sub-coracoid Dislocation of Right Shoulder. ] The head leaves the capsule through the rent made in its lower part, and, either from a continuation of the force or from contraction ofthe muscles inserted into the inter-tubercular (bicipital) groove, particularly the great pectoral, passes medially under cover of thebiceps and coraco-brachialis till it comes to rest against theanterior surface of the neck of the scapula, just below the coracoidprocess. The anatomical neck of the humerus presses against theanterior edge of the glenoid, and there is frequently an _indentationfracture of the head of the humerus_ where the two bones come intocontact (F. M. Caird). The subscapularis is bruised or torn, themuscles inserted into the great tuberosity are greatly stretched, orthe tuberosity itself may be avulsed, allowing the long tendon of thebiceps to slip laterally, where it may form an impediment toreduction. The axillary (circumflex) nerve is often bruised or torn, and the head of the humerus is liable to press injuriously on thenerves and vessels in the axilla. The _clinical features_ common to all dislocations are prominent, although Dugas' symptom is not constant. [Illustration: FIG. 19. --Sub-coracoid Dislocation of Humerus. (Sir H. J. Stiles' case. Radiogram by Dr. Edmund Price. )] _Treatment. _--The guiding principle in the reduction of thesedislocations is to make the head of the bone retrace the course ittook in leaving the socket. The main obstacles to reduction beingmuscular contraction and the entanglement of the head with tendons, ligaments, or bony points, appropriate means must be taken tocounteract each of these factors. A general anæsthetic is an invaluable aid to reduction, and should begiven unless there is some reason for withholding it. It is speciallyindicated in strong muscular subjects, and in nervous patients who donot bear pain well, and particularly when the dislocation has existedfor a day or two. In quite recent cases, however, the surgeon maysucceed in replacing the bone by taking advantage of a temporaryfaintness, or by engaging the patient's attention with other matterswhile he carries out the appropriate manipulations. When an anæsthetic is employed, the patient should be laid on amattress on the floor, or on a narrow, firm table; otherwise he shouldbe seated on a chair. _Kocher's method_ is suitable for the great majority of cases ofsub-coracoid dislocation. (1) The elbow is firmly pressed against theside, and the forearm flexed to a right angle. The surgeon grasps thewrist and elbow and firmly _rotates the humerus away from the middleline_ (Fig. 20) till distinct resistance is felt and the deltoidbecomes more prominent. In this way the rent in the lower part of thecapsule is made to gape, and the head of the humerus rolls away fromthe middle line till it lies opposite the opening, rotation takingplace about the fixed point formed by the contact of the anatomicalneck of the humerus with the anterior lip of the glenoid cavity (D. Waterston). (2) _The elbow is next carried forward, upward, andtowards the middle line_ (Fig. 21); the humerus acting as the long armof a lever on the fulcrum furnished by the muscles inserted in theregion of the surgical neck, the head, which forms the short arm ofthe lever, is carried backward, downward, and laterally, and is thusdirected towards the socket. (3) The humerus is now _rotated towardsthe middle line_ by carrying the hand across the chest towards theopposite shoulder (Fig. 22). The anatomical neck of the humerus isthus disengaged from the edge of the glenoid, and the head is pulledinto the socket by the tension of the surrounding muscles. [Illustration: FIG. 20. --Kocher's Method of reducing Sub-coracoidDislocation--First Movement; Rotation of Arm away from Middle Line. ] [Illustration: FIG. 21. --Kocher's Method--Second Movement; Elbowcarried forward, upward, and towards the Middle Line. ] [Illustration: FIG. 22. --Kocher's Method--Third Movement; Rotation ofArm towards Middle Line. ] A method of reduction has been formulated by A. G. Miller, which wehave found to be quite as successful as Kocher's method. The limb isgrasped above the wrist and elbow, the forearm flexed to a rightangle, and the upper arm abducted to the horizontal (Fig. 23). Whilean assistant makes counter-extension and fixes the scapula, thesurgeon gradually draws the arm away from the body till the head ofthe humerus is felt to pass laterally. The humerus is then rotatedmedially by dropping the hand (Fig. 24), and the bone gradually glidesinto the socket. [Illustration: FIG. 23. --Miller's Method of reducing Sub-coracoidDislocation--First Movement. ] [Illustration: FIG. 24. --Miller's Method of reducing Sub-coracoidDislocation--Second Movement. ] In a certain number of cases reduction can be effected by_hyper-abduction_ of the shoulder with traction. The patient is laidupon a firm mattress, and the surgeon, seated behind him while anassistant fixes the acromion, slowly and steadily extends the armuntil it is raised well above the head. In some cases the head of thehumerus spontaneously slips into its socket; in others it may bemanipulated into position by pressure from the axilla. This method isrestricted to recent cases, as in those of long standing the axillaryvessels are liable to be stretched or torn. The method of reduction by traction on the arm with the heel in theaxilla is only to be used when other measures have failed, as itdepends for its success on sheer force. _After-Treatment. _--After reduction, the part is gently massaged forten or fifteen minutes, a layer of wool is placed in the axilla, theforearm is supported by a sling, and the arm fixed to the side by acircular bandage. Massage is carried out from the first, and movementof the shoulder in every direction except that of abduction may becommenced on the first or second day. The circular bandage may bedispensed with at the end of a week, and abduction movementscommenced, and by the end of a month the patient should be advised touse the arm freely. The #sub-clavicular dislocation# (Fig. 17) is to be looked upon as anexaggerated degree of the sub-coracoid rather than as a separatevariety. It is produced by the same mechanism, but the violence isgreater, and the damage to the soft parts more severe. The head passesfarther upwards and towards the middle line under cover of thepectoralis minor, resting under the clavicle against the serratusanterior and chest wall. The symptoms are usually so marked that theyleave no doubt as to the diagnosis. The outline of the head of thehumerus in its abnormal position is visible through the skin, and theshortening of the limb is more marked than in the sub-coracoidvariety. The treatment is the same as for sub-coracoid dislocation. #Sub-glenoid dislocation# (Fig. 17) is less frequently met with thanthe sub-coracoid variety, and almost always results from forcibleabduction of the arm. The head of the humerus passes out through asmall rent in the lower and medial portion of the capsule, and restsagainst the anterior edge of the triangular surface immediately belowthe glenoid cavity, supported behind by the long head of the triceps, and in front by the subscapularis muscle. It is readily felt in theaxilla. All the tendons in relation to the upper end of the humerusare stretched or torn, and the great tuberosity is not infrequentlyavulsed. There is sometimes bruising of the axillary nerve. The projection of the acromion, the flattening of the deltoid, theincreased depth of the axillary fold, and the abduction of the elboware well marked; the arm is slightly lengthened, rotated out, andcarried forward. It is reduced by the hyper-abduction method (p. 60). #Sub-spinous Dislocation. #--Backward dislocation is usually termedsub-spinous, although in a considerable proportion of cases the headof the humerus does not pass beyond the root of the acromion process(_sub-acromial_) (Fig. 17). This dislocation is usually produced by afall on the elbow, the arm being at the moment adducted and rotatedmedially, so that the head of the humerus is pressed backwards andlaterally against the capsule, which ruptures posteriorly. All themuscles attached to the upper end of the humerus are liable to betorn, and the tuberosities are frequently avulsed. The long tendon ofthe biceps may slip from its position between the tuberosities, andprevent reduction or favour re-dislocation, necessitating an openoperation. In the milder cases the _clinical features_ are not always wellmarked, and on account of the swelling this dislocation is apt to beoverlooked. In addition to the ordinary symptoms, the shoulder isbroadened, there is a marked hollow in front in which the coracoidprojects, and the arm is held close to the side with the elbowdirected forward. The head of the bone may be seen and felt in itsabnormal position below the spine of the scapula. Reduction can usually be effected by making traction on the arm withmedial rotation, and pressing the head forward into position, whilecounter-pressure is made upon the acromion. _Prognosis. _--The ultimate prognosis in dislocations of the shouldershould always be guarded. The axillary nerve may be stretched or torn, and this may lead to atrophy of the deltoid; or other branches of thebrachial plexus may be injured and the muscles they supply permanentlyweakened. In a certain number of cases traumatic neuritis has resultedin serious disability of the limb. The movements of the shoulder-jointmay be restricted by cicatricial contraction of the torn portion ofthe capsule and of the damaged muscles. A marked tendency to recurrentdislocation may follow if abduction movements are permitted beforerepair of the capsule has had time to occur. #Dislocation of the Shoulder complicated with Fracture of the UpperEnd of the Humerus. #--In these injuries the dislocation is almostalways of the sub-coracoid variety, and the most common fractures bywhich it is complicated are those of the surgical neck, the anatomicalneck, or the greater tuberosity. The most common cause is a falldirectly on the shoulder, and it seems probable that the head of thebone is first dislocated, and, the force continuing to act, the upperend of the humerus is then broken; or the two lesions may be producedsynchronously. When seen soon after the accident, the existence of the fracture ofthe humerus is liable to be overlooked, the condition being mistakenfor dislocation alone, or for a fracture through the neck of thescapula. On careful examination under an anæsthetic, however, it isobserved that not only is the head of the humerus absent from theglenoid 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 isusually greater than that accompanying a simple dislocation, and thepain and shock are more severe. A fracture through the neck of thescapula alone is readily recognised by the ease with which thedeformity is reduced, and the way in which it at once recurs when thesupport is withdrawn. In many cases it is only by the aid of aradiogram that an accurate diagnosis can be made (Fig. 25). [Illustration: FIG. 25. --Dislocation of Shoulder with Fracture of Neckof Humerus. (Sir Robert Jones' case. Radiogram by Dr. D. Morgan. )] _Treatment. _--Unless the dislocation is reduced at once, the movementsof the arm are certain to be seriously restricted, and painfulpressure effects from excess of callus are liable to ensue. An attemptshould first be made, under anæsthesia, to replace the head in itssocket, by making extension on the arm in the hyper-abducted(vertical) position, and manipulating the upper fragment from theaxilla. On no account should the lower fragment be employed as a lever inattempting reduction. When reduction by manipulation fails, recourseshould be had to an open operation. The upper fragment should beexposed by an incision over its lateral aspect, and made to return tothe socket by using Arbuthnot Lane's levers or M'Burney's hook, or along steel pin may be inserted into the fragment to give the necessaryleverage. Reduction having been accomplished, the fracture is adjusted in theusual way, advantage being taken of the open wound, if necessary, tofix the fragments together by plates. The best position in which tofix the limb is that of abduction at a right angle. Massage andmovement should be commenced early to prevent stiffness of the joint. When it is found impossible to reduce the dislocation, it is usuallyadvisable to remove the upper fragment. The method of allowing the fracture to unite without reducing thedislocation, and then attempting reduction, usually results inre-breaking the bone, or else in failure to replace the head in thesocket, and has nothing to recommend it. #Old-standing Dislocation of the Shoulder. #--It is impossible to laydown definite rules as to the date after which it is inadvisable toattempt reduction by manipulation of an old-standing dislocation ofthe shoulder. Experience of a hundred cases in Bruns' clinic ledFinckh 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; butthat beyond that time reduction is exceptional. The patient is anæsthetised, and all adhesions broken down by free yetgentle movement of the limb. The appropriate manipulations for theparticular dislocation are then carried out, care being taken that noundue force is employed, as the humerus is liable to be broken. Ifthese are not successful, they should be repeated at intervals of twoor three days, as it is frequently found that reduction issuccessfully effected on a second or third attempt. Should manipulative measures fail, it may be advisable to haverecourse to operation if the age of the patient and his general healthwarrant it, and if the condition of the limb is interfering with hisoccupation or involves serious disability. If operation is deemedadvisable, a few days should be allowed to elapse to permit of theparts recovering from the effects of the manipulations. The joint isfreely exposed, the capsule divided, the head of the bone freed andreturned to the glenoid cavity. It is sometimes so difficult toreplace the head of the bone that it is necessary to resect it and aimat the formation of a new joint, an operation which usually yieldssatisfactory results. #Habitual or Recurrent Dislocation. #--Cases are occasionally met within which the shoulder-joint shows a marked tendency to be dislocatedfrom causes altogether insufficient to produce displacement underordinary circumstances. This condition is usually met with in youngwomen, and, in some cases at least, appears to be due to too early andtoo free movement of the joint after an ordinary dislocation, so thatthe capsule is stretched and remains lax. In some cases it wouldappear that the liability to dislocation is due to some structuraldefect in the joint, and under these conditions both sides aresometimes affected, and the accident is not attended with the usualpain and disability either at the time or after reduction. Thefacility and frequency with which dislocation recurs render the limbcomparatively useless, and may seriously incapacitate the patient. Wehave had cases under observation in which dislocation resulted fromthe hyper-abduction of the arm in swimming, from throwing the armsabove the head in dancing and in gymnastic exercises, and even in"doing" the hair. The _treatment_ consists in preventing the patient making theparticular movements which tend to produce the dislocation. These arechiefly movements of hyper-abduction and overhead movements; we havefound an apparatus consisting of a belt applied around the thorax, andfixed to another around the upper arm by a band which passes above theaxillary fold of the dress, useful in restraining these movements. Ifthese measures fail, it may be advisable to have recourse tooperation; this may consist in tightening up the capsule, the resultsof which are said to be uncertain, or in detaching a portion of thedeltoid or subscapularis muscle and stitching it beneath the joint tocover and strengthen the weakened portion of the capsule. It issuggestive that in performing this operation no rent in the capsule isdiscovered. The condition is also met with in epileptics; and it is generallyfound that the head of the bone is deficient, as a result either offracture or disease; that the muscles which naturally support thejoint are atrophied or torn; and that the capsule is unduly lax. #Sprain# of the shoulder-joint is comparatively rare, because of thewide range of movement of which it is capable. The region of theshoulder becomes swollen and tender to pressure, the point of maximumtenderness being over the front of the joint, just below the acromionprocess; pain is elicited also when the ligaments or tendons are putupon the stretch. #Contusion# of the region of the shoulder, on the other hand, isexceedingly common. In most cases it is merely the deltoid muscle andthe subcutaneous tissue over it that are bruised, but sometimes ahæmatoma forms either in the muscle or in the sub-deltoid bursa. Thereis pain on moving the limb, and the patient may be unable to abductthe arm at the shoulder-joint. Under treatment by massage andmovement, the symptoms usually pass off completely in two or threeweeks. The affections of the _bursa_ are described elsewhere. In other cases, the cords of the brachial plexus above the clavicleare stretched, or the axillary nerve is bruised, and these injuriesare liable to be followed by prolonged pain, loss of abduction, andstiffness in the arm. The deltoid frequently undergoes considerableatrophy, and there is severe neuralgic pain in the axillary nerve, especially marked in the region of the insertion of the deltoid. In addition to maintaining the limb in the abducted position, it isnecessary to keep up the nutrition of the muscles by massage andelectricity. FRACTURE OF THE SCAPULA Fractures of the scapula may implicate the body, the surgical neck, the acromion, or the coracoid process. They are rarely compound. #Fracture of the Body. #--Considering its exposed position, the body ofthe scapula is comparatively seldom fractured, doubtless because ofits mobility, and the support it receives from the elastic ribs andsoft muscular cushions on which it lies. Apart from gun-shot injuries, it is most frequently broken by a severe blow or crush. The scapulapresents two natural arches--one longitudinal, the othertransverse--and when the bone is crushed or struck, the force producesfracture by undoing its curves (E. H. Bennett). A main fissure usuallyruns transversely across the infra-spinous fossa, and secondary cracksradiate from it (Fig. 26). In other cases the line of the primaryfracture is longitudinal, passing through the spine and involving bothfossæ. [Illustration: FIG. 26. --Transverse Fracture of Scapula, with fissuresradiating into spinous process and dorsum. ] The _clinical features_ are obscured by swelling of the overlying softparts. Crepitus may sometimes be elicited by placing one hand firmlyover the bone, and with the other moving the arm and shoulder. Whenthe spine is implicated, the fragments may be grasped and made to moveone upon another. The displacement, which usually consists inoverlapping of the fragments--although sometimes they are drawnapart--is partly due to the action of the serratus anterior and teresmajor muscles, and partly depends on the direction of the force. Movement is restricted and painful. Osseous union usually takes placerapidly, and although displacement often persists, the function of thelimb is unimpaired. _Treatment. _--As these fractures are usually complicated by otherinjuries, especially of the thorax, and are accompanied by severeshock, it is necessary to confine the patient to bed. It is usuallysufficient to fix the arm and shoulder to the chest wall by a firmbinder, in the position which admits of the most complete appositionof fragments. This retentive apparatus is employed for about threeweeks, after which the patient is allowed to use his arm. The bandagesare removed daily to admit of massage. #Fracture of the surgical neck of the scapula#, although a rareaccident, is of importance, as it is liable to be mistaken fordislocation of the shoulder. The line of fracture runs through thescapular notch, downwards and laterally to the lower margin of theglenoid, so that the glenoid and the coracoid process are separatedfrom the rest of the bone. The coraco-acromial and coraco-clavicular ligaments are usually torn, and the detached fragment, along with the head of the humerus, sinksinto the axilla, causing a flattening of the shoulder, and leaving adepression below the projecting acromion. These signs may be obscuredby the general swelling of the shoulder. The arm may be lengthenedabout an inch. By supporting the arm the deformity is at once reduced, but recurs as soon as the support is withdrawn. Crepitus is usuallydetected on carrying out this manipulation; and the coracoid processis found to move with the arm and not with the scapula. By thesetests, and by the X-rays, this injury is distinguished from adislocation. A partial fracture carrying away the lower part of the _glenoidcavity_ simulates a sub-glenoid dislocation. This is, however, a rareinjury. The _treatment_ consists in bracing back the shoulders and supportingthe elbow, and this is most satisfactorily done by a body bandage andsling for the elbow, as for fracture of the middle third of theclavicle. Passive movements and massage are employed from the first. #Fracture of the acromion process# may result from a blow or fall onthe shoulder. It is often overlooked on account of the swellingresulting from bruising of the soft parts, and the absence of markeddisplacement. On palpation, crepitus and an irregularity at the seatof fracture may sometimes be detected. The shoulder is slightlyflattened, and abduction of the arm is difficult. In rare cases thefracture passes into the acromio-clavicular joint, and is associatedwith dislocation of the clavicle. In connection with this fracture, reference must be made to acondition frequently met with, in which the epiphysial portionof the acromion is found to be separate from the body of theprocess--_separate acromion_. This is by some (Symington, Hamilton)looked upon as a want of union of the epiphysis, but the weight ofevidence seems to prove that it is rather of the nature of anun-united fracture at this level, even when, as sometimes happens, itis bilateral (Struthers, Arbuthnot Lane). Between the fourteenth and twenty-second years a true _separation ofthe epiphysis_ may be met with, but it is seldom possible to make apositive diagnosis of this injury. As is the case in all fractures ofthe acromion, bony union seldom takes place. The _treatment_ is the same as for fracture of the lateral end of theclavicle. #Fracture of the coracoid process# is rare. It may result from directviolence, such as the recoil of a gun, but it is more often anaccompaniment of dislocation of the shoulder or of the lateral end ofthe clavicle upward. As the coraco-clavicular ligaments usually remainintact, there is no displacement; but when these are torn the coracoidis dragged downwards and laterally by the combined action of thepectoralis minor, biceps, and coraco-brachialis muscles. Crepitus maybe elicited on moving the fragment. _Separation of the epiphysialportion_ of the coracoid may occur up to the seventeenth year. The _treatment_ consists in placing the arm across the front of thechest, to relax the muscles causing the displacement, and retaining itin that position by a sling and roller bandage. FRACTURE OF THE UPPER END OF THE HUMERUS It is most convenient to study fractures of the upper end of thehumerus in the following order: (1) fracture of the surgical neck; (2)separation of the epiphysis; (3) fracture of head, anatomical neck, ortuberosities. [Illustration: FIG. 27. --Fracture of Surgical Neck of Humerus, unitedwith Angular Displacement. ] #Fracture of the Surgical Neck. #--The surgical neck of the humerusextends from the level of the epiphysial junction to the insertion ofthe pectoralis major and teres major muscles, and it is within theselimits that most fractures of the upper end of bone occur. Thisfracture is most common in adults, and usually follows direct violenceapplied to the shoulder, but may result from a fall on the hand orelbow, or from violent muscular action, as, for example, in throwing astone. It is usually transverse, and there is often little or nodisplacement, the fragments being retained in position by the longtendon of the biceps and the long head of the triceps. When thefracture is oblique, the fragments are often comminuted, and sometimesimpacted. The displacement of the upper fragment seems to depend uponthe attitude of the limb at the moment of fracture. When the upper armis approximated to the side, the upper fragment retains its verticalposition, but is slightly rotated laterally by the muscles insertedinto the greater tuberosity, while the lower fragment is drawn upwardsand medially towards the coracoid process by the muscles inserted intothe inter-tubercular groove and the longitudinal muscles of the upperarm, and can be felt in the axilla. The elbow points laterally andbackwards, and the upper arm is shortened. The shoulder retains itsrotundity, but there is a slight hollow some distance below theacromion. On grasping the elbow and moving the shaft, it is found thatthe head and tuberosities do not move with it, and unnatural mobilityand crepitus at the seat of fracture may be detected. When the upperarm is abducted at the moment of fracture, the upper fragment isretained in that position by the lateral rotator and abductor musclesinserted into it, while the lower fragment passes upwards andmedially. [Illustration: FIG. 28. --Impacted Fracture of Neck of Humerus, in manæt. 75. (Sir H. J. Stiles' case. Radiogram by Dr. Edmund Price. )] Although there is sometimes overlapping and broadening after union, beyond some limitation of the range of abduction the usefulness of thelimb is seldom impaired. _Treatment. _--Massage, by allaying spasm of the muscles, soonovercomes the moderate amount of displacement which is usually metwith. Further, the skin surfaces of the axilla having been separatedby a thin layer of cotton wool, a sling is applied to support thewrist, and the arm is bound to the side by a body bandage. In comminuted fractures and those with marked displacement, a generalanæsthetic may be required to ensure accurate reduction; and tomaintain the fragments in apposition, and to avoid any limitation ofabduction after union, the limb may be fixed in the position ofabduction at a right angle by means of a Thomas' arm splint withswivel ring, and extension applied, if necessary, to maintain thisattitude. After a week or ten days the patient is allowed up, wearingan abduction frame (Fig. 29), or a splint, such as Middeldorpf's, which consists of a double inclined plane, the base of which is fixedto the patient's side, while the injured arm rests on the other twosides of the triangle. Massage and movement are employed daily. [Illustration: FIG. 29. --Ambulatory Abduction Splint for Fracture ofHumerus. ] Should these measures fail, the fracture may be exposed by an incisioncarried along the anterior border of the deltoid, and the endsmechanically fixed, after which the limb is put up in the abductedposition for three or four weeks. Massage is commenced on the secondor third day. Union is usually complete in about four weeks. #Separation of Epiphysis. #--The upper epiphysis of the humerusincludes the head, both tuberosities, and the upper fourth of theinter-tubercular groove. On its under aspect is a cup-like depressioninto which the central pyramidal-shaped portion of the diaphysis fits. This epiphysis unites about the twenty-first year. [Illustration: FIG. 30. --Radiogram of Separation of Upper Epiphysis ofHumerus. ] Traumatic separation is met with chiefly between the fifth andfifteenth years, and is most common in boys. It usually results fromforcible traction of the arm upwards and away from the side, as inlifting a child by the upper arm, or from direct violence, but may becaused by a fall on the lateral side of the elbow. The epiphysis, especially in young children, may be separated withoutbeing displaced, or the displacement may be incomplete. When the epiphysis is completely separated from the shaft, theclinical features closely resemble those of fracture of the surgicalneck, and the diagnosis is made by a consideration of the age of thepatient, and the muffled character of the crepitus, when it can beelicited. The upper end of the diaphysis forms a projecting ridgewhich may be felt below and in front of the acromion. The diagnosiscan usually be established by the use of the X-rays (Fig. 30). Dislocation is rare at the age when separation of the epiphysisoccurs. Reduction is often difficult on account of the periosteum and othersoft tissues getting between the fragments, and on account of thesmall size of the upper fragment. Union almost invariably results, butthe growth of the limb may be interfered with and its shape altered, especially when the injury occurs at an early age and its nature isoverlooked. _Treatment. _--This injury is treated on the same general lines asfracture of the surgical neck. General anæsthesia is almost alwaysnecessary to secure satisfactory reduction, and retention is mosteasily secured if the patient is confined to bed with the upper armfixed in the fully abducted position. Operative treatment is calledfor in exceptional cases. #Fractures of the Head, Anatomical Neck, and Tuberosities ofHumerus. #--These fractures are met with as accompaniments ofdislocation of the shoulder, and as results of gun-shot injuries, blows, or falls. In sub-coracoid dislocation the _head_ of the humerus may be indentedby coming in contact with the anterior edge of the glenoid cavity (F. M. Caird). The _anatomical neck_ may be fractured in an old person by a directblow on the shoulder. In a few cases the fracture is entirelyintra-capsular, the head of the bone remaining loose in the cavity ofthe joint. As a rule, however, the fracture passes laterally andimplicates the tuberosities. In some cases there is impaction, and inothers comminution of the fragments. The use of the X-rays has shownthat in many cases in which prolonged stiffness has followed a severeblow of the shoulder, there has been a fracture of the anatomicalneck. The _tuberosities_ may be implicated in other fractures in this regionand in dislocation of the shoulder; and either of them may beseparated by muscular contraction or by direct violence. _Clinically_ all these injuries are difficult to diagnose withaccuracy, and, without the use of the X-rays, it is impossible in manycases to go further than to say that a fracture exists above the levelof the surgical neck. Fracture of the anatomical neck is attended withlittle deformity beyond slight flattening of the shoulder andsometimes slight shortening of the upper arm. When the _great tuberosity_ is torn off, considerable antero-posteriorbroadening of the shoulder may be recognised by grasping the region ofthe tuberosities between the fingers and thumb. Crepitus can beelicited on rotating the humerus. At the same time it will berecognised that the tuberosity does not move with the shaft. Firmunion, with considerable formation of callus and some broadening ofthe shoulder, usually results, but the usefulness of the joint is notnecessarily impaired. There may, however, be prolonged stiffness andimpaired movement from adhesion; or pain and crackling in the jointmay result from arthritic changes like those of arthritis deformans. _Treatment. _--These fractures are treated on the same lines asfracture of the surgical neck of the humerus. The combination of fracture of the upper end of the humerus withdislocation of the shoulder has already been referred to. FRACTURE OF THE SHAFT OF THE HUMERUS Fractures occurring in the shaft of the humerus between the surgicalneck and the base of the condyles may, for convenience of description, be divided into those above, and those below, the level of the deltoidinsertion--the majority being in the latter situation. Direct violence is the most common cause of these fractures, but theymay occur from a fall on the elbow or hand; and a considerable numberof cases are on record where the bone has been broken by muscularaction--as in throwing a cricket-ball. Twisting forms of violence mayproduce spiral fractures. The fracture is usually transverse in children and in cases in whichit is due to muscular action. In adults, when due to externalviolence, it is usually oblique, the fragments overriding one anotherand causing shortening of the limb. The displacement depends largelyon the direction of the force and the line of fracture, but to acertain extent also on the action of muscles attached to thefragments. Thus, in fractures above the insertion of the deltoid theupper fragment is usually dragged towards the middle line by themuscles inserted into the inter-tubercular groove, while the lower istilted laterally by the deltoid. When the break is below the deltoidinsertion the displacement of the fragments is reversed. The signs offracture--undue mobility, deformity, shortening, and crepitus--are atonce evident, and the patient himself usually recognises that the boneis broken. The nerve-trunks in the arm--the median, ulnar, and radial(musculo-spiral)--are apt to be damaged in these injuries; infractures of the lower part of the shaft the radial nerve is speciallyliable to be implicated. This may occur at the time of the injury, thenerve being contused by the force causing the fracture, or pressedupon by one or other of the fragments, or its fibres may be partly orcompletely torn across. When there is evidence of nerve injury, thepractitioner should draw the attention of the patient to it then andthere, and so guard himself against actions for malpraxis shouldparalysis of the muscles ensue. Later, the nerve may become involvedin callus, or be damaged by the pressure of ill-fitting splints. Weakness or paralysis of the extensors of the wrist and hand results, giving rise to the characteristic "wrist-drop. " The actions of themuscles should always be tested before applying splints, and each timethe apparatus is removed or readjusted, to assure that no unduepressure is being exerted on the nerves. Union takes place in from four to six weeks in adults, and in fromthree to four weeks in children. Delayed union, or want of union andthe formation of a false joint, is more common in fractures of themiddle of the shaft of the humerus than in any other long bone--apoint to be borne in mind in treatment. Arrest of growth in the bonefrom injury to the nutrient artery is also said to have occurred. _Treatment. _--To restore the alignment of the bone, extension is madeon the lower fragment and the ends are manipulated into position. Thismay necessitate the use of a general anæsthetic, and care must betaken that no soft tissue intervenes between the fragments, as isevidenced radiographically by the persistence of a clear space betweenthe ends even when they appear to be in apposition. In _transverse_ fractures the position may be maintained by a simpleferrule of poroplastic or Gooch-splinting. The elbow is flexed at aright angle, and the forearm supported in a sling midway betweenpronation and supination. For a few days the limb may be bound to thechest by a broad roller bandage. [Illustration: FIG. 31. --"Cock-up" Splint, for maintainingDorsiflexion at Wrist. ] The splints are removed daily to admit of massage and movement beingcarried out, and while the splints are off, the patient is allowed toexercise the fingers and wrist. If at the end of four or five weeks, osseous union has not occurred, the reparative process may be hastenedby inducing venous congestion by Bier's method. In _oblique and spiral_ fractures it is often necessary to control theshoulder and elbow-joints to prevent re-displacement. This can be doneby means of a plaster of Paris case enclosing the upper part of thethorax, together with the upper arm, abducted, and the elbow, at rightangles. [Illustration: FIG. 32. --Gooch Splints for Fracture of Shaft ofHumerus; and Rectangular Splint to secure Elbow. ] It is sometimes necessary to apply continuous extension to the lowerfragment to prevent overriding. For this purpose a Thomas' arm splintis employed, the extension tapes being attached to its lower end, butcare must be taken that the traction is not sufficient to separatethe fragments and leave a gap between them. The elbow should not beretained in the extended position for more than three weeks. In rare cases it is necessary to have recourse to operative treatment. When there is evidence that the radial nerve has been injured, and nosign of improvement appears within three or four days of the accident, operative interference is indicated. An incision is made on thelateral side of the arm, and the nerve exposed and freed frompressure, or stitched, as may be necessary; the opportunity shouldalso be taken of dealing with the fracture. The limb is put up in a"cock-up" splint, with the hand in the attitude of marked dorsiflexion(Fig. 31). Satisfactory results have been obtained without the use of splints, byrelying upon massage to overcome the spasm of muscles, and allowingthe weight of the arm to act as an extending force (J. W. Dowden andA. Pirie Watson). In cases of _un-united fracture_, a vertical or semilunar incision ismade over the lateral aspect of the bone, and the muscles separatedfrom one another till the fracture is exposed, care being taken toavoid injuring the radial nerve. The fibrous tissue is removed fromthe ends of the bone, and the rawed surfaces fixed in apposition; thewound is then closed, and appropriate retentive apparatus applied. Assoon as the wound has healed, massage and movement are employed. CHAPTER IV INJURIES IN THE REGION OF THE ELBOW AND FOREARM Surgical Anatomy--Examination of injured elbow--FRACTURE OF LOWER END OF HUMERUS: _Supra-condylar_; _Inter-condylar_; _Separation of epiphysis_; _Fracture of either condyle alone_; _Fracture of either epicondyle alone_--FRACTURE OF UPPER END OF ULNA: _Olecranon_; _Coronoid_--FRACTURE OF UPPER END OF RADIUS: _Head_; _Neck_; _Separation of epiphysis_--DISLOCATION OF ELBOW: _Both bones_; _Ulna alone_; _Radius alone_--FRACTURE OF FOREARM: _Both bones_; _Radius alone_; _Ulna alone_. The injuries met with in the region of the elbow-joint include thevarious fractures of the lower end of the humerus, and upper ends ofthe bones of the forearm, including the olecranon; and dislocationsand sprains of the elbow-joint. The differential diagnosis is oftenexceedingly difficult on account of the swelling and tension whichrapidly supervene on most of these injuries, the pain caused bymanipulating the parts, and the difficulty of determining whethermovement is taking place _at_ the joint or _near_ it. #Surgical Anatomy. #--The medial epicondyle of the humerus is morereadily felt through the skin than the lateral. The two epicondylesare practically on the same level, and a line joining them behindpasses just above the tip of the olecranon when the arm is fullyextended. On flexing the joint, the tip of the olecranon graduallypasses to the distal side of this line, and when the joint is fullyflexed the tip of the olecranon is found to have passed through half acircle. The head of the radius can be felt to rotate in the dimple onthe back of the elbow just below the lateral epicondyle. The coronoidprocess may be detected on making deep pressure in the hollow in frontof the joint. As the line of the radio-humeral joint is horizontal, while that of the ulno-humeral joint slopes obliquely downwards, thearm forms with the fully extended and supinated forearm an obtuseangle, opening laterally--the "carrying angle. " This angle is usuallymore marked in women, in harmony with the greater width of the femalepelvis. The ulnar nerve lies in the hollow between the olecranon andthe medial condyle, and the median nerve passes over the front of thejoint, with the brachial artery and biceps tendon to its lateral side. The radial nerve divides into its superficial and deep (posteriorinterosseous) branches at the level of the lateral condyle. In _examining an injured elbow_, the thumb and middle finger areplaced respectively on the two epicondyles, while the index locatesthe olecranon and traces its movements on flexion and extension of thejoint. The movements of the head of the radius are best detected bypressing the thumb of one hand into the depression below the lateralepicondyle, while movements of pronation and supination are carriedout by the other hand. The uninjured limb should always be examinedfor purposes of comparison. In injuries about the elbow much aid in diagnosis is usually obtainedby the use of the X-rays; but in young children it is sometimesimpossible, even with excellent pictures, to make an accuratediagnosis by means of radiograms alone. In cases of suspectedfracture, a radiogram should be taken with the back of the limbresting on the plate, the forearm being extended and supinated. If adislocation is suspected and a lateral view is desired, the arm shouldbe placed on its medial side. In obscure cases it is useful to takeradiograms of the healthy limb in the same position. FRACTURES OF THE LOWER END OF THE HUMERUS The following fractures occur at the lower end of the humerus: (1)supra-condylar fracture; (2) inter-condylar fracture; (3) separationof epiphyses; (4) fracture of either condyle alone; and (5) fractureof either epicondyle alone. All these injuries are common in children, and result from a directfall or blow upon the elbow, or from a fall on the outstretched hand, especially when at the same time the joints are forcibly moved beyondtheir physiological limits, more particularly in the direction ofpronation or abduction. While it is generally easy to diagnose theexistence of a fracture, it is often exceedingly difficult todetermine its exact nature. Although the ulnar and median nerves areliable to be injured in almost any of these fractures, they suffermuch less frequently than might be expected. Ankylosis, or, more frequently, locking of the joint, is a commonsequel to many of these injuries. This is explained by the difficultyof effecting complete reduction, and by the wide separation ofperiosteum which often occurs, favouring the production of anexcessive amount of new bone, particularly in young subjects. The #supra-condylar# fracture usually results from a fall on theoutstretched hand with the forearm partly flexed, from a direct blow, or from a twisting form of violence. The line of fracture is generallytransverse, or but slightly oblique from behind downwards andforwards, so that the lower fragment is forced backward together withthe bones of the forearm, simulating backward dislocation of theelbow; the lower end of the upper fragment lies in front (Fig. 33). [Illustration: FIG. 33. --Radiogram of Supra-condylar Fracture ofHumerus, in a child æt. 7. ] _Clinical Features. _--The elbow is flexed at an angle of 120° or 130°, and the forearm, held semi-pronated, is supported by the other hand. Around the seat of fracture great swelling rapidly ensues. Theolecranon projects behind, but the mutual relations of the bony pointsof the elbow are unaltered. The lower end of the upper fragment may befelt in front above the level of the joint, as a rough and sharpprojection, and this sometimes pierces the soft parts and renders thefracture compound. Movement at the joint is possible, but unnaturalmobility may be detected above the level of the joint. Crepitus andlocalised tenderness may be elicited. The displacement is readilyreduced by manipulation, but usually returns when the support iswithdrawn. The arm is shortened to the extent of about half an inch. In rare cases the obliquity of the fracture is downward and backward, and the lower fragment is displaced forward. The #inter-condylar# fracture is a combination of the supra-condylarwith a vertical split running through the articular surface, and soimplicating the joint. The condyles are thus separated from oneanother, as well as from the shaft, by a T- or Y-shaped cleft. As suchfractures usually result from severe forms of direct violence, theyare often comminuted and compound. In addition to the signs ofsupra-condylar fracture, the joint is filled with blood. The condylesmay be felt to move upon one another, and coarse crepitus, which hasbeen likened to the feeling of a bag of beans, may be elicited if thefragments are comminuted. [Illustration: FIG. 34. --Radiogram of T-shaped Fracture of Lower Endof Humerus. ] #Separation of the lower epiphysis# of the humerus is met with inchildren of three or four years of age, but it may occur up to thethirteenth or fourteenth year. The more common lesion, however, is acombination of separated epiphysis with fracture, and this lesion isproduced by the same forms of violence as cause supra-condylarfracture. If the periosteum is not torn, there is little or nodisplacement, but as a rule the clinical features closely resemblethose of transverse fracture above the condyles, or of dislocation ofthe elbow. In separation of the epiphysis there is a peculiardeformity of the posterior aspect of the joint, consisting of twoprojections--one the olecranon, and the other the prominent capitellumwith a scale of cartilage which it carries with it from the lateralcondyle (R. W. Smith and E. H. Bennett). The end of the diaphysis maybe palpated through the skin in front. Muffled crepitus can usually beelicited, and there is pain on pressing the segments against oneanother. Sometimes the separation is _compound_, the diaphysisprotruding through the skin. Union takes place more rapidly than in fracture, but, owing to theexcessive formation of callus from the torn periosteum in front of thejoint, full flexion is often interfered with. If the displacedepiphysis is imperfectly reduced, serious interference with themovements of the elbow is liable to ensue, and may call for operativetreatment. #Fracture of either Condyle alone. #--The lateral condyle or trochleais more frequently separated from the rest of the bone than is themedial or capitellum. In either, the size of the fragment varies, butthe line of fracture is partly extra-capsular and partlyintra-capsular, so that the joint is always involved. Pain, crepitus, and the other signs of fracture are present. As the ligaments of thejoint are not as a rule torn, there is little or no immediatedisplacement of the fragment. Secondary displacement is liable tooccur, however, during the process of union, producing alterations inthe "carrying angle" of the limb--_cubitus varus_ or _cubitus valgus_. #Fracture of Epicondyles. #--Fracture of the _lateral epicondyle_ aloneis so rare that it need only be mentioned. The _medial epicondyle_ may be chipped off by a fall on the edge of atable or kerbstone, or it may be forcibly avulsed by traction throughthe ulnar collateral (internal lateral) ligament, as an accompanimentof dislocation. It is usually displaced downwards and forwards by theflexor muscles attached to it, and may thus come to exert pressure onthe ulnar nerve. The fragment may be grasped and made to move on theshaft, producing crepitus. Fibrous union is the usual result. Up to the age of seventeen or eighteen the epiphysis of the epicondylemay be separated. #Treatment of Fractures in Region of Elbow. #--The administration of ageneral anæsthetic is a valuable aid to accurate reduction andfixation of fractures in this region. Much discussion has taken placeas to the best position in which to treat these fractures. In ourexperience the best approximation of the fragments, as shown by theX-rays, is obtained when the limb is fixed in the position of fullflexion with supination. American surgeons favour the position offlexion at a right angle. In the region of the elbow there is a riskof promoting too much callus formation by early and vigorous massage, with the result that the movements of the joint are restricted bylocking of the bony projections. This is probably due to bone cellsbeing forced into the surrounding tissues, where they multiply andform new bone on an exaggerated scale. The _supra-condylar fracture_ is reduced by first extending the elbowto free the lower fragment from the triceps, and then, while makingtraction through the forearm, manipulating the fragments intoposition, and finally flexing the elbow to an acute angle andsupinating the forearm. In this way the triceps is put upon thestretch and forms a natural posterior splint. A layer of wadding isplaced 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, andfixed to the side by a body bandage. This position is maintained forthree weeks, with daily massage and movement. The last movement to beattempted is that of complete extension. Operative treatment is rarelycalled for. _Separation of the epiphysis_ and _fracture of the medial epicondyle_are treated on the same lines as supra-condylar fracture. _T- or Y-shaped fractures_ and _fractures of the condyles_, inasmuchas they implicate the articular surfaces, present greater difficultiesin treatment, but they are treated on the same lines as thesupra-condylar. In young subjects whose occupation entails freemovement of the elbow-joint, it is sometimes advisable to expose thefracture by operation and secure the fragments in position. Thedetails of the operation vary in different cases, and depend upon theline of obliquity of the fracture, and the disposition of theindividual fragments, points which may usually be determined by theuse of the X-rays. In performing the operation, care must be taken todisturb the periosteum as little as possible, otherwise there mayfollow excessive formation of new bone. Operative interference is sometimes necessary for ankylosis or lockingof the joint after the fracture is united, or to relieve the ulnarnerve when it is involved in callus. _Volkmann's ischæmic contracture_is liable to occur after fractures in the region of the elbow fromimpairment of the blood supply as a result of tight bandaging. FRACTURE OF THE UPPER END OF THE ULNA #Fracture of the olecranon# is a comparatively common injury inadults. It usually follows a fall on the flexed elbow, and resultsfrom the direct impact, supplemented by the traction of the tricepsmuscle. In a few cases it has been produced by muscular action alone. The line of fracture may pass through the tip of the process, orthrough its middle, less frequently through the base. It may betransverse, oblique, T- or V-shaped, but is rarely comminuted orcompound. _Clinical Features. _--As the fracture almost invariably implicates thearticular surface, there is considerable swelling from effusion ofblood into the joint. The power of extending the forearm is impaired, and other symptoms of fracture are present. The amount of displacementdepends upon the level of the fracture, and the extent to which theaponeurotic expansion of the triceps is torn. As the fracture isusually near the tip, the displacement is comparatively slight, theprolongation of the fibres of insertion of the triceps on to the sidesand posterior part of the process holding the small fragment inposition; and the fracture may easily escape recognition. When theline of fracture is nearer the base, however, the contraction of thetriceps tends to separate the fragments widely (Fig. 35), and adistinct gap, which is increased on flexing the elbow, may often befelt between them, and if the elbow is passively extended, thefragments may be brought into apposition, and crepitus elicited. [Illustration: FIG. 35. --Radiogram of Fracture of Olecranon Process, showing marked degree of displacement. (Sir Robert Jones' case. Radiogram by Dr. D. Morgan. )] When there is little displacement, bony union may result, but in manycases the fragments are united only by fibrous tissue. The upperfragment sometimes forms attachments to the shaft of the humerus, andthis leads to stretching of the fibrous band between the fragments andto marked wasting of the triceps. Separation of the olecranon _epiphysis_ is one of the rarest forms ofepiphysial detachment (Poland). When the epiphysis is displacedupwards and unites in this position, it may interfere with completeextension of the elbow. _Treatment. _--It would appear that too much stress has hitherto beenlaid on the necessity of bringing the fragments into perfectapposition, and too little attention paid to the importance ofmaintaining the functions of the triceps and the movements of theelbow-joint. Massage and movements are carried out from the first, and the forearmis supported in a sling. Full flexion is the last movement to beattempted. In carrying out the movements, the tip of the olecranon ispressed down with the thumb, so that it is obliged to follow themovements of the ulna, and is prevented from adhering to the humerus. It was formerly the practice to have the arm almost, but not quite, fully extended, and a Gooch splint, extending from the lower border ofthe axilla to the finger-tips, and cut to the shape of the extendedlimb, applied anteriorly and fixed in position by a bandage, theregion of the elbow being covered by a convergent spica. _Operative Treatment. _--Operative treatment may be had recourse to, particularly in cases in which there is wide separation of thefragments. The fracture is exposed, the joint cavity opened up andcleared of clots, and silver-wire sutures passed through the fragmentswithout encroaching upon the articular cartilage. The limb is fixedwith the elbow-joint in the position of almost complete extension. Movement may be commenced at the end of a week, the angle at which thejoint is fixed being changed morning and evening. During the day theflexed position should be maintained and the arm carried in a sling;during the night the limb is fixed to a pillow in the extendedposition. The patient is allowed to use the joint cautiously within afortnight. _Old-standing Fracture. _--When union fails to take place, the intervalbetween the fragments tends to increase by the contraction of thetriceps gradually stretching the intermediate fibrous tissue, so thata wide gap comes to separate the fragments. It is quite common thatthe function of the arm is all that can be desired in spite of a gapbetween the fragments, but, if this is not the case, the fragments maybe united by operation. #Fracture of the coronoid process# is rare except as a complication ofbackward dislocation of the elbow. It may be produced by directviolence, as well as by muscular action. As the fracture is usuallywithin a quarter of an inch of the tip, the fibres of insertion of thebrachialis prevent displacement. The ordinary evidence of fracture isoften absent, and the diagnosis is seldom completed without the aid ofthe X-rays. The treatment consists in flexing the elbow and supportingthe forearm in a sling. In some cases associated with dislocation, however, the small fragment has been so far displaced as to becomeattached to the back of the humerus (Annandale). FRACTURE OF THE UPPER END OF THE RADIUS Intra-capsular fracture of the #head of the radius# may result fromdirect violence, from a fall on the pronated hand, or from forciblepronation or abduction--that is, deviation of the forearm to theradial side. It may accompany dislocation of the elbow or fracture ofadjacent bones. The head may be completely separated, or may be splitinto two or more fragments. Up to the seventeenth year, the_epiphysis_, which is entirely intra-articular, may be separated. The _clinical features_ are localised pain, crepitus, interferencewith pronation and supination, while the elbow can be almost fullyextended and flexed, and in some cases the fragment may be feltthrough the skin, although it usually continues to move with the shaftin pronation and supination. Union generally takes place satisfactorily, but in some cases thefragments form new attachments resulting in impaired movement at theelbow, and necessitating operative interference. Fracture of the #neck of the radius# between the capsule and thetubercle is rare. #Avulsion of the tubercle# may occur from forcible contraction of thebiceps, or, in children, from traction made on the forearm (A. L. Hall). These injuries are treated with the elbow in the flexed position, andmassage and movement are carried out as already described. DISLOCATION OF THE ELBOW Dislocations of the elbow-joint may involve one or both bones of theforearm, and may be complete or incomplete. #Dislocation of both bones backward# is the most common of alldislocations of the elbow, and is the only dislocation that isfrequently met with in children. It usually results from a fall on theoutstretched hand, causing hyper-extension of the joint withabduction--that is, deviation towards the radial side; but it mayfollow a direct blow on the back of the humerus, a fall on the elbow, or a twist of the forearm. [Illustration: FIG. 36. --Backward Dislocation of Elbow, in a boy æt. 10, caused by a fall off a wall, landing on the elbow. ] _Morbid Anatomy. _--All the ligaments of the elbow, except the annular(orbicular), are torn or stretched. The radius and ulna pass backward, the coronoid process coming to rest opposite the olecranon fossabehind the humerus, and the head of the radius behind the lateralcondyle. The condyles of the humerus bear their normal relations toone another. The olecranon and the triceps tendon form a markedprominence on the back of the elbow, the tip of the olecranon lyingabove and behind the condyles. The lower end of the humerus lies inthe flexure of the joint with the biceps tendon tightly stretched overit. The coronoid process is often broken, or the tendon of thebrachialis torn. The median and ulnar nerves may be stretched or torn. Not infrequently the bones of the forearm are displaced towards themedial side as well as backward. Occasionally, as a sequel to the dislocation, processes of bonedevelop in relation to the insertion of the brachialis and interferewith the movements of the joint. These outgrowths are due todisplacement of bone-forming elements, either at the time of theoriginal injury or as a result of forcible efforts at reduction. According to D. M. Greig, they do not develop in the tendon of thebrachialis, but under it, and are not of the nature of myositisossificans. In from four to six weeks after reduction of thedislocation, the movements begin to be restricted, and a hard mass canbe felt in the cubital fossa, which with the X-rays is seen to be abony outgrowth springing from the quadrilateral space on the front ofthe elbow below the coronoid process (Fig. 37). This graduallyincreases in size and leads to fixation of the joint. In most casesthe effects reach their maximum in about six months, and thenreabsorption of the mass begins. [Illustration: FIG. 37. --Bony Outgrowth in relation to insertion ofBrachialis Muscle, following Backward Dislocation of Elbow. (Sir Robert Jones' case. Radiogram by Dr. D. Morgan. )] If the disability shows no sign of abatement within a year, or if thebony outgrowth is producing pressure effects on the median nerve, itshould be removed by operation. It is important not to mistake this condition for the effects of afracture which has complicated the dislocation and been overlooked atthe time of the accident. [Illustration: FIG. 38. --Radiogram of Incomplete Backward Dislocationof Elbow. ] _Clinical features. _--The elbow is held fixed at an angle of about120°, pronated or midway between pronation and supination. Any attemptat movement causes great pain, and is followed by an elastic reboundto the abnormal position. The antero-posterior diameter of the jointis increased, and the forearm, as measured from the lateral epicondyleto the tip of the styloid process of the radius, is shortened to theextent of about an inch. If examined before swelling ensues, theoutlines of the articular surfaces may be recognised in their abnormalpositions, but swelling usually comes on rapidly, and, by obscuringthe bony landmarks, renders the diagnosis difficult. This injury has to be diagnosed from supra-condylar fracture withbackward displacement of the lower fragment and from separation of thelower humeral epiphysis. A general anæsthetic is often necessary toenable an accurate diagnosis to be made. When the deformity is oncereduced, there is no tendency to its reproduction unless thecoronoid process is also fractured. In a considerable number ofcases--according to E. H. Bennett, in the majority--this dislocationis _incomplete_, the coronoid process resting at the level of thetrochlea, and the backward projection of the olecranon being scarcelyappreciable. The head of the radius, however, is unduly prominent. Insuch cases the lesion is liable to be overlooked, and therefore to gountreated, leading to permanent stiffness at the elbow. #Dislocation forward# is much less common than the backward variety. It is produced by severe force acting from behind on the flexed elbow, the ulna being driven forward, tearing the ligaments of the joint andthe muscles attached to the condyles. The olecranon is frequentlyfractured at the same time (Fig. 39). When it remains intact, it mayrest below the condyles (incomplete or first stage of dislocation), ormay pass in front of them, especially if the triceps is ruptured(complete or second stage). The forearm is lengthened, the elbowslightly flexed, the posterior aspect of the joint flattened, and thecondyles, in their abnormal relationship, can be palpated from behind. #Medial and Lateral Dislocations. #--Dislocation towards the ulnar sideis always incomplete, some portion of the articular surface of thebones of the forearm remaining in contact with the condyles. The dislocation to the radial side is also incomplete as a rule, although cases have been recorded in which complete separation hadtaken place. These forms of dislocation are rare, that towards the ulnar side beingmore frequently observed. Each form is often combined with otherinjuries in the vicinity. The most common cause of these dislocations is a fall on theoutstretched hand, the forearm at the moment being strongly pronated. Forced abduction favours the displacement to the ulnar side; adductionto the radial side. The limb is held flexed and pronated, and thefacility with which the bony points can be palpated renders thediagnosis easy. In a few cases _diverging dislocations_ have been met with, the radiusand ulna being separated from one another, the annular (orbicular)ligament being torn and no longer holding them together. #Treatment of Dislocations of Elbow. #--The chief obstacle to reductionis the spasmodic contraction of the muscles passing over the joint, and, in the backward variety, the hitching of the coronoid processagainst the edge of the olecranon fossa. In recent cases, to effectreduction the patient is seated on a chair, while the surgeon graspsthe 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 thetriceps and free the coronoid process. Traction is then made inopposite directions upon the forearm and arm, the surgeon's kneemeanwhile making pressure, in a backward direction, upon the lower endof the humerus. The joint is next slowly flexed, and the bones slipinto position, often with a distinct snap. If the patient beanæsthetised, these manipulations must be adapted to the recumbentposition. When some days have elapsed before reduction is attempted, forciblemanipulations are to be deprecated as they greatly increase the riskof ossification occurring in relation to the brachialis (D. M. Greig);and recourse should be had to open operation, and the tearing orbruising of the soft parts should be reduced to a minimum. After reduction, the limb is flexed to rather less than a right angleand supported by a sling. Massage and movement are commenced at once. Fracture of the coronoid process predisposes to recurrence of thedislocation; when this complication exists, therefore, the limb shouldbe fixed at an acute angle, and movements of full extension postponedfor a fortnight. Massage and limited movements, however, may becarried out from the first. If there is a fracture of the olecranon, the treatment must bemodified accordingly (p. 87). [Illustration: FIG. 39. --Forward Dislocation of Elbow, with Fractureof Olecranon. (Sir Robert Jones' case. Radiogram by Dr. D. Morgan. )] Comminuted and compound injuries usually call for operative treatment, the fractured bones being wired after reduction of the dislocation, orthe loose fragments removed. The _forward dislocation_ is reduced by fully flexing the elbow, andthen pushing the bones of the forearm backward, while the humerus ispulled forward. _Old-standing Dislocations. _--No attempt should be made to reduce bymanipulation a dislocation of the elbow which has remained displacedfor five or six weeks, especially when it has been complicated by afracture. The joint surfaces become welded together by adhesions, andseparated fragments often form attachments which lock the joint. Attempts to break these down are attended with considerable risk ofre-fracturing the bone or of tearing the soft parts. In such cases itis best to expose the joint, and if reduction is not easily effected asufficient amount of the lower end of the humerus should be removed toprovide a movable joint. #Dislocation of the ulna alone# is a rare injury, and is usuallyassociated with fracture of one or other of its processes or of theinner condyle. #Dislocation of the radius alone#, on the other hand, is comparativelycommon, especially as a concomitant of fracture of the upper third ofthe shaft of the ulna (Fig. 40). The injury may result from a blow on the back of the upper end of theradius, a fall on the outstretched hand, or, in children, fromforcible traction on the forearm while in the pronated position. Thedisplaced head usually passes _forward_, and rests on the anterioredge of the capitellum, thus preventing complete flexion andsupination of the limb. The limb is held partly flexed and pronated. The displaced head of theradius 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 wherethe head should be. The radial side of the forearm is slightlyshortened. The superficial and deep (posterior interosseous) branchesof the radial nerve are liable to be pressed upon or torn by thedisplaced head of the radius, especially if the ulna is fractured, leading to disturbances in the area of their distribution. [Illustration: FIG. 40. --Radiogram of Forward Dislocation of Head ofRadius, with Fracture of Shaft of Ulna. ] In a few cases the displacement of the head has been _backwards_ or_laterally_. _Treatment. _--To effect reduction, the forearm should be alternatelyflexed and extended, while traction is made upon it from the wrist, and the head of the radius is pressed backward with the thumb in thefold of the elbow. When reduction is prevented by the interpositionof a portion of the torn ligaments between the bones, it is sometimesnecessary to open the joint to ensure accurate adjustment. The jointis fixed in acute flexion to relax the biceps, to allow of union ofthe torn ligaments, and to prevent recurrence. In old-standing cases, to obtain a useful joint, or to remove pressurefrom the branches of the radial nerve, resection of the head of theradius may be necessary. #Sub-luxation of the head of the radius#, or "dislocation byelongation, " is a comparatively common injury in children between theages of two and six. It almost invariably results from the child beinglifted or dragged by the hand or forearm. The traction and torsionthus put upon the radius causes the front part of its head to pass outof the annular ligament, the edge of which slips between the bones. The person holding the child may feel a click at the moment ofdisplacement. The child complains of pain in the region of the elbow:the arm at once becomes useless, and is held flexed, midway betweenpronation and supination. All movements are painful, but especiallymovements in the direction of supination. The deformity is slight, butthe head of the radius may be unduly prominent in front. From the wayin which the injury is produced the wrist also is often swollen, andin some cases the patient is brought to the surgeon on account of thecondition of the wrist, and attention is not directed to the elbow. _Treatment. _--Reduction frequently takes place spontaneously or duringexamination, the function of the arm being at once completelyrestored. In other cases it is necessary, under anæsthesia, tomanipulate the head of the bone into position. This is usually easilydone by flexing the elbow, making slight traction on the forearm, andalternately pronating and supinating it. After reduction, a few days'massage is all that is necessary, the joint in the intervals beingkept at rest in a sling. #Sprain# of the elbow is comparatively common as a result of a fall onthe hand or a twist of the forearm. The point of maximum tenderness isusually over the radio-humeral joint, the radial collateral andannular ligaments being those most frequently damaged. Effusion takesplace into the synovial cavity, and a soft, puffy swelling fills upthe natural hollows about the joint. The bony points about the elbowretain their normal relationship to one another--a feature which aidsin determining the diagnosis between a sprain and a dislocation orfracture. In children it is often difficult to distinguish between asprain and the partial separation of an epiphysis. Sprains of theelbow are treated on the same lines as similar lesions elsewhere--bymassage and movement. The condition known as _tennis elbow_ is characterised by severe painover the attachment of one or other of the muscles about the elbow, particularly the insertion of the pronator teres during the act ofpronation, and is due to stretching or tearing of the fibres of thatmuscle, and of the adjacent intermuscular septa. A similarinjury--_sculler's sprain_--occurs in rowing-men from feathering theoar. The treatment consists in massage and movement, care being takento avoid the movement which produced the sprain. FRACTURE OF THE FOREARM The _shafts_ of the bones of the forearm may be broken separately, butit is much more common to find both broken together. #Fracture of both bones# may result from a direct blow, from a fall onthe hand, or from their being bent over a fixed object. The line offracture is usually transverse, both bones giving way about the samelevel. The common situation is near the middle of the shafts. Inchildren, greenstick fracture of both bones is a frequent result of afall on the hand--this indeed being one of the commonest examples ofgreenstick fracture met with (Fig. 41). [Illustration: FIG. 41. --Greenstick Fracture of both Bones of theForearm, in a boy. ] The _displacement_ varies widely, depending partly upon the forcecausing the fracture, partly on the level at which the bones break, and on the muscles which act on the respective fragments. It is commonto find an angular displacement of both bones to the radial or to theulnar side. In other cases the four broken ends impinge upon theinterosseous space, and may become united to one another, preventingthe movements of pronation and supination. There may be shorteningfrom overriding of fragments. When the radius is broken above the insertion of the pronator teres, its upper fragment may be supinated by the biceps and supinatormuscles, while the lower fragment remains in the usual semi-proneposition. If union takes place in this position, the power of completesupination is permanently lost. The usual _symptoms_ of fracture are present, and there is seldom anydifficulty in diagnosis. The _prognosis_ must be guarded, especially with regard to thepreservation of pronation and supination. These movements areinterfered with if union takes place in a bad position with angular orrotatory deformity of one or both bones, or if callus is formed inexcess and causes locking of the bones. In some cases the callus fusesthe two bones across the interosseous space, and pronation andsupination are rendered impossible. Persistent angular deformity of the forearm is also liable to ensue, either from failure to correct the displacement primarily, or fromsubsequent bending due to ill-applied splints or slings. Want ofunion, or the formation of a false joint in one or both bones, issometimes met with, particularly in children, and, like thecorresponding fracture of the leg, is liable to prove intractable. A considerable number of cases of gangrene of the hand after simplefracture of the forearm are on record. This is sometimes attributableto damage inflicted upon the blood vessels by the fractured bones, orto the force that caused the fracture, but is oftener due to a rollerbandage applied underneath the splints strangulating the limb, toinjudiciously applied pads, or to too tight bandaging over thesplints. Volkmann's ischæmic contracture occasionally develops afterfractures of the forearm. In uncomplicated cases, union takes place in from three to fourweeks. _Treatment. _--To ensure accurate reduction and coaptation, a generalanæsthetic is usually necessary. In the greenstick variety the bonesmust be straightened, the fracture being rendered complete, ifnecessary, for this purpose. To retain the bones in position, anterior and posterior splints arethen applied. These are made to overlap the forearm by about half aninch 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 theknuckles, and the palmar one from the bend of the elbow to the flexurein the middle of the palm, a piece being cut out to avoid pressure onthe ball of the thumb (Fig. 42). The splints are applied with theelbow flexed to a right angle, and, except when the radius is brokenabove the level of the insertion of the pronator teres, with theforearm midway between pronation and supination. The limb is placed ina sling, so adjusted that it supports equally the hand and elbow inorder to avoid angular deformity. The use of special interosseous padsis to be avoided. [Illustration: FIG. 42. --Gooch Splints for Fracture of both Bones ofForearm. (These are applied with the wooden side towards the skin. )] When the fracture of the radius is above the insertion of the pronatorteres, the forearm should be placed in the position of completesupination, with the elbow flexed to an acute angle, and retained inthis position by a moulded posterior splint, and the arm fixed to theside by a body bandage. Great care is necessary in the adjustment ofthe apparatus to prevent pronation. Massage and movement should be carried out from the first. It isusually necessary to continue wearing the splints for about threeweeks. In cases of _mal-union_, especially when the bones are ankylosed toone another across the interosseous space, operation may be necessary, but it is neither easy in its performance nor always satisfactory inits results. The seat of fracture should be exposed by one or moreincisions so placed as to enable the muscles to be separated and togive access to the callus. When the limb is straight, it is onlynecessary to gouge away the exuberant callus that interferes withrotatory movements; but when there is an angular deformity the bonesmust, in addition, be divided and re-set, and, if necessary, mechanically fixed in good position. In comparatively recent cases itis sometimes possible, without operation, to re-fracture the bones andto set them anew. _Un-united fracture_ of both bones of the forearm is not uncommon andis treated on the usual lines; the gap between the fragments of theradius is bridged by a portion of the fibula, that should be longenough to overlap by at least an inch at either end; it is rarelynecessary to bridge the gap in the ulna, unless it alone is the seatof non-union. #Fracture of the shaft of the radius alone# may be due to a directblow; to indirect violence, such as a fall on the hand; or to forciblepronation against resistance, as in wringing clothes. It is rare incomparison with fracture of both bones. When broken above theinsertion of the pronator teres, the upper fragment is flexed andsupinated by the biceps and supinator, while the lower fragmentremains semi-prone, and is drawn towards the ulna by the pronatorquadratus. When the fracture is below the pronator teres, the displacementdepends upon the direction of the force and the obliquity of thefracture. In fractures of the lower third of the shaft, the hand maybe flexed toward the radial side, and the styloid lies at a higherlevel, as in a Colles' fracture. From the frequency with which thisfracture occurs while cranking a motor-car, it is convenientlydescribed as _Chauffeur's fracture_; we have observed in doctors, whohave sustained this fracture in their own persons, that they wereunder the impression that they had sustained a trivial sprain of thewrist. In addition to the ordinary signs of fracture, there is partial orcomplete loss of pronation and supination. The head of the radius as arule does not move with the lower part of the shaft, but may do so ifthe fracture is incomplete or impacted. #Fracture of the shaft of the ulna alone# is also comparatively rare. It is almost always due to a direct blow sustained while protectingthe head from a stroke, or to a fall on the ulnar edge of the forearm, as in going up a stair. The upper third is most frequently broken, and this injury is oftenassociated with dislocation of the head of the radius (Fig. 40), orsome other injury implicating the elbow-joint. On account of thesuperficial position of the bone, this fracture is frequentlycompound. The displacement depends on the direction of the force, the fragmentsbeing usually driven towards the interosseous space. There is seldommarked deformity unless the head of the radius is dislocated at thesame time. The diagnosis is, as a rule, easy. The _treatment_ is the same as for fracture of both bones, but thesplints may be discarded at the end of a fortnight. For some unexplained reason, a fracture of the upper third of theshaft of the ulna frequently fails to unite. CHAPTER V INJURIES IN THE REGION OF THE WRIST AND HAND Surgical Anatomy--FRACTURE OF LOWER END OF RADIUS: _Colles' fracture_; _Chauffeur's fracture_; _Smith's fracture_; _Longitudinal fracture_; _Separation of epiphysis_--FRACTURE OF LOWER END OF ULNA: _Shaft_; _Styloid process_; _Separation of epiphysis_--FRACTURE OF CARPAL BONES--DISLOCATION: _Inferior radio-ulnar joint_; _Radio-carpal joint_; _Carpal bones_; _Carpo-metacarpal joint_--SPRAINS--INJURIES OF FINGERS: _Fractures_; _Dislocations_; _Mallet finger_. INJURIES IN THE REGION OF THE WRIST These include fractures of the lower ends of the bones of the forearmand separation of their epiphyses; sprains and dislocations of theinferior radio-ulnar, and of the radio-carpal articulations; andfractures and dislocations of the carpus. #Surgical Anatomy. #--The most important landmarks in the region of thewrist are the styloid processes of the radius and ulna. The tip of theradial styloid is palpable in the "anatomical snuff-box" between thetendons of the long and short extensors of the thumb, and it liesabout half an inch lower than the ulnar styloid. The ulnar styloid isbest recognised on making deep pressure a little below and in front ofthe head of the ulna, which forms the rounded subcutaneous prominenceseen on the back of the wrist when the hand is pronated. The tubercle of the navicular (scaphoid) and the greater multangular(trapezium) can be felt between the radial styloid and the ball of thethumb, a little below the radial styloid; and the pisiform and hook ofthe hamatum (unciform) are palpable, slightly below and in front ofthe ulnar styloid. In examining an injured wrist, the different bony points should belocated, and their relative positions to one another and to theadjacent joints noted; and the shape, position, and relations of anyunnatural projection or depression observed, using the wrist on theother side as the normal standard for comparison. The power and rangeof movement--active and passive--at the various joints should also betested. FRACTURE OF THE LOWER END OF THE RADIUS #Colles' Fracture. #--This injury, which was described by Colles ofDublin in 1814, is one of the commonest fractures in the body, and isespecially frequent in women beyond middle age. It is almostinvariably the result of a fall on the palm of the hand, in thethree-quarters pronated position, the force being received on the ballof the thumb, and transmitted through the carpus to the lower end ofthe radius which is broken off, the lower fragment being drivenbackwards. The fracture takes place through the cancellated extremity of thebone, within a half to three-quarters of an inch of its articularsurface (Fig. 45). It is usually transverse, but may be slightlyoblique from above downwards and from the radial to the ulnar side. Ina considerable proportion of cases it is impacted, and notinfrequently the lower fragment is comminuted, the fracture extendinginto the radio-carpal joint. [Illustration: FIG. 43. --Colles' Fracture showing radial deviation ofhand. ] [Illustration: FIG. 44. --Colles' Fracture showing undue prominence ofulnar styloid. ] When impaction takes place, it is usually reciprocal, the dorsal edgeof the proximal fragment piercing the distal fragment, and the palmaredge of the distal fragment piercing the proximal. The periosteum isusually torn and stripped from the palmar aspect of the fragments, while it remains intact on the dorsum. In the majority of cases the styloid process of the ulna is torn offby traction exerted through the medial ulno-carpal (internal lateral)ligament, and in a considerable proportion there is also a fracture ofone of the carpal bones. The resulting _displacement_ is of a threefold character: (1) thedistal fragment is displaced backwards; (2) its carpal surface isrotated backwards on a transverse diameter of the forearm; while (3)the whole fragment is rotated so that the radial styloid comes to lieat a higher level than normal. [Illustration: FIG. 45. --Radiogram showing the line of fracture andupward displacement of the radial styloid in Colles' Fracture. ] _Clinical Features. _--In a typical case there is a prominence on thedorsum of the wrist, caused by the displaced distal fragment, with adepression just above it (Fig. 43); and the wrist is broadened fromside to side. The natural hollow on the palmar aspect of the radius isfilled up by the projection of the proximal fragment. The carpus iscarried to the radial side by the upward rotation of the distalfragment, and the radial styloid is as high, or even higher, than thatof the ulna. The lower end of the ulna is rendered unduly prominent bythe flexion of the hand to the radial side. The fingers are partlyflexed and slightly deviated towards the ulnar side; and the patientsupports the injured wrist in the palm of the opposite hand, andavoids movement of the part. Occasionally the median nerve is bruisedor torn, causing motor and sensory disturbances in its area ofdistribution. The general outline of the wrist and hand has been compared notinaptly to that of "an inverted spoon. " Pronation and stipulation arelost, the joint is swollen, and there is tenderness on pressure, especially over the line of fracture. Tenderness over the position ofthe ulnar styloid may indicate fracture of that process, although itis sometimes present without fracture. No attempt should be made toelicit crepitus in a suspected case of Colles' fracture as themanipulations are painful, and are liable to increase thedisplacement. _Treatment. _--It cannot be too strongly insisted upon that success inthe treatment of Colles' fracture with displacement and impactiondepends chiefly upon complete and accurate reduction, and to enablethis to be effected a general anæsthetic is almost essential. Thesurgeon grasps the patient's hand, as if shaking hands with him, and, resting the palmar surface of the wrist on his bent knee, makestraction through the hand, and counter-extension through the forearm, with lateral movements, if necessary, to undo impaction. When thefragments are freed from one another, the wrist is flexed, and thehand carried to the ulnar side, while the lower fragment is mouldedinto position by the thumb of the surgeon's disengaged hand. Whenreduction is complete, the deformity disappears, and the two styloidprocesses regain their normal positions relative to one another. As there is no tendency to re-displacement and no risk of non-union, no retentive apparatus is required, but, if it adds to the patient'ssense of security, a bandage or a poroplastic wristlet may be applied. In severe cases, however, anterior and posterior splints, similar tothose used for fracture of both bones of the forearm, or a dorsalsplint padded so as to flex the wrist to an angle of 45°, but somewhatnarrower, may be employed. The hand and forearm are in any casesupported in a sling. To avoid the stiffness that is liable to follow, massage and movementof the wrist and fingers should be carried out from the first, therange of movement being gradually increased until the function of thejoints is perfectly restored. If splints are used, they should bediscarded in a week, and the patient is then encouraged to use thewrist freely. The various special splints recommended for the treatment of Colles'fracture, such as Carr's, Gordon's, the "pistol splint, " and manyothers, are all designed to correct the deformity as well as tocontrol the fragments. It has already been pointed out that ifreduction is complete there is no deformity to correct, and if it isnot complete the deformity cannot be corrected by any form of splint. _Unreduced Colles' Fracture. _--When union has been allowed to takeplace without the displacement having been reduced, an unsightlydeformity results. In young subjects whose occupation is likely to beinterfered with, and in women for æsthetic reasons, the fracture isreproduced and the displacement of the lower fragment corrected. Thisis conveniently done by means of Jones' wrench, which grasps thedistal fragment and affords sufficient leverage to break the bone. #Chauffeur's Fracture. #--A fracture of the lower end of the radiusfrequently occurs from the recoil of the crank, "by back firing, " instarting the engine of a motor-car. The injury may be produced eitherby direct violence, the handle as it recoils striking the forearm, orby indirect violence, from forcible hyper-extension of the hand whilegrasping the handle. The fracture may pass transversely through thelower end of the radius, as in Colles' fracture, but is more often metwith two or three inches above the wrist (Fig. 46). It is treated onthe same lines as Colles' fracture. [Illustration: FIG. 46. --Radiogram of Chauffeur's Fracture. ] A fracture of the lower end of the radius _with forward displacementof the carpal fragment_, was first described by R. W. Smith of Dublin(_Colles' fracture reversed_, or #Smith's fracture#) (Fig. 47). It isnearly always due to forcible flexion, as from a fall on the back ofthe hand. Like Colles' fracture, it may be transverse or slightlyoblique, impacted, or comminuted. The deformity is characterised by anelevation on the dorsum running obliquely upwards from the ulnar tothe radial side of the wrist, and caused by the head of the ulna, which remains in position, and the distal end of the proximalfragment. Below this, over the position of the distal radial fragment, is a gradual slope downwards on to the dorsum of the hand. Anteriorlythere is a prominence in the flexure of the wrist, and the distalfragment may be felt under the flexor tendons. The hand deviates tothe radial side, and thereby still further increases the prominencecaused by the lower end of the ulna. The radial styloid is displacedforward, upward, and to the radial side, and the ulnar styloid may betorn off. [Illustration: FIG. 47. --Radiogram of Smith's Fracture. (Sir George T. Beatson's case. )] When the deformity is not well marked, this injury may be mistaken forforward dislocation of the wrist, for fracture of both bones low down, or for sprain of the joint. The _treatment_ is carried out on the same lines as in Colles'fracture. _Longitudinal fractures_ of the lower end of the radius opening intothe joint usually result from the hand being crushed by a heavy weightor in machinery. They are often compound and comminuted. #Separation of the lower epiphysis# of the radius, which is on thesame level as that of the ulna and lies above the level of thesynovial membrane of the wrist-joint, is comparatively common betweenthe ages of seven and eighteen, especially in boys, and is caused bythe same forms of violence as produce Colles' fracture. Although clinically the appearances in these two injuries bear ageneral resemblance to one another, separation of the epiphysis mayusually be identified by the directly transverse line of the dorsaland palmar projections, the folding of the skin observed in the palmardepression, the absence of abduction of the hand and the ease withwhich muffled crepitus can be elicited (E. H. Bennett). The deformityis readily reduced, and the fragments are easily retained in position. This injury is often complicated with fracture of the shaft or styloidprocess of the ulna, or with dislocation of the radio-ulnar joint, andit is not infrequently compound, the lower end of the shaft beingdriven through the skin on the palmar aspect immediately above thewrist. Impairment of growth in the radius seldom occurs; when it does, it results in a valgus condition of the hand (Fig. 48), calling forresection of the lower end of the ulna. [Illustration: FIG. 48. --Manus Valga following separation of lowerradial epiphysis in childhood. (Mr. H. Wade's case. )] The _treatment_ is the same as for Colles' fracture. #Fracture of the Lower End of the Ulna. #--The lower end of the _shaft_of the ulna is seldom fractured alone. The _styloid process_, as hasalready been pointed out, is frequently broken in association withColles' and other fractures of the lower end of the radius. Separation of the _lower epiphysis_ of the ulna sometimes occurs, andin rare cases results in arrest of the growth of the bone, leading toa varus condition of the hand and bending of the radius. Sometimes theseparated epiphysis fails to unite, and although this gives rise to nodisability, it is liable to lead to errors in the interpretation ofskiagrams. The _treatment_ is similar to that for the corresponding injuries ofthe radius. Simultaneous separation of the _epiphysis of both radius and ulna_sometimes occurs, and, as a result of severe violence, may becompound, the lower ends of the diaphyses projecting through the skinon the palmar aspect above the wrist. #Fracture of Carpal Bones. #--The use of the Röntgen rays has shownthat fracture of individual carpal bones is commoner than waspreviously supposed, and that many cases formerly looked upon assevere sprains are examples of this injury. The _navicular_ (scaphoid) and _lunate_ (semilunar) are those mostcommonly fractured, usually by indirect violence, by forceddorsiflexion from a fall on the extended hand. The clinical featuresare: localised swelling on the radial side of the wrist, increase inthe antero-posterior diameter of the carpus, marked tenderness in theanatomical snuff-box when the hand is moved laterally, especially inthe direction of adduction, and, rarely, crepitus. The median nerve issometimes over-stretched or partly torn. In many cases, however, thesymptoms are so obscure that an accurate diagnosis can only be made bythe use of the X-rays (Fig. 49). Codman recommends taking pictures ofthe navicular by placing the two wrists of the patient in adduction, and of the lunate, in abduction. [Illustration: FIG. 49. --Radiogram showing Fracture of Navicular(Scaphoid) Bone. ] The _treatment_ of simple fractures consists in massage and movement. Codman and Chase recommend excision of the proximal half of thefractured bone, through a dorsal incision to the lateral side of theextensor digitorum communis. When the fracture is compound, the loosefragments should be removed. DISLOCATIONS IN THE REGION OF THE WRIST Dislocation may occur at the inferior radio-ulnar, the radio-carpal, mid-carpal, inter-carpal, or carpo-metacarpal joints, but the strongligaments of these articulations, the comparatively free movement atthe various joints, and the relative weakness of the lower end of theradius whereby it is so frequently fractured, render dislocation arare form of injury. Dislocation of the #inferior radio-ulnar# articulation may complicatefracture of the lower end of the radius, or accompany sub-luxation ofthe head of the radius. The head of the ulna usually passes backward. In children, the commonest cause is lifting the child by the hand, andthe displacement is only partial. In adults, it may result fromforcible efforts at pronation or supination, as in wringing clothes, or from direct violence, the separation being frequently complete, andsometimes compound. The head of the ulna is unduly prominent, and there is a depression onthe opposite aspect of the joint. The hand is generally pronated, therotatory movements at the wrist are restricted and painful, whileflexion and extension are comparatively free. Reduction is effected by making pressure on the displaced bone andmanipulating the joint, especially in the direction of supination. Ifthe ligaments fail to unite, the head of the ulna tends to slip out ofplace in pronation and supination--_recurrent dislocation_. Dislocation at the #radio-carpal# articulation, usually spoken of as_dislocation of the wrist_, is attended by tearing of the ligamentsand displacement of tendons, and is frequently compound. The carpusmay be displaced backward or forward, and the articular edge of theradius towards which it passes may be chipped off. _Backward_ dislocation is commonest, the injury resulting from asevere form of violence, such as a fall from a height on the palmwhile the hand is dorsiflexed and abducted. The clinical appearancesclosely simulate those of Colles' fracture, or of separation of thelower radial epiphysis, but the unnatural projections, both in frontand behind, are lower down, and end more abruptly (Fig. 50). The handis more flexed, and the palm is shortened. The styloid processesretain their normal relations to one another, and the carpal bones lieon a plane posterior to the styloids, the articular surfaces may berecognised on palpation. The forearm is not shortened. _Forward_ dislocation of the carpus may result from any form of forcedflexion, such as a fall on the back of the hand, or from directviolence. The displaced carpus forms a marked projection on the palmaraspect of the wrist, and there is a corresponding depression on thedorsum. The attitude of the hand and fingers is usually one offlexion. In both varieties reduction is readily effected by making traction onthe hand and pushing the carpus into position. A moulded poroplasticsplint, which keeps the hand slightly dorsiflexed, adds to the comfortof the patient, but this should be removed daily to admit of movementand massage being employed. [Illustration: FIG. 50. --Dorsal Dislocation of Wrist at Radio-carpalArticulation, in a man, æt. 24, from a fall. ] #Dislocation of Carpal Bones. #--The two rows of carpal bones may beseparated from one another, or any one of the individual bones may bedisplaced. These injuries are rare, and result from severe forms ofviolence, usually from a fall on the extended hand. Pain, deformity, and loss of function are the ordinary symptoms. The treatment consistsin making direct pressure over the displaced bone, while traction ismade on the hand, which is alternately flexed and extended. Of these injuries that most frequently observed is displacement of the_head of the capitate bone_ (_os magnum_) from the navicular(scaphoid) and lunate (semilunar) bones. Frequently these bones arefractured, and fragments accompany the displaced os magnum. In fullpalmar flexion of the wrist the displaced head of the os magnum formsa prominence on the dorsum opposite the base of the third metacarpal, which temporarily disappears when the hand is dorsiflexed. There is anincrease in the antero-posterior diameter of the wrist, situated on alower level than that which accompanies fracture of the lower end ofthe radius; flexion and extension of the wrist are limited; and insome cases there are symptoms referable to pressure on the mediannerve. By keeping the hand in the dorsiflexed position for a week orten days, the bone may become fixed in its place and the function ofthe wrist be restored, but it is often necessary to excise the bone. The _lunate_ may be displaced forward by forcible dorsiflexion of thehand, and forms a projection beneath the flexor tendons; there isusually loss of sensibility in the distribution of the ulnar nerve inthe hand. The most satisfactory treatment is removal of the bone. In a few cases the _navicular_ has been displaced (Fig. 51), and hashad to be subsequently replaced by operation. Separation of any of theother bones is rare. [Illustration: FIG. 51. --Radiogram showing Forward Dislocation ofNavicular (Scaphoid) Bone. ] #Carpo-metacarpal Dislocations. #--Any or all of the metacarpal bonesmay be separated from the carpus by forced movements of flexion orextension. The commonest displacement is backward. The thumb seems tosuffer oftener than the other digits. These injuries, however, are sorare, and the deformity is so characteristic, that a detaileddescription is unnecessary. #Sprain of the wrist# is a common injury, and results from a fall onthe hand, a twist of the wrist, or from the back-firing of amotor-crank dorsiflexing the hand. The marked swelling which rapidlyensues may render it difficult to distinguish a sprain from the otherinjuries that are liable to result from similar causes--Colles'fracture, separation of the lower radial epiphysis, dislocation of thewrist, and fractures and dislocations of the carpal bones. In a sprain the normal relations of the styloid processes and otherbony points about the wrist are unaltered, and there is no radialdeviation of the hand, as in Colles' fracture. The most markedswelling is over the line of the articulation on the anterior andposterior aspects of the joint. There is usually some effusion intothe sheaths of the tendons passing over the joint, and in some caseson moving the fingers a peculiar creaking, which may simulatecrepitus, can be elicited. There is marked tenderness on makingpressure over the line of the joint, as well as over one or other ofthe collateral ligaments, depending upon which ligament has beenover-stretched or torn. Movements that tend to put the damagedligaments on the stretch also cause pain. It has to be borne in mind, however, that in many cases of Colles' fracture there is extremetenderness on pressing over the ulnar styloid and medial ulno-carpalligament, as these structures are frequently injured as well as theradius, but the point of maximum pain and tenderness is over the seatof fracture of the radius. In all doubtful cases the X-rays should beemployed to establish the diagnosis. The _treatment_ consists in the immediate employment of massage andmovement, supplemented by alternate hot and cold douches, on the samelines as in sprains of other joints. INJURIES OF THE FINGERS #Fracture. #--_Fractures of the metacarpals of the fingers_ arecomparatively common. When they result from direct violence, such asa crush between two heavy objects, they are often multiple andcompound. Indirect violence, acting in the long axis of the bone andincreasing its natural curve, such as a blow on the knuckle instriking with the closed fist, usually produces an oblique fractureabout the middle of the shaft, the proximal end of the distal fragmentprojecting towards the dorsum. Apart from this there is littledeformity, as the adjacent metacarpals act as natural splints and tendto retain the fragments in position. A sudden sharp pain may beelicited at the seat of fracture on making pressure in the long axisof the finger; and unnatural mobility and crepitus may usually bedetected. These fractures are readily recognised by the X-rays. Firmunion usually results in three weeks. The shaft of the _metacarpal of the thumb_ is frequently broken by ablow with the closed fist. The fracture is usually transverse, andsituated near the proximal end of the shaft; frequently it iscomminuted, and in some instances there is a longitudinal split. _Treatment. _--When the fracture is transverse, and especially when itimplicates the middle or ring fingers, the most convenient method isto make the patient grasp a firm pad, such as a roller bandage coveredwith a layer of wool, and to fix the closed fist by a figure-of-eightbandage. In this way the adjoining metacarpals are utilised as sidesplints. Active and passive movements must be carried out from thefirst, and the bandage may be dispensed with at the end of a week orten days. In oblique fractures with a tendency to overriding of the fragments, especially in the case of the index and little fingers, it issometimes necessary to apply extension to the distal segment of thedigit, by means of adhesive plaster, to which elastic tubing isattached and fixed to the end of a bow splint, reaching well beyondthe finger-tips (Fig. 52). This should be worn for a week or ten days. [Illustration: FIG. 52. --Extension apparatus for Oblique Fracture ofMetacarpals. ] #Bennett's Fracture of the Base of the First MetacarpalBone. #--Bennett of Dublin described an injury of the thumb which, although comparatively common, is often mistaken for a sub-luxationbackward of the carpo-metacarpal joint, or a simple "stave of thethumb. " It consists in an "oblique fracture through the base of thebone, detaching the greater part of the articular facet with thatpiece of the bone supporting it which projects into the palm" (Fig. 53). We have frequently observed the fracture extend for aconsiderable distance along the palmar aspect of the shaft. [Illustration: FIG. 53. --Radiogram of Bennett's Fracture of Base ofMetacarpal of Right Thumb. ] It usually results from severe force applied directly to the point ofthe thumb, driving the metacarpal against the greater multangular bone(trapezium), and chipping off the palmar part of the articularsurface, but it may result from a blow with the closed fist. The restof the metacarpal slips backward, forming a prominence on the dorsalaspect of the joint. The pain and swelling in the region of thefracture often prevent crepitus being elicited, and as the deformityis not at once evident, the nature of the injury is liable to beoverlooked. The fracture is recognised by the use of the X-rays. Unless properly treated this injury may result in prolonged impairmentof function, full abduction and fine movements requiring closeapposition of the thumb being specially interfered with. The _treatment_ consists in reducing the fracture by extension in theattitude of full abduction and applying an accurately fitting pad overthe extremity of the displaced bone, maintained in position by a lightangular splint. This splint is first fixed to the extended andabducted thumb, and while extension is made by pushing it downwardsthe upper end is fixed to the wrist (Fig. 54 A). The apparatus is wornfor three weeks, being carefully readjusted from time to time tomaintain the extension and abduction. A moulded poroplastic splintadded on the same principle may be employed, and is more comfortable(Fig. 54 B). Excellent results are obtained after reduction of thedisplacement, by massage and movement from the first, and the supportmerely of a figure-of-eight bandage (Pirie Watson). [Illustration: FIG. 54. --A. Splint applied as used by Bennett. B. Poroplastic Moulded Splint for Bennett's Fracture. ] #Fractures of phalanges# usually result from direct violence, and onaccount of the superficial position of the bones, are often compound, and attended with much bruising of soft parts. Force applied to thedistal end of the finger may also fracture a phalanx. The proximalphalanges are broken oftener than the others. The deformity is usuallyangular, with the apex towards the palm, and if union takes place inthis position, the power of grasping is interfered with. Unnaturalmobility and crepitus can usually be recognised, but, on account ofthe swelling and tenderness, the fracture is apt to be overlooked. Firm union takes place in two or three weeks. In oblique andcomminuted fractures, union may take place with overlapping, producinga deformity which may prevent the wearing of a glove or of rings. Incompound fractures, non-union sometimes occurs, and causes persistentdisability. In doubtful cases radioscopy renders valuable aid, as theparts are readily seen with the screen. _Treatment. _--Early movement and massage are all-important. Thecontiguous fingers may be utilised as side splints, and a long palmarsplint projecting beyond the fingers is applied. In oblique andcomminuted fractures it may be necessary to anæsthetise the patient toeffect reduction. When it is particularly desirable to avoiddeformity, an open operation may be advisable. #Dislocation. #--_Dislocation of the Metacarpo-phalangeal Joint of theThumb. _--The commonest dislocation at this joint is a _backward_displacement of the proximal phalanx, which may be complete orincomplete. Its special clinical importance lies in the fact that muchdifficulty is often experienced in effecting reduction. This dislocation is usually produced by extreme dorsiflexion of thethumb, whereby the volar accessory (palmar) and the collateralligaments are torn from their metacarpal attachments, the phalanxcarrying with it the volar accessory ligament and sesamoid bones. Thehead of the metacarpal passes forward between the two heads of theshort flexor of the thumb, and the tendon of the long flexor slips tothe ulnar side. The phalanx passes on to the dorsum of the metacarpal, where it is held erect by the tension of the abductor and adductormuscles. The attitude of the thumb is characteristic. The metacarpal isadducted, its head forming a marked prominence on the front of thethenar eminence, and the phalanges are displaced backwards, theproximal being dorsiflexed and the distal flexed towards the palm. Many explanations of the difficulty so often experienced in reducingthis variety of dislocation have been offered, but the consensus ofopinion seems to be that it is due to the interposition of the volaraccessory ligament and the sesamoid bones between the phalanx and themetacarpal, and that this is most frequently the result of ill-advisedefforts at reduction. In some cases the tension of the long flexortendon may be a factor in preventing reduction, but the"button-holing" by the short flexor is probably of no importance. Reduction is to be effected by flexing and abducting the metacarpalwhile the phalanx is hyper-extended and pushed down towards the jointand levered over the head of the metacarpal. When this manipulation fails, the volar accessory ligament should bedivided longitudinally through a puncture made with a tenotomy knifeon the dorsal aspect of the joint, so as to separate the sesamoidbones and permit the passage of the head between them. An openoperation is seldom necessary. Dislocation _forward_ is rare. It results from forced flexion of thethumb with abduction, tearing the posterior and medial collateralligaments. The deformity is characteristic: the rounded head of themetacarpal projecting behind the level of the joint, while the base ofthe phalanx forms a prominence among the muscles of the thenareminence. Reduction is easily effected by making traction on the phalanges andcarrying out movements of flexion and extension. The deformity, however, is liable to be reproduced unless a retentive apparatus issecurely applied. Dislocation of the thumb to one or other side is rare. Dislocations of the _metacarpo-phalangeal joint of the fingers_ may bebackward or forward. They are less common than those of the thumb, butpresent the same general characters. In the backward variety the samedifficulty in reduction occurs as is met with in the correspondingdislocation of the thumb, and is to be dealt with on the same lines. _Inter-phalangeal Dislocation. _--The second and the ungual phalangesmay be displaced backwards, forwards, or to the side. The clinicalfeatures are characteristic, and the diagnosis, as well as reduction, is easy. These dislocations are frequently the result of machineryaccidents, and being compound and difficult to render aseptic, oftennecessitate amputation. _Persistent flexion of the terminal phalanx_ of the thumb or fingers(_drop_ or _mallet finger_) may result from violence applied to theend of the digit when in the extended position--as, for example, inattempting to catch a cricket-ball. The terminal phalanx is flexedtowards the palm, and the patient is unable to extend it voluntarily. A palmar splint is applied securing extension of the distal joint forthree or four weeks. If the deformity has been allowed to occur it canonly be corrected by an open operation, suturing or tightening theextensor tendon at its insertion into the base of the terminalphalanx. CHAPTER VI INJURIES IN THE REGION OF THE PELVIS, HIP-JOINT, AND THIGH FRACTURES OF PELVIS: _Varieties_--INJURIES IN REGION OF HIP: Surgical anatomy; _Fracture of head of femur_; _Fracture of neck of femur_; _Fracture below lesser trochanter_--DISLOCATION OF HIP: _Varieties_--Sprains--Contusions--FRACTURE OF SHAFT OF FEMUR. FRACTURE OF THE PELVIS For descriptive as well as for practical purposes, it is useful todivide fractures of the pelvis into those that involve the integrityof the pelvic girdle as a whole, and those confined to individualbones. In all, the prognosis depends upon the severity of the viscerallesions which so frequently complicate these injuries, rather thanupon the fractures themselves. #Fractures implicating the pelvic girdle as a whole# usually resultfrom severe crushing forms of violence, such as the fall of a mass ofcoal or a pile of timber, or the passage of a heavy wheel over thepelvis. The force may act in the transverse axis of the pelvis, or inits antero-posterior axis. The pelvic viscera may be lacerated by thetearing asunder of the bones, or perforated by sharp fragments, orthey may be ruptured by the same violence as that causing thefracture. As a rule, more than one part of the pelvis is broken, the situationof the lesions varying in different cases. _Separation of the pubic symphysis_ may result from violence inflictedon the fork, as in coming down forcibly on the pommel of a saddle;from forcible abduction of the thighs; or it may happen duringchild-birth. In some cases the two pubic bones at once come intoapposition again, and there is no permanent displacement, the onlyevidence of the injury being localised pain in the region of thesymphysis elicited on making pressure over any part of the pelvis. Inother cases the pubic bones overlap one another, and the membranousportion of the urethra, or the bladder wall, is liable to be torn. Thedisplaced bones may be palpated through the skin, or by vaginal orrectal examination. The _pubic portion_ of the pelvic ring is the most common seat offracture. The bone gives way at its weakest points--namely, throughthe superior (horizontal) ramus of the pubes just in front of theilio-pectineal eminence, and at the lower part of the inferior(descending) ramus (Fig. 55). The intervening fragment of bone isisolated, and may be displaced. These fractures are frequentlybilateral, and are often associated with separation of the sacro-iliacjoint, with longitudinal fracture of the sacrum (Fig. 55), or withother fractures of the pelvic-bones. [Illustration: FIG. 55. --Multiple Fracture of Pelvis throughHorizontal and Descending Rami of both Pubes, and LongitudinalFracture of left side of Sacrum. ] Injuries of the membranous urethra and bladder are frequentcomplications, less commonly the rectum, the vagina, or the iliacblood vessels are damaged. Localised tenderness at the seat of fracture, pain referred to thatpoint on pressing together or separating the iliac crests, andmobility of the fragments with crepitus, are usually present. Thefragments may sometimes be felt on rectal or vaginal examination. Inall cases shock is a prominent feature. _The lateral and posterior aspects_ of the pelvic ring may beimplicated either in association with pubic fractures orindependently. Thus a fracture of the iliac bone may run into thegreater sciatic notch; or a vertical fracture of the sacrum orseparation of the sacro-iliac joint may break the continuity of thepelvic brim. In rare cases these injuries are accompanied by damage tothe intestine, the rectum, the sacral nerves, or the iliac bloodvessels. [Illustration: FIG. 56. --Fracture of left Iliac Bone; and of bothPubic Arches. ] _Treatment. _--It is of importance that the patient be moved andhandled with care lest fragments become displaced and injure theviscera. He should be put to bed on a firm mattress, which may bemade in three pieces, for convenience in using the bed-pan and for theprevention of bed-sores. Before the treatment of the fracture is commenced, the surgeon mustsatisfy himself, by the use of the catheter and by other means, thatthe urethra and bladder are intact. Should these or any other of thepelvic viscera be damaged, such injuries must first receive attention. The treatment of the fracture itself consists in adjusting thefragments, as far as possible by manipulation, applying a firm binderor many-tailed bandage round the pelvis, and fixing the knees togetherby a bandage (Fig. 57). [Illustration: FIG. 57. --Many-tailed Bandage and Binder for Fractureof Pelvic Girdle. ] When there is displacement of fragments extension should be applied toboth legs, with the limbs abducted and steadied by sand-bags. Compound fractures, being commonly associated with extravasation ofurine, are liable to infective complications. Loose fragments shouldbe removed, as they are prone to undergo necrosis. The patient is confined to bed for six or eight weeks, and it may beseveral weeks more before he is able to resume active employment. The #acetabulum# may be fractured by force transmitted through thefemur, usually from a fall on the great trochanter, less frequentlyfrom a fall on the feet or other form of violence. It may merely befissured, or the head of the femur may be forcibly driven through itsfloor into the pelvic cavity, either by fracturing the bone or, inyoung subjects, by bursting asunder the cartilaginous junction of theconstituent bones. When the femoral head penetrates into thepelvis--the _central dislocation of the hip_ of German writers--thecondition simulates a fracture of the neck of the femur, but thetrochanteric region is more depressed and the trochanter lies nearerthe middle line. The limb is shortened, and movements of the joint arepainful and restricted, especially medial rotation. In some casesthere is pain along the course of the obturator nerve. On rectal or vaginal examination there is localised tenderness overthe pelvic aspect of the acetabulum, and in some cases a convexprojection, or even crepitating fragments can be detected. Thediagnosis is completed by an X-ray picture. When the head of the femur penetrates the acetabulum, reduction shouldbe attempted by traction and manipulation. The pelvis is held rigid, and the thigh is flexed and forcibly adducted, while the medial sideof the thigh rests against a firm sand-bag; the femoral head is thuslifted out of the pelvis. In a recent injury the amount of forcerequired is relatively slight. The head is kept in its correctedposition by extension. Fracture of the _upper and back part of the rim_ of the acetabulum mayaccompany or simulate dorsal dislocation of the hip. Crepitus may bepresent in addition to the symptoms of dislocation, and afterreduction the displacement is easily reproduced. The treatment is byextension with the limb adducted. #Fracture of Individual Bones of the Pelvis. #--_Ilium. _--The expandedportion of the iliac bone is often broken by direct violence, thedetached fragments varying greatly in size and position (Fig. 56). The whole or part of the _crest_ may be separated by similar forms ofviolence. When the fracture implicates the _ala_ of the bone, it usually startsat the triangular prominence near the middle of the crest, and runsbackwards or forwards, passing for a variable distance into the iliacfossa. The displaced fragment can sometimes be palpated and made tomove when the muscles attached to it are relaxed. This is done byflexing the thighs and bending the body forward and towards theaffected side. Pain and crepitus may be elicited on making thisexamination. These fractures are treated by applying a roller bandage or broadstrips of adhesive plaster over the seat of fracture, and by placingthe patient in such a position as will relax the muscles attached tothe displaced fragment--in the case of the iliac spine by flexing thethigh upon the pelvis; in the case of the crest or ala by raising theshoulders. Union takes place in three or four weeks. In young persons, the _anterior superior spine_ has been torn off anddisplaced downwards by powerful contraction of the sartorius muscle;and the _anterior inferior spine_ by strong traction on theilio-femoral or [inverted Y]-shaped ligament. These injuries are besttreated by fixing the displaced fragment in position by a peg orsilver wire sutures and relaxing the muscles acting on it. Fracture of the _ischium_ alone is rare. It results from a fall on thebuttocks, the entire bone or only the tuberosity being broken. Thereis little or no displacement, and the diagnosis is made by externalmanipulation and by examination through the rectum or vagina. A longitudinal fracture of the _sacrum_ may implicate the posteriorpart of the pelvic ring, as has already been mentioned. In rare casesthe lower half of the bone is broken _transversely_ from a fall orblow, and the lower fragment is bent forward so that it projects intothe pelvis and may press upon or tear the rectum, or the sacral nervesmay be damaged, and partial paralysis of the lower limbs, bladder, orrectum result. These fractures are frequently comminuted and compound, and the soft parts may be so severely bruised and lacerated thatsloughing follows. On rectal examination the lower segment of the bonecan be felt, and on manipulating it pain and crepitus may be elicited. Fracture of the _coccyx_ may be due to a direct blow, or may occurduring parturition. As a result of this injury the patient may havesevere pain on sitting or walking, and during defecation. The loosefragment can be palpated on rectal examination. There is considerabledifficulty in keeping the fragment in position, and if it projectstowards the rectum it should be removed. If the lower fragment unitesat an angle so as to cause pressure on the rectum, it gives rise tothe symptoms of _coccydynia_, which may call for excision. INJURIES IN THE REGION OF THE HIP These include the various fractures of the upper end of the femur;dislocation and sprain of the hip-joint; and contusion of the hip. #Surgical Anatomy. #--The strength of the hip-joint depends primarilyon its osseous elements--the rounded head of the femur filling thedeep socket of the acetabulum, to the bottom of which it is attachedthrough the medium of the ligamentum teres. The edge of the acetabulumis specially strong above and behind, while at its lower margin thereis a gap, bridged over by the labrum glenoidale (cotyloid ligament). In relation to fractures of the upper end of the femur, it is to beborne in mind that as the antero-posterior diameter of the neck isless than that of the shaft, and as a considerable portion of thegreat 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 isborne by the neck of the bone and not by the trochanter. The head andneck of the femur are nourished chiefly by the thick, vascularperiosteum, and through certain strong fibrous bands reflected fromthe attachment of the capsule--the retinacular or cervical ligamentsof Stanley. The integrity of these ligaments plays an important partin determining union in fractures of the neck of the femur, both bykeeping the fragments in position and by maintaining the blood-supplyto the short fragment. Whether it be true or not that an alteration inthe angle of the femoral neck takes place with advancing years, it isgenerally recognised that this change is of no importance in relationto fractures in this region. The articular capsule of the hip is of exceptional strength. It isattached above to the entire circumference of the acetabulum, andbelow to the neck of the femur in such a way that while the whole ofthe anterior and inferior aspects of the neck lies within itsattachment, only the inner half of the posterior and superior aspectsis intra-capsular. The capsule is augmented by several accessorybands, the most important of which is the _ilio-femoral or [invertedY]-shaped ligament_ of Bigelow, which passes from the anteriorinferior iliac spine to the anterior inter-trochanteric line, itsfasciculi being specially thick towards the upper and lower ends ofthis ridge. The medial limb of this ligament limits extension of thethigh, while the lateral limits eversion and adduction. The weakestpart of the capsular ligament lies opposite the lower and back part ofthe joint. The hip-joint is surrounded by muscles which contribute to itsstrength, the most important from the surgical point of view being theobturator internus, which plays an important part in certaindislocations, and the ilio-psoas, which influences the attitude of thelimb in various lesions in this region. Except in thin subjects, the constituent elements of the hip-jointcannot be palpated through the skin. A line drawn vertically downwardsfrom the middle of Poupart's ligament passes over the centre of thejoint, which in adults lies on the same level as the tip of the greattrochanter. In children it is somewhat higher. For purposes of clinical diagnosis it is necessary to locate certainbony prominences, the most important being--(1) The _anterior superioriliac spine_, which is most readily recognised by running the fingersalong Poupart's ligament towards it. (2) The _ischial tuberosity_, which in the extended position of the limb is overlapped by the lowermargin of the gluteus maximus muscle, and is therefore not easilylocated with precision. By flexing the limb and making pressure frombelow upwards in the gluteal fold, the smooth, rounded prominence canusually be detected. (3) The quadrilateral _great trochanter_ isreadily recognised on the lateral aspect of the hip. Its highest pointor _tip_ can best be felt by pressing over the gluteal muscles fromabove downwards. _Clinical Tests. _--If a line is drawn from the anterior superior iliacspine to the most prominent part of the ischial tuberosity, it justtouches the tip of the great trochanter. This is known as _Nélaton'sline_ (Fig. 58). [Illustration: FIG. 58. --Nélaton's Line. ] _Bryant's test_ (Fig. 59) is applied with the patient lying on hisback, and consists in dropping a perpendicular AB from the anteriorsuperior iliac spine, and drawing a line CD from the tip of the greattrochanter to intersect the perpendicular at right angles. This isdone on both sides of the body, and the length of the lines CDcompared. Shortening on one side indicates an upward displacement ofthe trochanter, lengthening a downward displacement. The third side ACof the triangle indicates the distance between the anterior spine andthe tip of the trochanter. [Illustration: FIG. 59. --Bryant's Line. ] _Chiene's test_, which is simpler than either of these, consists inapplying a strip of lead or tape across the front of the body at thelevel of the anterior superior iliac spines, and another touching thetips of the two trochanters. Any want of parallelism in these linesindicates a change in the position of one or other trochanter. FRACTURE OF THE UPPER END OF THE FEMUR The fractures of the upper end of the femur that are liable to beconfused with one another and with dislocations of the hip, includefractures of the head, the neck, the trochanters, and separation ofthe upper epiphyses, and fracture of the shaft just below thetrochanters. Fracture of the #head of the femur# is rare, and is usually acomplication of backward dislocation of the hip. It takes the form ofa split of the articular surface caused by impact against the edge ofthe acetabulum, and is analogous to the indentation fracture of thehead of the humerus, which may accompany dislocation of the shoulder. The #epiphysis of the head#, which lies entirely within the capsuleof the joint (Fig. 60), is occasionally separated, and the symptomsclosely simulate those of fracture of the narrow part of the neck. Ifthe condition is overlooked or imperfectly treated, it may in courseof time be followed by coxa vara. [Illustration: FIG. 60. --Section through Hip-Joint to show epiphysesat upper end of femur, and their relation to the joint. _a_, Epiphysis of head. _b_, Epiphysis of great trochanter. _c_, Epiphysis of small trochanter. _d_, Capsular ligaments. (After Poland. )] FRACTURE OF THE NECK It has long been customary to divide fractures of the neck of thefemur into two groups--"intra-" and "extra-capsular"; but as in aconsiderable proportion of cases the line of fracture falls partlywithin and partly without the capsule, this classification is wantingin accuracy. It is more correct to divide these fractures into (1)those occurring _through the narrow part of the neck_, which arenearly always purely intra-capsular; and (2) those occurring _throughthe base of the neck_ in which the line of fracture lies inside thecapsule in front, but outside of it behind. It is of considerable importance to distinguish between fractures inthese two positions. The first group occurs almost exclusively in oldpersons as a result of slight forms of indirect violence, and it isliable, on account of the feeble vascular supply to the upperfragment, to be followed by absorption of the neck, which delays ormay even entirely prevent union (Fig. 61). The second group usuallyoccurs in robust adults, and results from severe forms of violenceapplied to the trochanter. In this group firm osseous union usuallytakes place. [Illustration: FIG. 61. --Fracture through Narrow Part of Neck of Femuron section. The Neck of the bone has undergone absorption. ] #Fracture of the Narrow Part of the Neck# or #Intra-capsularFracture#. --This fracture is most frequently met with in elderlypersons, especially women, and is usually produced by comparativelyslight forms of indirect violence--such, for example, as result fromthe foot catching on the edge of a carpet, a stumble in walking, ormissing a step in going downstairs. The line of fracture, which is usually transverse but may be obliqueor irregular, lies for the most part within the capsule, and theposterior part of the neck is more comminuted than the anterior. Thedistal fragment, which includes the base of the neck, thetrochanters, and the shaft, is usually displaced upward and rotatedlaterally. If the periosteum and the retinacular ligaments remainintact, displacement is prevented and union favoured. Impaction is less common than in fracture through the base of theneck; it usually results from the patient falling on the trochanter, the distal fragment being driven as a wedge into the proximal (Fig. 62). [Illustration: FIG. 62. --Impacted Fracture through Narrow Part of Neckof Femur. ] _Clinical Features. _--In non-impacted cases the limb is at oncerendered useless, and the patient is unable to rise. There is pain andtenderness in the region of the hip on making the slightest movement;and a specially tender spot may be localised, indicating the seat offracture. On placing the pelvis as square as possible, and comparing themeasurements of the limbs from the anterior superior spine to themedial malleolus, shortening of the injured limb to the extent of from1 to 3 inches may be found. On applying Nélaton's, Bryant's, orChiene's test, the tip of the great trochanter will be found elevated. It is also farther back and less prominent than normal. The whole limb is usually everted to a greater or less degree, and isslightly abducted. In some cases, when the impaction is of theanterior portion of the neck, the limb is inverted. On comparing theilio-tibial band of the fascia lata on the two sides, it is found tobe relaxed on the side of the injury. The violence being as a rule indirect, there is at first little or nodiscoloration in the vicinity of the hip, but this may appear a fewdays later. Crepitus is not a constant sign, and should not be sought for, as thenecessary manipulations are liable to disengage the fragments and toincrease the deformity. For the same reason rotatory movements are tobe avoided. In all cases in which the diagnosis is uncertain, the patient shouldbe put to bed, and treated as for a fracture. In the course of a fewdays it is nearly always possible to make an accurate diagnosis. In examining an old person who has sustained an injury in the regionof the hip, it should be borne in mind that the limb may be shortenedand everted as a result of arthritis deformans, and that the symptomsof that disease may simulate those of fracture. In arthritisdeformans, however, the ilio-tibial band of the fascia lata is notrelaxed as it is in fracture. [Illustration: FIG. 63. Fracture of Neck of Right Femur, showingshortening, abduction, and eversion of limb. ] In some cases, and particularly in those in which the periosteum ofthe neck and the retinacular ligaments remain intact, the shorteningdoes not become apparent till a few days after the accident. As theother symptoms are correspondingly obscure, the condition is apt to bemistaken for a bruise. In all doubtful cases the part should beexamined from day to day, and, if possible, the X-rays should be used. In _impacted_ cases the signs of fracture are often obscure, and thepatient may even be able to walk after the accident. The skin over thetrochanter is generally discoloured from bruising. Eversion is usuallypresent, but there may be little shortening. Crepitus is absent. Inold people it is never advisable to undo impaction, as theinterlocking of the bones favours the occurrence of osseous union. _Prognosis. _--A fracture of the neck of the femur in an old person isalways attended with danger to life, a considerable proportion of thepatients dying within a few weeks or months of the accident fromcauses associated with it. In some cases the mental and physical shockso far diminishes the vitality of the patient that death ensues withina few days. It is possible that fat embolism may account for death insome of the more rapidly fatal cases. In others, the continued dorsalposition induces hypostatic congestion of the lungs, or, owing to thedifficulties of nursing, bed-sores may form and death result fromabsorption of toxins. Frequently the prolonged confinement to bed, thecontinuous pain, and the natural impairment of appetite wear out thestrength. In many cases the patient becomes peevish, irritable, ormentally weak. Osseous union is the exception in intra-capsular fracture, especiallywhen the periosteum and the retinacular ligaments have been completelytorn, but in sub-periosteal and in impacted fractures it sometimesoccurs. As a rule, however, the neck of the femur becomes absorbed anddisappears, the head of the bone comes to lie in contact with the baseof the trochanter, and a false joint forms (Fig. 64). Chronic changesof the nature of arthritis deformans may occur in and around suchfalse joints. [Illustration: FIG. 64. --Fracture of Narrow Part of Neck of Femur. Theneck has become absorbed, the head has not united, and a false jointhas formed. ] When osseous union fails to take place, although the patient mayeventually be able to get about, he can do so only with the aid of astick or crutch, and as there is marked shortening, he walks with adecided limp. There is considerable antero-posterior thickening ofthe neck of the femur, and the femoral vessels may be pushed forwardin Scarpa's triangle. _Treatment. _--In treating a fracture through the narrow part of theneck, it is necessary to consider the age and general condition of thepatient; whether the fracture is impacted or not; and the site of thefracture--whether in the narrow part of the neck or at its base. "Thefirst indication is to save life, the second to get union, and thethird to correct or diminish displacements" (Stimson). In old and debilitated patients, bony or even firm fibrous unionseldom takes place, and it is generally advisable to get them out ofbed as speedily as possible. For the first few days the patient may bekept on his back, the limb massaged daily, and in the intervalsteadied by sand-bags; but on the first sign of respiratory or cardiactrouble he should be propped up in bed, and as soon as possible liftedinto a chair. In all such cases care should be taken to avoid undoingimpaction. When the general condition of the patient permits of it, an attemptshould be made to secure bony union. _Extension_ is applied by one or other of the methods described forfracture of the shaft (p. 149), so modified as to maintain the limb_in the abducted position_, which ensures the most accurate appositionof the fragments (Royal Whitman). This position may be maintained by ahinged long-splint, an adaptation of Thomas' hip splint. The fragmentsmay be fixed to one another by a long steel peg introduced through theskin over the great trochanter, and passed so as to transfix them; orthey may be exposed by operation and sutured together. Albe uses abone peg. #Fracture of the Neck of the Femur in Children. #--The use of theX-rays has shown that this fracture is comparatively common inchildren, as a result of a fall or a forcible twist of the leg. Thefracture is most frequently of the greenstick variety; when complete, it is usually impacted. There is shortening to the extent of a half orthree-quarters of an inch, a slight degree of eversion, the movementsof the hip are restricted, and there is some pain. The patient isoften able to move about after the accident, but walks with a limp. Unless the use of the X-rays reveals the fracture, the condition isliable to be overlooked. When the lesion is diagnosed, the deformity should be completelycorrected, any impaction that exists being undone; and the limb is putup in a wide abduction splint (p. 221) or in a plaster-of-Paris casein the position of extreme abduction. If the condition is not recognised and treated, it is liable to befollowed by the development of coxa vara (Royal Whitman) (Fig. 65). [Illustration: FIG. 65. --Coxa Vara following Fracture of Neck of Femurin a child. ] #Fracture through the Base of the Neck. #--This fracture is usuallyproduced by a fall on the great trochanter, although it isoccasionally due to a fall on the feet or knees. [Illustration: FIG. 66. --Non-impacted Fracture through Base of Neck. ] Although often spoken of as "extra-capsular, " the line of fracture isgenerally partly within and partly without the capsule. The fractureusually lies close to the junction of the neck with the shaft, and inthe great majority of cases is accompanied by breaking of one or bothtrochanters. This is due to the neck being driven as a wedge into thetrochanters, splitting them up. When the fragments remain interlocked, the fracture is of the _impacted_ variety (Fig. 67). [Illustration: FIG. 67. --Fracture through Base of Neck of Femur withImpaction into the Trochanters. ] _Clinical Features. _--Although this fracture is commonly met with instrong adults, it may occur in the aged. The lateral aspect of the hip shows marks of bruising, and there issevere pain and a considerable degree of shock. The limb lieshelpless; there is generally marked eversion, with shortening, which, in _non-impacted_ cases, may amount to 1-1/2 or 2 inches, and isevident immediately after the accident; it is due to the distalfragment being drawn up by the muscles inserted into the greattrochanter and upper end of the shaft. In a limited number of casesthe distal fragment lies in front of the proximal, and there isinversion of the limb. [Illustration: FIG. 68. --Non-impacted Fracture through Base of Neck. Union has occurred with diminution of angle of neck--Coxa Vara. ] On applying the various tests, the great trochanter is found to bedisplaced upwards, there is some antero-posterior broadening of thetrochanteric region, and the ilio-tibial band is relaxed. On pressingthe fingers into the lateral part of Scarpa's triangle, a massconsisting of the bony fragments may be felt, and is tender onpressure. Unnatural mobility with crepitus may be elicited. In the _impacted variety_, the shortening seldom exceeds one inch; theeversion is less marked; there is some power of voluntary movement;and crepitus is absent. The broadening of the trochanteric region isgreater, and the great trochanter is approximated to the acetabulum. _Prognosis. _--The risks to life in the aged are similar to those ofintra-capsular fracture. In youths and healthy adults the chief dangeris that the limb may be shortened and its function thereby impaired. As the periosteum and retinacular ligaments which transmit the bloodvessels to the proximal fragments are intact, bony union is the rule. There is always, however, considerable thickening in the region of thetrochanter due to displaced fragments and callus, and in a certainnumber of cases, even with the greatest care in treatment, there is avarying degree of shortening and eversion of the limb. In cases inwhich the distal fragment lies in front of the proximal there ispermanent inversion. _Treatment. _--As this fracture usually occurs in robust patients, there is no danger from prolonged confinement to bed; and as unionwithout deformity can be attained in no other way, this is alwaysadvisable. When the shortening and eversion are excessive, they shouldbe completely corrected under anæsthesia before the retentiveapparatus is applied, any impaction that exists being undone. When thedeformity resulting from impaction is slight, however, it is best toleave it, as it facilitates speedy and firm union. Extension is obtained by the same appliances as are used in fractureof the shaft, and the limb should be kept in the abducted position. Fracture of the #greater trochanter# occurring apart from fracture ofthe neck usually results from direct violence, but may be due tomuscular action. The trochanter is displaced by the gluteal muscles, causing broadening of the lateral aspect of the hip. In young personsthe _epiphysis_ of the great trochanter may be separated, but this israre. The treatment consists in retaining the fragments in position bykeeping the limb abducted between sand-bags, or by pegs driven inthrough the skin. #Fracture immediately below the lesser trochanter# may be produced bydirect or by indirect violence, and the displacement depends largelyon whether the line of fracture is transverse or oblique. The proximalfragment is kept tilted forward, rotated laterally, and abducted bythe ilio-psoas muscle and the lateral rotators inserted in the regionof the great trochanter. The lower fragment passes upward, and isrotated laterally by the weight of the limb; the displacement isaggravated by the contraction of the flexor and adductor muscles. Thetilting of the proximal fragment may be increased by the displaceddistal fragment pushing it forward. On account of the difficulty of controlling the short proximalfragment, union is liable to take place with considerable shorteningand deformity (Fig. 69). [Illustration: FIG. 69. --Fracture of the Femur just below the SmallTrochanter united, showing flexion and lateral rotation of upperfragment. ] _Treatment. _--When it is found, under an anæsthetic, that thedisplacement can be completely reduced, and does not tend to recur, this fracture is treated on the same lines as fracture of the shaft ofthe bone. In cases in which the proximal fragment cannot be brought into linewith the distal one, however, it is necessary to flex, evert, andabduct the thigh in order to get the fragments into apposition andinto line. A Hodgen's splint (Fig. 77) is applied with the highestsling under the upper end of the lower fragment and with sufficientextension to correct overriding. The upper end is then strongly liftedby a counter-weight of about 15 lbs. This secures apposition of thefragments with slight forward angulation at the seat of fracture. Bythe end of a month sufficient callus has formed to preventre-displacement, and if the counter-weight is gradually diminished thetwo fragments sag back together into a normal alignment (J. N. J. Hartley). A double-inclined plane (Fig. 70), with extension applied inthe axis of the thigh, gives satisfactory results. [Illustration: FIG. 70. --Adjustable Double-inclined Plane. ] DISLOCATION OF THE HIP It is unnecessary for our present purpose to attempt a comprehensiveclassification of the numerous varieties of dislocation that have beenmet with at the hip-joint. It will suffice if we divide them intothose in which the head of the femur passes backward, and comes torest on the dorsum ilii, or in the vicinity of the great sciaticnotch; and those in which it passes forward and comes to rest in theobturator foramen, or on the pubes (Fig. 71). [Illustration: FIG. 71. --Diagram of the most common Dislocations ofthe Hip. ] The backward are much more common than the forward dislocations, incontrast to what obtains at the shoulder, where the forward varietiespredominate. On account of the great strength of the hip-joint, dislocation is byno means a common injury. It occurs most frequently in strong adultsafter the epiphyses have ossified, and before the bones have commencedto become brittle; and it is much more common in men than in women. Itis invariably the result of severe violence, the limb at the momentbeing in such a position that the ligaments are on the stretch and themuscles taken at a disadvantage. The head of the femur usually leavesthe joint at the lower and back part, where the socket is most shallowand the ligaments weakest. The ligamentum teres is almost always tornfrom its femoral attachment, and one or more of the muscles insertedin the region of the trochanters may be ruptured. The [invertedY]-shaped ligament, on the other hand, is seldom torn, and so long asit remains intact the dislocation belongs to one or other of the typesabove 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 individualdescription. The central dislocation of German authors, in which thehead is driven through the floor of the acetabulum, is described onpage 126. Like other dislocations, those of the hip may be complicated bylaceration of muscles, blood vessels, or nerves, or by fracture of oneor other of the bones in the vicinity. #Dislocation on to the Dorsum Ilii. #--This, the commonest form ofdislocation of the hip, is usually the result of the patient fallingfrom a height, or receiving a heavy weight on the back while stoopingforward with the thigh flexed, slightly adducted, and rotatedmedially. It is also said to have occurred from muscular action. Theshaft of the femur acts as the long limb of a lever of which the neckis the short limb, the femoral attachment of the [inverted Y]-ligamentforming the fulcrum. The head, thus brought to bear upon the lower andback part of the capsule, tears it and leaves the socket, passingupwards and coming to rest on the dorsum of the ilium, above andanterior to the tendon of the obturator internus (Fig. 73). Thearticular surface is directed backward, while the trochanter looksforward. [Illustration: FIG. 72. --Dislocation of Right Femur on to DorsumIlii. ] _Clinical Features. _--The affected limb is flexed, adducted, andinverted, so that the knee crosses the lower third of the oppositethigh, and the ball of the great toe lies on the dorsum of the soundfoot. There is shortening to the extent of from 1-1/2 to 2 inches, thetrochanter being displaced above Nélaton's line, and lying nearer tothe anterior superior iliac spine than on the normal side. The patientis unable to move the limb or to bear weight upon it; abduction andlateral rotation are specially painful; and traction fails to restorethe limb to its proper length. On making these attempts acharacteristic elastic resistance is felt. The head of the femur in its new position may sometimes be feltthrough the fibres of the gluteus maximus, but swelling of the softparts often obscures this sign. The normal depression behind thegreat trochanter is lost, the gluteal fold is raised, and there isoften a degree of lordosis which compensates for the flexion. Thefingers can be pressed more deeply into Scarpa's triangle on thedislocated than on the normal side--a point in which this injurydiffers from fracture of the base of the neck of the femur. In a certain number of cases the lateral limb of the [invertedY]-ligament is ruptured and the limb is everted--_dorsal dislocationwith eversion_. [Illustration: FIG. 73. --Dislocation on to Dorsum Ilii. Note relationof neck of femur to tendons of obturator internus and gemelli(diagrammatic). ] #Dislocation into the Vicinity of the Great Sciatic Notch#, or"_dislocation below the tendon_. "--This variety of backwarddislocation is less common than that on to the dorsum, althoughproduced in the same way. The head of the femur passes beneath theobturator internus, and this tendon, catching on its neck, checks itsupward movement (Fig. 74). The _clinical features_ are the same as those of the dorsal variety, but, on the whole, are less marked. _Differential Diagnosis. _--Backward dislocation of the hip is usuallyeasily recognised. When dislocation below the tendon occurs in a stoutperson, however, it is liable to be overlooked on account of thedifficulty of feeling the displaced bone, and of the comparativelyslight amount of deformity present. The nature of the accident, theabsence of broadening of the trochanter, and the adduction andinversion of the limb are usually sufficient to prevent a dislocationbeing mistaken for an impacted extra-capsular fracture. #Dislocation into the Obturator Foramen# (Fig. 71). --This dislocationis produced by great force applied from behind while the thigh isflexed and abducted, as when a weight falls on the back of a manstooping forward with the legs wide apart. It may also result fromviolent abduction by wide separation of the thighs. The capsule gives way at its medial and lower part, and the head ofthe femur comes to rest on the surface of the external obturatormuscle, its articular surface looking forward, while the trochanterlooks backward. _Clinical Features. _--In the standing position the thigh is slightlyflexed and abducted, with the foot pointing directly forward or alittle outward. The body is bent forward to relax the ilio-psoasmuscle and the [inverted Y]-ligament, the foot is advanced and theheel drawn up. It is not uncommon for the patient to be able to walkafter the accident, and only to seek advice some time later on accountof inability to adduct and extend the limb. There is apparentlengthening of the limb due to tilting of the pelvis downward on theaffected side. The hip is flattened, the trochanter less prominentthan usual, and the head of the bone may sometimes be felt in itsabnormal position. [Illustration: FIG. 74. --Dislocation into the vicinity of theIschiatic Notch. Note relation of neck of femur to tendons ofobturator and gemelli, "Dislocation below the tendon" (diagrammatic). ] #Dislocation on to the pubes# is a further degree of the obturatorform (Fig. 71). It is usually produced by forcible hyper-extension andlateral rotation of the hip, such as occurs when the body is bent backwhile the thigh remains fixed. The capsule is torn farther forward than in the other varieties, andthe head rests on the horizontal ramus of the pubes against theilio-pectineal line. _Clinical Features. _--There is marked eversion, flexion, andabduction, but the shortening is inconsiderable. The ilio-psoas and[inverted Y]-ligament are tense. The head of the femur may be felt inthe groin, with the femoral vessels over, or to one or other side ofit. There is sometimes pain and numbness in the distribution of thefemoral (anterior crural) nerve. The prominence of the greattrochanter is lost. #Treatment of Dislocation of the Hip. #--For the reduction of adislocation of the hip complete anæsthesia is necessary, and thepatient should be placed on a firm mattress on the floor to give thesurgeon the best possible purchase upon the limb. The surgeon graspsthe ankle with one hand, while the other is placed behind the head ofthe tibia, the leg being held at right angles to the thigh. Anassistant meantime steadies the pelvis by making firm pressure overthe iliac crests. As the chief obstacle to reduction is the tension of the ilio-femoralligament, the first indication is to relax this structure by flexingthe hip _to its fullest extent_. In the _backward_ varieties (dorsal and sciatic) the [invertedY]-ligament is relaxed by flexing the thigh upon the pelvis in theposition of adduction. The thigh is then fully abducted, to cause thehead of the bone to retrace its steps forwards towards the rent in thecapsule; and at the same time rotated laterally to relax the rotatormuscles. This combined movement tends also to open up the rent in thecapsule. Finally, the limb is quickly extended to cause the head toenter the socket. This object is often aided by making verticaltraction or lifting movements on the abducted and laterally rotatedlimb before extending. For the reduction of the _forward_ varieties (obturator and pubic), the thigh is first fully flexed on the pelvis, but in the abductedposition. The limb is then strongly rotated medially and abducted, andfinally extended. Lifting movements may be found useful in these casesalso. All methods of reduction by forcible traction on the extended limb areto be avoided, as they fail to meet the primary indication of relaxingthe [inverted Y]-ligament. After reduction, the limb is steadied by sand-bags; massage is carriedout from the first, and movement after a few days. The range ofmovement is gradually increased, and the patient is allowed to use thelimb with caution in from two to three weeks. When the rim of the acetabulum has been fractured, the patient must beconfined to bed with extension for six to eight weeks, to avoid therisk of re-dislocation. Changes of the nature of chronic arthritis are liable to occur in andaround the joint in old and rheumatic subjects; and atrophy orparalysis of muscles may follow, if their nerves are implicated. #Old-standing Dislocation. #--It is impossible to lay down anytime-limit for attempting reduction in old-standing dislocations ofthe hip. Manipulation may succeed in cases of some months' standing, and may fail when the bone has been out only a few weeks. In certaincases, even after reduction has been effected, there is a markedtendency to re-displacement. In any case, the attempt does good bybreaking down adhesions, provided no undue force is employed such asmay damage the sciatic nerve or vessels, or fracture the neck of thefemur, and success may attend on a second or even a third attempt atintervals of from three to five days. If manipulation fails, and ifthe deformity is great and the usefulness of the limb seriouslyimpaired, an attempt may be made to effect reduction by operation; theoperation, however, is one of considerable difficulty, and in theevent of failure the head of the bone should be excised. If the headhas formed a new socket for itself and there is a fairly useful joint, the condition should be left alone. _Congenital dislocation of the hip_ is described with Deformities ofthe Extremities. #Sprain# of the hip is comparatively rare. It results from milderdegrees of the same forms of violence as produce dislocation. Theligaments are stretched or partly torn, and there is effusion of fluidinto the joint. Pressure over the joint elicits tenderness; and thelimb assumes the position of slight flexion, abduction, and lateralrotation, but there is no alteration in length. Such injuries, unlesscarefully treated by massage and movement from the outset, are apt tobe followed by the formation of adhesions, resulting in stiffness ofthe joint. #Contusion# in this region, on the other hand, is not uncommon. It isproduced by a fall on the trochanter, and gives rise to symptoms whichsimulate to some extent those of fracture of the neck. The limb liesin the position of slight flexion, but the bony points retain theirnormal relationship to one another, and there is no shortening. Theswelling and tenderness often prevent a thorough examination beingmade, and when any doubt remains as to the diagnosis, the patientshould be kept in bed till the doubt is cleared up by the use of theX-rays. If the bone has been broken, this will reveal itself in thecourse of a few days by the occurrence of shortening and otherevidence of fracture. In elderly patients, contusion of the hip may be followed by changesin the joint of the nature of arthritis deformans; and it has beenstated, although proof is wanting, that absorption of the neck of thefemur sometimes occurs. These injuries are treated by rest in bed, massage, and the other measures already described as applicable tosprains and contusions. FRACTURE OF THE SHAFT OF THE FEMUR This group includes all fractures between that immediately below thelesser trochanter and the supra-condylar fracture. _In adults_, when due to direct violence, the fracture is usuallytransverse, and may be attended with comparatively littledisplacement. Indirect violence, on the other hand, usually producesan oblique fracture, which is frequently comminuted and oftencompound. The break is most commonly situated a little above themiddle of the shaft, the obliquity being downward, forward, andmedially, and of such a nature that the fragments tend to override oneanother (Fig. 75). The most serious forms are those associated withgun-shot wounds. [Illustration: FIG. 75. --Longitudinal section of Femur showing recentFracture of Shaft with overriding of Fragments. ] The direction and nature of the displacement depend more upon thefracturing force, the weight of the lower part of the limb, and theaction of the muscles attached to the respective fragments, than uponthe direction of the obliquity. As a rule, the proximal fragmentpasses forward and laterally, and is maintained in this position bythe ilio-psoas and glutei muscles, while the distal fragment isdisplaced upward and medially and is rotated outward by the combinedaction of the weight of the limb, the longitudinal muscles, and theadductors. _Clinical Features. _--The limb is at once rendered useless, and thereis great swelling from effusion of blood in the region of thefracture. This, together with the muscularity of the part, oftenrenders an accurate diagnosis as to the site and direction of thefracture exceedingly difficult. The shortening varies from 1/2 inch to3 or 4 inches--averaging about 1 inch in adults--and eversion isalways marked. Mobility may be detected and crepitus elicited withoutdisturbing the patient, by placing the hand under the seat of fractureand gently attempting to raise the limb; or by fixing the proximalfragment by one hand placed in front of it while the distal part ofthe limb is carefully lifted. It will be found that the greattrochanter does not rotate with the lower segment of the femur. Thesetests must be employed with great caution lest the deformity beincreased or the fracture rendered compound. In many fractures of the thigh, and especially in those produced byindirect violence, the knee is sprained, and there is a considerableeffusion into the joint, and this may lead to stiffness unless massageis employed from the outset. _Treatment. _--Fracture of the shaft of the femur is one of the mostdifficult fractures in the body to treat successfully. In cases ofoblique fracture, the patient should be warned that shortening to theextent of from 3/4 to 1 inch is liable to result, however carefullythe treatment may be carried out. This does not necessarily imply apermanent limp, as by tilting the pelvis he may be enabled to walkquite well; if this is not sufficient to equalise the length of thelimbs, the sole of the boot may be raised. A general anæsthetic isnecessary to ensure accurate reduction, and extension must be appliedto maintain the fragments in apposition and prevent shortening. Thesplint which has been found most generally useful is the Thomas' kneesplint, the ring of which rests against the ischial tuberosity. Toadmit of flexion at the knee the Thomas' splint should have a hingedattachment on which the leg is supported. This leaves the knee freeand allows of movement being made to prevent stiffness. The limb issuspended by broad strips of flannel or linen, fixed to the side barsof the splint by means of safety pins or strong spring paper clips. In simple fractures extension may be obtained by means of broad stripsof adhesive plaster applied to each side of the thigh and reachingwell above its middle. The plaster is secured by a bandage, and to itslower ends are attached broad tapes which are buckled to a stirrupthrough which traction is made by means of a cord passing over apulley fixed to an upright at the foot of the bed. The lower end of the splint is suspended, and the counter-extension isobtained by pressing the ring against the ischial tuberosity. Toprevent the ring overriding the tuberosity and pressing on the softtissues of the buttock, it is slung by the rope to a cross-bar abovethe bed, _e. G. _ the Balkan frame (Fig. 81). In compound fractures the presence of a wound may prevent adhesiveplaster being used, and it is necessary to take the extension directlythrough the bone. A posterior gutter splint is applied to preventsagging. After pulling the skin upward, a small incision is made overthe upper expanded border of each condyle, and the points of anice-tong calliper are made to grip the bone without penetrating intothe cancellous tissue. A cord attached to the handles of the calliperpasses over a pulley and supports the weight necessary to give thedesired amount of traction (Fig. 81). An alternative method of exerting traction directly through the boneis by means of Steinmann's apparatus (Fig. 76). In a moderatelymuscular adult, a weight of from 12 to 15 pounds by means of strips ofplaster applied to the skin, or 10 to 25 pounds by direct traction onthe bone, should be applied in the first instance. The correct weightto employ is that which maintains the length of the limb at itsnormal, and is therefore liable to revision from time to time. [Illustration: FIG. 76. --Radiogram of Steinmann's Apparatus appliedfor Direct Extension to the Femur. ] _Hodgen's splint_ is a comfortable and efficient means of treatingthese fractures, as it allows the patient a certain amount ofmovement, admits of the part being massaged, and facilitates nursing. It consists of a wire frame (Fig. 77) to one side of which a series ofstrips of flannel about 4 inches wide are attached. Extensionstrapping is first applied, and then the frame, which extends from thelevel of Poupart's ligament to well beyond the sole, is placed overthe front of the limb, and the loose ends of the flannel stripsbrought round behind the limb, and fixed to the other side of theframe, convert it into a sling. The tapes attached to the extensionstrapping are now tied to the end of the frame. By suspending the limbin this splint by means of cords passing obliquely over a pulleyattached to an upright at the foot of the bed, the weight of the limbis made to act as the extending force. [Illustration: FIG. 77. --Hodgen's Splint. ] The retentive apparatus should be worn for from six to eight weeks, after which the patient is allowed up with crutches, which he usuallyrequires to use for three or four weeks longer, before he can bear hisweight upon the limb. The old dictum of Nélaton, that the treatment offracture of the thigh should last for a hundred days, is a safeworking-rule. In fractures of the shaft an ordinary Thomas' kneesplint, or a "walking calliper splint" which is fixed to the heel ofthe boot, may be worn when the patient gets up. Union may be exceedingly slow in fracture of the femur, and may evenbe delayed for months. Mal-union sometimes occurs, the fractureuniting with an angular deformity outward and forward. Re-fracture is liable to occur if the patient falls or twists the limbwithin a few months of the original injury. It has happened notinfrequently just after the retentive apparatus has been removed fromthe nurse raising the limb by the foot in order to wash it. _Liston's long splint_ is only employed as a temporary expedient forimmobilising the fragments during transport; a Thomas' splint, ifavailable, is better for this purpose. [Illustration: FIG. 78. --Long Splint with Perineal Band. ] _Operative treatment_ is sometimes called for when simpler measuresfail to reduce the displacement, and in cases of un-united fracture orof vicious union. The incision, which must be free, is preferablyplaced in the line of the lateral intermuscular septum; theperiosteum is interfered with as little as possible. The applicationof extension by the calliper method is often of great service, duringthe operation, in enabling the operator to get the fragments intoposition; sometimes no fixation is required, but, if necessary, recourse is had to plating or pegging, or an intra-medullary pin. Theextension apparatus is retained for three or four weeks. Theafter-treatment is carried out on the same lines as for simplefracture, but the retentive apparatus must be worn for a considerablylonger period. [Illustration: FIG. 79. --Fracture of Thigh treated by VerticalExtension. ] #Fracture of the Femur in Children. #--In children, especially belowthe age of ten, this fracture is quite common. It is often of thegreenstick variety, or, if complete, is transverse and sub-periosteal, and as it is accompanied by few symptoms and but little deformity, isliable to be overlooked. When there is displacement, the deformity is similar to that inadults, and the treatment is carried out on the same lines. In young children the nursing is greatly facilitated by applyingvertical extension to one or both lower extremities (Fig. 79). If thefracture is transverse and shows little tendency to displacement, thelocal Gooch splints may be dispensed with; in any case, massage shouldbe employed from the first. The patient may be allowed out of bed in from three to four weeks, wearing a retentive apparatus. The shaft of the femur is sometimes fractured _during delivery_, particularly in breech cases. The simplest and most efficient means ofcontrolling the fracture is by extension strapping fixed to the lowerend of a Thomas' knee splint. CHAPTER VII INJURIES IN THE REGION OF THE KNEE AND LEG _Surgical Anatomy_--FRACTURE OF LOWER END OF FEMUR: _Supra-condylar_; _T- or Y-shaped_; _Separation of epiphysis_; _Either condyle_--FRACTURE OF UPPER END OF TIBIA: _Of head_; _Separation of epiphysis_; _Avulsion of tubercle_--DISLOCATIONS OF KNEE: _Dislocations of superior tibio-fibular joint_--INTERNAL DERANGEMENTS OF KNEE--INJURIES OF PATELLA: _Fractures_; _Dislocations_--INJURIES OF LEG: _Fracture of both bones_; _Fracture of tibia alone_; _Fracture of fibula alone_. INJURIES IN THE REGION OF THE KNEE These include the supra-condylar fracture of the femur, the T- orY-shaped fracture opening into the joint, separation of the lowerfemoral epiphysis; fracture of the head of the tibia, and separationof its upper epiphysis; the various sprains and dislocations of theknee, as well as its internal derangements; and fractures anddislocations of the patella. #Surgical Anatomy. #--Of the two epicondyles the medial is the moreprominent and palpable. The adductor tubercle, which is situated onthe upper and back part of the medial epicondyle, gives attachment tothe round tendon of the adductor magnus, and marks the level of theepiphysial line and of the upper limit of the trochlear surface of thefemur. 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 thisis made use of in measuring the length of the tibia. The lateralcondyle (tuberosity) of the tibia can also be palpated, and must notbe mistaken for the head of the fibula, which lies farther back and ata slightly lower level, and can readily be identified by tracing to itthe tendon of the biceps. The tuberosity of the tibia, into which thequadriceps extensor tendon is inserted, lies on the same level as thehead of the fibula. In the extended position of the limb, the patellais loose and movable on the front of the trochlear surface of thefemur, while in the flexed position it sinks between the condyles, resting chiefly on the lateral one and becoming fixed. The popliteal artery and vein and the tibial (internal popliteal)nerve lie in close relation to the posterior aspect of the joint; andthe common peroneal (external popliteal) nerve passes behind and tothe medial side of the biceps tendon. The knee is an example of a joint which depends for its strengthchiefly on its ligaments. Not only are the tibial and fibularcollateral (external and internal lateral) ligaments and the posteriorpart of the capsular ligament particularly strong, but the cruciateligaments and the menisci (semilunar cartilages) inside the cavity ofthe joint further add to its stability. The powerful tendon of thequadriceps extensor muscle, in which the patella is developed as asesamoid bone, protects and strengthens the front of the joint andfunctionates as the anterior ligament of the joint. In the attitude ofcomplete extension in which the joint is locked, no demand is made onthe quadriceps apparatus; with the commencement of flexion, thestability of the joint, and the weight-bearing capacity of the limb asa whole, depend largely on the controlling influence of thequadriceps muscle; this becomes evident on going down an incline andmore markedly on going down stairs. Hence it is, that in recurrentsprains of the knee, including under this term the various forms ofinternal derangement of the joint, the wasting with loss of tone ofthe quadriceps is an important factor in aggravating the disability ofthe limb and in retarding and preventing recovery. In the treatment ofrecurrent sprains of the knee, therefore, special attention must bedirected towards the wasting of the quadriceps by means of massage andappropriate exercises. The synovial cavity extends from the level of the head of the tibia toan inch or more above the trochlear surface of the femur, passingslightly higher on the medial aspect of the joint than on the lateral(Fig. 80). The large bursa between the quadriceps muscle and the femur(_sub-crural bursa_) generally communicates with the cavity of thejoint. The synovial cavity of the superior tibio-fibular articulationis usually distinct from that of the knee-joint, but may communicatewith it through the popliteal bursa. [Illustration: FIG. 80. --Section of Knee-joint showing extent ofSynovial Cavity. _a_, Pre-patellar bursa. _b_, Infra-patellar bursa. _c_, Ligamentum mucosum. _d_, Ligamentum patellæ. _e_, Posterior cruciate ligament. _f_, Medial semilunar meniscus. (After Braune. )] A large bursa (_pre-patellar_) lies over the lower part of the patellaand upper part of the ligamentum patellæ; and a smaller one separatesthe ligamentum patellæ from the tuberosity of the tibia. Severalimportant bursæ are found in the popliteal space, one of which--thesemi-membranosus bursa--sometimes communicates with the knee-joint. FRACTURE OF THE LOWER END OF THE FEMUR Fractures involving the lower end of the femur, especially thesupra-condylar and T-shaped fractures, are to be looked upon asserious injuries, on account of the difficulties attending theirtreatment, and the risk of damage to the popliteal vessels and ofimpairment of the usefulness of the knee-joint. #Supra-condylar# fracture is usually the result of a fall on the feetor knees, or of direct violence, and is most common in adult males. The line of fracture is generally irregularly transverse, or it may beslightly oblique from above downwards and forwards, so that theproximal fragment passes forward towards the patella, while the distalis rotated backward on its transverse axis by the gastrocnemiusmuscle. _Clinical features. _--Soon after the accident a copious effusion ofblood and synovia takes place into the cavity of the knee-joint, adding to the swelling caused by the displaced bones, and rendering itdifficult to recognise the precise nature of the lesion. As it isimportant to make an accurate diagnosis, the X-rays should be employedif possible, and a general anæsthetic should be given when necessary. The proximal end of the distal fragment is usually palpable in thepopliteal space, while the proximal fragment is unduly prominent infront. By flexing the knee the fragments may be brought intoapposition and crepitus elicited. In oblique fractures, the pointedlower end of the proximal fragment may transfix the quadricepsextensor muscle and may be felt under the skin, or it may perforatethe skin and thus render the fracture compound. It should bedisengaged by fully flexing and making traction on the knee. The thighis shortened to the extent of from 1/2 to 1 inch. The popliteal vessels lie so close to the bone that they are liable tobe torn by the displaced distal fragment, giving rise to the usualsigns of ruptured artery. Sometimes, owing to the feeble state of thecirculation from shock, the bleeding does not take place at the timeof the accident, but ensues some hours later. The vessels may merelybe pressed upon by the displaced bone, but the nutrition of the limbbeyond is endangered and gangrene may ensue if early reduction be noteffected. _Treatment. _--The small size of the distal fragment, its depth fromthe surface, and the accompanying effusion into and around the joint, render its control difficult. In the majority of cases the twofragments can only be brought into apposition when the knee is flexedon the thigh and the thigh on the pelvis, and it is almost alwaysnecessary to carry out the reduction under anæsthesia. In the few cases in which the fragments can be accurately approximatedin the extended position of the limb, retention may be effected bymeans of a box splint reaching well up the thigh (p. 180). In the majority, however, flexion is necessary, and a Thomas' kneesplint with flexion attachment bent to an angle of 30° (Fig. 81) andextension by means of ice-tong callipers secures the best apposition. If this apparatus is not available the limb must be fixed on adouble-inclined plane, so constructed that the angle of flexion can beadjusted to meet the requirements of the individual case (Fig. 70). [Illustration: FIG. 81. --Extension applied by means of ice-tongcallipers for Fracture of Femur. ] Hodgen's splint, bent nearly to a right angle, may also be employed. A careful watch must be kept on the circulation of the limb during thefirst few days, lest it be interfered with by the pressure of theapparatus. In a considerable number of cases these means of retaining thefragments in apposition prove ineffectual, and it is necessary to haverecourse to operative measures for mechanical fixation. Division ofthe tendo calcaneus (Achillis) is not to be recommended as a means ofcombating the backward tilting of the distal fragment. In all cases the retentive apparatus must be worn for about fourweeks, after which the limb is flexed over a pillow; but massage andmovement should be employed as soon as possible, as persistentstiffness of the knee is one of the most troublesome sequelæ of theseinjuries. Compound and complicated fractures are dealt with on the generalprinciples governing the treatment of such injuries. Amputation maybecome necessary should gangrene ensue from injury to the poplitealvessels, or if infective complications threaten the life of thepatient. Operative interference may be called for to rectify deformitiesresulting from mal-union. The #T- or Y-shaped fracture# is, as a rule, produced by directviolence, the force first breaking the bone above the condyles andthen causing the proximal fragment to penetrate the distal and splitit up into two or more pieces. The fracture implicates the articularsurface, and the main fissure is usually through the inter-condylarnotch; the lower end of the bone is sometimes severely comminuted. The knee is broadened, and pain and crepitus are readily elicited onmoving the condyles upon one another or on pressing them together. Onmoving the patella transversely, it may be felt to hitch against theedge of one or other of the fragments. The shortening may amount toone or two inches. The treatment is carried out on the same lines as in supra-condylarfracture, but as the joint is implicated there is greater risk ofsubsequent impairment of its functions. #Separation of the lower epiphysis# is a comparatively common injury. It is seldom pure, a portion of the diaphysis usually being brokenoff and remaining attached to the epiphysis. It occurs usually in boysbetween the ages of thirteen and eighteen, from severe violence suchas results from the limb being caught between the spokes of arevolving wheel, or from hyper-extension of the knee. It has also beenproduced in attempting forcibly to rectify knock-knee and otherdeformities in this region, and in making traction on the limb tocorrect deformities following recovery from tuberculous disease of theknee. As a rule, there is little displacement of the loose epiphysis, but it may pass in any direction, forward being much the most common(Fig. 82), and when displaced it is difficult to reduce and tomaintain in position. The age of the patient, the mode of injury, thefinding of the smooth broad end of the diaphysis in the poplitealspace or on the front of the thigh, according to the displacement, usually serve to establish the diagnosis. The X-rays afford reliableinformation as to the position of the fragments. Pressure on thepopliteal vessels is a serious aggravation of the injury, and addsgreatly to the difficulties of treatment. [Illustration: FIG. 82. --Radiogram of Separation of Lower Epiphysis ofFemur, with backward displacement of the diaphysis; pressure onpopliteal vessels caused sloughing of calf. ] [Illustration: FIG. 83. --Separation of Lower Epiphysis of Femur, withfracture of lower end of diaphysis. ] The treatment is the same as for supra-condylar fracture, but, owingto the serious disability that follows on incomplete reduction, it maybe necessary to have recourse to operation. After an epiphysialseparation, the growth of the limb is sometimes, although not always, interfered with. #Either condyle# may be broken off without the continuity of the shaftbeing interrupted, by a direct blow or fall on the knee, or by violenttwisting of the leg. The separated condyle may not be displaced, or itmay be pushed upwards or rotated on its transverse axis. There is broadening of the knee but no shortening of the thigh, andthe ecchymosis, crepitus, and pain are localised to the affected sideof the joint; the knee can usually be moved towards the injured sidein a way that is characteristic. If allowed to unite with the condyledisplaced, the articular surface is oblique and bow- or knock-kneeresults. If there is difficulty in replacing the broken condyle and maintainingit in position, it may be fixed by means of a steel nail insertedthrough the skin. FRACTURE OF THE UPPER END OF THE TIBIA #Fracture of the head of the tibia# is a comparatively rare injury. Itmay result from a direct blow, such as the kick of a horse, or fromindirect forms of violence, and the line of fracture may betransverse or oblique. Occasionally the distal fragment is impactedinto the proximal and comminutes it. In oblique fracture a glidingdisplacement is liable to occur and cause bow- or knock-knee. Transverse fracture of the head of the fibula sometimes accompaniesfracture of the head of the tibia, and there is always considerableeffusion into the knee-joint. One or other of the condyles may bechipped off by forcible adduction or abduction at the knee. [Illustration: FIG. 84. --Radiogram of Fracture of Head of Tibia andUpper Third of Fibula. ] The ordinary clinical features of fracture are well marked, and thediagnosis is easy. From some unexplained cause this fracture may takea long time, sometimes several months, to consolidate. #Separation of the upper epiphysis# of the tibia, which includes thetongue-like process for the tubercle and the facet for the fibula, isalso rare. It usually occurs between the ages of three and nine. Thedisplacement of the epiphysis is almost always forward or lateral, andis accompanied by the usual signs of such lesions. The growth of thelimb is sometimes arrested, and shortening and angular deformity mayresult. _Treatment. _--After reduction under an anæsthetic these fractures areusually satisfactorily treated in a box splint (Fig. 91), carriedsufficiently high to control the knee-joint. When the head of thetibia is comminuted or split obliquely, weight-extension--direct fromthe bone, the ice-tong callipers grasping the malleoli or thecalcaneus--may be used. Massage and movement are employed from theoutset. Avulsion of the #tuberosity of the tibia# occasionally occurs inyouths, from violent contraction of the quadriceps--as in jumping. Thelimb is at once rendered powerless; the osseous nodule can be felt, and on moving it crepitus is elicited. This is best treated by pegging the tuberosity in position, and fixingthe extended limb on an inclined plane to relax the quadriceps muscle. In young, athletic subjects, the tongue-like process of the epiphysis(Fig. 85), into which the ligamentum patellæ is inserted, may bepartly or completely torn away, giving rise to localised swelling, andpain which is aggravated by any muscular effort--_Schlatter's disease_or "rugby knee. " It has been frequently observed in cadets as a resultof kneeling at drill. The treatment consists in rest and massage, butthe symptoms are slow to disappear. [Illustration: FIG. 85. --Radiogram illustrating Schlatter's disease. ] The condition is liable to be mistaken for some chronic inflammatorycondition of the bone, such as tubercle, unless an X-ray examinationis made. The #upper end of the fibula# is seldom broken alone. The chiefclinical interest of this fracture lies in the fact that it mayimplicate the common peroneal nerve, and cause drop-foot. DISLOCATIONS OF THE KNEE Dislocation of the knee is a rare injury, and occurs as a result ofextreme degrees of violence, especially of a wrenching or twistingcharacter. Rupture of the popliteal vessels, or pressure exerted on them by thedisplaced bones, may lead to gangrene of the limb, and necessitateamputation. The common peroneal nerve is frequently damaged. When thelesion is compound, also, amputation may become necessary on accountof infective complications. The varieties of dislocation are named in terms of the direction inwhich the tibia passes: forward, backward, medial, and lateral. #Dislocation forward# is the most common variety, and results fromsudden hyper-extension of the knee, tearing the collateral andcruciate ligaments. The leg remains fully extended, and lies on aplane anterior to that of the thigh. The condyles of the femur arepalpable posteriorly, and the skin is tightly stretched over them, ormay even be torn, rendering the dislocation compound. The patella isprojected forward, the quadriceps tendon is lax, and the skin over itis thrown into transverse folds. The limb is shortened by two or threeinches. #Dislocation backward# is usually due to a direct blow driving one ofthe bones past the other. The leg remains hyper-extended, the head ofthe tibia occupies the popliteal space, while the lower end of thefemur projects forward with the patella either in front or to one sideof it. The #medial and lateral dislocations# are generally incomplete, andare liable to be mistaken for separation of the lower epiphysis of thefemur. When the tibia passes _medially_, the lateral condyle of thefemur forms a prominence, and there is a depression below it. The headof the tibia projects on the medial side, and the medial condyle is ina depression. When the tibia is displaced _laterally_, the relative position of theprominences and depressions is reversed. _Treatment. _--In dislocations of the knee no special manipulations arenecessary to restore the displaced bone to its place, and reduction isnot accompanied by a distinct snap. If, while the patient is fully anæsthetised, traction is made on theleg and counter-traction on the thigh with the knee in the flexedposition, the bones can usually be replaced by manipulation. After reduction has been effected, in antero-posterior dislocations, the limb should be flexed and placed on a pillow, massage and movementbeing employed from the first. The patient is usually able to walkwithin a month. In medial and lateral dislocations there is at first considerabletendency to re-displacement, and it is therefore necessary to securethe joint in a box splint, specially padded, for about fourteen days, massage being employed from the first, and movement commenced when thesplint is removed. It is usually about six weeks before the patientcan use the limb with freedom. In compound dislocations, and in those complicated by injury to thepopliteal vessels, the question of amputation may have to beconsidered. #Dislocation of the Superior Tibio-Fibular Articulation. #--This jointmay be dislocated by twisting forms of violence applied to the foot orleg, or by forcible contraction of the biceps muscle. The displacementmay be forward or backward, and the head of the fibula can be felt inits new position with the prominent tendon of the biceps attached toit. The movements of the knee are quite free, but the patient isunable to walk on account of pain. Reduction and retention are, as arule, easy, and the ultimate result satisfactory. We have frequentlymet with this injury accompanying compound fractures of both bones ofthe leg resulting from railway and similar accidents. By applying direct pressure over the displaced bone with the kneeflexed, the dislocation is easily reduced. It is kept in position by afirm bandage or a light rigid splint. #Total Dislocation of Fibula. #--Very rarely the fibula is separatedfrom the tibia at both ends and displaced upwards. Bennett of Dublinhas pointed out that in some persons the upper end of the fibula doesnot reach the facet on the tibia--a condition which might be mistakenfor a dislocation. INJURIES OF THE SEMILUNAR MENISCI The semilunar menisci are two crescentic plates of whitefibro-cartilage, which lie upon the upper end of the tibia, and serveto deepen the articular surface for the condyles of the femur. Eachcartilage is firmly attached to the tibia by its anterior andposterior ends, and, through the medium of the coronary ligaments, isloosely attached along its peripheral, convex edge to the head of thetibia, the medial meniscus being connected also to the capsularligament of the joint. The tendon of the popliteus muscle intervenesbetween the lateral meniscus and the capsule. The central, concaveedges of the menisci are thin and unattached. The cartilages enjoy a limited range of movement within the joint, passing backwards during flexion, and forwards again when the limb isextended; under normal conditions the lateral moves more freely thanthe medial. While the limb is partly flexed, a slight degree ofrotation of the leg at the knee is possible, and during this movementthe cartilages glide from side to side, and the tibia rotates belowthem. Any abnormal laxity of the ligaments of the joint may render thecartilages unduly mobile, so that they are liable to be displaced fromcomparatively slight causes, and when so displaced it is not uncommonfor one or other to be torn by being nipped between the femur and thetibia. It is convenient to consider these "internal derangements ofthe knee-joint" separately, according to whether the meniscus ismerely abnormally mobile, or is actually torn. #Mobile Meniscus--Displacement of Medial Semilunar Cartilage# (Fig. 86). --The _medial_ meniscus exhibits undue mobility much morefrequently than the lateral, and the condition is usually met with inadult males who engage in athletics, or who follow an employment whichentails working in a kneeling or squatting position for long periods, with the toes turned outwards--for example, coal-miners. The tibialcollateral ligament, and through it the coronary ligament, are thusgradually stretched, so that the cartilage becomes less securelyanchored, and is rendered liable to be displaced towards the centre ofthe joint during some sudden movement which combines flexion of theknee with medial rotation of the femur upon the tibia, as, forexample, in rising quickly from a squatting position, or turningrapidly and pushing off with the foot, in the course of some game suchas football or tennis. It may occur also from tripping on a loosestone or slipping off the kerbstone. [Illustration: FIG. 86. --Diagram of Longitudinal Tear of Posterior Endof Right Medial Semilunar Meniscus. ] What actually happens when the meniscus is displaced would appear tobe, that the combined flexion and abduction of the knee opens up themedial side of the joint by separating the medial condyles of thefemur and tibia, and that the medial meniscus in its movement backwardduring flexion slips under the femoral condyle and is caught betweenit and the tibia. It may even slip past the condyle and into theintercondyloid notch, and come to lie against the cruciate ligaments. The mechanism by which this lesion is produced doubtless explains thegreater frequency with which the _left_ knee is affected, as mostsudden movements are made from right to left, thus throwing the strainupon the left knee. _Clinical Features. _--When seen immediately after the accident, thepatient usually gives the history that while making a sudden movementhe was seized with an intense sickening pain in the knee, accompanied, it may be, by a sensation of something giving way with a distinctcrack, and followed by locking of the joint. He may fall to theground and be unable to rise. On examination, the knee is found to befixed in a slightly flexed position; and while the surgeon may be ableto carry out movements of flexion to a considerable extent withoutincreasing the pain, any attempt to extend the joint completely isextremely painful. Tenderness may be elicited on making pressure tothe medial side of the ligamentum patellæ in the groove between thefemur and the tibia, but the meniscus cannot be recognised bypalpation. Considerable effusion rapidly takes place into the synovialcavity. The condition is liable to be mistaken for a sprain of the joint, particularly one implicating the tibial collateral ligament, butwhereas in the lesion of the meniscus the maximum tenderness is in theinterval _between_ the bones, in the sprain of the ligament themaximum tenderness is over its attachment to the bone, usually thetuberosity of the tibia. _Treatment. _--To reduce the displacement, the patient is placed on acouch, and, after the knee is fully flexed, the leg is rotatedlaterally and abducted, to separate the medial femoral condyle fromthe tibia, and while the rotation and abduction are maintained the legis quickly extended. The return of the meniscus to its place issometimes attended with a distinct snap, but in other cases reductionis only recognised to have taken place by the fact that the joint canbe completely extended without causing pain. Alternate flexion and extension combined with rotatory movements issometimes successful. Several attempts are often necessary, and ageneral anæsthetic may be called for. After reduction, the limb isfixed with sand-bags, and massage and movement are employed to get ridof effusion, care being taken that no rotatory movement at the knee ispermitted. Rest and support are necessary to allow of repair of thetorn ligaments, and when the patient begins to use the limb he must becareful to avoid movements which throw strain on the damagedligaments. In a considerable proportion of cases no recurrence takes place, andin the course of a month or two the patient is able to resume anactive life with a perfectly useful joint. In other cases there is atendency to recurrence of the displacement. #Recurrent Displacement. #--In cases of recurrent displacement, eachattack is accompanied by symptoms similar in kind to those abovedescribed, but less severe, and the patient usually learns to carryout some manipulation by which he is able to return the meniscus intoposition. He seeks advice with a view to having something done toprevent displacement occurring, and to restore the stability of thejoint, which, in many cases, is impaired, preventing him following hisoccupation. There persists a variable amount of fluid in the joint, the ligaments are stretched and slack, and the quadriceps muscle ismarkedly wasted. The symptoms closely resemble those of a "loose body, " and it is oftendifficult to differentiate between them. In the case of a body free inthe cavity of the joint, the site of the pain varies in differentattacks, and the body can sometimes be palpated. Loose bodies whollyor partly composed of bone may be identified with the X-rays. Attempts may be made to retain the meniscus in position by pads, bandages, or other forms of apparatus, so arranged as to preventrotation and side-to-side movement at the knee. In the majority ofcases, however, the best results are obtained by opening the joint andexcising the meniscus in whole or in part, as may be necessary. The limb is flexed on a splint until the wound has healed, after whichmassage should be employed and movement of the joint commenced. At theend of two or three weeks the patient is allowed up, wearing anelastic bandage. In most cases the use of the joint is completelyregained in from four to six weeks. As an indication of the perfectrecovery of the functions of the joint after removal of the meniscus, professional football players are often able to resume theiroccupation. #Displacement of the lateral meniscus# is comparatively rare. It is inevery way comparable to displacement of the medial meniscus, and istreated on the same lines. #Torn or Lacerated Meniscus. #--In a large proportion of cases ofdisplaced meniscus in which the condition assumes the recurrent type, it is found, on opening the joint, that, in addition to being undulymobile, the meniscus is torn or lacerated. The experience of surgeonsvaries regarding the nature of the laceration. In our experience themost common form is a longitudinal split, whereby a portion of theinner edge of the cartilage is separated from the rest and projects asa tag towards the centre of the joint (Fig. 86). As a rule, it is theanterior end that is torn, less frequently the posterior end. Sometimes the meniscus is split from end to end, the outer crescentremaining in position, while the inner crescent passes in between thecondyles and lies curled up against the cruciate ligaments. Occasionally the anterior end is torn from its attachment to thetibia, less frequently the posterior end. In one case we found themeniscus separated at both ends and lying between the bones and thecapsule. The _clinical features_ are similar to those of mobile meniscus withdisplacement, and as a rule the exact nature of the lesion is onlydiscovered after opening the joint. The _treatment_ consists in excising the loose tag or the wholemeniscus, according to circumstances. The recovery of function isusually complete. It is not advisable to attempt to stitch the tornportion in position. #Rupture of the Cruciate Ligaments. #--A few cases have been recordedin which, as a result of severe twisting forms of violence, thecruciate ligaments have been torn from their attachments, leaving thejoint loose and unstable, so that the tibia and the femur could bemoved from side to side on one another. When the disability persists, the joint may be opened and the ligaments sutured in position (MayoRobson). #Sprains# of the knee are comparatively common as a result of suddentwisting or wrenching of the joint. In addition to the stretching ortearing of ligaments, there is usually a considerable effusion offluid into the synovial cavity, and examination with the X-raysoccasionally reveals that a portion of bone has been torn away withthe ligament--_sprain-fracture_. The swelling fills up the hollows oneither side of the patella, and extends for some distance in thesynovial pouch underneath the quadriceps. The patella is raised fromthe front of the femur by the collection of fluid in thejoint--"floating patella"--and, if firmly pressed upon, it may be madeto rap against the trochlear surface. A sprain is to be diagnosed from separation of one or other of theadjacent epiphyses, fracture involving the articular ends of thebones, and displacement of the semilunar menisci. On account of theswelling, which obscures the outline of the part, the differentialdiagnosis is often difficult, but as the swelling goes down undermassage it becomes easier. Chief reliance is to be placed upon thebony points retaining their normal relationships, and upon the factthat the points of maximum tenderness are over the attachments of oneor other of the collateral ligaments. As the tibial collateralligament suffers most frequently, the most tender spot is usually overits attachment to the medial aspect of the head of the tibia--lessfrequently over the medial condyle of the femur. Unless efficiently treated, a sprain of the knee is liable to resultin weakness and instability of the joint from stretching of theligaments, and this is often associated with effusion of fluid in thesynovial cavity (_traumatic hydrops_). This is more likely to occur ifthe joint is repeatedly subjected to slight degrees of violence, suchas are liable to occur in football or other athletic exercises--hencethe name "footballer's knee" sometimes applied to the condition. A further cause of disability, following upon sprains of the knee, is_wasting of the quadriceps muscle_. The stability of the joint, whenever the position of full extension has been departed from, islargely dependent upon its capacity of controlling the amount offlexion, notably in descending a stair or in walking on uneven ground, hence it is that with a wasted quadriceps there is increasingliability to a repetition of the sprain. With each repetition of thesprain, there is an addition to the fluid in the joint, stretching ofligaments, and further wasting of the quadriceps. A form of viciouscircle is established in which there is at the same time increasedliability to sprain and diminished capacity of recovering from it. Even after the repair of the damaged ligament or the removal of themobile or torn meniscus, wasting of the quadriceps remains a source ofweakness and disability and calls for treatment by massage andelectricity. _Treatment. _--In recent and severe cases the patient must be confinedto bed, and firm pressure applied over the joint by means of cottonwool and a bandage. This may be removed once or twice a day to admitof the joint being douched, and at the same time it should be massagedand moved to promote absorption of the effusion and prevent theformation of adhesions. Chronic effusion into the joint is most rapidly got rid of by rest andblistering. If the patient is unable to lie up, massage should besystematically employed, and a firm elastic bandage worn. A patientwho has once had a severe sprain of the knee, or who has developed thecondition of "footballer's knee, " must give up violent forms ofexercise which expose him to further injuries, otherwise the conditionis liable to be aggravated and to result in permanent impairment ofthe stability of the joint. INJURIES OF THE PATELLA #Fracture of the patella# is a comparatively common injury in adultmales. Most frequently it is due to _muscular action_ the patellabeing snapped across the lower end of the femur by a sudden andforcible contraction of the quadriceps extensor muscle while the limbis partly flexed--as, for example, in the attempt to avoid fallingbackward. The bone is then broken as one breaks a stick by bending itacross the knee, and the line of fracture, which is transverse orslightly oblique, crosses the bone a little below its middle. Fractures produced in this way are almost never compound. [Illustration: FIG. 87. --Radiogram of Fracture of Patella. ] The degree of displacement of the fragments depends upon the extent towhich the expansion of the quadriceps tendon is lacerated. As a rule, it is but slightly torn, so that the separation of the fragments doesnot exceed an inch. In other cases it is widely torn, and thecontraction of the quadriceps muscle is then able to separate thefragments by three or four inches, and sometimes causes tilting of theupper fragment. The blood effused into the joint tends still furtherto increase the separation. As the periosteum is usually torn at alevel lower than the fracture, its free margin hangs as a fringe fromthe proximal fragment, and by getting between the broken ends may forma barrier to osseous union (Macewen). _Clinical Features. _--Immediately the bone breaks, the patient falls, and he is unable to rise again, as the limb is at once rendereduseless, and in attempting to do so we have known him to fracture thepatella of the other limb. The power of extending the limb is lost, and the patient is unable to lift his foot off the ground. Theknee-joint is filled with blood and synovia, which usually extend intothe bursa under the quadriceps. The two fragments can be detected, separated by an interval which admits of the finger being placedbetween them, and which is increased on flexing the knee. On relaxingthe quadriceps, the fragments may be approximated more or lesscompletely. _Prognosis. _--In cases with little displacement, if the fragments havebeen kept in perfect apposition, osseous union may take place, but inthe great majority of cases the union is fibrous. The shortening ofthe quadriceps and the gradual stretching and thinning of theconnecting fibrous band may allow of further separation of thefragments (Fig. 88), which to a variable extent interferes with thestability and functions of the limb. The proximal fragment sometimesbecomes attached to the front of the femur, and moves with it, and thefibrous band between the two fragments gradually becomes stretched. After bony union has occurred, it is not uncommon for the patella tobe fractured again by a fall within a month or two of the originalaccident. [Illustration: FIG. 88. --Fracture of Patella, showing wide separationof fragments, which are united by a fibrous band. (Anatomical Museum of the University of Edinburgh. )] _Treatment. _--It is probably true that the best functional results aremost speedily obtained by operative measures. The laceration of theaponeurosis of the quadriceps, the tilting of the fragments, and theinterposition of the torn periosteum between them, can in no other waybe rectified with certainty. The operation, however, should only beundertaken by those who are familiar with wound technique, and whohave the means at their disposal for carrying it out. Operativetreatment is specially indicated in young subjects who lead an activelife, and in labouring men, particularly those who follow dangerousemployments necessitating stability of the knee. As soon as the wound is healed, --in a week or ten days, --massage andmovement of the limb are commenced, and the patient is encouraged tomove his limb in bed. At the end of another week he may be allowed upwith sticks or crutches. _Non-operative Treatment. _--In the majority of cases occurring inpatients who do not follow a laborious occupation or otherwise lead anactive life, a satisfactory result can be obtained without havingrecourse to operation. We have reason to be satisfied with thefollowing method: the patient is kept in bed for a few days, theinjured region being supported on a pillow and massaged daily, and thepatella moved from side to side as a whole to prevent adhesion to thefemur. About the fourth day he is allowed to get about with crutches. As osseous union of the fragments is not essential to a goodfunctional result, and as fibrous union does not necessarily entailany material interference with the usefulness of the limb, no attemptneed be made to approximate the fragments, but every effort must bemade to maintain the function of the quadriceps muscle and themobility of the joint. If it is desired to bring the fragments into contact and to secureosseous union, the limb should be placed upon an inclined plane torelax the quadriceps muscle, and means taken to arrest effusion and todiminish the swelling by systematic massage and a supporting bandage. When, in the course of a few days, this has been accomplished, theattempt is made to approximate the fragments, by fixing a largehorseshoe-shaped piece of adhesive plaster to the front of the thigh, embracing the proximal fragment. Extension is made upon this by meansof rubber tubing, which is fixed to the foot-piece of the splint. Thebandage which binds the limb to the splint should make upward pressureon the distal fragment, or this may be done by a special piece ofadhesive plaster with elastic tubing pulling in an upward direction. The retentive apparatus is kept on for about three weeks, and a rigid, but easily removable, apparatus is thereafter applied, and the patientallowed up on crutches, the limb being massaged and exercised daily toimprove the tone of the muscles. When the fracture is caused by _direct violence_, such as a fall onthe knee or the kick of a horse, it may be transverse, oblique, orvertical, but in many cases it is stellate, the bone being broken intoseveral irregular pieces. These comminuted fractures are frequentlycompound. In transverse and oblique fractures, the displacementdepends upon the same causes as in fracture by muscular action. Invertical and stellate fractures, unless the knee has been forciblyflexed after the bone has been broken, there is little or nodisplacement. The treatment is governed by the same considerations asin fractures by muscular action. _Old-standing Fracture. _--As fibrous union, even with an interval ofseveral inches between the fragments, is not incompatible with auseful limb, it is not often necessary to operate for this condition, but when the usefulness of the limb is seriously impaired, operativetreatment is indicated. The operation is carried out on the same linesas for recent fracture, the ends of the bones being rawed andadhesions divided. When the proximal fragment has become attached tothe femur, it should be separated and a layer of fascia interposed; itis sometimes necessary to lengthen the quadriceps muscle by making anumber of V-shaped incisions through its substance; or a flap may beturned down from the rectus and stitched to the patella and theligamentum patellæ. When operative treatment is contra-indicated, the patient should befitted with a firm apparatus which will limit flexion of the knee andsupport the fragments. #Dislocation of the patella# is rare. It results from exaggeratedmuscular movements when the limb is in the fully extended position, orfrom a blow on one or other edge of the bone. Laxity of the ligamentsand knock-knee are predisposing factors. It is sometimes associatedwith fracture of the edge of the trochlear surface, which rendersretention in position difficult. The _lateral_ is the most common variety--the _medial_ being rare. Either may be complete or incomplete. Sometimes the bone is rotated sothat its edge rests on the front of the femur--_vertical_ dislocation;and in a few cases it has been completely turned round, so that thearticular surface is directed forwards. _Clinical Features. _--The joint is fixed, usually in a position ofslight flexion, and the displaced patella can readily be palpated. Thedeformity is a striking one, and at first sight suggests a much moreserious injury. Although easily reduced, the dislocation is liable torecur. To effect reduction, the quadriceps must be thoroughly relaxed byextending the leg upon the thigh and flexing the thigh upon thepelvis; the patella is then tilted by making firm pressure on thatedge which lies farthest from the middle of the joint, and at the sametime pushing towards the middle line. The limb is placed on aposterior splint, and firm elastic pressure made on the joint toprevent or diminish effusion. Massage and movement are carried outfrom the first. As the displacement is liable to recur, the patient should wear a firmelastic bandage or a strong knee-cap. _Permanent and recurrent dislocation of the patella_ will be describedlater. FRACTURE OF THE BONES OF THE LEG The bones of the leg may be broken together or separately. #Fracture of both Bones. #--The features of this injury depend to alarge extent upon the nature of the violence producing it. In fractureby _direct_ violence, such as the passage of a wheel over the limb ora severe blow, the bones give way at the point of impact, and the lineof fracture tends to be transverse, both bones being broken at thesame level (Fig. 89). There is little or no displacement, and such asthere is is angular, and is determined by the direction of thefracturing force. [Illustration: FIG. 89. --Radiogram of Transverse Fracture of bothBones of Leg by direct violence. ] When the violence is _indirect_, as from a fall on the feet, or atwist of the leg, the tibia usually gives way at the junction of itslower and middle thirds, and the fibula at a higher level (Fig. 90). Torsion of the tibia is probably the most important factor in theproduction of the fracture, the distal fragment being fixed by thepressure of the foot upon the ground, while the proximal fragment isrotated by the impetus of the body. Both fractures are usuallyoblique--that in the tibia running from above downward, forward, andmedially, and it is generally found that the obliquity of the fibularfracture corresponds with that in the tibia. [Illustration: FIG. 90. --Radiogram of Oblique Fracture of both Bonesof Leg by indirect violence. ] There is usually considerable displacement, the weight of the lowerportion of the limb causing it to fall backwards and to roll away fromthe middle line, and the traction of the calf muscles pulling up theheel and pointing the toes. The proximal fragment forms a projectionon the front of the limb. On account of the superficial position of the tibia and the pointedcharacter of the fragments, this fracture is frequently renderedcompound by the bone being forced through the skin. The projectingpiece of bone is usually the distal end of the proximal fragment. Thisfracture is often comminuted. It has been observed that when the lineof fracture forms the letter V on the subcutaneous surface of thetibia, there is invariably a fissure passing down along the back ofthe bone into the ankle-joint--a complication which adds to the riskof subsequent stiffness and impaired usefulness of the limb. Apartfrom this, the ankle is usually sprained in fractures by indirectviolence, and we have frequently found the superior tibio-fibulararticulation torn open in severe fractures of both bones of the legfrom indirect violence. _Clinical Features. _--The tibial fracture is readily recognised bydetecting an irregularity on running the fingers along the crest ofthe shin, and at this point abnormal mobility, tenderness, andcrepitus can usually be elicited. It is often difficult to detect thefibular fracture, and it is not always advisable to attempt to do so, especially if the manipulations cause pain or tend to increase thedisplacement. The condition of the fibula is usually to be inferred bynoting the amount of displacement and the extent of mobility of thetibial fragments. Not infrequently the seat of fracture may berecognised by locating a point at which pain is elicited on makingpressure over the bone at a distance--pain on distal pressure. On account of the close connection of the skin to the periosteum onthe subcutaneous aspect of the tibia, the tension caused byextravasated blood is often extreme; blisters frequently form over thearea of ecchymosis, and when these become infected, sloughing of theskin may take place and the fracture thus be rendered compound. The vessels and nerves of the leg are seldom seriously damaged. _Treatment. _--If there is marked displacement, reduction is mostsatisfactorily accomplished under anæsthesia. Traction is made uponthe foot and the fragments are manipulated into position, the pointingof the toes and the outward rotation of the foot being at the sametime corrected. The normal outline of the foot in relation to the legis restored when the ball of the great toe, the medial malleolus, andthe medial edge of the patella are in the same vertical plane. As inother fractures of the lower extremity, the limb should be placed inthe natural position of slight eversion: not with the toes pointingstraight forward. The retentive apparatus to be applied depends upon the tendency tore-displacement, the degree of swelling, and the extent of the damageto the skin. In the average case, the leg is supported between sand-bags, andmassage and movements are employed from the outset. When there is atendency to re-displacement, the limb may be immediately enclosed in arigid apparatus, such as lateral poroplastic splints retained inposition by an elastic bandage, or a Cline's splint, which can readilybe removed to admit of massage. When the fracture is in the lowerthird of the leg, the ambulatory splint gives excellent results, andis of special service in hospital practice (Fig. 95). As an emergency appliance, for example for purposes of transport, the_box splint_ (Fig. 91) is simple and efficient. We have not found iteffectual in controlling the fragments, particularly in obliquefractures, and it requires constant supervision and readjustment. Itconsists of two pieces of wood extending from above the knee to aninch or two beyond the sole, and a little broader than the maximumdiameter of the leg. These are rolled into the opposite ends of afolded sheet, so as to form two sides of a box, of which the sheetconstitutes a third side. It is found advantageous to insert anotherboard, fitted with a foot-piece, between the folds of the sheetforming the third side of the box, to add to the rigidity of thesplint, and to aid in controlling the foot. By folding one side of thesheet somewhat obliquely, the box is made a little wider at the kneethan at the ankle, and so fits the limb more accurately. [Illustration: FIG. 91. --Box Splint for Fractures of Leg. ] The limb is placed in this box, the sides of which have been carefullypadded. Ring pads are applied to take pressure off the condyles, thehead of the fibula, the malleoli, and the prominence of the heel, anda large supporting pad is placed behind the tendo calcaneus. A foldedtowel is laid over the front of the leg, forming a lid to the box, andthe whole is bound to the limb by three slip-knots. Finally, the footis fixed at right angles to the leg and slightly abducted by afigure-of-eight bandage or a piece of elastic webbing. Sand-bagsplaced alongside serve to steady the limb. In fractures of the lowerthird of the leg, the box splint may stop short of the knee and thelimb may then be suspended in a Salter's cradle, which allows thepatient to move about more freely in bed. [Illustration: FIG. 92. --Box Splint (applied). ] To prevent shortening in oblique fractures and in those near theankle-joint, where it is often difficult to control the lowerfragment, extension, applied by weight and pulley, or through aThomas' knee splint, may be of service. The strapping may be appliedonly to the distal fragment, but we prefer to carry it to the upperthird of the leg. If the overriding of the fragments persists, extension may be taken directly from the bone, the ice-tong callipersgripping the malleoli or the calcaneus. When the skin is damaged, as it so frequently is on the medial aspectof the tibia, means must be taken to prevent infection. Massage is carried out daily, and, to prevent stiffness, the ankle ismoved from the first. In the course of three weeks, lateralporoplastic splints retained by an elastic bandage may be substituted, and the patient allowed up on crutches. In simple fractures withoutdisplacement, union is usually complete in from six to eight weeks, but when the fracture is oblique, comminuted, or compound, union isoften delayed, and the functions of the limb may not be fully regainedfor three or even four months after the accident. _Operative Treatment. _--When overriding cannot otherwise be corrected, it is advisable to replace the fragments by operation. A curvedincision with its convexity backward is made over the medial side ofthe tibia, exposing the fragments, which are then levered intoposition and if necessary plated or otherwise fixed according tocircumstances. It is seldom necessary to deal separately with thefibula. A box splint is applied till the wound has healed, after whicha poroplastic splint is substituted and massage commenced. We do not share in the dissatisfaction expressed by some surgeons, notably Arbuthnot Lane, as to the results obtained by non-operativemeans in the common fractures of the leg, and do not recommend asystematic resort to operative treatment. _Un-united fracture_ of the bones of the leg is sometimes met with. Itis treated on the same lines as in other situations, but may proveextremely intractable, especially in children, in whom, indeed, it issometimes incurable. _Mal-union_, on account of the disability it entails, may call foroperative treatment in the form of osteotomy of one or both bones. _Compound fractures_ of the leg are common, and are treated on thelines already laid down for the treatment of compound fractures ingeneral (p. 25). #Fracture of the tibia alone#, when due to direct violence, is usuallytransverse, there is little displacement, and as the fibula retainsthe fragments in position, union usually takes place rapidly andwithout deformity. Oblique and spiral fractures result from indirectviolence. #Fracture of the fibula alone# may result from direct violence, and, on account of the support given by the tibia, is usually unattended bydisplacement. Bennett of Dublin has pointed out that it is common tomeet with an oblique fracture of the upper third of the fibula as theresult of an outward twist of the ankle while the foot is extended. Itis characterised by pain localised at the seat of the break, on movingthe foot in such a way as to bring the talus to bear against thefibula. Local pressure also may make the fibula yield and may elicitcrepitus. In some cases this fracture is associated with sprain of theankle-joint. It is often overlooked, and from want of proper treatmentmay result in prolonged impairment of usefulness. Fractures of the tibia or fibula alone are treated on the same linesas fractures of both bones, and splints are rarely necessary. Theambulant method is useful in these cases (Fig. 95). CHAPTER VIII INJURIES IN REGION OF ANKLE AND FOOT Surgical Anatomy--FRACTURES: _Pott's fracture_; _Converse of Pott's fracture_; _Separation of lower epiphysis_; _Fracture of talus_; _Fracture of calcaneus_; _Fractures of other tarsal bones_; _Fractures of metatarsal bones_; _Fractures of phalanges_--DISLOCATIONS: _Of ankle joint_; _Of inferior tibio-fibular joint_; _Complete dislocation of talus_; _Sub-taloid dislocation_; _Medio-tarsal dislocation_; _Tarso-metatarsal dislocation_; _Dislocations of toes_. The fractures in this region include Pott's fracture, and itsconverse; separation of the lower epiphysis of the tibia; fractures ofthe talus, calcaneus, and other tarsal bones; and fractures of themetatarsals and phalanges. Various dislocations also occur, the mostimportant being those of the ankle joint, of the talus, and thesub-taloid dislocation. #Surgical Anatomy. #--For the study of injuries in the region of theankle-joint it is of importance to define the terms employed indescribing the movements of the foot. Thus by _flexion_ or_dorsiflexion_ is meant that movement which approximates the dorsum ofthe foot to the front of the leg; while _extension_ or _plantarflexion_ means the drawing up of the heel so that the toes arepointed. In _inversion_ the medial edge of the foot is drawn up sothat the sole looks towards the middle line of the body, an attitudewhich is analogous to supination of the hand. In _eversion_ thelateral edge of the foot is drawn up, the sole looking away from themiddle line--analogous to pronation of the hand. _Adduction_ indicatesthe rotation of the foot so that the toes are turned towards themiddle line of the body; while in _abduction_ the toes are turned awayfrom the middle line. The most prominent bony landmarks in the region of the ankle are thetwo _malleoli_, the lateral lying slightly farther back, and abouthalf an inch lower than the medial. On the medial side of the footfrom behind forward may be felt the _medial process (internaltuberosity)_ of the calcaneus; the _sustentaculum tali_, which liesabout 1 inch vertically below the tip of the malleolus; the _tubercleof the navicular_, about 1 inch in front of the malleolus, and at aslightly lower level; the _first (internal) cuneiform_, and the base, shaft, and head of the _first metatarsal_. On the lateral side may be recognised the _lateral process (externaltuberosity)_ of the calcaneus; the _trochlear process (peronealtubercle)_ on the same bone; the _cuboid_; and the prominent base ofthe _fifth metatarsal_. The talo-navicular joint lies immediately behind the tuberosity of thenavicular, and a line drawn straight across the foot at this levelpasses over the calcaneo-cuboid joint. The _ankle-joint_, formed by the articulation of the tibia and fibulawith the talus, lies about half an inch above the tip of the medialmalleolus, and is so constructed that when the foot is at a rightangle with the leg it is only possible to flex and extend the joint. When the toes are pointed, however, slight side-to-side and rotatorymovements are possible. The chief seat of side-to-side movement of thefoot is at the talo-navicular and calcaneo-cuboid articulations--"themid-tarsal or Chopart's joint. " The ankle-joint owes its strength chiefly to the malleoli and thecollateral ligaments, and to the inferior tibio-fibular ligaments, which bind together the lower ends of the bones of the leg. Thenumerous tendons passing over the joint on every side also add to itsstability. The synovial membrane of the ankle-joint passes up between the bonesof the leg to line the inferior tibio-fibular joint; but it isdistinct from that of the intertarsal joints, which communicate withone another in a complicated manner. The epiphysial cartilage at thelower end of the fibula lies on the level of the talo-tibialarticulation, while that of the tibia is about half an inch higher(Fig. 93). [Illustration: FIG. 93. --Section through Ankle-Joint showing relationof epiphyses to synovial cavity. _a_, Lower epiphysis of tibia. _b_, Lower epiphysis of fibula. _c_, Talus. _d_, Calcaneus. (After Poland. )] FRACTURES IN THE REGION OF THE ANKLE #Pott's Fracture. #--It must be understood that various lesionsoccurring in the region of the ankle-joint are included under theclinical term "Pott's fracture. " Although of a similar nature, andproduced by the same forms of violence, these vary considerably intheir anatomy and clinical features. They are all the result of_combined eversion and abduction_ of the foot--produced, for example, by slipping off the kerbstone, or by jumping from a height and landingon the medial side of the foot. When forcible _eversion_ is the chief movement, the tightening of thedeltoid (internal lateral) ligament usually tears off the medialmalleolus across its base. The talus is then brought to bear on thelateral malleolus, and the force continuing to act, the lower end ofthe fibula is pressed laterally, and breaks close above themalleolus. The tibio-fibular interosseous ligament may rupture, or theouter portion of the tibia, to which it is attached, may be avulsed. This form is sometimes called _Dupuytren's fracture_. When the bonesare widely separated in Dupuytren's fracture the talus may be forcedup between them. When the movement of _abduction_ predominates, the deltoid ligament isusually ruptured, or the anterior edge or tip of the medial malleolustorn off. The tibio-fibular interosseous ligament usually resists, andan oblique fracture of the fibula 2 or 4 inches above its lower endresults. _Clinical Features. _--In a considerable proportion of cases--in ourexperience in the majority--this fracture is not accompanied by anymarked deformity of the foot, and the patient is often able to walkafter the injury with only a slight limp. In others, however, the deformity is marked and characteristic (Fig. 94). The foot is everted, its inner side resting on the ground. Themedial malleolus is unduly prominent, stretching the skin, which maygive way if the patient attempts to walk. The foot, having lost thesupport of the malleoli, is often displaced backward, and the toes arepointed by the contraction of the calf muscles. There is abnormalmobility--both from side to side and antero-posteriorly--and crepitusmay be elicited. The points of tenderness are over the deltoidligament or medial malleolus, the inferior tibio-fibular joint, and atthe seat of fracture of the fibula. Distal pressure over the shaft ofthe fibula, or on the extreme tip of the malleolus, may elicit painand crepitus at the seat of fracture. There is usually considerableecchymosis and swelling in the hollows below and behind the malleoli;and the malleoli appear to be nearer the level of the sole. InDupuytren's fracture, when the talus passes up between the tibia andfibula, there is great broadening of the ankle. [Illustration: FIG. 94. --Radiogram of Pott's Fracture with lateraldisplacement of foot. ] There is often considerable difficulty in distinguishing a _sprain_ ofthe ankle from a fracture without displacement, as both forms ofinjury result from the same kinds of violence, and are rapidlyfollowed by swelling and discoloration of the overlying soft parts. Ina sprain, the point of maximum tenderness is over the ligaments andtendon sheaths that have been damaged, while in fracture the site ofthe break is the most tender spot. The X-rays are useful in thediagnosis of doubtful cases. _Treatment. _--In those cases of fracture of the lower end of thefibula in which there is no marked displacement, --and they constitutea considerable proportion, --the limb should be massaged and laid on apillow between sand-bags, or placed in a box splint for two or threedays, until the swelling subsides. Some form of rigid apparatus, suchas side poroplastic splints fixed in position with an elastic bandage, which will allow the patient to get about with crutches, is thenapplied. This is removed daily to permit of massage and movement beingcarried out--a point of great practical importance, because, if thisis neglected, not only does union take place more slowly, but thestiffness of the ankle and œdema of the leg and foot which ensue, prolong the period of the patient's incapacity and endanger theusefulness of the limb. It is in cases of this kind that the _ambulatory method_ of treatmentyields its best results. When, in the course of two or three days, theswelling has subsided, a plaster-of-Paris case (Fig. 95) is applied insuch a way that when the patient walks the weight is transmitted fromthe condyles of the tibia through the plaster case to the ground, noweight being borne by the bones at the seat of fracture. The apparatusis applied as follows: A boracic lint bandage is applied to the limbas far as the knee, and protecting pads or rings of wool are placedover the condyles of the tibia, the head of the fibula, and themalleoli. A pad of wool about 3 inches thick is then placed under thesole and fixed in position by a plaster-of-Paris bandage, which iscarried up the limb in the usual way. The case is made speciallystrong on the sole, around the ankle, up the sides of the leg, and atthe bearing-point at the head of the tibia. After the plaster hasthoroughly set, the patient is allowed to walk about with a stick, crutches being unnecessary. In the course of three weeks the plastercase may be removed and the limb massaged. It is usually found thatthe movements of the ankle are scarcely interfered with, and thepatient is generally able to resume work within a month of theaccident. [Illustration: FIG. 95. --Ambulant Splint of plaster of Paris. ] When there is marked eversion of the foot, it may be necessary toadminister a general anæsthetic to reduce the deformity; and toprevent recurrence of the displacement _Dupuytren's splint_ (Fig. 96)may be used. This splint, which is of the same shape as Liston's longsplint, but on a small scale, is applied to the medial side of the legextending from just below the knee to well beyond the sole of thefoot. 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 limbthat when the foot is fully inverted it does not touch the splint. Theupper end of the splint having been fixed to the leg at the level ofthe condyles of the tibia, a bandage is applied to correct theeversion 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 betaken to avoid carrying the turns of this bandage over the seat offracture. The limb may then be slung in a cradle, or placed on apillow resting on its lateral side with the knee flexed. In the courseof a few days, a poroplastic splint may be substituted and massagecommenced. [Illustration: FIG. 96. --Dupuytren's Splint applied to correcteversion of foot. ] When backward displacement of the heel is the prominent deformity, _Syme's horse-shoe_ or _stirrup splint_ (Fig. 97) may be employed. Itis applied to the anterior aspect of the limb, which is carefullypadded to prevent undue pressure on the edge of the shin bone. Afterthe upper end of the splint has been fixed, the heel is pulled forwardby a few turns of bandage passed over the prongs at the lower end ofthe splint. The foot is then inverted and brought up to a right angleby a few supplementary turns of the bandage. In a few days thisappliance may be replaced by a poroplastic splint. [Illustration: FIG. 97. --Syme's Horse-shoe Splint applied to correctbackward displacement of foot. ] _Operative Treatment. _--If the displacement is not completelycorrected by the measures described, the fibular fracture is exposedby a free incision and the fragments are levered into position, and ifnecessary fixed by lashing with catgut or by other mechanical means. Mal-union of Pott's fracture may necessitate re-fracture by means of aJones' wrench, used in the same manner as for club-foot, or the partsare exposed by operation; the bone is divided by means of anosteotome, the foot forcibly inverted, and the limb put up in the sameway as in a recent fracture. #The Converse of Pott's Fracture--sometimes called "Pott's Fracturewith Inversion. "#--This injury is fairly common, and results fromforcible inversion of the foot. The lateral malleolus is broken acrossits base, or, in young subjects, along the epiphysial line. The medialmalleolus alone may be carried away, or a portion of the broad part ofthe tibia may accompany it. The foot is inverted, the heel falls back, and the toes are pointed. In other respects it corresponds to the typical Pott's fracture, andis treated on the same principles. When Dupuytren's splint isrequired, it is, of course, applied to the lateral side of the leg. #Separation of the lower epiphysis of the tibia# is not common. Itoccurs most frequently between the ages of eleven and eighteen, as aresult of forcible eversion or inversion of the foot. It is usuallyaccompanied by fracture of the diaphysis of the fibula (Fig. 98), andis not infrequently compound. When the epiphysis is displaced to oneside, the deformity is characteristic. In rare cases the growth of thetibia is arrested, the continued growth of the fibula causing the footto become inverted. The treatment is the same as for Pott's fracture. [Illustration: FIG. 98. --Radiogram of Fracture of lower end of Fibula, with separation of lower epiphysis of Tibia. ] #Fracture of the talus# usually occurs as a result of a fall from aheight, the bone being crushed between the tibia and the calcaneus. Itis usually associated with other fractures, and is sometimesimpacted, the foot assuming the position of equino-varus. Thediagnosis is only to be made by exclusion, or by the use of theRöntgen rays. In interpreting radiograms of injuries in this region, care must be taken not to mistake the _os trigonum tarsi_ for afracture. In uncomplicated cases, the treatment consists inimmobilising the foot and leg in a poroplastic splint and applyingmassage. In comminuted and in impacted fractures with persistentdeformity, complete excision of the bone yields good results. The #calcaneus# is most frequently broken by the patient falling froma height and landing on the sole of the foot, and the injury may occursimultaneously in both feet. The primary fracture is usually longitudinal, passing through thefacets for the talus and cuboid, and from this various secondaryfissures radiate; the cancellated tissue is much crushed, so that thewhole bone is flattened out. In spite of the great comminution, it isoften impossible to elicit crepitus, as the fragments are heldtogether by the investing soft parts. In other cases the foot may feellike "a bag of bones. " The lesion is often mistaken for a fracture ofthe lower end of the fibula, or is not diagnosed at all. The chiefclinical feature is pain on movement of the foot, or on attempting towalk; the foot appears flat, and the hollows on either side of thetendo Achillis are filled up. In many cases there is a persistenttenderness which delays restoration of function for some months, butthe ultimate result is usually satisfactory. _Treatment. _--In simple comminuted fractures the patient should beanæsthetised, and the foot moulded into position, care being taken torestore the arch in order to avoid any tendency to flat foot. The footis supported on a pillow, and to prevent stiffness, massage andmovements of the ankle and tarsal joints should be commenced withoutdelay. Compound fractures confined to the calcaneus may be treated onconservative lines, but if associated with other injuries of the footthey may necessitate amputation. _The tuberosity of the calcaneus_, into which the tendo Achillis isinserted, is sometimes separated by forcible contraction of the calfmuscles, or from a fall on the ball of the foot. The separatedfragment may be pulled up for a distance of 1 or 2 inches, and therough surface from which it has been torn may be recognisable. Thepatient may be able to walk immediately after the accident, althoughwith difficulty; or he may have pain for many months. A good functional result is usually obtained by relaxing the calfmuscles and fixing the foot in the position of extreme plantar flexionwith the knee flexed, but in some cases it is advisable to peg thefragments, either through the skin or after exposing them byoperation. The #other bones of the tarsus# are rarely fractured separately. The_tuberosity of the navicular_ is sometimes torn away by violenttraction on the ligaments attached to it. #Fractures of the metatarsals and phalanges# usually result fromdirect violence, such as a crush of the foot, in which the soft partsare severely damaged. The use of the Röntgen rays has shown, however, that certain painful conditions in the foot following comparativelyslight injuries, such as kicking a stone, are due to a fracture of oneof the metatarsals or phalanges. When simple, these injuries are often overlooked, on account of thedifficulty of eliciting the signs of fracture from the swelling whichaccompanies them. They are best treated in a moulded splint. Compound fractures are more common, and are to be treated on the sameprinciples as govern such injuries elsewhere. _A fracture of the base of the fifth metatarsal_ has been described bySir Robert Jones. It is produced by the patient coming down forciblyon the lateral edge of the foot while the foot is inverted and theheel raised--as, for example, in dancing. There is a localisedswelling over the base of the fifth metatarsal, and pain when thepatient puts weight on the foot. There is no crepitus or deformity. The fracture is readily recognised by the Röntgen rays. Massage andmovement are employed from the first. DISLOCATIONS IN THE REGION OF THE ANKLE #Dislocation of the Ankle-Joint. #--In describing dislocation of thetalus from the tibio-fibular socket, the varieties are named accordingto the direction in which the foot passes--backward, forward, medially, laterally, or upward. All of them may be complete, but they are more frequently incomplete, and are liable to be rendered compound, either from tearing of theskin at the time of the injury, or by its sloughing later. Although asa rule there is little difficulty in effecting reduction bymanipulation, these injuries are liable to be followed by stiffnessand impaired usefulness of the joint. The _backward_ dislocation is the most common, and results fromextreme plantar flexion of the foot, as from a fall backwards whilethe foot is fixed, wedging the talus between the tibia and fibula. The collateral ligaments are torn, and one or both malleoli may bebroken, or the posterior part of the articular edge of the tibiachipped off (Fig. 99). [Illustration: FIG. 99. --Radiogram of Backward Dislocation of Ankle. (Professor Chiene's case. )] The foot appears shortened, the heel is unduly prominent behind, andthe lower ends of the tibia and fibula project in front, sometimescoming through the skin. The tendons around the joint are stretched ortorn. _Forward_ dislocation results from extreme dorsal flexion at theankle-joint. The foot appears lengthened, the heel is less prominentthan normal, and the hollows on each side of the tendo Achillis areobliterated. The talus is felt in front of the tibia, and the malleoliappear to be displaced backwards and to lie nearer the sole. _Medial_ or _lateral_ dislocation is only possible after fracture ofone or both malleoli, and may be looked upon as a complication ofthese injuries. In cases in which the interosseous ligament is ruptured, and in severecases of Dupuytren's fracture, the talus may be driven _upwards_between the bones of the leg. There is great broadening in the regionof the ankle, and the malleoli are unduly prominent under the skin, which is tightly stretched over them. They are also nearer to the solethan normally. The movements of the ankle-joint are lost. Dislocation of the _inferior tibio-fibular joint_ is exceedingly rare, except in association with fractures of the lower ends of the bones ofthe leg, particularly Dupuytren's fracture, or with dislocation of theankle-joint proper. _Treatment of Dislocation of Ankle. _--The patient having beenanæsthetised, the foot is extended and the knee and hip joints flexedto relax the calf muscles as completely as possible. Traction is thenmade upon the foot, while counter-extension is applied to the leg, andthe bones are manipulated into position. Reduction usually takes placegradually without the characteristic snap which accompanies reductionof most dislocations. It is sometimes necessary to divide the tendoAchillis, particularly in cases of forward dislocation. When the talus passes upwards between the tibia and fibula, it issometimes impossible to effect reduction by manipulation, and the bestresults are then obtained by operation. The after-treatment consists in keeping the leg on a pillow betweensand-bags, and carrying out the usual massage and movement. In compound dislocations which have become infected, primaryamputation may be indicated, but in young and healthy subjects anattempt may be made to save the foot. #Dislocation of the talus# from its articulations with the bones ofthe leg above and the calcaneus and navicular below, is acomparatively common injury, and results from a violent wrench of thefoot. It may be incomplete or complete. When the foot is plantarflexed at the moment of injury, the displacement is generally_forward_ with a tendency outward. The talus comes to rest on thethird cuneiform and cuboid bones, the foot being abducted, inverted, and displaced medially. In a large proportion of cases thedislocation is compound, more or less of the talus being forcedthrough the skin (Fig. 100). [Illustration: FIG. 100. --Compound Dislocation of the Talus. ] When the foot is dorsiflexed at the moment of injury the displacementis _backward_, but this is rare, as is also _dislocation to one orother side_, and _dislocation by rotation_, in which the talus isrotated in its socket. In all these injuries the body of the talusloses its normal relationship with the malleoli. An attempt should be made to reduce the dislocation under anæsthesia, the limb being placed in the same position as for reduction ofdislocation of the ankle. While traction is made upon the foot, anassistant presses directly on the displaced bone and endeavours tomanipulate it into position. In incomplete dislocations this usuallysucceeds, but it not infrequently fails in those which are complete, and under these circumstances it may be necessary to chisel throughthe lateral malleolus to admit of reduction, or to excise the talus. In most cases of compound dislocation also, this bone should beremoved. #Sub-taloid Dislocation. #--In this dislocation, which results from thesame kinds of violence as the last, the talus retains its position inthe tibio-fibular socket, and the calcaneus and navicular, with therest of the foot, are carried away from it. The body of the talus, therefore, maintains its normal relationship with the malleoli--apoint of importance in the differential diagnosis between this injuryand dislocation of the talus. The displacement is usually incomplete, and the foot may either pass backward and medially, or backward andlaterally. When the foot passes _backward and medially_, the head ofthe talus projects on the outer part of the dorsum, resting on thecuboid. The dorsum of the foot is shortened, the heel lengthened, thetoes adducted, and the medial border of the foot raised. The lateralmalleolus is unduly prominent, and reaches nearly to the sole. [Illustration: FIG. 101. --Radiogram of Fracture-Dislocation of Talus. ] In the _backward and lateral_ variety, the medial malleolus and headof the talus project unduly towards the medial side of the foot, whichis abducted and everted. In neither variety is there any mechanical obstacle to movement at theankle-joint. The _treatment_ is carried out on the same lines as for dislocation ofthe talus, reduction being effected without difficulty in most cases. If this fails, as it occasionally does, it may be necessary to excisethe talus. #Mid-tarsal or transverse tarsal dislocation#--that is, at thetalo-navicular and calcaneo-cuboid articulations--is extremely rare. The distal segment of the foot is usually displaced towards the sole;the foot is foreshortened, the malleoli raised from the sole, thearch of the foot is lost, and the first row of tarsal bones projectson the dorsum. The treatment consists in reducing the displacement bymanipulation, after which massage and movement are employed. #Tarso-metatarsal Dislocations. #--One, several, or all of themetatarsals may be separated from the distal row of tarsal bones--theusual cause being a fall from a horse, the foot being fixed in thestirrup. The bases of the metatarsal bones are displaced laterally andtowards the dorsum. The base of the second metatarsal and the firstcuneiform are sometimes fractured. Reduction by manipulation isgenerally easy in dorsal dislocations, but may be difficult when thebones are displaced laterally. This may be due to fragments of bone orsoft parts getting between the bones, and may necessitate operativeinterference. In old-standing dislocations, operation is to be advisedonly when locomotion is seriously interfered with. #Dislocation of the Toes. #--The great toe may be dislocated at itsmetatarso-phalangeal joint, the base of the proximal phalanx passingtowards the dorsum (Fig. 102). Diagnosis and reduction are alike easy. [Illustration: FIG. 102. --Radiogram of Dislocation of Toes. (Sir Montagu Cotterill's case. )] #Inter-phalangeal# dislocations are rare and are easily reduced. CHAPTER IX DISEASES OF INDIVIDUAL JOINTS THE SHOULDER-JOINT The shoulder is seldom the seat of disease, and most affections of thejoint are met with in adults. In young subjects, infective processesresult chiefly from extension of disease from the upper epiphysialjunction of the humerus, which is partly included within the limits ofthe synovial cavity. The synovial membrane, in addition to lining thecapsular ligament, is prolonged down the inter-tubercular (bicipital)groove around the long tendon of the biceps, and pus may escape fromthe joint by this diverticulum and gravitate down the arm; we havealso observed loose bodies of synovial origin in this diverticulum. There is frequently a communication between the joint and thesub-deltoid bursa. There is no attitude characteristic of disease ofthe shoulder-joint, but the girdle is usually elevated, the upper armheld close to the side and rotated medially, while the elbow iscarried a little backwards. In the later stages, the head of thehumerus may be drawn upwards and medially towards the coracoidprocess. Fixation of the shoulder-joint is largely compensated for bymovement of the scapula on the thorax, so that when testing forrigidity the scapula should be fixed with one hand while passivemovements of the arm are carried out with the other. The deltoid isusually atrophied, allowing the acromion, coracoid, and greattuberosity of the humerus to stand out prominently beneath the skin. Swelling is rarely a prominent feature, except when there is acollection of synovial fluid or of pus in the bursa beneath thedeltoid. #Tuberculous Disease# is usually met with in young adults, and is morecommon in the right shoulder. The prominent features are pain, rigidity, and wasting of the deltoid and scapular muscles. The pain issometimes severe, shooting down the arm and interfering with sleep, and it may be associated with tenderness on pressure over the upperend of the humerus. In cases with carious destruction of thearticular surfaces there are starting pains, and the arm is shortened. If a cold abscess forms in the bursa underneath the deltoid, the pusmay burrow and appear at the anterior or posterior boundary of theaxilla or in the axillary space. Pus formed in the joint tends togravitate along the inter-tubercular groove. The axillary glands maybe infected. The primary lesion is either a caseating focus in one of thebones--most often in the upper end of the humerus--or it is of thenature of caries sicca. The greater part of the head may disappear, and the upper end of the shaft be drawn against the socket. Inexceptional cases, portions of the glenoid or humerus are foundseparated as sequestra, or the disease involves parts outside thejoint, such as the acromion or coracoid process. Hydrops withmelon-seed bodies is rare. In young subjects, destruction of thetissues at the ossifying junction may result in considerableshortening of the arm. The _diagnosis_ is to be made from (1) arthritis deformans, in whichthe movements are less restricted, and are attended with grating andcracking; (2) paralysis involving the deltoid and scapular muscles--bythe absence of pain, and the flail-like character of the movements;(3) disease in the sub-deltoid bursa--by the absence of rigidity andother evidence of implication of the articular surfaces; and (4)sarcoma of the upper end of the humerus--by the history of the case, the use of the X-rays or an exploratory incision. Injuries in theregion of the upper epiphysis resulting in loss of movement, may, inthe absence of a reliable history, be mistaken for tuberculousdisease. While the _prognosis_ is favourable on the whole, recovery is usuallyattended with fibrous ankylosis and incapacity to raise the arm abovethe level of the shoulder. The disease often progresses slowly, andmay last for years. _Treatment. _--The limb should be immobilised in the position ofabduction with the forearm and hand directed forwards; the mostefficient apparatus is a plaster spica embracing the thorax and theupper limb down as far as the wrist. If the articular surfaces areaffected and the disease is likely to lead to ankylosis, the armshould be abducted to a right angle. The severe pain of caries siccamay be relieved by blistering or by the application of the cautery. Toinject iodoform, the needle is introduced either immediately outsidethe coracoid process, or just below the junction of the acromionprocess and spine of the scapula. When the disease does not yield toconservative measures, or the X-rays show a gross lesion in the bone, excision of the joint should be performed; a close fibrous ankylosisusually results, and the arm is quite a useful one provided theabducted position has been maintained throughout. #Pyogenic Diseases. #--The shoulder-joint may be infected by extensionof suppurative osteomyelitis from the upper end of the humerus, orfrom suppuration in the axilla, or through the blood stream byordinary pus organisms, pneumococci, typhoid bacilli, or gonococci. Extension should be applied to the arm abducted at a right angle. Whenit is necessary to open the joint, the incision should be placedanteriorly in the line of the inter-tubercular groove; if acounter-opening is required it is made on the posterior aspect bycutting on the point of a dressing forceps introduced through theanterior incision. #Arthritis Deformans. #--The shoulder is seldom affected alone, exceptwhen the arthritis is a sequel to injury, such as a fracture of theneck of the humerus. The common type of lesion is a dry arthritis withfibrillation and eburnation of the articular surfaces. The long tendonof the biceps is usually destroyed, the head of the bone is drawnupwards, and, after wearing through the capsule, rubs on the undersurface of the acromion, which also becomes eburnated. The clinicalfeatures are pain, stiffness, and cracking on movement, and as thesesymptoms may also be caused by loose bodies in the joint, an X-raypicture should be taken to differentiate between them. #Neuro-arthropathies# of the shoulder are met with chiefly insyringomyelia. In some cases there is a large fluctuating andpainless swelling; in others marked and rapid wasting of the deltoidand scapular muscles with flail-like movements of the joint associatedwith disappearance of the upper end of the humerus (Fig. 104). [Illustration: FIG. 103. --Arthropathy of Shoulder in Syringomyelia. The upper end of the humerus has disappeared and the movements areflail-like (cf. Fig. 104). ] [Illustration: FIG. 104. --Radiogram of specimen of Arthropathy ofShoulder in Syringomyelia. The head of the humerus has disappeared andmasses of new bone have formed in the surrounding muscles (cf. Fig. 103). ] #Loose bodies# are rare in the shoulder; we have met with a case inwhich the joint-cavity was distended with loose bodies of synovialorigin, and as most of these had undergone ossification, the X-rayappearances were highly characteristic. They were removed through ananterior incision. #Ankylosis# is not so disabling at the shoulder as at other joints, asthe mobility of the scapula on the chest wall largely compensates forthe fixation of the joint. THE ELBOW-JOINT In disease of the elbow, the usual attitude is that of flexion withpronation of the hand. Swelling of the joint, whether from effusion offluid or from thickening of the synovial membrane, is observed chieflyon the posterior aspect, above and on either side of the olecranon, because the synovial sac is here nearest the surface. The freecommunication between the elbow and the superior radio-ulnar jointshould be borne in mind. [Illustration: FIG. 105. --Radiogram showing Multiple partiallyossified Cartilaginous Loose Bodies in Shoulder-joint. The lowest oneis in the synovial prolongation along the tendon of the biceps. ] #Tuberculous disease# is the most common and important affection (Fig. 106). It usually occurs in patients under twenty, but may be met withat any age; in children the age-incidence is earlier than in the otherlarge joints, a considerable proportion being met with in the firsttwo years of life (Stiles). When the disease is confined to thesynovial membrane, its onset is insidious, there is little or no pain, and no interference with any movement except complete extension. Thechief evidence of disease is a white swelling on either side of andabove the olecranon, obscuring the bony landmarks. The furtherprogress is attended with wasting of the triceps, symptoms ofinvolvement of the articular surfaces, and with abscess formation. [Illustration: FIG. 106. --Diffuse Tuberculous Thickening of SynovialMembrane of Elbow (white swelling) in a boy æt. 12. ] The occurrence of articular caries without swelling of the synovialmembrane is exceptional, and is associated with a good deal of painand considerable restriction of movement. Rigidity from muscularcontraction occurs late, and is rarely complete. Tuberculous foci inthe bones are met with chiefly in the lower end of the diaphysis ofthe humerus; in children, the epiphyses are so small that theossifying junction is intra-articular. Foci are also met with in theupper end of the ulna. The grosser osseous lesions cause enlargementof the bone, and are readily demonstrated by skiagraphy. Abscessformation most commonly occurs beneath the triceps, and the abscesspoints at one or other edge of that muscle. A subcutaneous abscessmay form over the upper end of the ulna or over the radio-humeraljoint. Tuberculous hydrops with melon-seed bodies is rare. [Illustration: FIG. 107. --Contracture of Elbow and Wrist following aburn in childhood. Treated by resection of both joints, and theinsertion, on the palmar aspect of each, of a flap from the abdominalwall. ] _Treatment. _--Conservative measures are persevered with so long asthere is a prospect of securing a movable joint. The limb is placed ina light form of splint reaching from the axilla to the wrist, flexedto rather less than a right angle and with the hand semi-pronated anddorsiflexed. To inject iodoform or other anti-tuberculous agent, theneedle of the syringe is easily introduced between the lateral condyleand the head of the radius. A localised focus of disease in one orother of the bones may be eradicated without opening into the synovialcavity. If the articular surfaces are so involved that recovery is likely tobe attended with ankylosis, the disease should be removed byoperation, and cure with a useful and movable joint may then bereasonably anticipated within two or three months. When the patient'soccupation is such that a strong stiff joint is preferable to a weakermovable one, bony ankylosis at rather less than a right angle shouldbe aimed at. #Arthritis deformans# occurs as a hydrops with hypertrophy of thesynovial fringes and loose bodies, or as a dry arthritis witheburnation and lipping of the articular margins. #Neuro-arthropathies# are met with chiefly in syringomyelia, and areattended with striking alterations in the shape of the bones and withabnormal mobility. #Pyogenic diseases# result from staphylococcal osteomyelitis--chieflyof the humerus or ulna--and from gonorrhœa. The remaining diseases at the elbow include syphilitic disease inyoung children, bleeder's joint, hysterical affections, and loosebodies, and do not call for special description. #Ankylosis# of the elbow-joint, if interfering with the livelihood ofthe patient, may be got rid of by resecting the articular ends ofthe bones, or by inserting between them a flap of fascia andsubcutaneous fat derived from the posterior aspect of the upperarm--_arthroplasty_. THE WRIST-JOINT The close proximity of the flexor sheaths to the carpal articulationspermits of infective processes spreading readily from one to theother. The arrangement of the synovial membranes also favours theextension of disease throughout the numerous articulations in theregion of the wrist. #Tuberculous disease# is met with chiefly in young adults, but mayoccur at any age. It usually originates in the synovial membrane, butfoci are frequently present in the carpal bones, and less commonly inthe lower ends of the radius and ulna, or in the bases of themetacarpals. The clinical features are almost invariably those ofwhite swelling, which is most marked on the dorsum where it obscuresthe bony prominences and the outlines of the extensor tendons. Wastingof the thenar and hypothenar eminences, and filling up of the hollowsabove and below the anterior annular ligament, render the appearanceon the palmar aspect characteristic. The attitude is one of slight flexion with drooping of the hand andfingers. The fingers become stiff as a result of adhesions in thetendon sheaths, and the power of opposing the thumb and fingers may belost. Pain is usually absent until the articular surfaces becomecarious. Softening of the ligaments may permit of lateral mobility, and sometimes partial dislocation occurs. Abscess may be followed bysinuses and infection of the tendon sheaths, especially those in thepalm. The localisation of disease in individual bones or joints can bedetermined by the use of the X-rays. _Treatment. _--Conservative measures may be persevered with over alonger period than in most other joints. The forearm, wrist, andmetacarpus are immobilised in the attitude of dorsal flexion, whilethe fingers and thumb are left free to allow of passive movements. Itmay be necessary to give an anæsthetic to obtain the necessary degreeof dorsiflexion. To inject iodoform, the needle is insertedimmediately below the radial or the ulnar styloid process. Sometimesthe carpal bones are so soft that the needle can be made to penetratethem in different directions. Operative treatment is indicated incases which resist conservative measures, or when the general healthcalls for speedy removal of the disease. _Other diseases of the wrist_ are comparatively rare. They includepyogenic affections, such as those resulting from infective conditionsin the palm of the hand, different types of gonorrhœal, rheumatic, andgouty affections, and arthritis deformans. An interesting feature, sometimes met with in arthritis deformans, consists in eburnation ofthe articular surfaces of the carpal bones, although the range ofmovement is almost nil. THE HIP-JOINT Owing to the depth of this joint from the surface, it is not possibleto detect the presence of effusion or of synovial thickening asreadily as in other joints, hence in the recognition of hip disease wehave to rely largely upon indirect evidence, such as a limp inwalking, an alteration in the attitude of the limb, or restriction ofits movements. The whole of the anterior and fully one-half of the posterior aspectof the neck of the femur is covered by synovial membrane, so thatlesions not only of the epiphysis and epiphysial junction, but also ofthe neck of the bone, are capable of spreading directly to thesynovial membrane and to the cavity of the joint. Conversely, diseasein the synovial membrane may spread to the bone in relation to it. Infective material may escape from the joint into the surroundingtissues through any weak point in the capsule, particularly throughthe bursa which intervenes between the capsule and the ilio-psoas, andwhich in one out of every ten subjects communicates with the joint. TUBERCULOUS DISEASE Tuberculous disease of the hip, morbus coxæ, or "hip-joint disease, "is especially common in the poorer classes. It is a frequent cause ofprolonged invalidism, and of permanent deformity, and is attended witha considerable mortality. It is essentially a disease of early life, rarely commencing after puberty, and almost never after maturity. #Pathological Anatomy. #--Bone lesions bulk more largely in hip diseasethan they do in disease of other joints--five cases originating inbone to one in synovial membrane being the usual estimate. The upperend of the femur and the acetabulum are affected with about equalfrequency. In addition to primary tuberculous lesions, secondary changes resultfrom the inflamed and softened bones pressing against one anothersubsequent to the destruction of their articular cartilages. The headof the femur undergoes absorption from above downwards, becomingflattened and truncated, or disappearing altogether. In the acetabulumthe absorption takes place in an upward and backward direction, whereby the socket becomes enlarged and elongated towards the dorsumilii. To this progressive enlargement of the socket Volkmann gave thesuggestive name of "wandering acetabulum" (Fig. 108). Thedisplacement of the femur resulting from these secondary changes isone of the causes of real shortening of the limb. [Illustration: FIG. 108. --Advanced Tuberculous Disease of Acetabulumwith caries and perforation into pelvis. (Anatomical Museum, University of Edinburgh. )] #Clinical Features. #--It is customary to describe three stages in theprogress of hip disease, but this is arbitrary and only adopted forconvenience of description. _Initial Stage. _--At this stage the disease is confined to a focus inthe bone which has not yet opened into the joint or to the synovialmembrane. The onset is insidious, and if injury is alleged as anexciting cause, some weeks have usually elapsed between the receipt ofthe injury and the onset of symptoms. The child is brought for advicebecause he has begun to limp and to complain of pain. There is ahistory that he has become pale and has ceased to take food well, thathis sleep has been disturbed, and that the pain and the limp, aftercoming 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 thehip, and to substitute for it movement at the lumbo-sacral junction. The child throws the weight of the trunk as little as possible on tothe affected limb, and inclines to rest on the balls of the toesrather than on the sole. There is usually some wasting of the musclesof the thigh and flattening of the buttock. Diminution or loss of thegluteal fold indicates flexion at the hip which might otherwise escapenotice. Pain is complained of in the hip, or is referred to the medialside of the knee, in the distribution of the obturator nerve. Sometimes the pain is confined to the knee, and if the examination isrestricted to that joint the disease at the hip may be overlooked. Atthis stage the attitude of the limb is not constant; at one time itmay be natural, and at another slightly flexed and abducted. Tenderness of the joint may be elicited by pressing either in front orbehind the head of the bone, but is of little diagnostic importance. Pain elicited on driving the head against the acetabulum mayoccasionally assist in the recognition of hip disease, but thediagnostic value of this sign has been overrated and, in our opinion, this test should be omitted. Most information is gained by testing the functions of the joint, andif 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 atable; and to reassure him the movements should be first practised onthe sound limb. On slowly flexing the thigh of the affected limb, itwill be found that the range of flexion at the hip is soon exhausted, and that any further movement in this direction takes place at thelumbo-sacral junction. The child is next made to lie on his face withthe knees flexed in order that the movements of rotation may betested. The thigh is rotated in both directions, and on comparing thetwo sides it will be found that rotation is restricted or abolished onthe side affected, any apparent rotation taking place at thelumbo-sacral junction. These tests reveal the presence of _rigidity_resulting from the involuntary contraction of muscles, which is themost reliable sign of hip disease during the initial stage, and theypossess the advantage of being universally applicable, even in thecase of young children. _Second Stage. _--This probably corresponds with commencing disease ofthe articular surfaces, and progressive involvement of all thestructures of the joint. The child complains more, and usuallyexhibits the attitude of abduction, eversion, and flexion (Fig. 109). [Illustration: FIG. 109. --Early Tuberculous Disease of Right Hip-jointin a boy æt. 14, showing flexion, abduction, and apparent lengtheningof the limb. ] At first the attitude is maintained entirely by the action of muscles;but when it is prolonged, the muscles, fasciæ, and ligaments undergoshortening, so that it becomes fixed. On looking at the patient, the abnormal attitude may not be at onceevident, as he usually restores the parallelism of the limbs bylowering the pelvis on the affected side and adducting the sound limb. This obliquity or tilting of the pelvis causes _apparent lengthening_of the diseased limb, and is best demonstrated by drawing one straightline between the anterior iliac spines, and another to meet it fromthe xiphoid cartilage through the umbilicus; if the pelvis is in itsnormal position, the two lines intersect at right angles; if it istilted, the angles at the point of intersection are unequal. Theflexion may be largely compensated for by increasing the forward curveof the lumbar spine (lordosis), and by flexing the leg at the knee. There may also be an attempt to compensate for the eversion of thelimb by rotating the pelvis forwards on the affected side. [Illustration: FIG. 110. --Disease of Left Hip: position of easeassumed by patient, showing moderate flexion and lordosis. ] [Illustration: FIG. 111. --Disease of Left Hip: disappearance oflordosis on further flexion of the hip. ] To demonstrate the lordosis, the patient should be laid on a flattable; in the resting position the lordosis is moderate, when the hipis flexed it disappears, when it is extended the lordosis isexaggerated, and the hand or closed fist may be inserted between thespine and the table (Fig. 112). [Illustration: FIG. 112. --Disease of Left Hip: exaggeration oflordosis produced by extending the limb. ] When the functions of the joint are tested, it will be found thatthere is rigidity, and that both active and passive movements takeplace at the lumbo-sacral junction instead of at the hip. Whilerigidity is usually absolute as regards rotation, it may sometimes bepossible with care and gentleness to obtain some increase of flexion. For diagnostic purposes most stress should therefore be laid on thepresence or absence of rotation. If the sound limb is flexed at the hip and knee until the lumbar spineis in contact with the table, the real flexion of the diseased hipbecomes manifest, and may be roughly measured by observing the anglebetween the thigh and the table (Fig. 113). This is known as "Thomas'flexion test, " and is founded upon the inability to extend thediseased hip without producing lordosis. [Illustration: FIG. 113. --Thomas' Flexion Test, showing angle offlexion at diseased (left) hip. ] _Swelling_ is seen on the anterior aspect of the joint; it may fill upthe fold of the groin and push forward the femoral vessels. It isdoughy and elastic, but may at any time liquefy and form a coldabscess. Swelling about the trochanter and neck of the bone may beestimated by measuring the antero-posterior diameter with callipers, and comparing with the sound side. Swelling on the pelvic aspect ofthe acetabulum can sometimes be discovered on rectal examination. _Third Stage. _--This probably corresponds with caries of the articularsurfaces, since pain is now a prominent feature, and there are usuallystartings at night. The attitude is one of adduction, inversion, flexion, and apparent or real shortening of the limb (Fig. 114). The_flexion_ is usually so pronounced that it can no longer be concealedby lordosis, so that when the patient is recumbent, although the spineis arched forwards, the limb is still flexed both at the hip and atthe knee; with the spine flat on the table, the flexion of the thighmay amount to as much as a right angle. The _adduction_ varies greatlyin degree; when it is slight, as is most often the case, the toes ofthe affected limb rest on the dorsum of the sound foot. When moderate, it is compensated for by raising the pelvis on the affected side, with_apparent shortening_ of the limb, this being the result of an efforton the part of the patient to restore the normal parallelism of thelimbs, the sound limb being abducted to the same extent as theaffected limb is adducted. It is important to recognise the cause ofthis shortening, as it can be corrected by treatment. As a result ofthe obliquity of the pelvis, the patient, when erect, exhibits alateral curvature of the spine with the dorso-lumbar convexity to thesound side. [Illustration: FIG. 114. --Tuberculous Disease of Left Hip: thirdstage, showing adduction and shortening. ] When adduction is pronounced, the patient is unable to restore thenormal parallelism of the limbs, and the knee on the affected side maycross the sound limb. There is a deep groove at the junction of theperineum and thigh, great prominence of the trochanter, and the pelvismay be tilted to such an extent that the iliac crest comes intocontact with the lower ribs. As a result of the pressure of the carious articular surfaces againstone another, the acetabulum is enlarged and the upper end of the femuris drawn gradually upwards and backwards within the socket. Examination will then reveal the existence of a variable amount of_actual shortening_; it will also be found that the trochanter isdisplaced above Nélaton's line, while above and behind the trochanterthere is a prominent hard swelling corresponding to the enlargedacetabulum. There may, therefore, be a combination of real and apparent shorteningtogether amounting to several inches (Fig. 115). [Illustration: FIG. 115. --Advanced Tuberculous Disease of LeftHip-joint in a girl æt. 14, showing flexion, adduction, shortening, and iliac abscess. ] In cases of long standing, beginning in childhood, the shortening isstill further added to by deficient growth in length of the femur, andit may be of all the bones of the limb; even the foot is smaller onthe affected side. The most reasonable explanation of the attitudes assumed in hipdisease is that given by König. If the patient walks without crutches, as he is usually able to do at an early stage of the disease, theattitude of abduction, eversion, and slight flexion enables him tosave the limb to the utmost extent; on the other hand, if he uses acrutch, as he is obliged to do at a more advanced stage, he no longeruses the limb for support, and therefore draws it upwards and mediallyinto the position of adduction, inversion, and greater flexion. Similarly, if he is confined to bed, he lies on the sound side, andthe affected limb sinks by gravity so as to lie over the normal one inthe position of adduction, inversion, and flexion. König's explanationaccords with the fact that in the exceptional cases which begin withadduction and inversion we have usually to deal with a severe type ofthe disease, associated with grave osseous lesions--precisely thosecases in which the patient is compelled from the outset to lie up orto adopt the use of crutches. Further, the transition from theabducted to the adducted position usually follows upon such anaggravation of the symptoms that the patient is no longer able to walkwithout the assistance of a crutch. During the third stage the other signs and symptoms become morepronounced; the patient looks ill and thin, he is usually unable toleave his bed, his sleep is disturbed by startings of the limb, andthe rigidity of the joint and the wasting of the muscles are wellmarked. The temperature may rise slightly after examination of thelimb, or after a railway journey. #Abscess Formation in Hip Disease. #--The formation of abscess is notrelated to any stage of the disease; it may occur before there isdeformity, and it may be deferred until the disease is apparentlycured. Its importance lies in the fact that if a mixed infection withpyogenic organisms occurs, the gravity of the condition is greatlyincreased. An abscess may appear _in the thigh_ in front or behind the joint. The_anterior abscess_ emerges on one or other side of the psoas muscle;from the resistance offered by the fascia lata, the pus may gravitatedown the thigh before perforating the fascia. It has occasionallyhappened that when such an abscess has been opened and become infectedwith pyogenic organisms, the femoral vessels have been eroded, andserious or even fatal hæmorrhage has resulted. The _posterior abscess_appears in the buttock and may make its way to the surface through thegluteus maximus; more often it points at the lower border of thismuscle in the region of the great trochanter, or it may gravitate downthe thigh. Abscesses which form _within the pelvis_ originate either inconnection with the acetabulum or in relation to the psoas musclewhere it passes in front of the joint. Those that are directlyconnected with disease of the acetabulum may remain localised to thelateral wall of the pelvis, or may spread backwards towards the hollowof the sacrum. They may open into the bladder or rectum, or may ascendinto the iliac fossa and point above Poupart's ligament (Fig. 115), ordescend towards the ischio-rectal fossa. The abscess which develops inrelation to the psoas muscle may be shaped like an hour-glass, one sacoccupying the iliac fossa, the other filling up Scarpa's triangle, thetwo sacs communicating with each other through a narrow neck beneathPoupart's ligament. So long as the skin is intact, the abscess is unattended withsymptoms, and may escape notice. If it bursts externally, pyogenicinfection is almost inevitable, and the patient gradually passes intothe condition of hectic fever or chronic toxæmia; he loses ground fromday to day, may become the subject of waxy disease in the viscera, ormay die of exhaustion, tuberculous meningitis, or generaltuberculosis. #Dislocation# is a rare complication of hip disease, and is mostlikely to occur during the stage of adduction with inversion. It hasbeen known to take place during sleep, apparently from spasmodiccontraction of muscles. In the dorsal dislocation, which is the mostcommon form, adduction and inversion are exaggerated, the trochanterprojects above and behind Nélaton's line, and the head of the bone maybe felt on the dorsum ilii. It is a striking fact that afterdislocation has occurred there is less complaint of pain or ofstartings than before, and passive movements may be carried out whichwere previously impossible. #Diagnosis of Hip Disease. #--The diagnosis is to be made not only fromother affections of the joint, but also from morbid conditions in thevicinity of the hip, as in any of these the patient may seek advice onaccount 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 examinedlying on his back, and attention is directed to the comparative lengthof the limbs, to the attitude of the limbs and pelvis, and to themovements at the hip-joint, especially those of rotation. When thereis any doubt as to the diagnosis, the examination should be repeatedat intervals of a few days. In children, there are three non-febrileconditions attended with a limp and with shortening of the limb, whichmay be mistaken for hip disease, --_congenital dislocation_, _coxavara_, and _paralysis following poliomyelitis_--but in all of thesethe movements are not nearly so restricted as they are in disease ofthe joint. In tuberculous disease of the _sacro-iliac joint_, while the pelvismay be tilted, and the limb apparently lengthened, the movements atthe hip are retained. In tuberculous disease of the _greattrochanter_, or of either of the _bursæ_ over it, while there may beabduction, eversion, impairment of mobility, and swelling in theregion of the trochanter followed by abscess formation, the movementsare less restricted than in disease of the joint. In _psoas abscess_ associated with spinal disease, or in _disease ofthe bursa underneath the psoas_, the limb is flexed and everted, theremay be lordosis, and the patient may limp in walking, but themovements at the hip are restricted only in the directions ofextension and inversion, while in hip disease they are restricted inall directions. _New-growths_ in the vicinity of the hip--especially central sarcomaof the upper end of the femur--are difficult to differentiate from hipdisease without the help of the X-rays. Among other conditions which by interfering with the free mobility ofthe hip may simulate hip disease, are appendicitis, inflammation ofthe glands in the groin, staphylococcal disease of the upper end ofthe femur, and sciatica. The diagnosis _from other diseases of the hip-joint_ is made bycareful consideration of the history, symptoms, and X-ray appearances. #Prognosis. #--The prognosis in hip disease is more serious than intuberculosis of other joints, excepting only those of the spine, andit is most unfavourable when there are gross lesions of the bones andinfected sinuses. Whatever the stage of the disease, recovery is a slow process, andeven in early and mild cases it seldom takes place in less than one ortwo years, and is liable to be attended with some impairment offunction. During the process of cure, complications are liable tooccur, and after apparent recovery relapses are not uncommon. Whenarrested during the initial stage, recovery may be complete; but whenthere has been destruction of the articular surfaces, there is apt tobe ankylosis of the joint and shortening of the limb. In cases which terminate fatally, death usually results frommeningeal, pulmonary, or general tuberculosis, or from pyogeniccomplications and waxy degeneration. #Treatment. #--A large proportion of cases recover under conservativetreatment, and the functional results are so much better than thosefollowing operative interference that unless there are specialindications to the contrary, conservative measures should always beadopted in the first instance. _Conservative Treatment. _--The first essential is to take the weightoff the limb and secure its fixation in the attitude of almostcomplete extension and moderate abduction. When the symptoms are wellmarked, the child is kept in bed and the limb is extended with aweight and pulley. _Extension by Weight and Pulley_ (Fig. 116). --The weight employedvaries from one to four pounds in children, to ten or more pounds inadolescents and adults, and must be adjusted to meet the requirementsof each case. If pain returns after having been relieved, it is due tostretching of the ligaments, and the weight should be diminished orremoved for a time. If there is deformity, the line of traction shouldbe in the axis of the displaced limb until the deformity is got ridof. The extension should be continued until pain, tenderness, andmuscular contraction have disappeared, and the limb has been broughtinto the desired attitude. [Illustration: FIG. 116. --Extension by adhesive plaster and Weight andPulley. ] In restless children, in addition to the extension, a long splint isapplied on the sound side and a sand-bag on the affected one; or, better still, a double long splint and cross-bar, the long splint onthe affected side being furnished with a hinge opposite the hip topermit of varying the degree of abduction (Fig. 117). [Illustration: FIG. 117. --Stiles' Double Long Splint to admit ofabduction of diseased limb. ] When the deformed attitude does not yield rapidly to extension, itshould be corrected under an anæsthetic, and if the adductor tendonsand fasciæ are so contracted that this is difficult, they should beforcibly stretched or divided. The immediate correction of deformed attitudes under anæsthesia haslargely replaced the more gradual method by extension with weight andpulley; and in hospital practice it is usually followed by theapplication of a plaster case. The plaster bandages are applied over apair of knitted drawers; the pelvis and both thighs, the diseased onein the abducted position, are included. The case may be strengthenedby strips of aluminium, and should be renewed every six weeks or twomonths. _Ambulant Treatment. _--When the patient is able to use crutches, theaffected limb is prevented from touching the ground by fixing a pattenon the sole of the boot on the sound side. This may suffice, or, inaddition, the hip-joint is kept rigid by a Thomas' (Fig. 118) or aTaylor's splint. The Thomas' splint must be fitted to the patientunder the supervision of the surgeon, who must make himself familiarwith the construction of the splint, and its alteration by means ofwrenches. [Illustration: FIG. 118. --Thomas' Hip Splint applied for disease ofRight Hip. Note patten under sound foot. The foot on the affected sideis too near the ground. ] In children who are unable to use crutches, a double Thomas' splint isemployed; the child thereby is converted into a rigid object, capableof being carried from one room to another and into the open air. Personally we have obtained satisfaction from the double Thomas'splint employed for spinal disease, which extends from the occiput tothe soles of the feet. The fixation of the hip-joint and the taking of the weight off thelimb by one or other of the above methods, should, as a general rule, be continued for at least a year. Should an abscess develop, it is treated on the usual lines. _Operative Interference. _--Widely diverse opinions are held on thequestion as to whether or not recourse should be had to operativeinterference. Some surgeons are opposed to operative interference, on the groundsthat however advanced the disease may be it will yield to conservativemeasures if judiciously and perseveringly carried out. Other surgeonsadvocate operative treatment in all cases which do not speedily showimprovement under conservative treatment. An intermediate attitude maybe adopted which recommends operation in cases in which the diseaseprogresses in spite of conservative treatment, and in which periodicexamination with the X-rays shows that there are progressive lesionsin the upper end of the femur or in the acetabulum. It is claimed by those who advocate operation under these conditionsthat pain and suffering are at once got rid of, sleep is restored, appetite returns, and there is a marked improvement in the generalhealth, and that this result is obtained in months instead of years, and that the cure is more likely to be permanent. It is certainlyunwise to delay operation until sinuses have formed, as such a courseis largely responsible for the bad results which formerly followedexcision of the joint. _Amputation_ for tuberculous disease of the hip has become one of therarest of operations, but is still required in cases which havecontinued to progress after excision, and when there is disease of thepelvis or of the shaft of the femur, with sinuses, albuminuria, andhectic fever. #The Correction of Deformity resulting from Antecedent Disease of theHip. #--From neglect or from improper treatment, deformity may havebeen allowed to persist, while the disease has undergone cure. It isassociated with ankylosis of the joint, or contracture of the softparts or both. The contracture of the soft parts involves speciallythe tendons, fasciæ, and ligaments on the anterior and medial aspectsof the joint, and is usually present to such a degree that, even ifthe joint were rendered mobile, these shortened structures wouldprevent correction of the deformity. The usual deformity is acombination of shortening, flexion, and adduction. #Bilateral Hip Disease. #--Both hip-joints may become affected withtuberculous disease, either simultaneously or successively, andabscesses may form on both sides. The patient is necessarily confinedto bed, and if the disease is recovered from, his capacity for walkingmay be seriously impaired, especially if the joints become fixed in anundesirable attitude. The most striking deformity occurs when bothlimbs are adducted so that they cross each other--one variety of the"scissor-leg" or "crossed-leg" deformity--in which the patient, ifable to walk at all, does so by forward movements from the knees. Anattempt should be made by arthroplasty to secure a movable joint atleast on one side. OTHER DISEASES OF THE HIP-JOINT #Pyogenic Diseases# are met with in childhood and youth as a result ofinfection with the common pyogenic organisms, gonococci, pneumococci, or typhoid bacilli. While the organisms usually gain access to thetissues of the joint through the blood stream, a direct infection isoccasionally observed from suppuration in the femoral lymph glands orin the bursa under the ilio-psoas. The _clinical features_ are sometimes remarkably latent and are muchless striking than might be expected, especially when the hipaffection occurs as a complication of an acute illness such as scarletfever. It may even be entirely overlooked during the active stage, andonly noticed when the head of the femur is found dislocated, or thejoint ankylosed. In the acute arthritis of infants also, the clinicalfeatures may be comparatively mild, but as a rule they assume a typein which the suppurative element predominates. The limb usuallybecomes flexed and adducted, and a swelling forms in front of thejoint at the upper part of Scarpa's triangle; the upper femoralepiphysis may be separated and furnish a sequestrum. The flexion and adduction of the limb favour the occurrence ofdislocation. A child who has recovered with dislocation on to thedorsum ilii is usually able to walk and run about, but with a limp orwaddle which becomes more pronounced as he grows up. The conditionclosely resembles a congenital dislocation, but the history, and thepresence of gross alterations in the upper end of the femur as seenwith the X-rays, should usually suffice to differentiate them. _Treatment. _--In the acute stage the limb is extended by means of theweight and pulley, and kept at rest with the single or double longsplint, or by sand-bags. If there is suppuration, the joint should beaspirated or opened by an anterior incision, and Murphy's plan offilling the joint with formalin-glycerine may be adopted. In children, it is remarkable how completely the joint may recover. If there is dislocation, the head of the femur should be reduced bymanipulation with or without preliminary extension; it has beensuccessful in about one-half of the cases in which it has beenattempted. Preliminary tenotomy of the shortened tendons is requiredin some cases. When reduction by manipulation is impossible, the jointstructures should be exposed by operation and the head of the bonereplaced in the acetabulum. When the upper end of the femur hasdisappeared, the neck should be implanted in the acetabulum, and thelimb placed in the abducted position. #Arthritis Deformans. #--This disease is comparatively common at thehip, either as a mon-articular affection or simultaneously with otherjoints. [Illustration: FIG. 119. --Arthritis Deformans, showing erosion ofcartilage and lipping of articular edge of head of femur. ] _The changes in the joint_ are characteristic of the dry form of thedisease, and affect chiefly the cartilage and bone. The atrophy andwearing away of the articular surfaces are accompanied by newformation of cartilage and bone around their margins. The head of thefemur may acquire the shape of a helmet, a mushroom, or a limpetshell, and from absorption of the neck the head may come to be sessileat the base of the neck, and to occupy a level considerably below thatof the great trochanter (Fig. 120). These changes sometimes extend tothe upper part of the shaft, and result in curving of the shaft andneck, suggesting a resemblance to a point of interrogation (Fig. 121). The acetabulum may "wander" backwards and upwards, as in tuberculousdisease. It is usually deepened, and its floor projects on the pelvicaspect; its margins may form a projecting collar which overhangs theneck of the femur, or grasps it, so that even in the maceratedcondition the head is imprisoned in the socket and the joint locked. There is eburnation of the articular surfaces in those areas mostexposed to friction and pressure. [Illustration: FIG. 120. --Upper End of Femur in advanced ArthritisDeformans of Hip. The shaft is curved and the head of the bone is at alower level than the great trochanter. ] [Illustration: FIG. 121. --Femur in advanced Arthritis Deformans of Hipand Knee Joints. The upper end of the bone shows the condition of coxavara; the lower end shows enlargement of the medial condyle andalteration in the axis of the articular surface. ] These changes are necessarily associated with restriction of movement, and in advanced cases with striking deformity, which consists inshortening of the limb, usually with eversion and displacement of thetrochanter upwards and backwards in relation to Nélaton's line. The _clinical features_ are usually so characteristic that there islittle difficulty in diagnosis. Restriction of the movements ofabduction and adduction, the presence of cracking and of grating ofthe articular surfaces, and the aggravation of the pain and stiffnessafter resting the limb, are characteristic of arthritis deformans. Theprominence of sciatic pain may lead to the disease being regarded assciatica. The greatest difficulty is met with in cases in which the diseaseoccurs as mon-articular affection in adolescents, for the resemblanceto tuberculous disease of the hip and to coxa vara may be close. Skiagrams do not always enable one to differentiate between them. _Treatment_ is conducted on the same lines as in other joints. Thenormal movements are maintained by suitable exercises, and an effortis made to diminish the pressure on the articular surfaces in walkingby the use of sticks or crutches. Shortening of the limb may be compensated by raising the sole of theboot. When the X-rays show that the disability is mainly due to newbone locking the head of the femur, such new bone may be removed byoperation, _cheilotomy_ (Sampson Handley). Excision of the joint hasin some cases yielded satisfactory results; it is indicated in youngpatients who are otherwise healthy, and who are unable to walk onaccount of pain and deformity. #Osteo-chondritis Deformans Juvenilis. #--Under this term Perthesdescribes an affection of the hip in children which differs in manyrespects from the juvenile form of arthritis deformans. Islands ofcartilage appear in the epiphysis of the head of the femur, and theepiphysis itself becomes flattened without involvement of thearticular surface or of the acetabulum. The disease is met with in children between five and ten; there is alimp in walking without pain or sensitiveness, so that the childcontinues to take part in games. Abduction is markedly restricted andthe trochanter is elevated and prominent. There is no crepitation onmovement or other signs of involvement of the articular surfaces. TheX-rays show the deformity of the head and clear areas in the interiorof the upper epiphysis corresponding to the islands of cartilage;these clear areas resemble those due to caseous foci in tuberculouscoxitis. The disease runs a chronic course, and in the course of a year or twothe limp and the restriction of abduction disappear, so that no activetreatment is called for. #Neuro-Arthropathies. #--_Charcot's disease_ is usually met with in menover thirty who suffer from tabes dorsalis. One or both hip-joints maybe affected. Sometimes the first manifestation is a hydrops and afluctuating swelling in the upper part of Scarpa's triangle. In manyof the recorded cases, however, attention has first been directed tothe disease by the deformity and limp associated with disappearance ofthe head of the femur, or by the occurrence of pathologicaldislocation. The absence of pain and tenderness is characteristic. When dislocation has occurred, the limb is short, and the upper end ofthe femur is freely movable on the dorsum ilii. When both hips aredislocated, the attitude and gait are similar to those observed inbilateral congenital dislocation. The rotation arc of the greattrochanter may be much reduced as a result of the disappearance of thehead of the femur. There may be considerable formation of new bone, giving rise to large tumour-like masses in relation to the capsularligament and the muscles surrounding the joint. The _treatment_ consists in protecting and supporting the joint. Whenthe affection is unilateral, advantage may be derived from a Thomas'or other form of splint, along with a patten and crutches; inbilateral cases, from the use of crutches alone. _Loose bodies in the hip_ are mostly the result of hypertrophy ofsynovial fringes in arthritis deformans and in Charcot's disease, anddo not figure in the clinical features of these affections; Caird hasobserved a case in which the cavity of the joint and the bursa beneaththe psoas were filled with loose bodies, many of which had undergoneossification and gave a characteristic picture with the X-rays. _Hysterical affections_ of the hip resemble those in other joints. THE KNEE-JOINT The knee is more often the seat of disease than any other joint in thebody. The synovial membrane extends beneath the quadriceps extensor as acul-de-sac, which either communicates with the sub-crural bursa, orforms with it one continuous cavity. When the joint is distended withfluid, this upper pouch bulges above and on either side of thepatella, and this bone is "floated" off the condyles of the femur. When there is only a small amount of fluid, it is most easilyrecognised while the patient stands with his feet together and thetrunk bent forwards at the hip-joints, and the quadriceps completelyrelaxed; the fluid then bulges above and on each side of the patella, and its presence is readily detected, especially on comparison withthe joint of the other side. On account of the great extent of the synovial membrane, a largequantity of serous effusion may accumulate in the joint in acomparatively short time, as a result either of injury or disease. Thevillous processes and fringes may take on an exaggerated growth, andgive rise to pedunculated and other forms of loose body. The bursæ in the popliteal space, especially that between thesemi-membranosus and the medial head of the gastrocnemius, as well asthe sub-crural bursa, frequently communicate with the synovial cavityof the knee and may share in its diseases. As the epiphyses at the knee are mainly responsible for the growth inlength of the lower extremity, and are late in uniting with theirrespective shafts--twenty-one to twenty-five years--serious shorteningof the limb may result if their functions are interfered with, whetherby disease or injury. The epiphysial cartilages lie beyond the limitsof the synovial cavity, so that infective lesions at the ossifyingjunctions are less likely to spread to the joint than is the case atthe hip or shoulder, where the upper epiphysis lies partly or whollywithin the joint; disease in the lower end of the femur is more likelyto implicate the knee-joint than disease in the upper end of thetibia. One of the commonest causes of prolonged disability and feeling ofinsecurity in the knee, is to be found in the wasting and loss of tonein the quadriceps extensor muscle; the feeling of insecurity is mostmarked in coming down stairs. The instability of the joint is oftenadded to by stretching of the ligaments and lateral mobility. As aresult of both of these factors the joint is liable to repeatedslight strains or jars which irritate the synovial membrane and tendto keep up the effusion and excite the overgrowth of its tissueelements. TUBERCULOUS DISEASE While tuberculous disease of the knee is specially common in childhoodand youth, it may occur at any period of life, and is not uncommon inpatients over fifty. The disease originates in the synovial membraneand in the bones respectively with about equal frequency. When the synovial membrane is diseased, it tends to grow inwards overthe articular surfaces (Fig. 122), shutting off the supra-patellarpouch and fixing the knee-cap to the femur, and diminishing the areaof the articular surfaces. The ingrowth of synovial membrane may fillup the cavity of the joint, or may divide it up into compartments. Ulceration of the cartilage and caries of the articular surfaces arecommon accompaniments. [Illustration: FIG. 122. --Tuberculous Synovial Membrane of Knee, spreading over articular surface of femur. ] The femur and tibia are affected with about equal frequency, and thenature and seat of the bone lesions are subject to wide variations. Multiple small foci may be found beneath the articular cartilage ofthe tibia, or along the margins of the femoral condyles--especiallythe medial. Caseating foci are comparatively rare, but they sometimesattain a considerable size--especially in the head of the tibia, wherethey may take the form of a caseous abscess. Sclerosed foci, whichform sequestra, are comparatively common (Fig. 123). [Illustration: FIG. 123. --Lower End of Femur from an advanced case ofTuberculous Arthritis of the Knee. Towards the posterior aspect of themedial condyle there is a wedge-shaped sequestrum, of which thesurface exposed to the joint is polished like porcelain. (Anatomical Museum, University of Edinburgh. )] #Clinical Types. #--(1) _Hydrops_ usually arises from a purely synoviallesion, but the joint may suddenly become distended with fluid when anosseous focus ruptures into the synovial cavity. It is met with chiefly in young adults. As the fluid accumulates itgradually stretches the capsule, and pushes the patella forwards, sothat it floats. There is little pain or interference with function;the patient is usually able to walk, but is easily tired. The amountof fluid diminishes under rest, and increases after use of the limb. In a certain number of cases it may be possible to recognise localisedthickening of the synovial membrane, or the presence of floatingmasses of fibrin or melon-seed bodies. This is best appreciated if theknee is alternately flexed and extended by the patient while thesurgeon grasps and compresses it with both hands. If the joint isopened, fibrinous material, often in the form of melon-seed bodies, may be found lining the synovial membrane. Tuberculous hydrops is to be diagnosed from the effusion that resultsfrom repeated sprain, from the hydrops of loose body, gonorrhœa, arthritis deformans, Charcot's disease, and Brodie's abscess in theadjacent bone, and from the hæmarthrosis met with in bleeders. (2) _Papillary or Nodular Tubercle of the Synovial Membrane. _--This isa condition in which there is a fringy, papillary, or polypoidalgrowth from the synovial membrane. It is most often met with in adultmales. The onset and progress are gradual, and the chief complaint isof stiffness and swelling which are worse after exertion. Sometimesthere are symptoms of loose body, such as occasional locking of thejoint, with pain and inability to extend the limb; but the locking iseasily disengaged, and the movements are at once free again. Thepatient may give a history of several years' partial and intermittentdisability, with lameness and occasional locking, although he may havebeen able to go about or even to continue his occupation. There is a moderate degree of effusion into the joint, and when thishas subsided under rest it may be possible to feel ill-defined cords, or tufts, or nodular masses, and to grasp between the fingers those inthe supra-patellar pouch. There is little wasting of muscles, and itis exceptional to have signs of disease of the articular surfaces orof cold abscess. On opening the joint, there may escape fluid and loose bodies similarto those described under hydrops, and if the finger is introduced intothe cavity, the upper pouch is felt to be occupied by fringes orpolypoidal processes derived from the synovial membrane. The diagnosis is to be made from arthritis deformans, and in somecases from loose body of other than tuberculous origin. (3) _Cold abscess_ or _empyema_ of the knee is a rare condition, inwhich the joint becomes filled with pus. It usually results from aprimary tuberculosis of the synovial membrane occurring in childrenreduced in health and the subject of tuberculosis elsewhere. (4) _Diffuse Thickening of the Synovial Membrane--White Swelling. _--Solong as this form of the disease remains confined to the synovialmembrane, the chief feature is that of an indolent elastic swelling inthe area of the joint. The swelling tapers off above and below, sothat it acquires a fusiform shape, and from the wasting of the musclesit appears greater than it really is. The range of movement ismoderately restricted. At first the patient limps, keeps the knee slightly flexed, andcomplains of tiredness and stiffness after exertion. As the articularsurfaces become affected, there is pain, which is readily excited byjarring of the limb, or by any attempt at movement; the joint is heldrigid, and there may be startings at night. If untreated, flexionbecomes more pronounced--it may be to a right angle--the leg and footare everted, and, in children, the tibia may be displaced backwards(Fig. 124). The wasting of muscles continues, the part becomes hot tothe touch, the swelling increases, and may show areas of softening orfluctuation from abscess formation. [Illustration: FIG. 124. --Advanced Tuberculous Disease of Knee, withbackward displacement of Tibia. ] White swelling is to be differentiated from peri-synovial gummata, from myeloma and sarcoma of the lower end of the femur, and frombleeder's knee. In the first of these the swelling is nodular and lessuniform, and there may be tertiary ulcers or depressed scars in theneighbourhood of the patella. In tumours the swelling is more markedon one side of the joint, it is uneven or nodular, it does notcorrespond to the shape of the synovial membrane, and may extendbeyond the limits of the joint, and it involves the bone to a greaterextent than is usual in disease of the joint. Skiagrams show expansionof the bone in central tumours, or abundant new bone in ossifyingsarcoma. The diagnosis of bleeder's knee is to be made from thehistory. (5) _Primary Tuberculous Disease in the Bones of the Knee. _--So longas the foci are confined to the interior of the bone, it is impossibleto recognise their existence, unless they are of sufficient size tocause enlargement of the bone or to be discernible in a skiagram. #The formation of peri-articular abscess# takes place in rather morethan fifty per cent. Of cases. When left to themselves, such abscessestend to spread up the thigh, or down the back of the leg between thesuperficial and deep layers of calf muscles, and numerous sinuses mayresult from their rupture through the skin. #Attitudes of the Limb in Knee-Joint Disease. #--The attitude mostoften assumed is that of _flexion_, with or without _eversion of theleg and foot_. The flexion is explained by its being the restingattitude of the joint, and that which affords most ease and comfort tothe patient. Once the joint is flexed, the involuntary contraction ofthe flexor muscles maintains the attitude, and if the patient is ableto use the limb in walking, the weight of the body is a powerfulfactor in increasing it. The eversion of the leg is probablyassociated with contraction of the biceps muscle. _Backwarddisplacement of the tibia_ is met with chiefly in neglected cases ofchronic disease of the knee when the child has walked on the limbafter it has become flexed. In certain cases, _genu valgum_ or abduction of the leg is presentalong with a slight degree of flexion. The valgus attitude isassociated with slight lateral displacement of the patella, withprominence and apparent enlargement of the medial condyle, withdepression of the pelvis on the diseased side and apparent lengtheningof the limb. #Treatment of Tuberculous Disease of the Knee. #--Conservative measuresare always indicated in the first instance, and are persevered with solong as there is a prospect of obtaining a movable joint. _Conservative Treatment. _--If the joint is sensitive and tends to beflexed, the patient is confined to bed, the limb is secured to aposterior splint, and extension with weight and pulley persevered withuntil these symptoms have disappeared; during this time, from three tosix weeks, methods of inducing hyperæmia and other anti-tuberculousprocedures are employed. If it is proposed to inject iodoform or otherdrug, the needle is inserted into the interval between the bones onthe medial side of the ligamentum patellæ or into the upper pouch whenthis is distended with fluid. If there is no pain or tendency to flexion, or when these have beenovercome, the limb is put up in a Thomas' splint (Fig. 125) and thepatient allowed to go about. The splint is worn for a period varyingfrom six to twelve months; before being discarded it may be left offat night; it is ultimately replaced by a bandage. [Illustration: FIG. 125. --Thomas' Knee Splint applied. Note extensionstrapping applied to affected leg, and patten under sound foot. ] The indications for _operative treatment_ are: (1) marked symptoms ofdestruction of the articular cartilages; (2) a deformed attitudeincapable of being rectified without operation; (3) a condition of thegeneral health which requires that the disease should be got rid of asspeedily as possible; (4) progress or persistence of the disease inspite of conservative treatment. When there is no prospect of recoverywith a movable joint it is a waste of time and a possible source ofdanger to persevere with conservative measures. Operation permits ofthe disease being eradicated and the restoration of a useful limbwithin a reasonable time, averaging from three to six months. In adults, the operation consists in excising the joint; in childrenthe aim is to remove the diseased tissues without damaging theepiphysial cartilages. Amputation is performed when the disease has relapsed after excisionand there is persistent suppuration, and when life is threatened bythe occurrence of tuberculosis in the lungs or elsewhere. #Treatment of Deformities resulting from Antecedent Diseases of theKnee. #--Flexion is the commonest of these; when due to contracture ofthe soft parts, these are either stretched by degrees, the limb beingencased in plaster after each sitting, or they are divided by opendissection in the popliteal space. If there is fibrous or osseousankylosis, the choice lies between arthroplasty, the removal of awedge of bone which includes the joint, or, in patients who are stillgrowing, of a wedge from the femur above the level of the epiphysialcartilage. Backward displacement of the tibia, genu recurvatum, andgenu valgum also require operative treatment. OTHER DISEASES OF THE KNEE-JOINT #Pyogenic diseases# result from infection through the blood stream, from one of the adjacent bones, or from a penetrating wound of thejoint. The commoner types include the _synovitis_ associated withdisease in the adjacent bone, _acute arthritis of infants_, jointsuppuration in _pyæmia_, _pyogenic arthritis_ following uponpenetrating wounds, and the affections which result from _gonorrhœal_or _pneumococcal_ infection. _Treatment. _--The limb is immobilised on a posterior splint so paddedas to allow slight flexion at the knee, and extension applied withsufficient weight to relieve the pain; it is also of benefit to inducehyperæmia by one or other of the methods devised by Bier. To tap thejoint, the needle is introduced obliquely into the supra-patellarpouch, and if it is necessary to open the joint, the incision is madeon one or on both sides of the patella, and Murphy's plan of insertingformalin-glycerine may be employed. If the infection progresses andthreatens the life of the patient, it may be necessary to lay thejoint freely open from side to side, sawing across the patella, and, the limb being flexed, the whole wound is left open and packed withgauze. As the infection subsides, the limb is gradually straightened. If these methods fail, amputation through the thigh may be the onlymeans of saving life. #Arthritis deformans# affects the knee more frequently than any of theother large joints. The changes related to the synovial membrane hereattain their maximum development, and may assume the form of hydropswith or without fibrinous bodies, or of overgrowth of the synovialfringes and the formation of pedunculated loose bodies. It issuggested that these synovial changes follow upon repeated sprains orupon a previous pyogenic infection of the joint. The effusion andstretching of the ligaments that follow upon a sprain are incompletelyrecovered from; the synovial membrane becomes puckered, the quadricepsatrophies and no longer puts the ligamentum mucosum on the stretch;and the infra-patellar pad of fat, not undergoing the normalcompression during extension, is readily nipped between the femur andtibia. Each nipping implies a fresh sprain, with return of theeffusion, and so a vicious circle is set up which terminates in whathas been called a _villous arthritis_, with fringes and loose bodies;in time, the articular cartilage at the line of the synovialreflection undergoes fibrillation and conversion into connectivetissue, and the process spreading to the articular surfaces, thepicture of a rheumatoid arthritis is complete. Fibrillation of thecartilage imparts a feeling of roughness when the joint is graspedduring flexion and extension, and lipping of the margins of thetrochlear surface of the femur may be felt when the joint is flexed;it is also readily seen in skiagrams. When a portion of the "lipping"is broken off, it may give rise to a loose body. In advanced caseswith destruction of the cartilages, there may be movement from side toside, with grating of the articular surfaces. In the early stages, treatment consists in limiting the movements ofextension by means of a splint provided with a hinge that locks atthirty degrees from full extension and vigorous massage of thequadriceps. In the dry, creaking forms of arthritis, the symptoms arerelieved by introducing liquid vaseline into the joint. When thesymptoms are due to the presence of fringes and loose bodies, thesemay be removed by operation. When the disease is of a severe type, andis confined to one knee, the question of excising the joint may beconsidered. _Bleeder's knee_, _Charcot's disease_, _hysterical knee_, and _loosebodies_ in the joint have already been described. THE ANKLE-JOINT There is a common synovial cavity for the ankle and the inferiortibio-fibular joints. The epiphysial cartilage of the tibia lies abovethe level of this synovial cavity, but that of the fibula is includedwithin its limits (Fig. 93). The talus is related to threearticulations--the ankle above, the talo-navicular joint in front, andthe calcaneo-taloid joint below. The tendon sheaths, especially thoseof the peronei and of the tibialis posterior, are liable to beinfected by the spread of infective disease from the joint. #Tuberculous Disease. #--Tuberculous disease at the ankle is met withat all ages. In the majority of cases the disease affects both boneand synovial membrane. Gross lesions in the bones are comparativelyrare, and are chiefly met with in the head or neck of the talus. _Primary synovial disease_ usually exhibits the features of whiteswelling, projecting beneath the extensor tendons on the dorsum, and, posteriorly, filling up the hollows on either side of the tendoAchillis and below the malleoli (Fig. 126). The foot may retain itsnormal attitude, or the toes may be pointed and adducted. The calfmuscles are wasted, there is little complaint of pain, and themovements of the joint may be so little interfered with that thepatient can walk without a limp. When the disease involves thearticular surfaces, there is pain and sensitiveness, the movements arerestricted or abolished, and the patient is unable to put the foot onthe ground. [Illustration: FIG. 126. --Tuberculous Disease in a man æt. 35, of sixweeks' duration. ] _A primary focus in the bone_ causes localised pain and tenderness, and a limp in walking, but the first sign may be the formation ofabscess or the rapid development of articular symptoms. In such casesskiagrams afford valuable information. Abscess formation is an early and prominent feature, whether thedisease is of osseous or synovial origin, and sinuses are liable toform around the joint. Outlying abscesses and sinuses are usually theresult of infection of the tendon sheaths in the neighbourhood. _Diagnosis. _--When teno-synovitis occurs independently of disease ofthe ankle, the swelling is confined to one aspect of the joint. Insarcoma of the lower end of the tibia, the swelling lacks the uniformdistribution of that met with in joint disease. In Brodie's abscess ofthe lower end of the tibia there may be swelling of the ankle, butthere is an area of special tenderness on percussion over the bone. _Treatment. _--The foot is immobilised at a right angle to the leg bysplints or plaster of Paris; if articular symptoms are absent or havesubsided, a Thomas' knee splint should be applied to enable thepatient to move about without bearing his weight on the affected foot(Fig. 125). To inject iodoform, the point of the needle is insertedbelow either malleolus, and is then pushed upwards alongside of thetalus. If localised disease in one of the bones is recognised beforethe joint is infected, it should be eradicated by operation. When the disease is diffuse and resists conservative treatment, excision should be performed, the articular surfaces of theconstituent bones being removed, and if necessary the whole of thetalus. Amputation is only called for in adults with rapidly progressingdisease and diffuse suppuration, and in cases which have relapsedafter excision. The other diseases of the ankle include _pyogenic_, _gonorrhœal_, _rheumatic_, _gouty_, and _hysterical_ affections, _arthritisdeformans_, and _Charcot's disease_. The last-named is generallyassociated with a rapid and painless disintegration of the bones ofthe ankle and tarsus, resulting in great deformity and loss of thearch of the foot--sometimes associated with perforating ulcer of thesole. Tuberculous disease in the #tarsus#, #metatarsus#, and #phalanges# hasbeen considered in the chapter on Diseases of Bone. CHAPTER X DEFORMITIES OF THE EXTREMITIES The origin of deformities: (1) Those arising before birth; (2) those produced during birth; and (3) those acquired after birth. Palsies of children: _Anterior Poliomyelitis_. Cerebral palsies: _Spastic paralysis_. THE LOWER EXTREMITY: Congenital dislocation of hip--Snapping hip--Paralytic deformities--Contracture and ankylosis of hip--Coxa vara and coxa valga--Congenital dislocation of knee and patella--Genu recurvatum--Paralytic deformities--Contracture and ankylosis of knee--Genu valgum and genu varum--Congenital deformities of leg--Bow-leg--Club-foot: _Talipes equino-varus_; _Pes equinus_; _Pes calcaneus_; _Pes calcaneo-valgus and varus_; _Pes cavus_; Flat-foot and pes valgus--Painful affections of heel--Metatarsalgia--Hallux valgus and bunion--Hallux varus--Hallux rigidus and flexus--Hammer-toe--Hypertrophy of toes--Supernumerary toes--Webbed toes. THE UPPER EXTREMITY: Congenital absence of clavicle--Elevation of scapula--Winged scapula--Congenital paralytic deformities of shoulder--Deformities of elbow--Club-hand--Deformities of wrist--Madelung's deformity--Deformities of fingers--Dupuytren's contraction--Polydactylism. The surgery of the extremities is so largely concerned with thecorrection of deformities that it is necessary at the outset to referbriefly to some points relating to the time and mode of origin ofthese. 1. _Congenital deformities_--that is, those which originate _in utero_and are present at birth--are comparatively common and may be due to avariety of causes. Some result from errors of development--forexample, supernumerary fingers or toes, and deficiencies in the bonesof the leg or forearm. A larger number are to be attributed to apersistent abnormal attitude of the fœtus, usually associated withwant of room in the uterus--for example, the common form of club-footand congenital dislocation of the hip. Less frequently amniotic bandsso constrict the digits or the limbs as to produce distortion, or evento sever the distal part--_intra-uterine amputation_. Lastly, certaindiseases of the fœtus, and particularly such as affect theskeleton--for example, achondroplasia--cause congenital deformities. 2. _Deformities originating during birth_ are all traceable to theeffects of injuries sustained in the course of a difficult labour. Examples of these are: wry-neck resulting from rupture of thesterno-mastoid; lesions of the shoulder-joint and brachial plexus dueto hyper-extension of the arm; a spastic condition of the lowerlimbs--Little's disease--resulting from tearing of blood vessels onthe surface of the brain with hæmorrhage and interference with thefunction of the cortical motor area. 3. _Deformities acquired after birth_ arise from widely differentcauses, of which diseases of bone, including rickets, diseases ofjoints, and affections of the nervous system attended with paralysis, are amongst the commonest. Other deformities are produced byunsuitable clothing, such as a tight corset, or ill-fitting shoesdistorting the toes, prolonged standing in growing subjectsoverstraining the mechanism of the foot and giving rise to the commonform of flat-foot. The part played by the palsies of children in the surgical affectionsof the extremities necessitates a short description of their moreimportant features. #Anterior poliomyelitis# is the lesion underlying what was formerlyknown as _infantile paralysis_--a name to be avoided, because thecondition is not confined to infants and it is not the only form ofparalysis met with in young children. Anterior poliomyelitis ischaracterised by an illness attended with fever, in which the child isfound to have lost the power of one, less frequently of both lowerextremities; or, it may be, of one or both arms. After a period, varying from six weeks to three months, the paralysis tends todiminish both in extent and degree, and in the majority of cases itultimately persists only in certain muscles or groups of muscles. Atthe onset of the paralysis the affected limb is helpless and relaxed, the reflexes are lost, the muscles waste, and those that are paralysedexhibit the reaction of degeneration. In severe cases, and especiallyif proper treatment is neglected, the nutrition of the limb isprofoundly affected; its temperature is subnormal, the skin is bluishin cold weather and readily becomes the seat of pressure sores. Incourse of time the limb lags behind its fellow in growth, and tends toassume a deformed attitude, which at first can easily be corrected, but later becomes permanent. [Illustration: FIG. 127. --Female child showing the results ofPoliomyelitis affecting the left lower extremity; the limb is shortand poorly developed, the pelvis is tilted and the spine is curved. ] When the acute stage of the illness is past, the chief question is towhat extent recovery of function can be looked for in the paralysedmuscles. It would appear to be established that if a muscle reacts to faradismit will recover, but the contrary proposition does not follow. It wasformerly accepted that a muscle which exhibits the reaction ofdegeneration is incapable of recovery, but observation has shown thatthis is not the case. Complete destruction of the motor cells in theanterior horn of grey matter as a result of poliomyelitis is now knownto be exceptional; as a matter of fact, damage to the nerve cells isusually capable of being repaired. The muscles governed by these cellsmay appear to be completely paralysed, but with appropriate treatmenttheir functional activity can be restored. As functional disability isfrequently due to the affected muscle being _over-stretched_, it is ofthe first importance, when the acute symptoms are on the wane, thatevery care should be taken to prevent the weak muscular groups beingput upon the stretch, and the greatest attention should be paid to_the posture of the limb during convalescence_. For example, if thechild is allowed to lie with the wrist flexed, the flexor musclesundergo shortening, and the extensors are over-stretched and aretherefore placed at a mechanical disadvantage. As the inflammatorychanges in the anterior horn of the cord subside, the flexor tendons, from their position of advantage, are in a condition to respond to thefirst stimuli that come from their recovering motor cells, while theextensors are not in a position to do so. If, on the other hand, thewrist and fingers are maintained in the attitude of extremedorsiflexion, the extensors become shortened, and, relieved of strain, they soon begin to respond to the stimuli sent them from therecovering nerve cells. Similarly in the lower extremity, when, forexample, the muscles innervated through the peroneal (externalpopliteal) nerve are paralysed, if the foot is allowed to remain inthe attitude of inversion with the heel drawn up--paralyticequino-varus--an attitude which is rendered more pronounced by thepressure of the bedclothes, the chance of the muscles recovering theirfunction is seriously diminished. Another potent factor in preventingrecovery, especially in the lower limbs, is _erroneous deflection ofthe body weight_. If, for example, there is weakness in the tibialgroup of muscles, and the child is allowed to walk, the eversion ofthe foot will steadily increase, the tibial muscles will be more andmore stretched, the opposing peroneal muscles will shorten, and, intime, the bones of the tarsus will undergo structural alterationswhich will perpetuate the deformity. If, on the other hand, by somealteration of the boot, the foot is maintained in the attitude ofinversion, the weakened or paralysed tibial muscles are placed in amuch more favourable condition for recovery. It must be emphasised that no operation should be performed in thesecases until the question whether it be possible or not to restore theapparently paralysed muscle is settled. The clinical test of therecoverability of a muscle is to keep it for a long period--six oreven twelve months--in a condition of relaxation. This test should bemade, no matter how many months or years the muscle may have beenparalysed. The first stage in the treatment, therefore, is the correction ofexisting deformity, after which the limb should be kept immovableuntil the ligaments, muscles, and even the bones have regained theirnormal length and shape. The slightest stretching of a muscle which isin process of recovery disables it again. The age of the patient influences the method of treatment. In youngchildren in whom the structures are soft and yielding, gradualcorrection of the deformity is to be preferred to the more rapidmethods employed in older children. The proper sequence consists incorrecting the deformity, providing the simplest apparatus to keep thelimb in good position, preventing erroneous deflection of body weightduring walking, and then allowing the child to grow and develop untilhe has reached the age of five before considering such an operation astransplanting tendons, and the age of ten before deciding to ankylosea flail-like joint. _Reposition, Manipulations, Supports. _--An attempt is made to correctthe deformity by manipulation, and the proper attitude is maintainedby a mechanical support. If the foot has become rotated so that thesole looks laterally, the medial side of the boot must be raised, andan iron worn which extends from the knee down the lateral side of theleg, 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 intothe waist of the boot, to keep the foot at right angles to the leg andto relax the weak extensor muscles. _Division of Contractions. _--Bands of fascia and contracted tendonswhich prevent correction of deformity may have to be divided orlengthened. This is best done by the open method. _Removal of Skin. _--To assist in maintaining the desired attitude, Jones recommends the plan of excising an area of the redundant skin onthe weaker aspect of the limb; in equinus, the skin is taken from thedorsum; in equino-varus, from the front and lateral aspect of thefoot. When the edges of the gap have united, the foot is maintained inthe desired attitude for some months, even if parents carelesslyremove the iron support to let the child run about. _Tendon transplantation_, a procedure introduced by Nicoladoni, is tobe considered in children of five and upwards. It may be employed fordifferent purposes: (1) To reinforce a weak muscle by a healthyone--for example, by transplanting a hamstring tendon into the patellato reinforce a weak quadriceps, or reinforcing the weak invertors ofthe foot by a transplanted extensor hallucis longus. (2)Transplantation may also be performed to replace a muscle which isquite inactive and does not show any sign of recovery--for example, the tibiales being paralysed, the peroneus longus may be implantedinto the navicular or first metatarsal to act as an invertor of thefoot. Wherever possible a tendon should be transplanted directly into bone, as, if it is attached to soft parts it rarely holds firmly enough. Thebone should if possible be tunnelled, and the tendon passed throughthe tunnel and securely fixed. When bringing a tendon to its new pointof attachment, it should pass in as straight a line as possible, avoiding any bend or angle which might impair its action. Fat is thebest medium for the transplanted tendon to traverse, as it acts as asheath and prevents the formation of adhesions which would interferewith the function of the new tendon. All deformity must be correctedbefore transferring the tendon; if the tendon is too short to admit ofthis, it can be lengthened by means of silk threads (Lange). According to Jones, the most successful transplantations are thefollowing, in order: (1) The tibialis anterior into the lateral tarsusin paralysis of the peronei; (2) the peroneus longus into thenavicular in paralysis of the tibial group; (3) the extensor hallucislongus into any part of the foot where it may be wanted; (4) thehamstrings into the patella, to reinforce the quadriceps, provided thestrictest after-treatment can be secured; (5) deflection of part ofthe tendo Achillis to one or other side of the foot. _Arthrodesis. _--This operation, first performed by Albert in 1877, consists in removing the cartilage covering the articular surfaces ofbones with the object of producing a firm ankylosis. The procedure ismost successful in the ankle and mid-tarsal joints, and as a result ofit there is obtained a secure and firm base of support in walking. Before performing arthrodesis, the surgeon must decide whether thepatient will be better off with a stiff joint or with a weak andmovable ankle supported by apparatus. This is often a matter of socialposition; in the poor, an ankylosed joint is more useful and lessexpensive. An arthrodesis should seldom be performed at the ankleuntil the child has passed his eighth year, or at the knee until hehas reached his twentieth year. There is plenty to be done during theperiod of waiting, and if this is done well, it is possible that theoperation may not be required. The existing deformities, for example, will have to be corrected, areas of skin removed to relievefunctionless muscles of strain, the body weight appropriatelydeflected, and the child must be taught to walk with the aid of asupport, swinging his limb about, and using it effectively in acorrect position. Such exercise is a powerful agent in promotingphysiological and functional development. _Nerve anastomosis_, which seeks to provide a new channel for thetransmission of motor impulses to the paralysed muscles, has as yet arestricted field of application--for example, the tibial and peronealnerves may be anastomosed when the muscles supplied by one of them areparalysed. Stoffel of Heidelberg lays stress on regard being paid tothe anatomical arrangement of the nerve bundles within the nerve-trunkso that motor fibres may be joined to motor ones and not to sensory. It is necessary also to cut across some of the fibres of the healthynerve in order that they may grow into the nerve which is degenerated. In extreme cases in which the limb is hopelessly paralysed anduseless, it may be _amputated_ to admit of an artificial limb beingworn; it must be borne in mind, however, that such limbs furnish poorstumps, usually quite unable to bear pressure. #Cerebral Palsies of Childhood--Spastic Paralysis. #--These may be dueto arrest of development of the brain, to injuries of the head atbirth, to meningeal hæmorrhage, or to other lesions of the brain, withsecondary degenerative changes in the spinal cord. The commonest causeis hæmorrhage occurring during child-birth from the veins which ascendfrom the middle part of the convexity of the hemisphere to open intothe superior sagittal (superior longitudinal) sinus. The blood ispoured out beneath the dura on one or on both sides of the falxcerebri, and as it accumulates near the vertex, the damage to themotor centres for the legs is usually more extensive than that to thecentres for the arms. The paralysis may affect one side of thebody--_hemiplegia_, or both sides--_diplegia_; less commonly oneextremity alone is involved--_monoplegia_. In diplegia, in which botharms and both legs are affected in the first instance, the arms mayrecover while the lower extremities remain in a spastic state, acondition known as _Little's disease_. The mental functions may benormal but more frequently they are imperfectly developed, theimpairment in some cases amounting to idiocy. The affected limbsexhibit muscular rigidity or spasm, which is aggravated on movementbut disappears under an anæsthetic; the reflexes are exaggerated, andsometimes there are perverted involuntary movements (_athetosis_). Thegrowth of the limb is impaired, and contracture deformities maysupervene (Fig. 131). The amount of power in the limb is oftenastonishing, in marked contrast to what is observed to follow uponanterior poliomyelitis. The degree of natural improvement is by nomeans great, and normal function is almost never regained. The _treatment_ is concerned in the first place with improving thecondition of the muscles by methodical exercises and massage. Whenreflex irritability of the muscles with consequent spasm is aprominent feature, the reflex arc may be interrupted by _resection ofthe posterior nerve roots_ corresponding to the part affected. Thisoperation, first suggested by Spiller but chiefly popularised byFoerster, has yielded the best results in cases of Little's disease, in which there still remains a considerable amount of voluntarymovement, and yet there is inability to walk on account of involuntaryspasm. In the case of the lower extremities, three or more of thelumbar and one or more of the sacral nerve roots are resected withinthe vertebral canal. Sensation is diminished but not abolished in thearea of skin involved. Massage and exercises and, it may be, splintsor apparatus are essential factors in promoting the recovery offunction. It has not yet been decided whether the results of theresection of nerve roots justify the risk. Apart from Foerster's operation, or when it has failed, the spasm ofany individual muscle or group of muscles may be got rid of bydiminishing the nerve supply to the muscle or by lengthening thetendon. Diminishing the nerve supply was suggested by Stoffel; itconsists in exposing the motor nerve as it enters the muscle andresecting one-third or one-half of the fibres so as to reduce theinnervation to the required degree. The method is still on its trial. _Lengthening the Tendons. _--In spastic paraplegia, for example, Jonesresects the origins of the adductors longus and brevis, lengthens thetendo Achillis, divides the popliteal fascia and hamstrings, andtransplants the biceps into the quadriceps; after which the limbs areput up in the attitude of wide abduction for six weeks. It isimportant that the patient should begin to walk with the legs wideapart and learn to balance himself without any feeling of insecurity;he should be taught to look at an object straight in front of himrather than on the ground. THE LOWER EXTREMITY CONGENITAL DISLOCATION OF THE HIP This is the commonest of all congenital dislocations. Its frequencyvaries in different countries, being greater on the continent ofEurope than in this country. It is more often unilateral thanbilateral (about 4 to 1), and is about three times more common ingirls than in boys. The dislocation takes place in the early months of intra-uterine life, and may be associated with deficiency of the liquor amnii. #Pathological Anatomy. #--_In the infant_, the anatomical changes inthe joint are less marked than they are after the child has borne itsweight on the limb. The acetabulum, never having been occupied by thehead of the femur, is imperfectly developed; it remains flat andshallow, is partly filled with fibro-fatty tissue derived from thesynovial membrane, and is always too small for the head of the femur. The cotyloid ligament being broader and thicker than usual, makes theosseous portion of the socket appear deeper than it really is. Inunilateral cases the affected half of the pelvis is contracted, sothat the pelvic basin is narrowed and oblique. The head of the femuris small, flattened, and, in some cases, conical; and the angle formedby the neck with the shaft is altered, sometimes diminished, it may beto a right angle--_coxa vara_ (Fig. 129); sometimes increased--_coxavalga_. There is also a variable degree of torsion of the neck, ante-torsion being of practical importance as it increases thedifficulty of retaining the head in the socket. The capsule is lax andadmits of the head passing upwards for a variable distance on to thedorsum ilii. In unilateral cases the ligamentum teres is elongated andthickened; in bilateral cases it is frequently absent. [Illustration: FIG. 128. --Radiogram of Double Congenital Dislocationof Hip in a girl æt. 4. ] [Illustration: FIG. 129. --Innominate Bone and upper end of Femur froma case of Congenital Dislocation of Hip. ] In _children who have walked_, the head of the femur is pushed fartherupwards on the dorsum ilii; the capsule becomes lengthened bysupporting the weight of the body. That part of the capsule whicharises from the lower margin of the acetabulum stretches across thesocket and partly shuts it off from the rest of the joint cavity. Incourse of time the capsule becomes greatly thickened, and may presentan hour-glass constriction about its middle, which may prove a seriousobstacle to reduction. The socket becomes small and triangular, andthere is almost no ledge against which the head of the femur can rest. A superficial depression may form on the ilium where it is pressedupon by the head of the femur, covered by the capsule; and in thecourse of years, as the head changes its position, several secondarysockets may be formed. No proper new bony socket forms like that intraumatic dislocations that remain unreduced because in the congenitalvariety the thickened capsule intervenes between the head of the boneand the dorsum ilii. The displacement of the head is most frequentlybackwards (dorsal luxation), and as the point of support thus fallsbehind the acetabulum the pelvis tilts forwards, and the lumbar spinebecomes unduly concave (lordosis). The muscles of the hip and thighalter 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 butlittle altered. In rare cases the head is displaced upwards and liesimmediately above the acetabulum. [Illustration: FIG. 130. --Congenital Dislocation of Left Hip in a girlæt. 8. The patient is putting the whole weight on the dislocatedlimb. ] _Clinical Features. _--The condition rarely attracts attention untilthe child begins to walk, but sometimes the unusual breadth of thepelvis, the presence of a lump in the buttock, snapping about the hip, or a peculiar way of holding the limb, leads the parents to seekadvice early. In _unilateral cases_, when the child has learned towalk at the late age of two, three, or it may even be four years, itis noticed that the back is hollow and the buttocks unduly prominent, and that there is a peculiar and characteristic limp; each time theweight of the body is put upon the affected limb, the trunk makes asudden dip towards that side. There is no pain on walking. Theaffected limb is shortened, as is shown by the projection of the greattrochanter above Nélaton's line; the shortening gradually increases, and in time may amount to several inches. It is partly compensated forby resting the affected limb on the balls of the toes and flexing theknee on the sound side. The gluteal fold is shorter, deeper, andhigher than on the healthy side, and on account of the obliquity ofthe pelvis the spine shows a lateral curvature, with its concavity tothe affected side. The movements at the hip-joint are free in alldirections except abduction; on practising external rotation it isoften found to be abnormally free; lastly, in young children, if thepelvis is fixed, the head of the bone may be made to glide up and downon the ilium. _In bilateral cases_ the trunk appears well grown in contrast to theshort lower limbs, the hollow of the back is exaggerated, the abdomenprotrudes, the perineum is broadened, and the buttocks are undulyprominent. The gait is waddling like that of a duck, the trunklurching from one side to the other with each step. In untreated casesthe deformity and disability become more pronounced as the capsularand round ligaments are further stretched, the shortening and limpbecome more marked, the patient is easily fatigued by walking orstanding, and is usually unfitted for earning a living. We have hadunder observation, however, an adult male with bilateral dislocationand extroversion of the bladder, who efficiently performed the dutiesof a carrier for many years. Except in fat infants, the _diagnosis_ is not difficult; the absenceof pain and tenderness, the freedom of motion and the absence of thehead of the femur from its normal position, differentiate thecondition from tuberculous disease of the joint, and from coxa varaand other deformities in the region of the hip. _Trendelenburg's test_consists in noting the relative level of the buttocks when the patientstands on the affected leg. Normally the buttocks remain on the samelevel when the patient stands on one leg; in congenital dislocationthe buttock of the limb raised from the ground drops to a lower level;in coxa vara it rises higher. In paralytic conditions at the hip there may be considerableresemblance to dislocation, but the muscles are slack and wasted, andthe normal attitude can easily be restored by pulling on the limb. Themost certain means of diagnosis is by the X-rays, which show theposition of the head of the bone in relation to the acetabulum, andany torsion of the neck of the femur that may be present. This lastpoint is determined by taking a series of skiagrams in differentpositions of the limb; these are also useful in correcting erroneousimpressions as to the angle of the neck of the femur. _Treatment. _--We are indebted to Paci, Schede, Calot, Lorenz, andHoffa for the rational treatment which seeks to reduce the dislocationby manipulation. #Reduction by Manipulation# (_Method of Lorenz_). --The child isanæsthetised and placed on its back with the legs over the end of thetable. While an assistant steadies the pelvis, the surgeon pulls onthe limb so as to bring the trochanter down to Nélaton's line; this isfollowed by forced rotation outwards and inwards and forcibleabduction to a right angle, and by kneading the adductors till theyare stretched and torn. The next step is to stretch the hamstrings, and this is done by raising the foot, without bending the knee, untilthe front of the thigh meets the abdomen, and the toes the face. Tostretch the anterior muscles, the patient is turned on the side orface, and the hip is hyper-extended both in the straight and in theabducted position. The stage is now reached at which attempts atreduction may be made; the child is again laid on its back, thesurgeon grasps the knee, flexes the thigh to a right angle, rotateslaterally, and slowly flexes and abducts, while the thumb pushes frombehind on the trochanter, trying to guide and lift it over the rim ofthe socket as the hip reaches the over-abducted position. Lorenz usesa wedge of wood padded with leather about 3 inches high to rest thetrochanter upon while attempting to lift it forward. When reductiontakes place, there is generally a sound and a sudden jump, as inreducing a traumatic dislocation. To keep the head in the socket, the limb must be maintained in theposition of right-angled abduction and external rotation (90°) by aplaster case, which includes the lower part of the trunk and bothlimbs down to the knee. Under the plaster, stockinette drawers areworn, and the bony prominences are padded with cotton wool. Theplaster should overlap the costal margin. The first case is worn fortwo months or more, and is then renewed at shorter intervals, thedegree of abduction being diminished at each renewal until the limbsare 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 onthe affected side, but should not use crutches. At the end of sixmonths, by which time the capsule has become tightened up round thehead of the femur, the plaster is given up and massage and exercisesare employed. _In bilateral cases_ both dislocations are reduced at one sitting ifpossible, and a plaster case applied with both thighs abducted andflexed to a right angle, the so-called "frog position. " In the event of failure to reduce a dislocation at the first attempt, the limb should be fixed in plaster in the abducted attitude for tendays or a fortnight, and then another attempt made. The greatestnumber of successes in bilateral cases is met with under five years ofage, and in unilateral cases under seven. Reduction may sometimes beaccomplished, however, in older children. If it is found impossible to restore the head of the femur to theacetabulum, an attempt should be made by similar manipulations towedge it under the long head of the rectus femoris, or, failing this, below the anterior iliac spine under the sartorius and tensor fasciæfemoris. By thus converting a posterior into an anterior dislocation, the tilting of the pelvis and the lordosis are greatly diminished. This procedure, named by Lorenz _anterior transposition of the head ofthe femur_, is specially applicable to cases in which relapse hastaken place after reduction, and to those above the age when reductionshould be attempted. _Reduction by open operation_ may be had recourse to in cases inwhich, after several attempts, reduction has failed, or in whichre-dislocation has occurred; it is, however, a serious operation. Attempts have also been made by means of pegs and other contrivancesto fix the head of the bone and prevent it sliding upwards on theilium. When reduction is impossible by any means, a stiff leatherjacket with prolongations around the thighs may diminish the deformityand improve the walking. #Snapping Hip# (_Hanche à ressort_). --This is a rare affection, metwith in children and young adults, and characterised by the occurrenceof a sudden, snapping sound, sometimes attended with pain in theregion of the great trochanter. This usually occurs when the limb isslightly flexed or adducted, and rotated either inwards or outwards. On palpation a cord-like structure may be felt, which slips forwardsand backwards over the trochanter when the position of the limb isaltered. The condition was formerly described as a voluntary dislocation of thehip; it is now believed to be due to a cord-like band of tissueslipping backwards and forwards over the trochanter. The band isusually derived from the fascia lata, sometimes reinforced by theanterior fibres of the gluteus maximus, sometimes by the tensor fasciæfemoris. The condition seldom gives rise to any appreciable disabilityand surgical treatment is rarely called for. In a number of cases themuscle has been fixed by sutures with satisfactory results. In arecent case, an extensive open dissection proved negative, but thestitching of the gluteus to the trochanter was followed by thedisappearance of the snapping. #Paralytic Deformities of the Hip. #--In anterior poliomyelitis theparalysis of muscles may be so widespread that the limb is unable tosupport the weight of the body, or certain groups of muscles only areparalysed and the child may be able to walk with the help ofapparatus. Even if the ilio-psoas is paralysed, flexion is stillpossible by the anterior fibres of the gluteus medius, the anterioradductors, and when the leg is rotated out by the tensor fasciæ andsartorius, the dislocation differs from the traumatic variety in thatthe head, although it leaves the socket, remains within the capsule. Dislocation tends to occur from the disturbance of muscular balance, anterior dislocation being commoner than posterior in about theproportion of two to one; the nature of the dislocation is bestdemonstrated by means of the X-rays. Reduction is rarely possiblewithout an open operation. Tendon and nerve-transplantation arescarcely possible, and arthrodesis is rarely to be recommended;contracture deformities, however, are often benefited by tenotomy inyoung children, and in older children by osteotomy through thetrochanter, and putting the limb up in the abducted position. In _spastic paralysis_ of cerebral origin, the tendency is towardscontracture, usually in the attitude of flexion, with adduction andinversion. This may result in dislocation backwards on to the dorsumilii, and may occur in patients confined to bed (Fig. 131). [Illustration: FIG. 131. --Contracture Deformities of Upper and LowerLimbs resulting from Spastic Cerebral Palsy in infancy. (Photograph taken after death by Dr. Thomson of Norwich. )] #Contractures and Ankyloses of the Hip. #--Various forms of contractureare met with as a result of cicatricial contraction, or fromshortening of the fasciæ, muscles, and ligaments when the hip has beenmaintained in the flexed position for long periods--for example, inpsoas abscess, chronic rheumatism, or hysteria. The majority, however, result from tuberculous disease of the hip-joint. In osseousankylosis, an attempt may be made to restore movement by the operationof Murphy, which consists in chiselling through the osseous junctionbetween the bones, deepening the acetabulum if necessary, and theninterposing between the bony surfaces a portion of fat-bearing fasciaderived from the fascia lata over the great trochanter. The operationof Jones consists in detaching the great trochanter (the insertions ofthe glutei into it being left intact), dividing the neck of the femur, and then securing the separated portion of the trochanter to theproximal end of the neck to prevent union of the fragments. COXA VARA AND COXA VALGA These deformities depend on abnormalities of the angle of the neck ofthe femur; the average or normal elevation is 125° for the adult and135° for the child; variations between 120° and 140° are considerednormal. If the angle is less than 120° the condition is one of coxavara; if greater than 140°, coxa valga. The angle of inclination ofthe neck of the femur is dependent upon the adjustment of certainforces, namely, the weight of the body, the action of muscles, and theresistance of the bone. The most obvious cause of deviation of theneck from the normal angle is some condition which causes softeningof the bone so that it yields under weight-pressure, the most commonbeing partial fractures, rickets, and other diseases of the bone. #Coxa Vara--Incurvation of the Neck of the Femur. #--There may be asimple adduction bend of the neck, the head sinking to, or even below, the level of the great trochanter (Fig. 132); or this may be combinedwith a curve of the neck, of which the convexity is upwards andforwards, so that the lower border of the neck is greatly shortenedand the head approximated to the lesser trochanter. At the same timethe shaft of the femur is adducted and rotated outwards. [Illustration: FIG. 132. --Rachitic Coxa Vara. (Sir Robert Jones' case. Radiogram by Dr. Morgan. )] _Adolescent Coxa Vara. _--This, the most common clinical type, is metwith in boys between the ages of twelve and eighteen. The _unilateral_form is nearly always the result of injury to the neck of the femur orto the epiphysial junction, although the deformity may not show itselffor months or a year or two after the injury. The deformity may be thefirst indication, or it is preceded by pain and stiffness; the patientcomplains of being easily tired, of difficulty in kneeling andsitting, difficulty in riding, and of an increasing limp in walking. On examination, the limb is found to be shortened, the greattrochanter is displaced upwards and backwards and is unduly prominent, and the muscles of the buttock and thigh are a little smaller andsofter than on the normal side. The limb is adducted, its normal rangeof abduction, and sometimes also of flexion, is restricted, and thereis, as a rule, some degree of lateral rotation, so that the toes pointoutwards. It should be noted that the same picture--shortening witheversion and stiffness at the hip--results from the common fracture ofthe neck of the bone in old people. The adduction element of thedeformity is partly compensated for by upward tilting of the pelvis onthe affected side and curvature of the spine with its concavitytowards the affected limb. _When the condition is bilateral_ it is usually the result of diseasein the bone, rickets most frequently in this country. The attitude andgait are highly characteristic, as the adducted and everted legs tendto cross each other at the knee, the deformity being of thescissors-like type (Fig. 134), and in extreme cases the patient isonly able to walk with the aid of crutches. _Diagnosis. _--Pain in the hip and a limp in walking suggest _hip-jointdisease_, but while in coxa vara the movements are chiefly restrictedin the direction of abduction, in hip disease they are restricted orabsent in all directions. From _congenital dislocation of the hip_the diagnosis can usually be made by the history, the examination ofthe joint and of its movements; and by the Trendelenburg test (p. 252). In _sacro-iliac disease_, the pain and tenderness are over thesacro-iliac joint and the movements at the hip are free in alldirections. Valuable evidence is obtained from skiagrams. _Treatment. _--In the early stages, especially if there is pain andtenderness, the patient must lie up and extension is applied in theabducted position of the limb; after a fortnight or so recourse is hadto massage and exercises and the patient is allowed up for a littleeach day, attention being paid to flat-foot, which is a commonaccompaniment. When deformity is the prominent feature and interfereswith locomotion it must be corrected. The bloodless method is to bepreferred; under general anæsthesia, the shortened adductors arestretched or divided, and forcible movements are carried out in alldirections, until the limb can be brought into an attitude of markedabduction and internal rotation. A plaster-case is then applied, fromthe pelvis to the middle of the calf, the knee being slightly flexedfor 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 timeleaving the knee free. After another six weeks or so a moulded splintis used, which can be removed at bedtime. The traumatic forms cannearly always be corrected by this bloodless method. In advanced casesthe deformity can only be corrected by open operation, which consistsin dividing the femur obliquely downwards and medially through thegreat trochanter, and, the adductor muscles having been ruptured ordivided, the limb is put up in the abducted position along with, ifrequired, powerful weight extension. [Illustration: FIG. 133. --Coxa Vara, showing adduction curvature ofneck of femur associated with arthritis of the hip and knee. ] [Illustration: FIG. 134. --Bilateral Coxa Vara, showing scissors-legdeformity. ] In cases of traumatic origin--epiphysial separation--Sprengel hasobtained good results by forcibly abducting and internally rotatingthe limb under an anæsthetic, and then applying a plaster-case whichextends down to the knee. #Other Forms of Coxa Vara. #--In _rickety children_, coxa vara is mostoften associated with pronounced eversion of both lower extremities, without the capacity for abduction being necessarily restricted, andwith but little impairment of function. The child should be treatedfor rickets, and put up in a double long splint with the limbsabducted and inverted. In _arthritis deformans_ of the hip, it is not uncommon to haveconsiderable depression of the head of the bone and diminution in theangle of its neck, with consequent restriction of abduction. Sometimesthe upper end of the shaft is also curved. In _osteomyelitis fibrosa_, involving the upper end of the femur, agross form of coxa vara may be observed, of which a marked example isshown in figures on pp. 476, 478, Volume I. The _congenital variety_ of coxa vara is due to various intra-uterineconditions, of which the chief is defective development of the upperend of the femur; as it does not manifest itself until the childbegins to walk, the resemblance to congenital dislocation of the hipis very close. #Coxa Valga. #--Coxa valga is the reverse of coxa vara, the angle atthe neck of the femur being over 140°. It is not nearly so importantin practice as coxa vara. It may result from incomplete fractures orepiphysial separations, rickets, or various forms of osteomyelitis, but it is also a frequent accompaniment of other deformities, such ascongenital dislocation of the hip and paralysis following anteriorpoliomyelitis. It is commoner in boys than in girls, and is more oftensingle than bilateral. The limb is lengthened, abducted, and rotatedoutwards; there is flattening of the buttock, and the trochanter isdepressed so that it lies below Nélaton's line. The patient is unableto adduct the limb, and shows a peculiar gait, which has frequentlycaused the condition to be mistaken for unilateral congenitaldislocation at the hip. In recent cases it may be possible under anæsthesia forcibly to adductthe limb and rotate it inwards, and to retain it in this position witha plaster bandage. In advanced cases the length of the limbs may beequalised by a high sole on the sound side, or by performing anosteotomy through the great trochanter. THE REGION OF THE KNEE #Congenital dislocation# at the knee-joint is rare; it is usuallyincomplete, and the patella is sometimes absent. The dislocation maybe permanent, or may only occur from accidental movements of the limb. In some cases it can be produced at will by the patient or thesurgeon. We have observed one such case in a professional cyclist inwhom this capacity of partially dislocating the knee entailed nodisability. When the child begins to walk, an apparatus which willprevent hyper-extension and lateral motion should be fitted to thelimb. #Congenital absence of the patella# usually complicates otherabnormalities of the knee-joint. The tubercle of the tibia isprominent and the extensor tendon unusually thick. In flexion thetendon rises on to the lateral condyle of the femur. #Congenital Dislocation of the Patella Laterally. #--This may bepersistent or intermittent. In the _persistent form_ the dislocationis present from birth; the patella rests on the trochlear surface ofthe lateral condyle, and when the knee is flexed may pass fartheroutwards and become completely dislocated, lying against the lateralaspect of the condyle. In _the intermittent_ or _recurrent_ form the patella lies in itsnormal place, but is liable to be displaced outwards when the joint isflexed; the displacement occurs suddenly and unexpectedly in walking, and the patient may fall to the ground, suffering intense pain. Theknee-cap is readily replaced on extending the joint, but the sprain ofthe joint is followed by effusion, and the patient is usually disabledfor a day or two. It is met with chiefly in girls, and there may be ahistory that the child was late in walking and learned withdifficulty. On examination, the patella is found to have an abnormalrange of movement outwards, although it cannot be completelydislocated without considerable pain. If the child is brought foradvice when there is fluid in the joint, the condition is liable to bemistaken for tuberculous synovitis. The observation that the unduemobility of the knee-cap is present in both knees is of assistance inarriving at a diagnosis, and also the history that the girl hasrepeatedly hurt her knee in falling. The cause of the abnormal mobility of the patella varies in differentcases; in some there is congenital laxity of the ligaments, in othersa faulty formation of the lower end of the femur. Bade has observedfamilies in which several children were affected, and although therewas nothing abnormal in the shape of the bones, the knee was slenderand delicately formed. The use of a strong knee-cap may prevent falling, but as a rule anoperation is required, and there is quite a number to choose from, theprinciple of them all being to prevent displacement of the bonewithout unduly restricting flexion of the joint. That devised byGoldthwait consists in exposing, by means of a vertical incision, thewhole length of the patellar ligament, splitting it longitudinally, separating the lateral half from the tibia, passing it under themedial portion and suturing it to the periosteum; this gives thequadriceps a straight line of pull. We have achieved the same resultby dividing the lax capsule and synovial membrane on the medial sideof the patella, and overlapping the edges with a double line of catgutsutures. Lateral dislocation of the patella is met with in extreme forms of_knock-knee_, and after correction of this deformity by osteotomy, andits possible occurrence should be guarded against at the time of theoperation. #Genu Recurvatum. #--In this deformity the knee is hyper-extended, thethigh and leg forming an angle which is open forwards; the attitudemay be permanent or may only appear on walking. It is an extremelydisabling and unsightly deformity. There are several varieties. In the _congenital form_, which isapparently due to a faulty attitude of the lower extremities _inutero_, the patella may be imperfectly developed or absent; the kneeis convex backwards, and attempts to flex the joint cause pain. Otherdeformities frequently coexist. The treatment consists in flexing thejoint to a right angle under an anæsthetic, and maintaining thisattitude by means of plaster-of-Paris or splints until the growth ofparts overcomes any tendency to relapse. _Acquired Forms. _--The most common acquired form is the result ofanterior poliomyelitis, and is described in the next section. The deformity may also be due to rickets which has caused a backwardbend of the tibia immediately below its upper epiphysis--sometimescombined with an exaggerated forward curve of the femur. If there isno prospect of spontaneous rectification, the upper end of the tibiashould be divided with the osteotome, and the limb straightened. It may result also from fracture or from separation of one of theepiphyses in the region of the knee, or from cicatricial contractionof the quadriceps. As a result of bone and joint disease, it is metwith chiefly in neuro-arthropathies when the knee has becomedisorganised and flail-like. #Deformities of the Knee resulting from Anterior Poliomyelitis andfrom Spastic Paralysis. #--When there is paralysis of all the musclesacting on the knee, the joint may be so flail-like that the patient isunable to stand without the aid of a crutch, or when weight is put onthe limb, it assumes the attitude of genu recurvatum. The usefulnessof the limb may be improved by the application of a rigid apparatuswith a lock at the joint so that it can be used in the extendedposition for walking or in the flexed position for sitting. The rigidknee produced by arthrodesis affords good support but is inconvenientin sitting. When the _quadriceps alone_ is paralysed, the patient is obliged tomaintain the joint in the position of extreme extension, because theleast degree of flexion results in the limb giving way under him. Incourse of time the posterior ligament is stretched, and the jointbecomes hyper-extended, acquiring the attitude of _genu recurvatum_. When it is bilateral the gait is seriously impaired. The treatmentconsists in applying an apparatus which prevents hyper-extension, inimproving the condition of the thigh muscles, and in wearing a splintat night which secures the flexed position. Recourse may be had tooperative measures, such as transplanting one of the hamstrings intothe patella, so as to compensate for the loss of power in thequadriceps, arthrodesis, or supra-condylar osteotomy of the femur. When the quadriceps is overcome by a _contraction of the hamstrings_, as in spastic paraplegia, the knee is fixed in the flexed position andthe child is unable to walk. The flexion may be corrected bylengthening the hamstring tendons, bringing the divided biceps tendonthrough an opening in the vastus lateralis, and attaching it to therectus and to the patella. If there is a combination of flexion andgenu valgum, the knee-joint should be resected and ankylosed in thestraight position. #Contracture and Ankylosis at the Knee. #--In addition to the differentparalytic forms above described, contracture may result fromulceration and suppuration in the popliteal space, and from disease(osteomyelitis) in one of the adjacent bones. The greater number ofcontractures and ankyloses are the result of disease in the joint, andhave already been described. GENU VALGUM AND GENU VARUM In the normal limb, a line drawn from the centre of the head of thefemur to a point midway between the malleoli passes through thecentre of the knee-joint. If the line passes outside the centre of theknee-joint, the condition is one of genu valgum; if inside, it is oneof genu varum (Fig. 135). [Illustration: FIG. 135. ] #Genu Valgum--Knock-knee. #--In this deformity the leg joins the thighat an angle which is open outwards, and when the affection isbilateral, the projecting knees tend to knock against each other inwalking; the term X-legs is sometimes applied to it. _Etiology. _--The observations of Macewen and of Mikulicz, andinformation afforded by the Röntgen rays, have shown that the primarycause of the deformity is an inequality of growth at the ossifyingjunction of the femur or tibia or of both. This inequality of growthis nearly always due to rickets, and its direction is determined by afaulty attitude of the limbs in standing and walking. The legs beingabducted, the weight of the body falls unequally on the medial andlateral parts of the ossifying junctions, and inequality of growthresults. _Pathological Anatomy. _--Examination of the femur usually shows thatthe lower third of the diaphysis is lengthened on its medial side andshortened on its lateral side, and that the epiphysis, itselfunaltered, is fitted on to the diaphysis obliquely, so that the medialcondyle appears to be increased in length and to occupy a leveldistinctly below that of the lateral condyle. In many cases the tibiashows corresponding alterations. On section of the bones, theepiphysial cartilage and the zone of ossification are found to beunduly broad and irregular. [Illustration: FIG. 136. --Female child with right-sided Genu Valgum, the result of Rickets. The pelvis is tilted, and the spine is curved. ] The neck of the femur is shortened and its angle diminished. The bonesof the leg are sometimes bent inwards in their lower thirds, and thiscompensates partly for the valgus deformity at the knee. The articularcartilage of the lateral condyle and the lateral meniscus are usuallythickened. In pronounced cases the quadriceps tendon and the patellaare displaced laterally, and this may be so pronounced that on flexionof the joint the patella is dislocated on to the lateral condyle ofthe femur. The biceps tendon and ilio-tibial band are shortened andmore prominent as a result of the approximation of their attachments, and they are also displaced laterally. The sartorius and gracilis aredisplaced backwards, so that they descend behind instead of on themedial side of the knee. The popliteal artery lies on the back of thelateral condyle instead of in the hollow between the condyles, and thetibial (internal popliteal) nerve is displaced even farther outwards. The capsular and other ligaments are slack, so that the joint isunstable and easily hyper-extended. There is often some effusion intothe joint. [Illustration: FIG. 137. --Female child with Rickety deformities ofupper and lower extremities. (Mr. D. M. Greig's case. )] _Radiograms_ reveal the changes in the bones (Fig. 138); the shaft ofthe femur or tibia, or both, which may also be curved, is setobliquely on its epiphysis; and the clear zone, corresponding to theepiphysial cartilage, is uneven and broader than normal. There arealso less obvious changes in the density of the shadow and in thearrangement of the trabecular structure of the bones. [Illustration: FIG. 138. --Radiogram of case of Double Genu Valgum in achild æt. 4. ] _Clinical Features. _--In the infantile form (Fig. 139) the knock-kneeis commonly associated with rickets in other parts of the skeleton, and especially with bending of the tibia and femur, and in extremecases the child may be unable to walk. [Illustration: FIG. 139. --Genu Valgum in a child æt. 4. Patientstanding. ] The deformity is about as frequently bilateral as unilateral. Theremay be knock-knee on the one side and bow-knee on the other. If, as isusually the case, the deformity is due to obliquity of the femur, itdisappears on flexing the joint (Fig. 140), because in flexion thetibia glides behind the projecting median condyle; if the deformityaffects the tibia only, the influence of flexion in disguising it isnot so marked. It is usually possible to hyper-extend the joint, and, in the extended position, to rotate the leg outwards to a greaterextent than is normal. In unilateral knock-knee, the affected limb isa little shorter than its fellow, but the patient compensates for thisby depressing the pelvis on the affected side. [Illustration: FIG. 140. --Genu Valgum. Same patient as Fig. 139. Sitting, to show disappearance of deformity on flexion of knee. ] _Prognosis. _--In children below the age of six, the bones naturallytend to straighten if the child is kept off its feet. After this age, there is no such prospect. The _treatment of knock-knee in children_ is directed towards curingthe rickets and preventing the child from putting its feet to theground. If it cannot have the services of a nurse and the use of aperambulator, a light padded splint is applied on the lateral side ofthe limb, extending from the iliac crest to 3 inches beyond the foot. The splint is fixed above and below by bandages, and the projectingknee is drawn towards it by a few turns of elastic webbing. A methodspecially applicable to hospital out-patients, is to straighten thelimbs as far as possible under anæsthesia, and apply a plasterbandage; the bandage is renewed at intervals of three weeks until thedeformity is corrected. Whatever plan is adopted, it must bepersevered with for at least six months, until the rickety changes inthe bones have been entirely recovered from. If the child is approaching the age of five or six before it comesunder treatment, or if the deformity does not yield to treatment bysplints, it is better to straighten the limb by _osteotomy_. In _adolescent knock-knee_ the patient seeks advice because of thedeformity or of pain after exertion, especially at the medial side ofthe epiphysial junctions, of being easily tired, and of incapacity forany occupation involving standing. The bones are coarse and badlyformed, and there is frequently a spinous process projecting downwardsfrom the medial side of the tibia about three finger-breadths belowthe joint. When the deformity is bilateral, the patient abducts the thigh androtates the limb outwards at the hip to disguise the deformity, and toallow the projecting knees to pass each other. He usually supinates orinverts the foot, with the object of bringing the whole length of thelateral border of the sole into contact with the ground. Flat-foot isexceptional. The boots are usually more worn along the lateral thanalong the medial border of the sole and heel. No apparatus that allows of the patient walking is of any value. Ifthe deformity is marked, there should be no hesitation in havingrecourse to operation by one or other of the various methods ofosteotomy. In severe cases it may be found that when the deformity is correctedby osteotomy, the patella shows a tendency to be dislocated laterallyon flexion of the knee. This may be prevented by putting up the limbin the attitude of slight genu varum. The most difficult cases to treat are those in which, owing to curvingof the lower part of the shaft of the femur with the convexityforwards, the knee is permanently flexed and cannot be completelyextended. #Other forms of genu valgum# are relatively rare. There is acongenital form arising from faulty position of the limbs _in utero_;a traumatic form following fracture or epiphysial separation in theregion of the knee; and a paralytic form, usually combined withflexion, in cases of spastic paralysis. Finally, genu valgum may be aresult of various forms of osteomyelitis of the lower end of thefemur, or of disease in the knee-joint, such as tuberculosis, arthritis deformans, or Charcot's disease. #Genu Varum--Bow-knee. #--In this deformity, which is the converse ofgenu valgum, the leg joins the thigh at an angle which is openmedially. It is almost invariably bilateral, is of rachitic origin, and is frequently associated with bow-legs (Fig. 141). The tibia takesa greater share in its production than the femur. Although an ungainlydeformity, it is much less frequently the source of complaint thanknock-knee, because it scarcely interferes with locomotion--as amatter of fact, the subjects of bow-knee, although short in stature, are unusually sturdy on their legs. An extreme example of thedeformity is shown in Fig. 141. [Illustration: FIG. 141. --Bow-knee in Rickety Child. ] Treatment is carried out on the same lines as in genu valgum. #Rickety Deformities of the Bones of the Leg--Bow-leg. #--Thesedeformities are common in children; are nearly always bilateral andsymmetrical, and may be associated with knock-knee or bow-knee. Theymay occur before the child is able to walk, the bones bending in theattitude in which the limbs are habitually placed--over the nurse'sknee, for example, or as they are crossed underneath the child insitting. In children who are able to walk, the curve is due to theweight of the body acting on the softened bones. In either case, thebending may be increased by the traction of muscles, and sometimes bythe occurrence of greenstick fracture. The most common deformity is auniform curvature of the bones laterally and forwards, or a moreacute bend in the lower thirds of their shafts. In some cases thechief curvature is forwards. The ungainliness in walking may be addedto by flat-foot. Backward curving of the upper end of the tibia hasbeen already described as one of the causes of genu recurvatum. Themost extreme deformities are met with in rickety dwarfs. _Treatment. _--Under the age of six, and particularly in children, whoare actively growing, the bones will probably straighten if the childis treated for rickets and kept off his feet; well-padded lateralsplints are applied as recommended for knock-knee, and these should betaken off at intervals for massage and douching. Above the age of six, the choice lies between osteoclasis and osteotomy. In performingosteotomy the bone is either simply divided or a segment is resected. The fibula can usually be forcibly straightened, but may require to bedivided through a separate incision. In aggravated cases it may alsobe necessary to lengthen the tendo Achillis. The deformities of the bones of the leg in _inherited syphilis_, _ostitis deformans_, and _osteomalacia_ have already been described. #Congenital Deficiencies of the Bones of the Leg. #--The _tibia_ may beabsent completely or in part, more often on one side than on bothsides. In either case the leg is short and stunted, the knee isflexed, the foot occupies the position of extreme equino-varus, andthe limb is useless. The extent of the defects is demonstrated by theRöntgen 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 withthe lateral condyle of the femur. The operative treatment aims atcorrecting the flexion at the knee, the equino-varus deformity of thefoot, and at substituting the fibula for the absent tibia. Thedeficiency of the upper end may be compensated for by implanting thehead of the fibula between the condyles of the femur, and that at thelower end by splitting the fibula so as to form a socket for thetalus. Amputation should be avoided, as even a dwarfed leg and footimproves the service of an artificial limb. A modification of theO'Connor extension boot may be employed. The _fibula_ may be absent completely or in part. The clinicalappearances depend upon the condition of the tibia. When the tibia isnormal, the most notable feature is the absence of the lateralmalleolus, and the extreme valgus attitude of the foot. More commonlythe tibia makes a sharp forward bend just below its middle, and theoverlying skin presents a dimple or scar-like depression. This hasusually been regarded as an evidence of intra-uterine fracture, butthe observations of Hoffa suggest that both the bend of the bone andthe depression on the skin are due to pressure exercised upon the legfrom without by an amniotic band or adhesion. The leg fails to grow, the deformity becomes more pronounced, and the toes become pointed. Ifthe tibia is markedly bent, it may be straightened by osteotomy; andthe tendons, Achillis and peronei, may require to be lengthened. Ifthe ankle is unstable as a result of the absence of the lateralmalleolus, it may be artificially ankylosed, or the lower end of thetibia may be split vertically so as to make a socket for the talus. Ineither case, the foot is placed in the equinus attitude to compensatefor the shortening of the leg. Deficiency of the tibia is frequentlyassociated with imperfect development of the great toe; deficiency ofthe fibula with absence of the lateral toes and their metatarsalbones. _Volkmann's Supra-malleolar Deformity. _--This condition, which isclosely allied to that just described, consists in a congenitaldeficiency in the development of the bones of the leg, and especiallyof the fibula, as a result of which the articular surface is obliqueand the foot deviates to one or other side. The foot usually occupiesa valgus position, the sole looking laterally, and only its medialborder coming into contact with the ground. It is treated bysupra-malleolar osteotomy. THE FOOT Various deformities are met with in the region of the ankle andtarsus. The term "talipes" is commonly used to include all these, buthere it will be restricted to that form in which the heel is more orless elevated, and the foot supinated so that it rests on its lateralborder--_talipes equino-varus_. In _pes equinus_ the foot is in theposition of plantar-flexion, and the patient walks on the toes. In_pes calcaneus_ the foot is dorsiflexed so that the tip of the heelcomes in contact with the ground; this deformity may be combined witheversion of the foot, _pes calcaneo-valgus_, or with inversion, _pescalcaneo-varus_. When the instep is unduly arched, the terms _pescavus_, _pes arcuatus_ or _hollow claw-foot_ are employed; while lossof the arch constitutes _flat-foot_, and eversion of the sole, _pesvalgus_. CLUB-FOOT #Talipes Equino-varus. #--This deformity may be congenital oracquired. #Congenital talipes equino-varus# (Fig. 142) is a common malformationwhich is sometimes associated with other deformities, such as hare-lipor 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 morefrequently bilateral than unilateral. Its etiology is obscure, andvarious hypotheses have been put forward to account for it, but no oneis convincing. It may be pointed out, however, that the fœtal foot isvery easily moulded into abnormal attitudes by external pressure suchas might be exercised by the wall of the uterus when the liquor amniiis deficient. In a number of cases there are indications of suchpressure over the bony prominences of the foot, in the shape ofcircumscribed scar-like areas in which the skin is atrophied; and inthe infant, the intra-uterine position can be reproduced, thusdemonstrating its method of origin. The occurrence of club-foot inseveral generations is alleged to support the Mendelian law. [Illustration: FIG. 142. --Bilateral Congenital Club-foot in aninfant. ] _Pathological Anatomy. _--In well-marked cases the foot presents aconcavity towards the medial side, the maximum point of the curvebeing opposite the mid-tarsal joint. When the patient attempts tostand, only the lateral border of the foot touches the ground, and theweight is borne on the fifth metatarsal, the cuboid, and the greaterprocess of the calcaneus. [Illustration: FIG. 143. --Radiogram of Bilateral Congenital Club-footin an infant. ] The individual tarsal bones, especially the talus and calcaneus, arealtered in shape as well as in their relations to one another and tothe tibio-fibular socket. The navicular and cuboid are rotatedmedially around the anterior ends of the talus and calcaneusrespectively, and the tubercle of the navicular comes to lie close tothe medial malleolus. The lower third of the tibia is twisted mediallyon its vertical axis. The changes in the soft parts follow the general law that tissueswhich are relaxed become shortened, while those that are put on thestretch are lengthened. All the tissues on the medial, concave side ofthe foot are shortened, the structures most affected being the medialand the posterior ligaments of the ankle, and the inferiorcalcaneo-navicular ligament. There is also shortening of the musclesinserted into the tendo Achillis, and to a less extent of the tibialesanterior and posterior. The extensor tendons on the dorsum aredisplaced medially. _Clinical Features. _--_In children who have not walked_, the degree ofdeformity varies, sometimes being very slight; in pronounced cases, the foot is turned medially, and in that position forms a right anglewith the leg; the sole looks backwards and the medial border upwards. The foot appears shortened because it is curved on itself, the heel isnarrower and more vertical than normal, the medial malleolus isobscured by the approximation of the navicular, and the lateralmalleolus is unduly prominent. In extreme cases, the supinated foot forms an acute angle with theleg, and there is frequently a deep transverse depression across thesole, the result of contraction of the plantar fascia--a feature whichis distinctive of the congenital form of club-foot. _In children who have walked_, the deformity becomes aggravated. Thedorsum of the foot is markedly uneven, partly because of theprominence of the individual tarsal bones, and especially of the headof the talus and greater process of the calcaneus, and partly becauseof a depression over the neck of the talus. Instead of resting on itslateral border, the foot may finally rest on the dorsum, the solelooking upwards and backwards. While the skin over the heel remainscomparatively thin and delicate, that covering the lateral border anddorsum of the foot becomes the seat of callosities, beneath whichadventitious bursæ are formed. These bursæ are liable to becomeinflamed, and are then a source of great suffering, and if theysuppurate may cause persistent sinuses. The muscles of the leg andfoot, although not paralysed, undergo atrophy from disuse. In walking, the patient lifts one foot over the other in an ungainly and laboriousmanner, without any spring, as if walking on stilts. _In adults_, these features are further aggravated, and there arepermanent changes in the bones (Fig. 144). [Illustration: FIG. 144. --Congenital Talipes Equino-varus in a man æt. 24; seen from behind. ] _Treatment. _--This should be commenced as soon as the viability of theinfant is beyond question, as the younger the patient the more easilyand completely is the deformity rectified. Manipulations to correctthe deformity should be carried out twice or thrice daily, and thelimbs are also massaged and douched. At the end of two or threemonths, assistance may be derived from the use of a simple lateralporoplastic or aluminium splint with a foot-piece, or more simply by astrip of rubber plaster. The foot is held in the over-correctedattitude and the plaster is applied so as to maintain this attitude. If this regime is systematically persevered with from within a fewdays after birth, by the time the child begins to walk the sole can bebrought into contact with the ground, and the weight of the body willaid in correcting the deformity. If the equinus element resistscorrection, the tendo Achillis should be lengthened. The turning in of the toes may be overcome by strapping the feet atnight to a wooden board with the whole lower limb rotated laterally sothat the toes of each foot point directly outwards. On account of thetendency towards relapse, the manipulations and massage must bepersevered with for at least a year. _Tenotomy and Forcible Correction under Anæsthesia. _--In more severecases we have to deal not only with the contracted soft parts, butwith changes in the bones resulting from their having grown inadaptation to the deformed attitude. The majority of surgeons deferoperative measures until the child is about a year old. The soft parts to be divided are the tendo Achillis, the medial andposterior ligaments of the ankle, the plantar fascia, thecalcaneo-navicular ligaments, and the tibialis posterior tendon. Thevarus deformity may then be corrected by laying the foot on itslateral side on a padded triangular wooden block, and pressingforcibly on the anterior and posterior ends of the foot so as to undothe curve on its medial side and allow of abduction of the foot; thisis usually attended with cracking as the shortened ligaments give way. The equinus element is next dealt with by forcibly dorsiflexing thefoot until the deformity is over-corrected. If it is preferred tocorrect the deformity in stages instead of at one sitting, the equinuselement is left to the last. In older children, the strength of thehands is usually insufficient to stretch the tissues, and mechanicalwrenches may be employed, such as those devised by Thomas, Bradford, or Lorenz. _Resection of a wedge from the tarsus_ (Davies Colley, 1876) isreserved for the most severe cases in which the shape and rigidity ofthe bones prevent correction of the deformity by any other means. Thebase of the wedge is on the lateral aspect, and the bone removedincludes parts of the calcaneus, cuboid, talus, and navicular. _Removal of the talus_ is an alternative operation to resection of thetarsus, and may yield equally good results. In children, before the tarsal bones have become completely ossified, Ogston's method yields good results; instead of removing a wedge fromthe tarsus, the osseous nucleus of each bone is gouged out, leavingthe cartilaginous shell. In this way the intertarsal joints are notinterfered with, and the cartilaginous tarsus can be moulded so thatwhen ossification is completed the bones differ but little from thenormal. After any of these operative procedures, manipulations, massage, exercises, electrical stimulation of the muscles, and the wearing ofsome apparatus must be persevered with for at least twelve months. Failures are due to not sufficiently over-correcting the deformity inthe first instance, and to neglect of after-treatment; in hospitalpractice it is difficult to ensure continuous supervision over longperiods. Finally, _amputation_ may be called for when other methods havefailed, and the patient is unable to put the foot to the groundbecause of suppurating bursæ and ulceration of the skin. #Acquired Talipes Equino-varus. #--In the great majority of cases thiscondition results from anterior poliomyelitis. It especially affectsthe peronei and the extensors of the toes, and is unilateral. Thepatient is unable to dorsiflex and abduct the foot, which hangs withthe toes pointed and the sole turned medially. At first the joints are flaccid, and the attitude can easily becorrected by manipulation. In course of time, however, the opposingmuscles--those inserted into the tendo Achillis, the tibialisposterior, and the long flexors of the toes--become shortened, andthere is secondary contraction of the plantar fascia and of theligaments on the medial side of the foot, and the deformity is thusrendered permanent. The bones also are altered in their shape andmutual relations, the talus being rotated forwards so that a largeportion of its trochlear surface protrudes from the tibio-fibularsocket. The skin is cold and livid, and readily suffers from pressuresores. The whole limb is ill-developed, and may be shorter than itsfellow, and the paralysed muscles are wasted and exhibit for a timethe reaction of degeneration. A similar deformity may result from section of the peroneal (externalpopliteal) nerve, from the peroneal form of progressive muscularatrophy, and from peripheral neuritis. The _treatment_ of paralytic equino-varus, short of operation, hasbeen referred to under anterior poliomyelitis (p. 242). If tendontransplantation is indicated, the tendon of the tibialis anterior isattached to the cuboid, and a strip of the tendo Achillis to thedorsal aspect of the tarsus. Jones displaces the tibialis anteriorinto the base of the fifth metatarsal. If the paralysis is widely distributed, and the joints are flail-like, it is better to ankylose the ankle and mid-tarsal joints. It may benecessary to divide in several places the plantar fascia and otherstructures that have undergone secondary shortening. As using the limb hastens the restoration of function, the childshould be got on to his feet as soon as possible. The spastic form of talipes equino-varus is comparatively rare. Theplantar flexors and invertors distort the foot into the equino-varusattitude. The heel is drawn up, the anterior part of the foot isadducted and inverted at the mid-tarsal joint. The muscles are tenseand rigid, and the reflexes exaggerated. The condition is frequentlybilateral, and is often associated with other deformities of the lowerlimb and with a characteristic spastic gait. Considerable improvementmay be brought about by lengthening the tendons of the shortenedmuscles. In severe cases it may be necessary to resect a portion ofthe tarsus. The occurrence of #varus without equinus# is so exceptional as not tocall for separate description. #Pes Equinus. #--This deformity, in which the foot is in the positionof plantar-flexion with the heel drawn up and the toes pointed, isnearly always acquired as a result either of poliomyelitis or ofspastic paralysis. In typical cases the patient walks on the balls ofthe toes (Fig. 145). It is seldom met with as a congenital condition. Occasionally it is due to nerve lesions such as peripheral neuritis, or to injuries and diseases in the region of the ankle, when the foothas been allowed to remain for long periods in the attitude ofplantar-flexion. In a limited number of cases the equinus attitude isassumed to compensate for shortening of the limb. [Illustration: FIG. 145. --Bilateral Pes Equinus in a boy æt. 7, theresult of Spastic Paralysis. ] In _poliomyelitis_ the deformity is most often unilateral (Fig. 146), while in _spastic paralysis_ it is frequently bilateral (Fig. 145), and is usually accompanied by excessive arching of the foot--pescavus--as a result of plantar-flexion at the mid-tarsal joint, andhyper-extension of the first phalanges and plantar-flexion of thesecond and third phalanges of the toes--"clawing of the toes. " [Illustration: FIG. 146. --Extreme form of Pes Equinus in a girl æt. 8, the result of Anterior Poliomyelitis. ] _Clinical Features. _--In the mildest cases the patient is able tobring the foot to a right angle. In average cases the heel is raisedoff the ground, and the foot rests on the balls of the toes. Inextreme cases, and especially when the extensors are completelyparalysed, the toes may be flexed towards the sole, and the weight isborne on the dorsum of the foot (Fig. 146). The patient suffers frompainful corns and callosities, and from inflammation of bursæ whichform over the points of pressure. When unilateral, the patientcompensates for the lengthening of the limb by flexing the knee andthrowing the limb outwards in walking. In severe cases, especiallywhen both limbs are affected, the patient may be dependent oncrutches. The talus projects on the dorsum, the anterior part of its trochlearsurface escapes from the tibio-fibular socket, and the calcaneus isdrawn up so that it comes into contact with the bones of the leg (Fig. 147). [Illustration: FIG. 147. --Skeleton of Foot from case of Pes Equinusdue to Poliomyelitis. ] Shortening of the soft parts affects chiefly the muscles inserted intothe tendo Achillis, the posterior ligament, and posterior parts of thelateral ligaments of the ankle. The fasciæ, ligaments, and muscles ofthe sole of the foot are also shortened. The flexors of the toes, thetibialis posterior, and the peroneus longus are shortened to a lessdegree. _Treatment. _--Of all the deformities of the foot, pes equinus is thatmost easily rectified. In recent cases a great deal may be done byregular manipulations, and by the wearing of some corrective splint orapparatus between times. In well-marked cases it is necessary to lengthen the shortenedstructures, and especially the tendo Achillis. When the equinus iscorrected, the excessive arching of the foot (pes cavus) and theclawing of the toes usually disappear, but it may be necessary tolengthen the flexor tendons, especially that of the great toe, andalso the plantar fascia. Jones divides the tendo Achillis and the flexors of the toessubcutaneously, and maintains the dorsiflexion by excising an ovalflap of skin from the front of the ankle. In aggravated cases, the bones must be attacked, for example byexcising the talus. Arthrodesis of the ankle alone or along with themid-tarsal joint may be indicated when these joints are flail-like. Amputation is reserved for cases which are otherwise hopeless, such asthat shown in Fig. 147. When the deformity is compensatory to shortening of the limb, it isusually said to be a mistake to correct the equinus. Experience shows, however, that in young patients growth is stimulated by walking on thelimb after the deformity has been corrected; the sole of the boot isthen raised to the necessary extent. #Pes Calcaneus. #--In this deformity the foot is dorsiflexed at theankle-joint. It is sometimes combined with eversion of the foot--_pescalcaneo-valgus_, or with inversion--_pes calcaneo-varus_. Pes calcaneus may be congenital or acquired. In the _congenital form_the deformity is frequently bilateral. There is dorsiflexion at theankle-joint, and if an attempt is made to flex the foot towards thesole, the extensor tendons stand out prominently. In marked cases thelong axis of the calcaneus is vertical, the tendo Achillis lies inclose contact with the tibia, and the hollows on either side of thetendon are absent. The peronei are displaced from their grooves, andmay lie in front of the lateral malleolus. Corrective manipulations are commenced within a few days after birth, and a malleable splint is worn between times. When the child begins towalk there is a natural tendency towards recovery. In severe cases itmay be necessary to lengthen the contracted tendons--the extensordigitorum, the extensor hallucis, and, it may be also, the peroneustertius and tibialis anterior; the tendo Achillis may require to beshortened. In the _acquired form_, the appearances are different, because theanterior part of the foot is usually flexed towards the sole, thusdisguising to a certain extent the dorsiflexion at the ankle. Thisform is nearly always due to poliomyelitis, but it may also resultfrom accidental division of the tendo Achillis. The anterior part ofthe foot is flexed towards the sole by the contraction of the plantarfascia and short muscles of the sole, the balls of the toes areapproximated to the heel, and a deep transverse groove is formed inthe sole opposite the mid-tarsal joint. The deformity presents acombination of the hollow foot--pes cavus--with pes calcaneus, andresembles that of a Chinese lady's foot. The foot rests on the heeland on the balls of the great and little toes, the sole of the footbeing so deeply hollowed that even the lateral border does not touchthe ground. In paralysis of the calf muscles alone, the tendons of the peronei orflexor digitorum longus may be divided and stitched to the calcaneus, to take the place of the tendo Achillis. If the calf muscles are notcompletely paralysed and the tendo Achillis is merely stretched, thistendon may be shortened by splitting it longitudinally and making theends overlap, or its insertion may be displaced downwards. When theankle is flail-like, it may be necessary to perform arthrodesis. Jones gets rid of the cavus deformity by resecting a wedge with itsbase towards the dorsum from the middle of the tarsus; the foot isthen placed in a position of extreme calcaneus, the dorsum coming intocontact with the front of the leg. Four weeks later a wedge is takenfrom the posterior part of the talus large enough to bring the footdown to a right angle with the leg; the articular surfaces of thetibia and fibula being denuded of cartilage, ankylosis takes place ina good position. #Pes Calcaneo-valgus. #--This deformity, which consists in acombination of dorsiflexion at the ankle and eversion of the foot, isas common as pure calcaneus (Figs. 148 and 149); the heel isdepressed, the sole looks laterally, and its medial border is convex. Although it may be congenital, it is usually acquired as a result ofpoliomyelitis. The calf muscles are paralysed while the peronei retaintheir power, and, along with the tibialis anterior and the extensorsof the toes, become secondarily contracted. Treatment is conducted onthe same lines as in pes calcaneus, and the valgus may be controlledby implanting the peroneus brevis into the navicular. [Illustration: FIG. 148. --Pes Calcaneo-valgus with excessive archingof foot. ] [Illustration: FIG. 149. --Pes Calcaneo-valgus, the result ofPoliomyelitis. ] #Pes Calcaneo-varus. #--In this rare deformity the heel is depressedand the sole of the foot looks inwards. #Pes Cavus. #--In this deformity, which is known also as _hollowclaw-foot_, _pes arcuatus_, or _pes excavatus_, the longitudinal archof the foot is exaggerated as a result of the approximation of theballs of the toes to the heel (Fig. 150). It is most frequently metwith as an addition to pes equinus or pes calcaneus of paralyticorigin, and has already been described. There is a mild form which iscongenital, and which is quite independent of paralysis; anothervariety occurs in diseases of the spinal cord, such as Friedreich'sataxia. The name hollow claw-foot appropriately indicates the clinicalappearances. The arch is exaggerated and the instep abnormally high;there is hyper-extension of the toes at the metatarso-phalangealjoints, and plantar-flexion at the inter-phalangeal joints; theplantar fascia and muscles are shortened. The footprint shows thatneither border of the foot touches the ground. The patient complainsof pain in the instep, of painful corns over the heads of themetatarsal bones, and of difficulty in getting properly fittingboots. _Treatment_ should first be directed towards the equinus or calcaneuselement of the deformity, for if these are corrected the cavuscondition tends to disappear. Exercises and massage should bepersevered with, and boots without heels should be worn. Thecontracted structures in the sole may require to be divided, eithersubcutaneously or by the open method, as a preliminary to forciblecorrection, and the hallucis tendon may be brought through the head ofthe first metatarsal. In aggravated cases the talus and the heads ofthe metatarsal bones may be excised. FLAT-FOOT--PES PLANUS AND PES VALGUS Flat-foot or splay-foot is that deformity in which there is loss ofthe arch, and the foot tends to be pronated and abducted. The term_pes planus_ is applicable when there is merely loss of the arch; _pesvalgus_ when the foot is pronated and the sole looks laterally. Of alldeformities of the foot, flat-foot is the one for which advice is mostfrequently sought; it is also a common complication of otherdisabilities of the foot and of the lower extremity. It is usuallybilateral, 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, gonorrhœal, and tabetic. [Illustration: FIG. 150. --Pes Cavus in association with Pes Equinus, the result of Poliomyelitis. ] [Illustration: FIG. 151. --Radiogram of Foot of adult, showing thechanges in the bones in Pes Cavus. ] #Static or Adolescent Flat-foot. #--This, by far the most common andimportant variety (Fig. 152), generally develops between the ages offourteen and twenty. It is called static because the essential factorin its production is a disproportion between the weight of the bodyand the supporting power of the arch of the foot. [Illustration: FIG. 152. --Adolescent Flat-foot. ] It is met with in rapidly growing children or adolescents of feeblemuscular development and with long narrow feet, and those especiallywho, after leaving school, begin some occupation which entails muchstanding--such as that of a factory hand, message boy, or domesticservant. To enable him to stand with the least effort for longperiods, the patient adopts an attitude which makes little demand onthe muscles, and throws nearly all the strain of the body weight onthe ligaments and bones of the feet. This, which has been called "theattitude of rest, " consists in standing with the limbs apart, theknees slightly flexed, the legs slightly rotated laterally at theknee, and the feet pronated, with the toes pointing laterally. Themost important local factors predisposing to flat-foot are weakness ofthose muscles which normally support the ankle and the tarsal arches, especially the tibiales; weakness of the ligaments of the foot; andsoftness of the tarsal bones. When these conditions are present and afaulty method of standing and walking is adopted, the undue strain towhich the tendons and ligaments are exposed results in their beingstretched; the bones are altered in position, and flat-foot results. The head of the talus is displaced medially, and is protruded betweenthe calcaneus and navicular, tending to separate them from oneanother, stretching the inferior calcaneo-navicular ligament andcausing the anterior part of the foot to be abducted. The plantarligaments--especially the inferior calcaneo-navicular--are stretchedand lengthened. In something like 80 per cent. There is the combineddeformity--pes plano-valgus--in those who apply for treatment. [Illustration: FIG. 153. --Flat-foot, showing loss of arch. ] _Clinical Features. _--The patient complains of being easily tired, andof pain in the foot after walking or standing. There is generally morepain before the appearance of the deformity than when it hasdeveloped, and at this stage it is not so easily recognised, and isapt to be called "rheumatism. " The most common seat of pain is at themedial border of the foot behind the tubercle of the navicular, andthis is due to stretching of the inferior calcaneo-navicular ligament. Pain is also complained of in the middle of the dorsum across theinstep, from stretching of the interosseous ligaments. Later, there ispain over the greater process of the calcaneus in front of the lateralmalleolus, from these bones coming into contact. There may benocturnal cramp in the muscles of the leg and foot. The faulty attitude of the foot in standing and walking is usuallyevident. The foot appears longer and broader than normal, and when thebody weight is put on it, it spreads out with the toes extended untilthe entire sole is in contact with the ground. In advanced cases, themedial border of the foot may be actually convex. Below and in frontof the prominent medial malleolus, the head of the talus forms arounded eminence, and a little farther forwards and lower still is theprojection of the tubercle of the navicular. The eversion of the footas a whole is best seen from behind; if the central axis of the leg isprolonged downwards, it approaches the medial border of the heelinstead of passing through its centre; or, stated differently, insteadof the axis of the calcaneus being a continuation of that of the leg, it deviates laterally and the medial malleolus is abnormallyprominent. When the eversion is more pronounced, the sole lookslaterally and the tendons of the peronei stand out in relief. Theanterior part of the foot is displaced laterally. Flat-foot isfrequently associated with stiff great toe; the patient having lostthe power of dorsiflexing the toe, the first phalanx and firstmetatarsal are in a straight line, instead of forming an angle opentowards the dorsum. The muscles of the leg are flabby and poorly developed. When thepatient is seated and asked to move the foot in different directions, there is a characteristic stiffness, ungainliness, and restriction inthe range of movement. The feet are usually cold and sweatexcessively. The gait is slouching, and there is a want of spring andelasticity. The lengthening of the foot results in the tendons, especially the flexors, being too short, hence hammer-like contractionof the toes may be brought about. The boots, after being worn, show abulging of the instep towards the sole, greater wearing away of thesole along the medial border, and, when there is stiff great toe, anabsence of the transverse crease on the dorsum opposite the balls ofthe 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 ofthe foot, and the balls and tips of the toes. In flat-foot the medialborder appears in the print to a greater or less extent (Fig. 154). Ifa record is wanted to estimate the progress of treatment, the sole ofthe foot is painted with a 5 per cent. Solution of ferro-cyanide ofpotassium, and the patient stands on paper painted with the liquor ofthe perchloride of iron diluted one-half; the print appears dark blueon a yellow ground. [Illustration: FIG. 154. --Imprint of Normal and of Flat Foot. ] _Skiagrams_ are useful for showing displacement of bones anddifferences between sitting and standing, and for recording theresults of treatment. _Prophylaxis of Flat-foot. _--Stress is to be laid on a supervisedtraining of the whole muscular system, and especially of that of thelegs. In walking and standing, the feet should be kept parallel andnot pointed outwards, as was formally taught in schools of gymnasticsand insisted upon by drill instructors. Children should be taught towalk properly, rising on the balls of the toes with each foot insuccession. Attention should also be directed to the boots, whichshould be so fashioned that the medial side of the boot is keptstraight and the end of the boot is opposite the big toe. _Treatment. _--This is directed towards restoring and maintaining thearch of the foot. As the measures adopted necessarily vary with theextent to which the condition has progressed, it is convenient forpurposes of treatment to recognise the following four degrees. A firstdegree, in which the arch reappears when the weight is taken off thefoot or the patient rises on the balls of the toes; a second, in whichthe normal attitude can be restored by manipulation; a third, in whichthis is only possible under anæsthesia; a fourth, in which the bonesare so displaced and altered in shape that correction is impossiblewithout operation. _Cases of the First Degree. _--If there is marked pain and tenderness, the patient must lie up. The general health is improved by anourishing diet and by cod-liver oil and tonics; and the legs and feetare douched and massaged thrice daily. When pain and tenderness havedisappeared, the patient is instructed how to walk and exercise thefeet. In walking, the medial edges of the feet should be parallel withone another, first the heel should touch the ground and then the ballsof the toes. He should neither stand nor walk long enough to causefatigue, and in standing he should alter the attitude of the feet fromtime to time, and occasionally rise on the balls of the toes. Thefollowing exercises, devised by Ellis of Gloucester, should bepractised: (1) Rising on the balls of the toes, the toes beingdirected straight forwards; (2) rising on the balls of the toes, withthe points of the great toes touching each other, and the heelsdirected out, so that the medial borders of the feet meet in front ata right angle; (3) in the same attitude, after rising on to the ballsof the toes, the knees are flexed and then extended before the heelsdescend again; (4) while seated in a chair, one leg crossed over theother, circumduction movements of the foot are carried out; (5) whilestanding, the medial border of the foot is raised off the groundseveral times, then the patient walks to and fro on the lateral borderof the foot, and in the same attitude lifts one foot over the other. These exercises should be carried out slowly and deliberately, withthe feet bare, and they should be carefully supervised until thepatient thoroughly understands what is aimed at. The movements shouldbe performed a definite number of times at regular intervals, butshould not be pushed so as to cause pain or fatigue. The patientshould be fitted with well-made lacing boots, with the heel and soleraised about half an inch on the medial side so that the foot restsmainly on its lateral border. The additional leather, which can beapplied by any bootmaker, is in the form of a wedge, with its base tothe medial side, one on the sole and one on the heel. The wedge fadesaway towards the lateral border, and also forwards towards the tip. Intime, the limbs are further strengthened by sea-bathing, cycling, skipping, and other exercises. In _cases of the second degree_, the patient should be provided with ametal plate inside the boot. That known as Whitman's spring is themost popular. A plaster cast is taken of the sole while the foot isheld in its proper position, and on this a metal plate, preferably ofaluminium bronze, is modelled. This is covered with leather andinserted into the boot. We have found the supports devised by Schollsimple and efficient. The treatment described for cases of the firstdegree is carried out in addition. In _cases of the third degree_, the deformity is corrected under ananæsthetic. The foot is forcibly moved in all directions so as tostretch the shortened ligaments and to break down adhesions, it isthen rotated into an extreme varus position, and fixed inplaster-of-Paris or to a Dupuytren's splint. It may be necessary tohave recourse to the Thomas' wrench, employed in the correction ofclub-foot. When the reaction consequent upon this procedure hassubsided, the question of shortening or of reinforcing the tendonsconcerned in the support of the arch of the foot may be considered;one of the peronei, for example, may be attached to the tubercle ofthe navicular. We have not found it necessary to employ thisprocedure. In _cases of the fourth degree_, in which the displacement andalterations in shape of the bones constitute an insuperable bar tocorrection, operative treatment may be considered, either resection ofa wedge including the talo-navicular joint or forward displacement ofthe tuberosity of the calcaneus. #Spasmodic Flat-foot. #--There are cases of flat-foot in which pain andspasm of the peronei muscles are the predominant features. If thespasm is not allayed by rest in bed and hot fomentations, the footshould be inverted under an anæsthetic; and in this position it isencased in plaster-of-Paris. Jones resects an inch of each of theperoneal tendons about 2-1/2 inches above the tip of the lateralmalleolus; Armour and Dunn claim to have obtained better results fromcrushing the peroneal nerve in the substance of the peroneus longus. #Paralytic Flat-foot# (Fig. 155). --In typical cases this results frompoliomyelitis affecting the tibial muscles. When other groups ofmuscles are affected at the same time, compound deformities, such aspes calcaneo-valgus, are more likely to result. [Illustration: FIG. 155. --Bilateral Pes Valgus and Hallux Valgus in agirl æt. 15, the result of Anterior Poliomyelitis. ] In paralytic valgus the medial border of the foot is depressed andconvex towards the sole, and although the foot can readily be restoredto the normal position by manipulation, it at once resumes the valgusattitude. The leg is wasted, the skin is cold and livid, and the ankleis flail-like. The treatment consists in reinforcing the paralysedtibial muscles by attaching the peronei, or a strip of the tendoAchillis, to the scaphoid, or in bringing about an ankylosis of thejoints above and in front of the talus. #Traumatic flat-foot# is that form which results directly from injury. It is most often due to a fall from a height on to the feet; theligaments supporting the arch are ruptured, and the bones aredisplaced, either at the time of the injury or later when the patientgets out of bed. The arch can only be restored by a wedge-resection ofthe tarsus. Loss of the arch may follow as a result of walking on theeverted foot after injuries about the ankle, especially a badly unitedPott's fracture; the foot may be displaced laterally and pronated, thesole looking laterally. This variety is very unsightly and disabling;it is treated by supra-malleolar osteotomy of the tibia and fibula. #Other Forms of Flat-foot. #--Flat-foot is sometimes met with inrickety children, in association with knock-knee or curvature of thebones of the leg, and is treated on the same lines as other ricketydeformities. It may follow upon an attack of acute rheumatism or upondiseases in the region of the ankle and tarsus, such as gonorrhœa, arthritis deformans, tuberculosis, and Charcot's disease; thegonorrhœal flat-foot is extremely resistant to treatment. There is acongenital form in which the sole is convex and the dorsum concave, the result of the persistence of an abnormal attitude of the fœtus _inutero_. Lastly, there is a racial variety, chiefly met with in thenegro and in Jews, which is inherited and developmental, and which, although unsightly, is rarely a cause of disability. #Pes Transverso-planus. #--Lange describes under this head a sinking orflattening of the anterior arch formed by the heads of the metatarsalbones, of which normally only the heads of the first and fifth rest onthe ground. In this condition all may be on the same level or the archis actually convex towards the sole. It may coexist along with thecommon form of flat-foot, or it may be associated with the neuralgicpain known as metatarsalgia. #Painful Affections of the Heel. #--These include inflammation of thebursa between the posterior aspect of the calcaneus and the lower endof the tendo Achillis, inflammation of the tendon itself and itssheath of cellular tissue, and the presence of a spur of boneprojecting from the plantar aspect of the tuberosity of the calcaneus. The spur of bone is the source of considerable pain on standing andwalking, and tenderness is elicited on making pressure on the plantaraspect of the heel; it is well demonstrated by the X-rays (Fig. 156). The condition is usually bilateral. Complete relief is obtained byremoving the spur by operation. Sever of Boston calls attention to a painful condition of the heel metwith in children, and associated with changes in the epiphysialjunction, allied to those met with in the epiphysis of the tubercle ofthe tibia in Schlatter's disease. The changes in the epiphysialjunction can be demonstrated in skiagrams. Treatment is conducted onthe same lines as in teno-synovitis of the tendo Achillis. #Metatarsalgia. #--This affection, which was first described by Mortonof Philadelphia (1876), is a neuralgia on the area of the anteriormetatarsal arch, specially located in the region of the heads of thethird and fourth metatarsal bones. It is most often met with in adultsbetween thirty and forty, is commoner in women than in men, and isoften combined with flat-foot. The patient complains of a dull achingor of intense cramp-like pain in the anterior part of the foot. Thepain is usually relieved by rest and by taking off the boot. It may beexcited by pressing the heads of the metatarsals together or bygrasping the fourth metatarso-phalangeal joint between the finger andthumb. In advanced cases the pain may be so severe as to cripple thepatient, so that she is obliged to use a crutch. On examination, thesole may be found to be broadened across the balls of the toes, andthere may be corns over the heads of the third and fourth metatarsals. Skiagrams may show a downward displacement of the head of one or otherof these bones, and prints of the foot may show an increased area ofcontact in the region of the balls of the toes. The affection is ofinsidious development, and is usually ascribed to sinking of thetransverse arch of the foot--pes transverso-planus--the result ofweakness or of wearing badly fitting boots. The intense pain isbelieved to be due to stretching of, or pressure upon, theinterdigital nerves or the communicating branch between the medial andlateral plantar nerves; Whitman believes it is due to abnormal sidepressure on the depressed articulations. [Illustration: FIG. 156. --Radiogram of Spur on under aspect ofCalcaneus. ] _Treatment. _--Great improvement usually results from treatingcoexisting flat-foot, and pain is relieved by rest, massage, anddouching. A tight bandage or strip of plaster applied round theinstep before putting on the stocking may relieve pain. Boots shouldbe made from a plaster cast of the foot, high and narrow at the instepso as to compress the bases of the metatarsals, and with the medialedge of the sole and heel slightly raised; a support may be worn inthe sole, like that used for flat-foot, with both the longitudinal andtransverse arches exaggerated. Scholl has devised a support for theanterior arch which we have used with benefit. When the head of one ofthe metatarsals is displaced, it may be removed through a dorsalincision running parallel with the tendon of the long extensor. #Hallux Valgus and Bunion. #--_Hallux valgus_ is that deformity inwhich the great toe deviates towards the middle line of the foot andcomes to lie on the top of, or beneath, the second toe (Figs. 155, 157). The head of the first metatarsal projects on the medial borderof the foot, and, as a result of the pressure of the boot, anadventitious bursa is formed, which, when thickened by chronicinflammation, constitutes a prominent swelling or _bunion_. It is acommon affection in civilised and especially in urban communities, andreaches its acme of development in adult women. It may occur on one oron both sides, and is sometimes associated with flat-foot. [Illustration: FIG. 157. --Radiogram of Hallux Valgus. The sesamoidbone is seen displaced towards middle line of the foot. ] The deformity develops slowly, and is usually attributed to thewearing of stockings which are unduly tight at the toes, and ofimproperly made boots. The boot that favours the occurrence of halluxvalgus is one which is too short and has pointed toes, with the apexin the middle line of the foot instead of being in line with the greattoe. The pressure of the boot displaces the great toe into the valgusposition, especially if a high heel is worn, as the toes are thendriven forward into the apex of the boot. Once the great toe isabducted by the pressure of the boot, the deformity is increased bybearing unduly on the medial side of the ball of the great toe, and bypointing the foot outwards in walking. Arthritis deformans is rarely the cause of hallux valgus, but thechanges characteristic of that affection are commonly present in thejoint of the great toe. In pronounced cases, the base of the firstphalanx is displaced on to the lateral aspect of the head of the firstmetatarsal, the exposed head of which frequently shows fibrillationand wearing away of the cartilage, and is often surrounded by newbone, sometimes amounting to an exostosis. There are also fringes fromthe synovial membrane that may be caught between the articularsurfaces. The distal end of the first metatarsal is displacedmedially, broadening the tread of the foot, and in severe cases itsshaft is rotated on its long axis, so that its dorsal surface looksmedially; the great toe is then similarly rotated (Fig. 157). Theflexor and extensor tendons and the sesamoid bones are displacedlaterally. The ligaments and other soft parts on the medial side areelongated, while those on the lateral side are contracted. In women, the chief complaint may be of the disfigurement of the boot;in others, of pain and disability resulting from the sensitiveness ofthe joint and of the enlarged bursa over the head of the firstmetatarsal. The inflamed bursa, which sometimes communicates with thejoint, may suppurate, and the infection may spread to the joint. The _treatment_ varies with the severity of the deformity. In mildcases, a great deal can be done by wearing properly made boots andstockings with a separate compartment for the great toe, or a pad ofcotton wool or tent of rubber between the great and second toes. Thepatient should practise manipulations and exercises of the toes andfeet, and putting the foot to the ground properly in walking. Inpronounced cases, the pain and tenderness must first be got rid of byrest and soothing applications. At night, the attitude of the toe maybe corrected by a moulded splint fixed to the medial aspect of thefoot by strips of plaster; the toe is then bandaged to the distal endof the splint. Scholl has devised a prop, made of rubber, to be wornbetween the great and second toes. If there is flat-foot, this mustreceive appropriate treatment. In aggravated cases, the deformity can only be corrected by anoperation which consists in resecting the head of the metatarsal bone, and the tendon of the long extensor may be detached from itsinsertion and secured to the medial side of the first phalanx. A barmay be placed across the sole just behind the balls of the toes, andthe boot should also comply with the anatomical shape of the foot. #Hallux Varus or Pigeon-toe# (Fig. 158). --In this deformity, which isextremely rare, the great toe deviates from the middle line of thefoot; it occurs chiefly in children in conjunction with otherdeformities, and interferes with the wearing of boots. Treatmentconsists in straightening the toe and retaining it in position by asplint or plaster of Paris. The medial collateral ligament and thetendon of the abductor hallucis may require to be divided. [Illustration: FIG. 158. --Radiogram of Hallux Varus or Pigeon-toe. ] #Hallux Rigidus and Hallux Flexus# (Fig. 159). --These terms indicatetwo stages of an affection of the metatarso-phalangeal joint of thegreat toe, first described by Davies Colley. In the earlierstage--_hallux rigidus_--the toe is stiff and incapable of beingdorsiflexed, although plantar-flexion is, as a rule, but littlerestricted. When the joint, in addition to being stiff, is painful, sensitive, and swollen, the term _hallux dolorosus_ is applied. [Illustration: FIG. 159. --Hallux Rigidus and Flexus in a boy æt. 17. There is a suppurating corn over the head of the first metatarsalbone. ] As the disease progresses, the toe is drawn towards the sole andbecomes permanently flexed--_hallux flexus_--and any attempt atdorsiflexion is attended with pain. The condition is met with chiefly in adolescent males, is nearlyalways associated with flat-foot, and is then usually bilateral. Thepatient's gait, in addition to having the characteristic featuresassociated with flat-foot, is peculiarly wooden and inelastic, asinstead of rising on the balls of the toes with each step, he putsdown and lifts the sole as if it were a rigid plate. The pain isincreased by walking. The boot tends to become worn away at the pointof the toes and at the posterior edge of the heel, and the usualcrease across the dorsum is absent. On dissection it is found, especially in hallux flexus, that theinferior portions of the collateral ligaments are contracted, and thatthe cartilage of that part of the head of the metatarsal which isexposed on the dorsum is converted into fibrous tissue; there may alsobe other changes characteristic of arthritis deformans. Bony ankylosishas not been observed. _Treatment. _--In early cases, great benefit results from measuresdirected towards the cure of the accompanying flat-foot, andespecially the wearing of the support of the anterior arch devised byScholl. If the joint of the big toe is painful and sensitive, absoluterest should be enforced until these symptoms have disappeared. Thepatient must wear a properly shaped boot with a pliable sole, and beinstructed how to manipulate and exercise the toe. Later, when the toeis already rigid or flexed towards the sole, the above treatment isnot feasible. It is then best to correct the deformity either bywrenching the toe into the dorsiflexed position, under anæsthesia, andfixing it with a plaster-of-Paris bandage; or, when this isimpossible, by excising the articular end of the metatarsal bone andinterposing a layer of fatty or bursal tissue between the distal endof the metatarsal and the base of the first phalanx. When thesemeasures are impracticable, the suffering may be relieved by insertingin the boot a rigid metal plate which will prevent any attempt atdorsiflexion in walking. #Hammer-toe. #--This is a flexion-contracture which generally involvesthe second, but sometimes also other toes. It may be congenital andinherited, but usually develops about puberty, and is then, as a rule, bilateral, and often associated with flat-foot. The first phalanx is dorsiflexed, and the second is plantar-flexed, while the third varies in its attitude, sometimes being in line withthe second (Fig. 160), sometimes even more plantar-flexed, andsometimes dorsiflexed. When the second toe alone is affected, as iscommonly the case, it is partly buried by those on either side of it, only the knuckle of the first inter-phalangeal joint projecting abovethe level of the other toes (Fig. 160). The skin over the head of thefirst phalanx being pressed upon by the boot usually presents a corn, under which a bursa forms (Fig. 161). Both the corn and the bursa aresubject to attacks of inflammation, which cause suffering anddisability in walking. The soft parts at the distal extremity of thetoe are flattened out by contact with the sole of the boot--hence thesupposed resemblance to the head of a hammer. [Illustration: FIG. 160. --Hammer-toe. ] On dissection, it is found that the contracture is maintained byshortening of the plantar portions of the collateral ligaments of thefirst inter-phalangeal joint and of the glenoid ligament upon whichthe head of the first phalanx rests. Hammer-toe is usually ascribed to the use of tight socks and ofill-fitting boots, especially those which are median-pointed and aretoo short for the feet, but in some persons there appears to be aninherited predisposition to the deformity. [Illustration: FIG. 161. --Section of Hammer-toe. _a_, Corn. _b_, Bursa over first inter-phalangeal joint. ] While corrective manipulations, strapping, and the use of splints maybe of service in slight cases, it is usually necessary to perform anoperation in order to extend the toe permanently. Before operating, any infective condition, such as a suppurating corn or bursa, must becorrected. The collateral and glenoid ligaments are dividedsubcutaneously--Spitzy also divides the flexor tendons andcapsule--and if the toe can then be straightened, the foot is securedto a metal splint moulded to the sole and provided with longitudinalslots opposite the intervals on either side of the toe affected. Thetoe is drawn down to the splint by passing a loop of cotton or elasticbandage round the toe and through the slots. In many cases thecontraction of all the tissues on the plantar aspect, including theskin, prevents the toe being straightened even after division of theligaments, and it is then necessary to remove the head and neck of thefirst phalanx through a lateral incision. This is more satisfactorythan amputation of the affected toe at the metatarso-phalangealjoint, as after this the adjacent toes tend to fall together andfavour hallux valgus. If amputation is performed, a pad of cotton woolor rubber prop should be worn to fill up the vacant space. The term _Gampsodactyly_ has been applied to a deformity in which allthe toes assume the position of hammer-toe, usually from a spasticcondition of the muscles controlling the toes. #Hypertrophy of the Toes. #--One or more of the toes may be the seat ofhypertrophy or local giantism. This is usually present at birth orappears in early childhood, and may form part of an overgrowthinvolving the entire lower extremity (Fig. 162). The overgrowth mayinvolve all the tissues equally, or the subcutaneous fat may bespecially affected. The medial toes are those most commonlyhypertrophied. In addition to being enlarged, the toe may be displacedfrom its normal axis. The hypertrophy may affect two or more toeswhich are fused together or webbed (Fig. 162). The treatment consistsin amputating as much of the toe as will allow of an ordinary bootbeing worn. [Illustration: FIG. 162. --Congenital Hypertrophy of Left LowerExtremity in a boy æt. 5. The second and third toes are fused. ] #Supernumerary Toes# (_Polydactylism_). --These vary from mereappendages of skin to fully developed toes (Fig. 163); if theyinterfere with the wearing of boots they should be removed. #Webbing of the Toes# (_Syndactylism_). --This may affect two or moretoes, which may be united merely by a web of skin, or so completelyfused that the individual digits are only indicated by the nails; thedegree of fusion is shown by means of skiagrams. Unless associatedwith congenital hypertrophy, no treatment is called for. [Illustration: FIG. 163. --Supernumerary Great Toe. (Photograph lent by Sir George T. Beatson. )] THE UPPER EXTREMITY #Congenital Absence of the Clavicle. #--Both clavicles may be absent, and it is possible for the patient voluntarily to bring his shouldersinto contact with one another in front of the chest; there is littleor no impairment of function. #Displacements of the Scapula. #--_Congenital Elevation of the Scapula_(Sprengel's shoulder, 1891). --This abnormality is rare, and is notusually recognised till several years after birth. In one varietythere is a bridge of bone or fibrous tissue connecting the superiorangle of the scapula with the spinous process of one of the cervicalvertebræ, and there may be a false joint at one end of the bridgepermitting a certain amount of movement of the scapula. Associatedabnormalities in the vertebræ and in the ribs are shown in skiagrams. In the more common type, the scapula seems to be held in its elevatedposition by shortening of the muscles attached to its body, and it isoften rotated so that its lower angle is close to the spine and itsaxillary border nearly horizontal, or the axillary border may lie inclose to the ribs, and the vertebral border project from the chestwall. The shoulder is generally higher and farther forward on theaffected side, and there is a moderate degree of scoliosis. There is awant of purchase in the movements of the shoulder and upper arm. [Illustration: FIG. 164. --Congenital elevation of Left Scapula in agirl: also shows hairy mole over Sacrum. (Mr. D. M. Greig's case. )] When the deformity is bilateral, which is rare, the neck is short andthick, the chin lies close to the sternum, and the arms can scarcelybe raised to the horizontal. Gymnastic exercises and the wearing of a brace to hold the shouldersback and down may be followed by some improvement, but, as a rule, itis necessary to mobilise the scapula by operation. An X-ray photographshould first be taken, because, when the scapula is connected with thespine by a bridge of bone, this must be resected. The muscles attachedto the vertebral border and spine of the scapula are divided, thebone is drawn down to its proper position, and the parts are fixed byplaster bandages. _Winged Scapula. _--This condition consists in a marked displacementbackwards of the lower angle and vertebral border of the scapula, whenthe patient attempts to raise the arm from the side (Fig. 165). Undernormal conditions, in making this movement the serratus and rhomboidmuscles pull forward the vertebral border and inferior angle of thescapula, and so fix the bone firmly against the chest wall. When thesemuscles are paralysed, as a result of anterior poliomyelitis, neuritis, or injury of the long thoracic nerve of Bell, or of thefifth and sixth cervical nerve-roots through which they receive theirsupply, the patient is unable to abduct the arm, and the deltoidhaving lost its _point d'appui_, its contraction merely results intilting the angle of the scapula backward (Fig. 165). [Illustration: FIG. 165. --Winged Scapula; the patient is holding thearms out in front. ] _Treatment. _--In the majority of recent cases the condition yields tothe administration of strychnin and other muscle and nerve tonics, andthe use of massage and the faradic current. The application of acarefully adjusted padded belt is sometimes useful. The method oftreatment by stitching the latissimus dorsi over the lower angle ofthe scapula is based on the erroneous assumption that the displacementis due to the slipping of that muscle off the bone; at the same time, it must be admitted that the operation sometimes diminishes thedeformity and adds to the patient's comfort. A more efficient method consists in detaching the clavicular portionof the pectoralis major from its insertion, and stitching it to theserratus anterior so as to make it take on the function of thismuscle, or stitching it to the axillary border of the scapula. Successhas also followed suture of the vertebral border of the scapula to thesubjacent ribs (Eiselsberg). _Displacement of the scapula upwards and laterally_ has been observedas a result of partial paralysis of the trapezius when the nervessupplying it have been divided in removing tuberculous glands from theneck. In these acquired displacements, treatment is directed towardsthe nerve lesion and towards the improvement of the muscles byelectricity, massage, and exercises; when the paralysis of thetrapezius is permanent, the disability is gradually overcome by thecompensatory hypertrophy of the levator muscle. #Congenital Dislocation of the Shoulder. #--This rare condition isusually bilateral, and is associated with other congenital defects. The glenoid cavity is deformed or absent, and the dislocation may besub-coracoid, sub-acromial, or sub-spinous. The movements of the armare restricted, and the development of the extremity as a whole isimperfect. It is sometimes possible to reduce the dislocation bymanipulation, or, if this fails, by operation. Unilateral dislocationis sometimes mistaken for dislocation that has occurred duringdelivery and _vice versa_. #Habitual Dislocation# is described on p. 65. #Paralytic Deformities--Paralytic Dislocation of the Shoulder. #--Themuscles in the region of the shoulder may have their innervationinterfered with as a result of various conditions, of whichpoliomyelitis and injuries of the brachial plexus at birth are themost important. The capsular ligament of the shoulder-joint, being nolonger kept tense by the scapular muscles--especially the deltoid andlateral rotators--becomes relaxed, and is gradually stretched by theweight of the arm. The appearances are characteristic; the muscles ofthe shoulder are wasted, the acromion is prominent, and between it andthe upper end of the humerus there is a marked hollow into which oneor more fingers may be inserted. The arm hangs flaccid by the side, rotated medially and pronated, and moves in a flail-like fashion inall directions, the patient having little control over it. The bestresults are obtained by the transplantation of muscles, the trapeziusbeing detached from the clavicle and stitched to the surface of thedeltoid, and the upper arm fixed in the position of horizontalabduction with the arm rotated laterally and supinated. Bradfordinserts a portion of the trapezius into the humeral insertion of thedeltoid. When these methods are impracticable, the upper arm may befixed to the trunk by some form of apparatus, or arthrodesis isperformed so that the movements of the scapula are communicated to theupper arm; the best attitude for ankylosis is one of abduction withmedial rotation, so that the hand can be brought to the mouth. In cases of poliomyelitis, when all the muscles governing the elboware paralysed while the muscles of the hand have escaped, it may be ofgreat service to fix this joint permanently at rather less than aright angle. This may be effected by arthrodesis, or by removing anextensive diamond-shaped portion of skin from the flexor aspect of thejoint and bringing the raw surfaces together, commencing the stitchingat the lateral apices of the gap. [Illustration: FIG. 166. --Arrested Growth and Wasting of Tissues ofRight Upper Extremity, the result of Anterior Poliomyelitis inchildhood. ] #Congenital Dislocations at the Elbow. #--_The head of the radius_ maybe dislocated forwards, backwards, or laterally--usually inassociation with imperfect development of the radius and of thelateral condyle of the humerus. When the displaced head of the boneinterferes with supination, or with extension, it should be removed. Congenital dislocation of both bones of the forearm is extremely rare. #Cubitus Valgus# and #Cubitus Varus#. --When the normal arm hangs bythe side with the palm of the hand directed forward, the forearm andupper arm form an angle which is open outwards--known as the "carryingangle"; it is usually more marked in women in association with thegreater breadth of the pelvis and the relative narrowness of theshoulders. When this angle is increased, the attitude is described asone of _cubitus valgus_. This deformity may be acquired as a result ofrickets, but more commonly it is due to fracture of the lateralcondyle of the humerus, in which the separated fragment has beendisplaced upwards. _Cubitus varus_ is the reverse of cubitus valgus. It is more common, is always pathological, and is nearly always a result of fracture ofthe lower end of the humerus or separation of the lower humeralepiphysis and subsequent interference with growth. These deformitiesmay be corrected by supra-condylar osteotomy of the humerus. [Illustration: FIG. 167. --Lower end of Humerus from case of CubitusVarus. ] #Synostosis of the superior radio-ulnar joint# is a rare congenitalcondition, in which the hinge movements at the elbow are free, butsupination is impossible; an attempt may be made by operation to forma new joint. #Volkmann's ischæmic contracture# of the muscles of the forearm, resulting in the production of claw-hand, is described in Volume I. , p. 415. #Deformities of the Forearm and Hand. #--The _radius_ may be absentcompletely or in part, frequently in combination with othermalformations. The most evident result is a deviation of the hand tothe radial side--one variety of _club-hand_. The forearm isshortened, the ulna thickened and often bent, and the thumb and itsmetacarpal bone are often absent, so that the usefulness of the handand arm is greatly impaired (Fig. 171). For this condition Bardenheuerdevised an operation which consists in splitting the lower end of theulna longitudinally and inserting the proximal bones of the carpusinto the cleft. Congenital deficiency of the _ulna_ is extremely rare. #Intra-uterine amputation# by constriction of amniotic bands sometimesoccurs (Figs. 168, 169). [Illustration: FIG. 168. --Intra-uterine Amputation of Forearm. ] [Illustration: FIG. 169. --Radiogram of Arm of patient shown in Fig. 168. ] #Drop Wrist from Anterior Poliomyelitis. #--In this condition thecapacity of extending the fingers is deficient or absent. Recovery canbe confidently predicted if, on still further flexing the fingers, they can be voluntarily extended towards the point from which they areflexed (Tubby and Jones). Considerable improvement may result fromfixing the hand by means of a splint in the attitude of dorsalflexion. The splint is removed at frequent intervals to allow ofmassage and other treatment being carried out, and it has usually tobe worn for a period of one to two years. In some cases recourseshould be had to arthrodesis. [Illustration: FIG. 170. --Congenital absence of Left Radius and Tibiain a child æt. 8. (Mr. D. M. Greig's case. )] In _spastic paralysis_ the most pronounced deformity is flexion of theforearm and pronation and flexion of the hand (Fig. 166). Gradualextension at the wrist may be brought about by the use of a malleablesplint, in which the angle is gradually increased, over a period of atleast twelve months. Failing success by this method, operation may behad recourse to, and this consists in lengthening of tendons, andtendon transplantation. Tubby has devised an operation for convertingthe pronator radii teres into a supinator, and Robert Jones another inwhich the flexors of the carpus are made to take the place of theextensors. "These operations, combined if necessary with elongation ofthe flexors of the fingers, pave the way for diminution of the angleof flexion at the elbow, lessening of the pronator spasm, increase ofthe supinating power, reduction of the carpal flexion, and addition tothe extensor power at the wrist" (Tubby and Jones). #Congenital Club-hand. #--This rare deformity corresponds to congenitalclub-foot, and probably arises in the same way. The hand and fingersare rigidly flexed to the ulnar or radial side, so that the patient isincapable of moving them. Treatment is carried out on the same linesas for club-foot. A deformity resembling this, _acquired club-hand_, is brought aboutwhen the growth of either of the bones of the forearm has beenarrested as a result of disease or of traumatic separation of itslower epiphysis. The hand deviates to the side on which the growth hasbeen arrested--_manus valga_ or _vara_. The treatment consists inresecting a portion of the longer bone. [Illustration: FIG. 171. --Club-hand, the result of imperfectdevelopment of radius. The thumb is absent. (Photograph lent by Sir George T. Beatson. )] #Madelung's Deformity of the Wrist. #--In 1878, Madelung calledattention to a deformity also called sub-luxation of the hand, inwhich the lower articular surface of the radius is rotated so that itlooks towards the palm; there is palmar displacement of the carpus, and the lower end of the ulna projects on the dorsum. The cause of thecondition is obscure, but it is met with chiefly in young women withslack ligaments, whose laborious occupation or athletic pursuitssubject the hand and wrist to long-continued or repeated strain. It isas frequently unilateral as bilateral and may recur in successivegenerations. There is a good deal of pain, the grasping power of thehand is impaired, and dorsiflexion is considerably restricted. Thedeformity disappears on forcible traction, but at once reappears whenthe traction is removed. A wristlet of poroplastic or leatherextending from the mid-forearm to the knuckles is moulded to the limbin the corrected position, and is taken off at intervals for massageand exercises. When _operative treatment_ is called for, it takes the form ofosteotomy of the radius and ulna about an inch or more above theirarticular surfaces. #Congenital dislocation of the wrist# is rare. #Deformities of the Fingers. #--Various forms of _congenitaldislocation_ of the fingers are met with, but they are of littleclinical importance, as they interfere but slightly with theusefulness of the digit affected. _Congenital lateral deviation of the phalanges_ is more unsightly thandisabling; it is met with chiefly in the thumb, in which the terminalphalanx deviates to the radial or to the ulnar side in extension; thedeviation disappears on flexion. _Congenital contraction of the fingers_ is comparatively common. It isan inherited deformity, and is often met with in several members ofthe same family. It most frequently affects the little or the ring andlittle fingers (Fig. 172), and is usually bilateral. The second andthird phalanges are flexed towards the palm; the first phalanx isdorsiflexed, this being the reverse of what is observed in Dupuytren'scontraction. Duncan Fitzwilliams suggests that it should be called"hook-finger, " and that it is probably due to imperfect development ofthe anterior ligament of the first inter-phalangeal joint. He hasobserved it in association with laxity of the ligaments of the otherjoints of the body. [Illustration: FIG. 172. --Congenital Contraction of Ring and LittleFingers. ] The affection is usually disregarded in infancy and childhood as beingof no importance. In young children, the deformity is corrected bywearing a light splint fixed with strips of plaster, or a piece ofwhalebone or steel inside the finger of a glove. In older children, the finger may be straightened by subcutaneous division of theligament over the palmar aspect of the base of the middle phalanx, orfailing this by lengthening the flexor tendons and resecting a wedgefrom the dorsal aspect of the first phalanx close to theinter-phalangeal joint. #Dupuytren's Contraction. #--This is an acquired deformity resultingfrom contraction of the palmar fascia and its digital prolongations(Fig. 173). It is rare in childhood and youth, but is common aftermiddle life, especially in men. It is often hereditary, and is said tooccur in those who are liable to gout and to arthritis deformans. While it is met with in the working-classes and attributed to thepressure of some hard object on the palm of the hand--such as a hammeror shovel or whip--its greater frequency in those who do no manualwork, and the fact that it is very often bilateral, indicate that theconstitutional factor is the more important in its causation. [Illustration: FIG. 173. --Dupuytren's Contraction. ] In the initial stage there is a localised induration in the palmopposite the metacarpo-phalangeal joint, and the skin over it ispuckered and closely adherent to the underlying fascia. After avariable interval, the finger is gradually and progressively flexed atthe metacarpo-phalangeal joint. The ring finger is usually the firstto be affected, less often the fifth, although both are commonlyinvolved. It is rarest of all in the index. The flexion may beconfined to the metacarpo-phalangeal joint, or the middle and distalphalanges may also be flexed; and as the deformity becomes morepronounced, the nail of the affected finger may come into contact withthe skin of the palm. Dissections show that the flexion of the fingeris the result of a chronic interstitial overgrowth or fibrositis andsubsequent contraction of the palmar fascia and of its prolongationson to the sides of the fingers. The digital processes of the fasciaare thickened and shortened, and come to stand out like the string ofa bow. The adipose tissue in the skin of the palm disappears, and theskin and fascia thus brought into contact become fused. The tendonsand their sheaths are not implicated; they are found lying deeply inthe concavity of the curve of the flexed digit. There is no pain, butthe grasp of the hand is interfered with, the patient is unable towear an ordinary glove, and he may be incapacitated from following hisoccupation. The condition is easily diagnosed from congenital contraction by thefact that in the latter the proximal phalanx is dorsiflexed. _Treatment. _--When seen in the initial stage, contraction may beprevented by passive movements of the finger and by massage of theindurated fascia; we have observed cases in which these measures haveheld the malady in check for many years, but when flexion has alreadyoccurred, they are useless, and according to the social position, habits, or occupation of the patient, the condition is left alone orthe deformity is corrected by operation. Adam's operation consists in multiple subcutaneous division of thecontracted fascia in the palm and of its prolongations on to thefinger; in addition to dividing the fascia, the tenotomy knife shouldbe used also to separate the skin from the fascia. The finger is thenforcibly extended, and a well-padded splint secured to the hand andforearm. The skin on the palmar aspect opposite the firstinter-phalangeal joint may give way when the finger is extended;should this occur, the resulting gap may be covered by a skin graft. After healing has occurred, massage and movements must be perseveredwith, and a splint (Fig. 174) worn at night, as there is an inveteratetendency to recurrence of the contraction. In view of this tendencythere is much to be said in favour of the radical operation whichconsists in removal of the fascia by open dissection. Owing to thelong time required for healing and the sensitiveness of the scar, theresults of excision of the fascia are sometimes disappointing. Greighas obtained good results by resecting the head of the metacarpalbone. When the little finger is completely flexed towards the palm itmay be amputated, as it is always in the way. [Illustration: FIG. 174. --Splint used after Operation for Dupuytren'sContraction. ] #Supernumerary Fingers (Polydactylism). #--These may coexist withsupernumerary toes, and the condition is often met with in severalmembers of the same family. Sometimes the extra finger is representedby a mere skin appendage, the nature of which may only be indicated bythe presence of a rudimentary nail; sometimes it contains bonerepresenting one or more phalanges, or it may be fully formed (Fig. 175). In the majority of cases the superfluous finger should beremoved. [Illustration: FIG. 175. --Supernumerary Thumb. (Photograph lent by Sir George T. Beatson. )] #Congenital Deficiencies in the Number of Fingers. #--One or morefingers may be absent, such deficiency being often associated withimperfect development of the radius or ulna; or they may berepresented by short rounded stumps, which are ascribed to thestrangulation of the digits by amniotic bands _in utero_--theso-called intra-uterine amputation. #Webbing of Fingers (Syndactylism). #--Congenital webbing or fusion ofthe fingers may be associated with polydactylism or with congenitalhypertrophy, and, like other digital deformities, may affect severalmembers of the same family. The degree of fusion ranges from a web ofskin joining the fingers to a fusion of the bones, the latter beingwell seen in skiagrams. If an operation is decided upon, it should notbe performed until the age of five or six years. In the simplest casesit is only necessary to divide the web and to unite the cut edges ofskin along each finger by sutures, a skin graft being inserted intothe angle between the fingers. An operation in which the skin isdissected up in the form of flaps may be required, but it should notbe lightly entered upon, as in young children it has been known to befollowed by gangrene of one or more of the digits. #Congenital Hypertrophy of the Fingers. #--This is a form of localgiantism affecting one or more digits, and involving all the tissues. The finger is usually of abnormal size at birth, and continues togrow more rapidly than the others, and it may also come to deviatefrom its normal axis. Such a finger should be trimmed down or removed, to permit of the use of the other digits. #Trigger Finger# (Fig. 176). --This is an acquired condition in whichmovement of a finger or thumb, either in flexion or extension, isarrested, and is only completed with the assistance of the other hand. The obstacle to movement is usually overcome with a jerk or snapsuggesting a resemblance to the trigger of a gun or the blade of aclasp-knife. The commonest cause is a disproportion between the sizeof the tendon and its sheath, such as may result from a localisedthickening of the tendon. Recovery usually takes place under massageand passive movements. Failing this, the thickened portion of thetendon is pared down to its normal size; if it is the sheath of thetendon that is narrow, it is laid freely open. [Illustration: FIG. 176. --Trigger Finger. (Photograph lent by Sir George T. Beatson. )] #Drop# or #mallet finger# is described on p. 121. CHAPTER XI THE SCALP Surgical Anatomy--Injuries: _Contusion_; _Hæmatoma_; _Cephal-hæmatoma_; _Wounds_; _Avulsion_--Diseases: _Infective conditions_; Cystic and solid tumours; Air-containing swellings; Vascular tumours. #Surgical Anatomy. #--The _skin_ of the scalp is intimately united tothe _epicranial aponeurosis_ by a network of firm fibrous tissuecontaining some granular fat, and representing the subcutaneousconnective tissue. These three layers constitute the scalp proper, andthey are so closely connected as to form a single structure which canbe moved to a certain extent by the action of the epicranius muscle. The epicranius (occipito-frontalis) muscle with its aponeurosisextends from the superciliary ridge in front to the superior nuchal(curved) line of the occipital bone behind, and laterally to the levelof the zygoma where it blends with the temporal fascia. Between thescalp proper and the _pericranium_ is a quantity of loose areolartissue, in the meshes of which extravasated blood or inflammatoryproducts can rapidly spread over a wide area. Blood extravasated underthe pericranium is limited by the attachments of this membrane at thesutures. The _blood supply_ of the frontal region is derived from the internalcarotid arteries through their supra-orbital branches; the remainderof the scalp is supplied from the external carotids through theirtemporal, posterior auricular and occipital branches. The vessels, which run in the subcutaneous tissue, superficial to the epicranialaponeurosis, anastomose freely with one another and across the middleline. The main branches run towards the vertex, and incisions should, as far as possible, be directed parallel with them. The _venous return_ is through the frontal, temporal, and occipitalveins. These have free communications, through the _emissary veins_, with the intra-cranial sinuses, and by these routes infectiveconditions of the scalp may readily be transmitted to the interior ofthe skull. The most important of the emissary veins are: the_mastoid_, _condyloid_, and _occipital_, passing to the transverse(lateral) sinus; the _parietal_, which enters the superior sagittal(longitudinal) sinus; and a branch from the nose which traverses theforamen cæcum and enters the anterior end of the superior sagittalsinus. The supra-trochlear, supra-orbital and auriculo-temporal branches ofthe trigeminal nerve, together with the greater and lesser occipitalnerves, supply the scalp with sensation, while the muscles aresupplied from the facial nerve. The _lymph vessels_ pass to the parotid, occipital, mastoid, andsubmaxillary groups of glands, the different areas of drainage beingill-defined. INJURIES OF THE SCALP #Subcutaneous Injuries. #--_In simple contusion_ of the superficiallayers, owing to the density of the tissues, the blood effused issmall in quantity and remains confined to the area directly injured, which is firm and tender to the touch, swollen and discoloured. Thedisappearance of the swelling may be hastened by elastic pressure andmassage. _Hæmatoma of the scalp_ results when lacerated vessels bleed into thesub-aponeurotic space. Owing to the laxity of the connective tissue inthis area, the effused blood tends to diffuse itself widely, and, according to the position assumed by the patient, gravitates to theregion of the eyebrow, the occiput, or the zygoma. When a large arteryis torn the swelling may pulsate. A hæmatoma of the scalp may readilybe mistaken for a depressed fracture of the skull, owing to the factthat the margins of the effusion are often raised and of a firmresistant character. A differential diagnosis can usually be made byobserving that the swelling is on a higher level than the rest of theskull; that the raised margin can to a large extent be dispersed bymaking firm, steady pressure over it with the finger; and that, ondoing so, the smooth and intact surface of the skull can berecognised. When a fracture exists, the finger sinks into thedepression and the irregular edge of the bone can be felt. In doubtfulcases, if cerebral symptoms are present, an exploratory incisionshould be made. Even a large hæmatoma is usually completely absorbed, but thedispersion of the clot may be hastened by massage and elasticpressure. Any excoriation or wound of the skin must be disinfected. Sometimes a blood-cyst, consisting of a connective-tissue capsulefilled with a yellowish-red fluid, remains, and may require to beemptied with a hollow needle. These effusions are to be distinguished from the _cephal-hæmatoma_, inwhich the blood collects between the pericranium and the bone. This isoftenest seen in newly born children as a result of pressure on thehead during delivery, and is characterised by its limitation to oneparticular bone--usually the parietal--the further spread of the bloodbeing checked by the attachment of the pericranium at the sutures. Occasionally a permanent thickening of the edges of the bone remainsafter the absorption of the extravasated blood. This condition is tobe diagnosed from traumatic cephal-hydrocele (p. 390). #Wounds of the Scalp. #--So long as a scalp wound, however extensive, is kept free from infection, it involves comparatively little risk, but the introduction of organisms to even the most trivial wound isfraught with danger, on account of the ease and rapidity with whichthe infection may spread along the emissary veins to the meninges andintra-cranial sinuses. The deeper the wound, the greater is the risk. If the epicranialaponeurosis is divided, the "dangerous area" between it and thepericranium is opened, and if infection occurs, it may lead towidespread suppuration. Should the wound extend through thepericranium, infection is more liable to spread to the bone and to thecranial contents. The usual varieties of wounds--incised, punctured, contused, andlacerated--are met with in the scalp, and they vary in degree from asimple superficial cut to complete avulsion. For medico-legal purposesit is important to bear in mind that a scalp wound produced by thestroke of a blunt weapon, such as a stick or baton, may closelysimulate a wound made with a cutting instrument. On account of the density of the integument and its close connectionwith the aponeurosis, scalp wounds do not gape unless the epicranialaponeurosis is widely divided. This facilitates union in incisedwounds, but interferes with drainage in the long narrow tracts whichresult from punctures, and which are so liable to be infected and toimplicate the sub-aponeurotic space, the pericranium, or even thebone. 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 bleedingfrom scalp wounds is often profuse and difficult to control, becausethe vessels, fixed as they are in the dense subcutaneous tissue, cannot retract and contract so as to bring about the natural arrest ofhæmorrhage, and it is difficult to apply forceps or ligatures to theircut ends, suture ligatures are more efficient. On account of the freearterial anastomosis in the deeper layers of the integument, largeflaps of scalp will survive when replaced, even if badly bruised andtorn, and it is never advisable to cut away any un-infected portion ofthe scalp, however badly it may be lacerated or however narrow may bethe pedicle which unites it to the head. _Gun-shot wounds_ of the scalp are usually associated with damage tothe skull and brain. A spent shot, however, may pierce the scalp, andthen, glancing off the bone, lodge in the soft parts. _Complete Avulsion. _--In women, the scalp is sometimes torn from thecranium as a result of the hair being caught in revolving machinery. The portion removed, as a rule, consists of integument and aponeurosiswith portions of muscle attached. In a few cases the pericranium alsohas been torn away. So long as any attachment to the intact scalpremains, the parts should be replaced, and, if asepsis is maintained, a satisfactory result may be hoped for. When the scalp is entirelyseparated, recourse must be had to skin-grafting. _Treatment of recent Scalp Wounds. _--To ensure asepsis, the hairshould be shaved from the area around the wound, and the part thenpurified. Gross dirt ground into the edges of lacerated wounds is bestremoved by paring with scissors. Undermined flaps must be furtheropened up and drained--by counter-openings if necessary. When there isreason to suspect their presence, foreign bodies should be sought for. Bleeding is arrested by forci-pressure or by ligature; when, as isoften the case, these measures fail, the hæmorrhage may be controlledby passing a needle threaded with catgut through the scalp so as toinclude the bleeding vessel. The wound is stitched with horse-hair orsilk, and, except in very small and superficial wounds, it is best toallow for drainage. With the use of iodine as a disinfectant, it isoften advantageous to dispense with dressings altogether. #Complications of Scalp Wounds. #--The most common complications arethose 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 sequelæare liable to follow infection of any scalp wound, but more especiallysuch as implicate the sub-aponeurotic area, or the pericranium. In theintegument, a small localised abscess, attended with pain and œdema ofsurrounding parts, may form. Pus forming under the aponeurosis isliable to spread widely, pointing above the eyebrow, in the occipitalregion, or in the line of the zygoma. Suppuration under thepericranium tends to be limited by the inter-sutural attachments ofthe membrane. Necrosis of the outer table, or even of the wholethickness of the skull, may follow, although it is by no meansuncommon for large denuded areas of bone to retain their vitality. The onset of infection is indicated by restlessness, throbbing painand heat in the wound, a feeling of chilliness or the occurrence of arigor, and tension of the stitches from œdema of the surroundingtissues. The œdema often extends to the eyelids and face; a puffinessof the eyelids, indeed, is not infrequently the first evidence of theoccurrence of infection in the wound. _Treatment. _--When suppuration ensues, the stitches should be removed, the wound opened up and purified with eusol, and packed. A dressing ofichthyol and glycerine should be employed for a few days. _Erysipelas of the scalp_ may originate even in wounds so trivial asto be almost invisible, or from suppurative processes in the region ofthe frontal sinuses or nasal fossæ. It tends to be limited by theattachments of deep fasciæ, and seldom spreads to the cheek or neck. Symptoms of cerebral complications, in the form of delirium or coma, and of meningitis may supervene. Cellulitis beneath the aponeurosisfrom mixed infection is a dangerous complication. DISEASES OF THE SCALP #Infective Conditions. #--It is not uncommon for _localised abscesses_to occur in the subcutaneous cellular tissue in delicate children, andsuch 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 notimprobable that they result from a mixed infection by pyogenic andtuberculous organisms. As a rule they heal quickly after incision anddrainage, but when they are allowed to burst, tedious superficialulcers may form. Localised abscesses may also form in connection withdisease of the cranial bones. _Suppuration_ following upon injurieshas already been referred to. _Boils and carbuncles_ are not common on the hairy part of the scalp. _Lupus_ rarely originates on the scalp, although it may spread thitherfrom the face. _Syphilitic_ lesions are common and present the samecharacters as elsewhere. Gummata may develop in the soft parts, butmore commonly they take origin in the pericranium or bone. _Eczemacapitis_ is of surgical importance only in so far as it often formsthe starting-point of infection of lymph glands by pyogenic and otherorganisms. #Cystic and Solid Tumours. #--A great variety of swellings is met within the scalp. _Sebaceous cysts_ or _wens_ are of frequent occurrence, and have beendescribed in Volume I. A _dermoid cyst_ is most commonly situated over the position of theanterior fontanelle, in the region of the occipital protuberance, orat the lateral angle of the orbit. As it frequently lies in a gap inthe skull, it may be connected by a pedicle with the dura mater, andis liable to be mistaken for a meningocele. [Illustration: FIG. 177. --Multiple Wens. (Photograph lent by Sir George T. Beatson. )] _Serous cysts_ are occasionally found in the occipital region, and arebelieved to be meningoceles that have become shut off from theinterior of the skull before birth. _Adenomas_ originating in the sebaceous or sweat glands are sometimesmultiple, of a purplish colour, and the skin covering them is thin andglistening. They show a tendency to ulcerate and fungate, giving riseto a fœtid discharge, and may be mistaken for epithelioma; they arealso liable to become the seat of epithelioma. They are treated byexcision. Large, flat _papillomas_ or warts may be single or multiple; they areof slow growth, and as they may also become the starting-point ofepithelioma, they should be removed. [Illustration: FIG. 178. --Adenoma of Scalp. ] The _plexiform neuroma_ forms a loose soft tumour situated in thecourse of one or more branches of the trigeminal nerve, especiallythe supra-orbital branch. In its most aggravated form the tumour hangsover the face or neck in large pendulous masses, and is described as a_pachydermatocele_ (V. Mott). A _sarcoma_ usually has its origin in the bones of the skull, and onlyimplicates the scalp secondarily. _Epithelioma_ of the scalp may originate in relation to a wart, anulcerated wen or sebaceous adenoma, or the cicatrix of a burn. It mayaffect comparatively young persons, may spread over a wide area, orpass deeply and involve the bone. Free and early removal is indicated. _Rodent cancer_ may originate on the scalp, but usually spreadsthither from the face. In operating for extensive tumours of the scalp the hæmorrhage issometimes formidable. It may be controlled by an elastic tourniquetapplied horizontally round the head, or if, on account of the positionof the tumour or from other causes, this is not practicable, byligation or temporary clamping of the external carotid on one or onboth sides. #Air-containing Swellings#--_Pneumatocele Capitis. _--Cases have beenrecorded in which, as a result of pathological or traumaticperforations of the mastoid, and less frequently of the frontal cells, air has passed under the pericranium and given rise to a tense roundedtumour, resonant on percussion, and capable of being emptied by firmpressure. Such swellings exhibit neither pulsation nor fluctuation;and as they are painless, and give rise to almost no inconvenience, they do not call for treatment. _Emphysema of the scalp_ may follow fractures implicating any of theair sinuses of the skull, the air infiltrating the loose cellulartissue between the pericranium and the aponeurosis, and on palpationyielding a characteristic crepitation. It usually disappears in a fewdays. #Vascular Tumours. #--_Nævi_ on the scalp present the same features aselsewhere. If placed over one of the fontanelles, a nævus may derivepulsation from the brain, and so simulate a meningocele. _Cirsoid aneurysm_ is usually met with in the course of the temporalartery, and may involve the greater part of the scalp. Large, distended, tortuous, bluish vessels pulsating synchronously with theheart are seen and felt. They can be emptied by pressure, but fill upagain at once on removal of the pressure. The patient complains ofdizziness, headache, and a persistent rushing sound in the head. Ulceration of the skin over the dilated vessels, leading to fatalhæmorrhage, may take place. They may be treated by excision, after division and ligation of thelarger vessels entering the swelling; or the dilated vessels may becut across at several points and both ends ligated. Krogius recommendsthe introduction of a series of subcutaneous ligatures so as tosurround the whole periphery of the pulsating tumour, and interruptthe blood flow. Ligation of the main afferent vessels, or of theexternal or common carotid, has been followed by recurrence, owing tothe free anastomatic circulation in the scalp. In some caseselectrolysis has yielded good results. _Traumatic aneurysm_ of the temporal artery was comparatively commonin the days when the practice of bleeding from this vessel was invogue, but it is seldom met with now. _Arterio-venous aneurysm_ may also occur in the course of the temporalartery, as a result of injury, and is best treated by completeextirpation of the segments of the vessels implicated. CHAPTER XII THE CRANIUM AND ITS CONTENTS Anatomy and physiology--Cerebral localisation--Lumbar puncture. HEAD INJURIES--Concussion--Cerebral irritation--Compression--Contusion and laceration of the brain, and traumatic intra-cranial hæmorrhage: _Middle meningeal hæmorrhage_; _Hæmorrhage from internal carotid and venous sinuses_--Intra-cranial hæmorrhage of the newly born. Cerebral œdema--Wounds of brain--After-effects of head injuries--Traumatic epilepsy and insanity--Infective complications. #Anatomy and Physiology. #--The _Cranium_ is irregularly ovoid inshape, and its floor is broken up by various projections to form threeseparate fossæ--anterior, middle, and posterior--in which restrespectively the frontal, the temporal, and the occipital lobes of thebrain; the cerebellum, pons, and medulla oblongata also occupy theposterior fossa. The _outer_ table is the most elastic layer of the calvarium, and itvaries greatly in thickness in different skulls and in different partsof the same skull. It is nourished chiefly from the pericranium whichis firmly bound down along the lines of the sutures. The _inner_ orvibreous table is thin and fragile, and its smooth internal surface isgrooved by the middle meningeal and other arteries of the dura mater, and by the large venous sinuses. The intermediate layer--the_diploë_--is highly vascular, branches of the meningeal vesselsanastomosing freely in its open porous substance with branches derivedfrom the pericranial vessels. Some of its veins open into the externalveins, and others into the intra-cranial sinuses, and they communicatewith the emissary veins as these pass through the bone, which explainsthe spread of infective processes from the structures outside theskull to those within. The possibility of withdrawing blood from theinterior of the skull by leeching, bleeding, or cupping depends on theexistence of the emissary veins. _The Membranes of the Brain. _--The _dura mater_ is a fibro-serousmembrane, the outer, fibrous layer constituting the endosteum of theskull, the inner, serous layer forming one of the coverings of thebrain. Between the fibrous layer and the bone the meningeal vesselsramify; and along certain lines the two layers split to form channelsin which run the cranial venous sinuses. Inside the dura, andseparated from it by a narrow space--the _sub-dural space_--lies the_arachno-pial membrane_, consisting of an outer (_arachnoid_) layerwhich envelops the brain but does not pass into the sulci, and ahighly vascular inner layer--the _pia mater_--which closely investsthe brain and lines its entire surface. The space between these layers--the _sub-arachnoid space_--istraversed by a network of fine fibrous strands, in the meshes of whichthe cerebro-spinal fluid circulates. Each nerve-trunk as it leaves theskull or spinal canal carries with it a prolongation of each of thesemembranes and their intervening spaces. The membranes gradually becomelost in the fibrous sheaths of the nerves, and the sub-dural andsub-arachnoid spaces become continuous with the lymph spaces of thenerves. The _cerebro-spinal fluid_ is secreted by the choroid plexuses andfills the cerebral ventricles, the central canal of the cord, thesub-dural and sub-arachnoid spaces, and the sheaths of theintra-cerebral blood vessels. At the base of the brain, particularlyin the posterior fossa, the sub-arachnoid space is wider thanelsewhere, forming "cisterns" filled with cerebro-spinal fluid whichsupports the cerebral structures. Through the foramen of Magendie inthe roof of the fourth ventricle the sub-arachnoid fluid of thecranial cavity communicates with that of the vertebral canal. Although it differs in its chemical constitution from true lymph, thecerebro-spinal fluid seems to functionate as lymph, in addition toacting as a lubricating agent, and playing a part in regulating thevascular supply of the brain. In cases of cerebral hæmorrhage, abscess, tumour, or depressed fracture, room is made up to a certainpoint for the extraneous matter by displacement of cerebro-spinalfluid. _Vascular supply. _--The free anastomosis between the vessels enteringinto the formation of the circulus arteriosus (circle of Willis)ensures an abundant supply of blood to the brain. The larger arteriesrun in the sub-arachnoid space and give off branches which ramify inthe pia mater before entering the cerebral substance. Within thebrain, each artery being more or less terminal, there is no freeanastomosis between adjacent vessels, with the result that if anyindividual artery is obstructed the vitality of the area supplied byit is seriously impaired. The venous arrangements are also peculiar inthat 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 anyincrease in the pressure of this vessel is immediately transmittedback to the cerebral veins. As the blood vessels project into a rigidcase filled with incompressible material, and as the total _volume_ ofblood in the brain is constant (Munro and Kelly), any alteration inthe supply of blood to the cerebral tissue must be due to an increased_velocity_ of flow, and this in turn depends upon changes in theaortic and vena cava pressure. Thus, if the aortic pressure rises, more blood will enter the cerebral vessels and will move along morerapidly; while if the pressure in the vena cava rises there isobstruction to the passage of blood in the arteries and diminishedvelocity of flow. The ebb and flow of cerebro-spinal fluid in and outof the spinal canal may also help to control the pressure. #Nerve Elements. #--The nervous system is composed of a multitude ofunits, called _neurones_, each neurone consisting of a nucleated cell, with branching protoplasmic processes or _dendrites_ and one_axis-cylinder_ or _axon_. The nutrition of an axis cylinder dependson its continuity with a living cell. If the cell dies, the axiscylinder degenerates. If the axis cylinder is severed at any point, itdegenerates beyond that point, and the nucleus of the nerve-celldisintegrates--chromatolysis. The axis cylinder of one cell ends in a number of fine filaments whicharborise around another nerve-cell, thus bringing it intophysiological, if not anatomical, relationship with the first cell. The termination is called a cell-station or _synapsis_. In this waythe various sections of the nervous system are kept in associationwith one another and with the rest of the body. _Motor Functions and Mechanism. _--The nerve centres, which togethermake up the motor area, and govern the voluntary muscular movements ofthe body, are situated in the grey matter of the præcentral orascending frontal gyrus, and of the frontal aspect of the centralsulcus (fissure of Rolando). The upper limit of the motor area reacheson to the mesial aspect of the paracentral lobule, and the lower limitstops short of the lateral cerebral fissure (fissure of Sylvius) (Fig. 179). [Illustration: FIG. 179. --Relations of the Motor and Sensory Areas tothe Convolutions and to Chiene's Lines. (After Cunningham. )] Each group of muscles has its own regulating centre, the size of thearea representing any group depending upon the character andcomplexity of the movements performed by the muscles, rather than uponthe amount of muscular tissue that is governed by the centre--forexample, the centre for the mouth, tongue, and vocal cords is largerthan that for the muscles of the trunk. The motor centres have been localised on the surface of the brain withapproximate accuracy. For example, above the superior genu of thepræcentral gyrus, the centres governing the hip, knee, and toes aregrouped; opposite the genu are the centres for the movements of thetrunk; between the superior and middle genua lie the centres for theupper extremity; opposite the middle genu, those for the neck, andbelow it, those for the face, jaws, and tongue, pharynx and larynx. #The Motor Tracts. #--It is now generally accepted that there are twopaths by which motor impulses pass from the brain: one--the_rubro-spinal tract_--which controls the more elemental movements ofthe body, such as standing, walking, breathing, etc. ; the other--the_pyramidal tract_--developed later in the evolution of the nervoussystem, and concerned with the finer and more skilled movements. The pyramidal tract is the more important clinically. From thepyramidal cells in the cortex of the Rolandic area, the axis cylinderspass through the centrum ovale towards the base of the brain. Theyconverge at the internal capsule, and pass through the anteriortwo-thirds of its posterior limb (Figs. 180 and 195). The fibres forthe eyes, face, and tongue lie farthest forward, and next in orderfrom before backward, those for the arm and the leg. From the internal capsule, the motor fibres pass as the _pyramidaltract_ through the crusta of each crus cerebri, the pons and themedulla oblongata. Throughout this part of its course, numerous axonsleave the tract, and enter the mid-brain, pons, and medulla in whichlie the nuclei of the motor cranial nerves. At the _decussation of the pyramids_ in the lower third of themedulla, the main mass of the motor fibres crosses the middle line, and enters the lateral column of the spinal cord as the _crossedpyramidal tract_. The remaining fibres pass down as the _directpyramidal tract_, and decussate in the cord near their termination. The fibres forming the second path pass through the red nucleus in thecerebral peduncle (crus cerebri) and thence by way of the rubro-spinaltract in the lateral column of the cord. The existence of this double motor path explains how after ahemiplegic stroke in which the pyramidal tract is destroyed while therubro-spinal tract escapes, the patient is able to perform suchprimitive movements as are involved in walking or standing, while heis unable to carry out finer movements that require higher education. The pyramidal and rubro-spinal tracts, in addition to conveying motorimpulses, convey impulses that influence muscle tonus and the deepreflexes. The pyramidal tract conveys impulses that inhibit muscletonus, while the rubro-spinal tract is the path by which excitatoryimpulses travel. When the inhibitory influences are cut off, as in alesion of the internal capsule, the paralysed muscles become spastic, and the deep reflexes are exaggerated. When the excitatory impulsesare also lost, as in a total transverse lesion of the cord, theparalysed muscles are flaccid and the deep reflexes disappear. Indestructive lesions of the lower neurones, the muscles are alwaysflaccid. The axons passing from the cerebral cortex terminate at differentlevels in the cord by breaking up into dendrites which arborise aroundthe cells on the grey matter of the posterior horns--this system ofcells, axons, and dendritic processes forming an _upper neurone_. Fromthis synapsis the _lower neurone_ proceeds, its axons travelling tothe anterior horn and arborising around the motor cells. The axiscylinders pass out in the anterior nerve roots to the spinal nervesand are continued in them to their distribution in voluntary muscles. If the continuity of any group of these lower neurones is interrupted, not only do the nerve fibres degenerate, but the nutrition of themuscles supplied by them is interfered with and they rapidlydegenerate and waste, and after an interval show the reaction ofdegeneration. In addition, the reflex arc is disturbed, and reflexesare lost. As these changes do not occur in lesions of the upperneurones, an appreciation of the differences enables us to distinguishbetween lesions implicating the upper and the lower neurones. #Sensory Functions and Mechanism. #--Three kinds of sensory impulsespass from the periphery to the brain; (1) deep, or muscularsensibility, (2) protopathic sensibility, and (3) epicriticsensibility. _Deep sensibility_ includes the recognition of (_a_) deep pressure, say by the blunt end of a pencil; (_b_) the position of a joint onpassive movement (joint sense); (_c_) active muscular contraction(kinesthetic sense). The fibres that convey these impulses to thespinal cord pass in the afferent nerves from the muscles, tendons, andbones, and so long as these nerves are intact these sensations areretained, even if the surface of the skin is quite anæsthetic. _Protopathic sensibility_ is of a lower order than epicritic. Itconsists in the recognition of painful cutaneous stimuli and ofextreme degrees of heat and cold. The fibres concerned arenon-medullated and regenerate comparatively quickly after injury, sothat protopathic sensibility is regained before epicritic. _Epicritic sensibility_ is the most highly specialised and permits ofthe recognition of light touch, _e. G. _, with a wisp of cotton wool, offine differences of temperature, and of discriminating as separate thepoints of a pair of compasses 2 cm. Apart. These sensations arecarried by medullated nerve fibres, and are slow to return afterinjury to the nerves. The sensory nerve fibres conveying these different impulses pass tothe ganglionic cells of the posterior nerve roots. From each of thesecells a process passes into the cord and bifurcates into an ascendingand a descending branch. In the cord the fibres rearrange themselvesand pass to the brain by a double path. Those that convey sensationsof pain and of temperature pass by the spino-thalamic route by way ofthe tract of Gowers and the fillet to the optic thalamus; those thatare concerned with the muscular sense, the joint sense, and tactilediscrimination pass up the posterior columns in the tracts of Goll andBurdach to the nuclei gracilis and cuneatus in the medulla, whencethey pass to the optic thalamus. From the cell station in the optic thalamus the fibres proceed to the_cortical sensory centres_, that for tactile sensation being situatedin the post-central (ascending parietal) gyrus; that for muscular andstereognostic sense lying probably in the adjacent portions of theparietal lobe. In a unilateral lesion of the cord, pain and the temperature sense maybe disturbed in one limb, and motor power and tactile sensibility inthe other, as the fibres that convey impressions of pain, and thosethat subserve the discrimination of temperature, pass up and decussatein the cord a few segments above their point of entrance. [Illustration: FIG. 180. --Diagram of the Course of Motor and SensoryNerve Fibres. ] #Effects of Lesions of the Motor and Sensory Mechanisms. #--Lesions ofthe _motor mechanism_ differ in their fundamental characters accordingas they affect the upper or the lower neurones. The signs also varyaccording as the affected area is _destroyed_ or merely _irritated_, say by the pressure of a tumour. Irritative lesions in general producemuscular spasms or convulsions, while destructive lesions causeparalysis. The essential differences in the effects of destructivelesions of upper and lower neurones may be indicated thus:-- _Upper Neurone Lesion. _ _Lower Neurone Lesion. _ Spastic paralysis of voluntary Flaccid paralysis of voluntary muscles. Muscles. No marked wasting of paralysed Marked wasting of paralysed muscles. Muscles. No reaction of degeneration. Reaction of degeneration. Exaggeration of reflexes. Loss of reflexes. Irritative lesions of the sensory mechanism cause numbness andtingling (paræsthesia); more extensive paralytic lesions produceanæsthesia, astereognosis, loss of muscle sense, loss of pain, orinability to distinguish temperature, according to the tracts that areaffected. _Lesions of the Upper Motor Neurone_ may occur in any part of itscourse. _Localised lesions of the motor cortex_ of an irritative kind, for example, a patch of meningitis, a tumour, meningeal hæmorrhage, ora spicule of bone, produce spasms in those groups of muscles on theopposite side of the body that are supplied by the centresimplicated--Jacksonian epilepsy. The cortical discharge may overflowinto neighbouring centres and cause more widespread convulsivemovements, or, if strong and long-continued, may even lead to generalconvulsions. Consciousness is usually lost before the whole of oneside becomes implicated in the spasms; always before they spread tothe opposite side. Contracture may occur in the muscles affected afterthe spasms cease. If an area of the cortex is destroyed by the lesion, paralysis isproduced of the corresponding muscles on the opposite side of thebody. At first the paralysed muscles are flaccid, but spasticity soondevelops. In some cortical lesions, for reasons not yet understood, the paralysis remains of the flaccid type. The seat and extent of theparalysis depend upon the area of the cortex destroyed. In rare casesthe whole motor area is destroyed--_cortical hemiplegia_; moregenerally the lesion affects one or more groups of muscles, andoccasionally all the muscles of one limb are paralysed--_corticalmonoplegia_. Lesions are often both irritative and destructive, andlead to paralysis of one or more groups of muscles associated withspasms and convulsions of the muscles governed by neighbouring areasof the cortex. Irritation or destruction of the sensory centres mayalso exist, giving rise to areas of paræsthesia and anæsthesia. Lesions in the _centrum ovale_, which destroy the fibres proceedingfrom the overlying cortex, produce a corresponding spastic paralysison the opposite side of the body. No irritative phenomena areassociated with such a sub-cortical lesion. Lesions in the region of the _internal capsule_ often produce completespastic hemiplegia of the opposite side of the body. When theposterior part of the capsule is involved, there are, in addition, hemianæsthesia and hemianopia, and sometimes disturbances of hearing, smell, and taste. A lesion of the _crus_ may in like manner produce spastic hemiplegiaand hemianæsthesia of the opposite side, often associated with a lowerneurone paralysis of the third and fourth nerves of the same side(crossed paralysis). The optic tract, which crosses the crus, may alsobe affected, and hemianopia result. Lesions of the _corpora quadrigemina_ cause interference with thereaction of the pupil, disturbance of the functions of the oculo-motornerve and of mastication, ataxia, and inco-ordination of the movementsof the limbs. The symptoms produced by lesions of the _pons and medulla_ varyaccording to the position of the lesion. If it is unilateral, theremay be spastic hemiplegia and hemianæsthesia of the opposite side; ifit is situated in the lower part of the pons or in the medulla, thereis often also a lower neurone paralysis of one or more of the cranialnerves on the same side as the lesion (crossed paralysis). Paralysisof the external rectus of one eye and of the internal rectus of theother (conjugate paralysis) is frequently found in pontine, and incortical and internal capsule lesions. _Cerebellar_ lesions are associated with special symptoms. In ataxia, there is inco-ordination of muscular movements, especially of thecoarse movements, such as walking. The gait becomes irregular andstaggering, with a tendency to fall, sometimes to the side on whichthe lesion is situated, sometimes to the opposite side. In patientswho cannot walk, ataxia may be tested by ordering repeated pronationand supination of the forearm. Paresis or asthenia may be found in thetrunk muscles, or evidenced by weakness of the grip, or drooping ofthe head to one side. Changes in muscle tone may arise and lead toexaggerated or decreased reflexes, often varying from day to day. Vertigo and nystagmus may also be present, in addition to occipitalheadache and tenderness on percussion. When one lateral lobe isimplicated, the symptoms are referred to the same side; when themedian lobe is involved, they are bilateral, and there may beretraction of the neck with extension of the legs, probably as theresult of the associated internal hydrocephalus. A unilateral lesion of the _spinal cord_ causes a lower neuroneparalysis of the muscles supplied from the cord at the level of thelesion, with spastic paralysis of the muscles of the same side of thebody supplied from a lower level of the cord. The sensory symptoms arevariable. Typically there is some anæsthesia in the structuressupplied from the damaged section of the cord--incomplete owing to theoverlapping by other sensory nerves. Just above the lesion there isirritation of spinal nerves, and hyperæsthesia and pain referred totheir distribution. On the same side below the lesion, there is a lossof epicritic, stereognostic and deep sensibility, and on the oppositeside below the lesion, loss of the sense of pain and thediscrimination between heat and cold. Ordinary tactile sensibility, which is governed by a double path, may or may not be lost on eitherside below the lesion. #Other Special Centres. #--The cortical centres for _vision_ lie on themedian surfaces of the occipital lobes in the neighbourhood of thecalcarine fissure. Each half-vision centre--for there is one in eachoccipital lobe--receives the fibres from the same side of both retinæ. Destruction of one half-vision centre produces the condition known as_homonymous hemianopia_, in which the medial (nasal) half of onevisual field and the lateral (temporal) half of the other is affected, so that there is an inability to see objects situated on the sideopposite to the lesion. _Auditory impulses_ are received in the posterior part of the superiortemporal convolution. _Aphasia. _--The use of language, spoken or written, as a means ofexpression depends upon the co-ordination of four different centres:the visual, the auditory, the graphic, and the articulatory. These aresituated in different parts of the brain and are connected bysub-cortical association tracts, the main pathway of which lies in thevicinity of the upper end of the fissure of Sylvius. Marie has provedthat aphasia results from lesions in this area. The _olfactory_ and _gustatory_ centres are situated in the uncusclose to the pituitary fossa. Lesions of the frontal cortex anterior to the motor centres, even ifextensive, may produce few or no symptoms, and in consequence thisregion has been called a "silent" area. Occasionally there results achange in temperament or intelligence, and the region is on thisaccount supposed to be concerned with the higher psychical functions. There is evidence that the pre-frontal cortex has a centre for theconscious initiation of movements, and that lesions produce "apraxia, "_i. E. _, inability to perform, or clumsiness in voluntarily performingfine movements such as touching the nose with the finger, though suchmovements may be perfectly carried out unintentionally. This centre isprobably situated in the superior and middle left frontal convolutionsin right-handed people. The fibres from the centre to the right motorarea cross in the anterior part of the corpus callosum. #Cerebral Localisation. #--The various parts of the brain can belocalised in relation to the surface by various methods. That devisedby Professor Chiene has been found reliable. #Relation of Cerebral Centres to the Surface. #--Numerous attempts havebeen made to formulate rules for locating the different parts of thebrain in relation to the surface of the head. The method devised byChiene is free from many of the difficulties and fallacies common tomost other methods, inasmuch as the results obtained do not dependupon making definite measurements in inches, or determining particularangles. Certain fixed and easily recognised bony landmarks--theglabella, the external occipital protuberance, the lateral angularprocess, and the root of the zygoma--are taken, and connected bylines, which are further subdivided--_always being bisected_. Figs. 179 and 181 explain the method. The head being shaved, a line (GO) isdrawn along the vertex from the glabella (G) to the external occipitalprotuberance (O). This line is bisected in M, which constitutes the"mid-point. " The posterior half of the line MO is bisected in T, constituting the "three-quarters point, " and the posterior half TO isbisected in S--"the seven-eighths point. " The lateral angular process(E) is next connected to the root of the zygoma (P) by a line EP, andthe root of the zygoma with the seven-eighths point by PS; the lineEPS thus forms the base line. The lateral angular process is nowjoined to the three-quarters point by ET. The two segments of the baseline EP and PS are bisected in N and R respectively, and these pointsconnected with the mid-point (M) by lines NM and RM. These lines cutoff a part of ET--AB, which is now bisected in C, and from C the lineCD is drawn parallel to AM. [Illustration: FIG. 181. --Chiene's Method of Cerebral Localisation. ] In this way practically all the points of the brain which are wantedfor operative purposes may be mapped out. Thus the quadrilateral spaceMDCA contains the Rolandic area. MA represents the præcentral sulcus, and if it be trisected in K and L, these points will correspond to theorigins of the superior and inferior frontal sulci. The pentagon ABRPNcorresponds to the temporal lobe. The apex of the temporal lobeextends a little in front of N. The supra-marginal convolution lies inthe triangle HBC. The angular gyrus is at B. A is over the anteriorbranch of the middle meningeal artery, and the bifurcation of thelateral or Sylvian fissure; AC follows the horizontal limb of thelateral fissure. The transverse or lateral sinus at its highest pointtouches the line PS at R (Fig. 181). The _fissure of Rolando_ or _central sulcus_ may be marked out bytaking a point half an inch behind the mid-point (M) (Fig. 181), anddrawing a line downwards and forwards for a distance of about threeand a half inches, at an angle of 67. 5° with the line GO. The angle of67. 5° can be readily determined by folding a square piece of paper onitself so as to make a triangle. The angle at the fold equals 45°. Byfolding the paper again upon itself in the same direction, the rightangle of the paper is divided into four angles of 22. 5° each. Three ofthese angles taken together make up the 67. 5°. If the straight edge ofthe paper be placed along the sagittal suture with the angle offolding over the upper end of the fissure of Rolando, the folded edgefalls over the line of the fissure (Chiene). [Illustration: FIG. 182. --To illustrate the site of various operationson the skull. ] LUMBAR PUNCTURE Quincke, in 1891, first suggested the withdrawal of cerebro-spinalfluid from the theca in the lumbar region, as a means of relievingexcessive intra-cranial tension in tuberculous meningitis, and toobtain specimens of the fluid for diagnostic purposes. The scope ofthe procedure, both as a therapeutic and as a diagnostic measure, hassince been widely extended. _Technique. _--The puncture may be made with the patient either lyingon his left side, the spine being fully flexed by approximating theknees and shoulders; or sitting on the table with the knees drawn upand the body bent forward. The upper edge of the fourth lumbar spineis identified by drawing a horizontal line across the back at thelevel of the highest part of the iliac crests (Fig. 183). The spacebetween the fourth and fifth lumbar vertebræ being the widest, is thatusually selected. The skin having been purified, an exploring needle, about three inches long, is introduced about half an inch below thefourth lumbar spine in the middle line, and passed for about twoinches in a direction forwards and slightly upwards. The needleusually encounters some resistance as it pierces the interspinousligament, and then enters the sub-arachnoid space. If bone is struck, the needle should be withdrawn and introduced at a different level. Ifthe cerebro-spinal fluid does not escape at once, a stylet should bepassed through the needle to clear it of blood-clot or shreds oftissue. When the intra-thecal tension is normal, the fluid tricklesaway drop by drop, but if it is increased, as, for example, inmeningitis, intra-cranial tumour, hydrocephalus, or uræmia, it mayescape in a jet. [Illustration: FIG. 183. --Localisation of site for introduction ofneedle in Lumbar Puncture. ] The _normal cerebro-spinal fluid_ is clear and colourless, has aspecific gravity of 1004-1008, and contains a trace of serum globulinand albumose, some chlorides, and a substance which reduces Fehling'ssolution. Microscopically, it may contain some large endothelial cellsand a few lymphocytes, or may be entirely devoid of cells. It does notcontain the antitoxins and opsonins which are normally found in theplasma and lymph, hence the liability to infective meningitis afterinjuries and operations on the central nervous system. With a view todiminishing these risks, hexamine, which is excreted into thecerebro-spinal fluid, is administered for its antiseptic properties incases of head injury and before intra-cranial operations. _Diagnostic Puncture. _--Examination of the fluid withdrawn has proveduseful in diagnosis in cases of intra-cranial and intra-spinalhæmorrhage, in various forms of meningitis, in cerebral abscess, andin some cases of cerebral tumour. The first few drops should be discarded, as they may be stained withblood from the puncture, and about 5 c. C. Collected in each of twosterile tubes. To determine whether blood in the fluid is due to thepuncture or to a pre-existing intra-cranial or intra-thecalhæmorrhage, the fluid should be centrifugalised; in the former casethe supernatant fluid is clear and limpid, in the latter it retains ayellow tinge. In extra-dural hæmorrhage there is no blood in thecerebro-spinal fluid. In acute meningitis the fluid is turbid, and contains an excess ofalbumin. Organisms also are present, such as the diplococcusintracellularis in acute cerebro-spinal meningitis; staphylococci, streptococci, and pneumococci, particularly in the intra-cranialcomplications of middle ear disease. In all cases of acute microbicinfection, and especially in the suppurative forms, polynuclearleucocytes are found in the fluid; while in chronic affections, suchas tubercle and syphilis, there is an excess of lymphocytes (PurvesStewart). The detection of the tubercle bacillus is confirmatory of adiagnosis of tuberculous meningitis, but, as it is often difficult tofind, its absence does not negative this diagnosis. In tuberculousmeningitis the clot which forms floats in the centre of the fluid, andis translucent, grey, and flaky; in the pyogenic forms it is yellow, and sticks to the side of the vessel. In a few cases of malignant tumour of the spinal cord and itsmembranes, characteristic cells have been found in the fluid aftercentrifugalising. In uræmia there is a diminution of chlorides, and an increase ofphosphates and sulphates. The Wasserman test is sometimes positive in the cerebro-spinal fluid, when it is negative in the blood. _Therapeutic Puncture. _--In certain cases of cerebral tumour, and oftuberculous meningitis associated with an excessive quantity of fluidin the arachno-pial space, temporary relief of such symptoms ofincreased intra-cranial tension as headache, vertigo, blindness, orcoma, 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 inthe head, delirium, and even coma, in cases of basal fracture. Carrière has found it beneficial in some cases of uræmia. The quantitywithdrawn must not exceed 40 c. Cm. , lest the ventricles be emptied andpressure be exerted directly on the basal ganglia (Tuffier). In anumber of cases sudden death has followed the withdrawal ofcerebro-spinal fluid. This route is sometimes selected for the induction of spinalanæsthesia, and for the injection of antitoxin in cases of tetanus. HEAD INJURIES The brain is protected from injury by moderate degrees of violenceapplied to the head, by the dense and mobile scalp, the dome-likeshape of the skull, the elasticity of its outer table and thebuffer-like sutural membrane between the numerous bones of which it iscomposed, and the various internal osseous projections with themembranes attached to them, all of which tend to diminish vibrationsand to disperse forces so that they expend themselves before theyreach the brain. Further protection is provided by the water-bed ofcerebro-spinal fluid, and by the external buttresses formed by thezygomatic arch and the thick muscular pads related to it, as well asby the mobility of the skull upon the spine. In all cases of head injury, the questions that dominate the wholeclinical outlook are, whether the brain is directly damaged or not, and whether it is likely to become the seat of infection. It is impossible to consider separately in their clinical aspectsinjuries of the cranium and injuries of the brain. It seldom happensthat one is seriously damaged without the other suffering to a greateror less extent. Sometimes the skull suffers comparatively little, while the brain is severely damaged, but it is rare for a seriousinjury to the bone to be unaccompanied by definite brain lesions. Inany case it is the damage to the brain, however slight, that gives tothe injury its clinical importance. It is an old and a true sayingthat "no injury of the head is so trivial as to be despised or soserious as to be despaired of. " Injuries at first sight apparentlyslight may prove fatal from hæmorrhage or infection; on the otherhand, recovery has followed injuries of great severity--for example, the famous "American crowbar case, " in which a bar of iron three and ahalf feet long and one and a half inches thick passed through thehead, and yet the patient recovered. It is convenient to consider the injuries of the brain before those ofthe skull. TRAUMATIC LESIONS OF THE BRAIN It is probable that in all cases of injury to the head in which apatient loses consciousness, there is some definite damage to thecerebral tissue. This takes the form of a greater or less degree ofcontusion or laceration, and the lesions are usually most severe anddangerous when the skull is fractured and fragments are driven in uponthe brain, but they may exist--indeed they may be very extensive--inthe absence of fracture. Several degrees are recognised. (1) Numerous minute _petechial hæmorrhages_ may be found widelyscattered throughout the brain substance, as a result of a diffusedblow on the head, which has shaken up the brain and caused symptoms ofcerebral shock or "concussion. " We have found, on microscopicexamination in such cases, in addition to these small extravasations, collections of colloid bodies, patches of miliary sclerosis, andchromatolysis and vacuolation of nerve-cells. [3] [3] Miles, _Laboratory Reports, Royal College of Physicians, Edinburgh_, vol. Iv. (2) In more severe cases there are often several _visible areas ofextravasation_, most commonly in the grey matter of the cortex (Fig. 184). These foci vary in size from a split-pea to a hazel-nut, andconsist of a dark central zone of extravasated blood, surrounded by anarea of "red softening" of the brain matter, beyond which are numerousminute capillary hæmorrhages. These intra-cerebral lesions may beaccompanied by an effusion of blood into the meshes of thearachno-pial membrane, and they may occur either at the part of thehead struck, or at the opposite pole of the axis of percussion--theso-called point of _contre-coup_. The symptoms vary with the size andsite of the extravasations. It is probable that the phenomena of"cerebral irritation" are to be explained by the occurrence of suchhæmorrhages widely scattered through the cerebral cortex. Effusionsinto the cortical motor areas give rise to irritation or paralysis ofthe muscles governed by the affected centres. Different forms ofaphasia and interference with vision or with hearing followimplication of the centres governing these functions. In thepre-frontal and in the lower temporal convolutions no special symptomsseem to follow. When the hæmorrhages are extensive and numerous, symptoms of compression may ensue, and these are aggravated when œdemaof the brain is superadded. Localised hæmorrhages also occur, although less frequently, in thecrura cerebri, the pons, the floor of the fourth ventricle, and thecerebellum. In these situations they usually prove fatal by causingrapidly advancing coma and interference with the respiratory andcardiac centres. The temperature immediately rises to 106° or even108° F. , and a modified form of Cheyne-Stokes respiration is present. (3) Still more gross lesions, in the form of distinct _lacerations_, are comparatively common at the tips of the frontal, temporal, andoccipital lobes, on the surface of the cerebellum, and at the base ofthe brain. These are usually associated with symptoms of compressionin its most typical form, and as a rule prove fatal. The grey matteris torn, and extensive effusion of blood takes place into the brainsubstance, and on the surface, filling up the sulci, and distendingthe arachno-pial space (Fig. 184). In a compound fracture, brainmatter may be extruded through the opening in the skull. (4) The extravasated blood may burst _into the lateral ventricles_, in which case the pulse becomes small and rapid--130, 160, or even170. The respiration also is rapid--45 to 60--and greatly embarrassed, and the temperature suddenly rises to 103° or 104° F. , and continuesto rise till death ensues. (5) _Traumatic Œdema. _--It is not uncommon for a diffuse œdematousinfiltration of the brain substance or of the arachno-pial membrane totake place in the vicinity of the injured portion of brain. Thisserous exude, on account of the natural adhesions of the arachno-pia, usually remains limited to the damaged area, but it may becomegeneralised. _Mechanism. _--The explanation of these widespread hæmorrhages is to befound, according to Duret, in the disturbance of the cerebro-spinalfluid which accompanies a severe blow on the head. This fluid not onlysurrounds the brain, but it also fills the ventricles, and permeatesits substance in every direction in the peri-vascular andperilymphatic spaces. As the brain tissue is incompressible, if anarea of the skull is momentarily depressed by a localised blow, spaceis provided for it by displacement of a quantity of cerebro-spinalfluid, which sets up a fluid wave, and this by hydrostatic pressureincreases the tension of the fluid throughout the entire brain. Vessels may be lacerated at any point, either by the flow of this waveor during the ebb which follows the recoil. Hence it is that thelesion is not always at the seat of impact, but may be at the oppositeside of the skull or at other remote points. [Illustration: FIG. 184. --Contusion and Laceration of Brain. Notelimited lesion at point of impact on left side, and more extensivedamage at point of _contre-coup_ on right. (After Sir Jonathan Hutchinson. )] _Repair. _--As the disintegrated brain matter is replaced bycicatricial tissue, neither the nerve cells nor the fibres beingregenerated, the loss of function of the parts destroyed is usuallypermanent. A localised extravasation of blood may become encapsulated, and constitute a "hæmorrhagic cyst. " We have experimentally confirmedDuret's observations and agree with his conclusions. CLINICAL MANIFESTATIONS OF INJURIES TO THE BRAIN For convenience, the clinical manifestations of cerebral injury areusually described under the terms "concussion, " "cerebral irritation, "and "compression, " but no precise pathological significance attachesto these terms, they are essentially clinical. As the conditions sodescribed do not occur as independent entities and may overlap ormerge into one another their differentiation is more or lessarbitrary, and cases are frequently met with that do not run thecourse characteristic of any of these groups. #Concussion of the Brain or Cerebral Shock. #--The symptoms associatedwith concussion of the brain are to all intents and purposes those ofsurgical shock (Volume I. , p. 250), the activity of the vital centresbeing disturbed by violence acting directly upon the brain tissueinstead of by impulses transmitted to it by way of the afferentnerves. Various theories have been put forward to account for thedepression of the vital functions in concussion. According to Duret, with whose views we agree, the wave of cerebro-spinal fluid set inmotion by the impact of the blow on the skull, passes, both in theventricles and in the sub-arachnoid space, towards the base, where itimpinges upon the pons and medulla, stimulating the restiform bodiesand so inducing a fall in the blood pressure and a profound anæmia ofthe brain. The disturbance of the cerebro-spinal fluid may at the sametime produce the microscopic lesions in the brain tissues described onp. 341. The symptoms of shock may be the only evidence of injury, or they maybe superadded to those of fracture of the skull, or laceration of thebrain. The _clinical features_ vary according to the severity of theviolence. In the slightest cases the patient does not loseconsciousness, but merely feels giddy, faint, and dazed for a fewseconds. His mind is confused, but he rapidly recovers, and, perhapsafter vomiting, feels quite well again, save for a slight shakiness inhis limbs. In more severe cases, immediately on receiving the blow the patientfalls to the ground unconscious. Sometimes he suffers from a generaltetanic seizure associated with arrest of respiration, which isusually of short duration and is frequently overlooked, but may provefatal. The pulse is slow, small, and feeble, and is sometimesirregular in force and frequency. The respirations are short, shallow, slow, and frequently sighing in character. The temperature falls to97° F. , or even lower. The skin is cold and pallid and covered withclammy sweat, and the features are pinched and pale. In uncomplicated cases the pupils are usually equal, moderatelydilated, and react sluggishly to light. The patient can be partiallyroused by shouting or by other forms of external stimulation, but hesoon subsides again into a lethargic condition. Although voluntarymovement and the deep reflexes are abolished, there is no truemuscular paralysis. After a period, varying from a few minutes to several hours, herallies, the first evidence often being vomiting, which is usuallyrepeated. Sometimes reaction is ushered in by a mild epileptiformseizure. He then turns on his side, the face becomes flushed, andgradually the symptoms pass off and consciousness returns. Thetemperature rises to 99° or 100° F. , and in some cases remainselevated for a few days. In most cases it falls again to 97° or 97. 5°, and remains persistently subnormal for one or two weeks. Duringreaction the pulse becomes quick and bounding, but after a few hoursit again becomes slow, and usually remains abnormally slow (40 to 60)for ten or fourteen days. There is sometimes a tendency toconstipation, and for the bladder to become distended, although he hasno difficulty in passing water. Very commonly the patient complains ofpain in the head for some days after the return of consciousness. Children often sleep a great deal during the first few days, butsometimes they are very fretful. In cases complicated by gross brain lesions the symptoms of concussionmay imperceptibly merge into those of compression or there may be a"lucid interval" of some hours duration. _After-Effects of Concussion. _--The majority of patients recovercompletely. A number complain for a time of headache, languor, muscular weakness, and incapacity for sustained effort--_traumaticneurasthenia_. Sometimes there is a condition of mental instability, the patient is easily excited, and is unduly affected by alcohol orother stimulants. Occasionally there is permanent mental impairment. It is not uncommon to find that the patient has entirely forgotten thecircumstances of the injury and of the events which immediatelypreceded it. In some instances the memory is permanently impaired. Onthe other hand, it has occurred that a patient, after concussion, hasrecovered his memory of a foreign language long since forgotten. As it is never possible to determine the precise extent of the damageto the brain, the immediate prognosis, even in the mildest cases ofconcussion, should always be guarded. If the patient has been actuallyunconscious, the condition should be looked upon as a serious one, andtreated accordingly. _Treatment. _--The immediate treatment is the same as that of shock. Absolute rest and quietness are called for. When the symptoms begin topass off, the head should be raised on pillows to prevent congestionand to diminish the risk of bleeding from damaged blood vessels in thebrain. The value of applying an ice-bag or Leiter's tubes with a viewto arresting hæmorrhage inside the skull, is more than doubtful. Lumbar puncture, venesection, or the application of leeches over thetemple or behind the ear may be employed with benefit. The use ofsmall doses of atropin and ergotin was recommended by von Bergmann. The bowels should be thoroughly opened by calomel, croton oil, orHenry's solution, and a light milk diet given. The patient is kept ina shaded room, and should be confined to bed for from fourteen totwenty-one days. It is often difficult to convince the patient of thenecessity for such prolonged confinement, but the responsibility forcurtailing it must rest upon him or his friends. Reading, conversation, and argument must be avoided to ensure absolute rest tothe brain. #Cerebral Irritation. #--In some cases of injury to thehead--particularly of the anterior part and the parietal region--asthe symptoms of concussion are passing off, the patient begins toexhibit a peculiar train of symptoms, which was graphically describedby Erichsen under the name of cerebral irritation. "The attitude ofthe patient is peculiar, and most characteristic: he lies on one sideand is curled up in a state of general flexion. The body is bentforwards and the knees are drawn up on the abdomen, the legs bent, thearms flexed, and the hands drawn in. He does not lie motionless, butis restless, and often, when irritated, tosses himself about. But, however restless he may be, he never stretches himself out nor assumesthe supine position, but invariably maintains an attitude of flexion. The eyelids are firmly closed, and he resists violently every effortmade to open them; if this be effected, the pupils will be found to becontracted. The surface is pale and cool, or even cold. The pulse issmall, feeble, and slow, seldom above 70. The sphincters are notusually affected, and the patient will pass urine when the bladderrequires to be emptied; there may, however, though rarely, beretention. "The mental state is equally peculiar. Irritability of mind is theprevailing characteristic. The patient is unconscious, takes no heedof what passes, unless called to in a loud tone of voice, when heshows signs of irritability of temper or frowns, turns away hastily, mutters indistinctly, and grinds his teeth. It appears as if thetemper, as much as or more than the intellect, were affected in thiscondition. He sleeps without stertor. "After a period varying from one to three weeks, the pulse improves intone, the temperature of the body increases, the tendency to flexionsubsides, and the patient lies stretched out. Irritability gives placeto fatuity; there is less manifestation of temper, but more weaknessof mind. Recovery is slow, but though delayed, may at length beperfect.... " The _treatment_ consists in keeping the patient quiet, in a darkenedroom, on much the same lines as for concussion. #Compression of the Brain. #--This term is used clinically to denotethe train of symptoms which follows a marked increase of theintra-cranial tension produced by such causes as hæmorrhage, œdema, the accumulation of inflammatory exudate, or the growth of tumourswithin the skull. The only pathological idea the term conveys is thatthere is more inside the skull than it can conveniently hold. _Clinical Features. _--The following description refers to compressiondue to hæmorrhage within the skull as a result of injury. In amajority of such cases, the symptoms of compression supervene on thoseof concussion; in certain conditions, notably hæmorrhage from themiddle meningeal artery, there is an interval, during which thepatient regains complete consciousness, in others the symptoms ofconcussion gradually and imperceptibly merge into those ofcompression. The rapidity of onset of the symptoms and their courseand duration vary widely according to the nature and extent of thebrain lesion. Death may occur in a few hours, or recovery may takeplace after the patient has been unconscious for several weeks. The first symptoms are of an irritative character--dull pain in thehead, restlessness, and hyper-sensitiveness to external stimuli. Theface is suffused, and the pupils at first are usually contracted. Thetemperature falls to 97°, or even to 95° F. Vomiting is notinfrequent. As the pressure increases, paralytic symptoms ensue. The patientgradually loses consciousness, and passes into a condition of coma. The face is cyanosed, and the distension of the veins of the eyelidsfurnishes an index of the severity of the intra-cranial venous stasis(Cushing). The pulse becomes slow, full, and bounding. The respirationis slow and deep, and eventually stertorous or snoring in characterfrom paralysis of the soft palate, and the lips and cheeks are puffedout from paralysis of the muscles of these parts. The temperature, which at first falls to 97° or even 95° F. , in the course of three orfour hours usually rises (100. 5° or 102. 5° F. ). If the temperaturereaches 104° F. , or higher, the condition usually proves fatal. Sometimes it rises as high as 106° or 108° F. --_cerebral hyperpyrexia_(Fig. 185). Retention of urine from paralysis of the bladder, andinvoluntary defecation from paralysis of the sphincter ani, arecommon. [Illustration: FIG. 185. --Two Charts of Pyrexia in Head Injuries. ] During the progress of the symptoms there is frequently evidence ofdirect pressure upon definite cortical centres or cranial nerves, giving rise to _focal symptoms_. Particular groups of muscles on theside opposite to the lesion may first show spasmodic jerkings orspasms (unilateral monospasm), and later the same groups becomeparalysed (monoplegia). The paralysis frequently affects the whole ofone side of the body (hemiplegia) and the oculo-motor nerve is oftenparalysed at the same time. The pupils vary so widely in different cases that their condition doesnot form a reliable diagnostic sign. Perhaps it is most common for thepupil on the same side as the lesion to be contracted at first andlater to become fully dilated, while that on the opposite side remainsmoderately dilated. As a rule, they are irresponsive to light. Ophthalmoscopic examination shows swelling of the disc, and thevessels of the papilla are distended and tortuous. In cases which go on to a fatal termination, the coma deepens and themuscular and sensory paralyses become general and complete. The vitalcentres in the medulla oblongata gradually become involved, and deathresults from paralysis of the respiratory centre. The fatal issue isoften hastened by the onset of hypostatic pneumonia. Not infrequentlya modified type of Cheyne-Stokes respiration is observed for some timebefore death ensues. A similar train of symptoms may ensue in cases of head injury as aresult of _pyogenic infection_ having given rise to meningitis orabscess with accumulation of inflammatory exudate. _Pathology. _--When any addition is made to the bulk of matter insidethe cranial cavity, room is gained in the first instance by thedisplacement into the vertebral canal of a certain amount ofcerebro-spinal fluid. The capacity of the spinal sheath, however, islimited, and as soon as the tension oversteps a certain point, thepressure comes to bear injuriously on the cerebral capillaries, disturbing the circulation, and so interfering with the nutrition ofthe brain tissue. As the intra-cranial tension still furtherincreases, the pressure gradually comes to affect the cerebral tissueitself, and so the extreme symptoms of compression are produced. Thevagus and vaso-motor centres are irritated, and this causes slowing ofthe pulse, contraction of the small arteries, and increase of thearterial tension which tends to maintain an adequate circulation inthe vital centres in the medulla. The Cheyne-Stokes respiration is dueto rhythmical variations in the arterial tension: during the period offall the centres become anæmic and the respiration fails; during therise the medulla is again supplied with blood, and breathing isresumed (Eyster). The parts of the brain directly pressed upon become anæmic, while theother parts become congested, and the nutrition of the whole brain isthus seriously interfered with. Different parts of the brain and cordshow varying powers of resistance to this circulatory disturbance. Thecortex is the least resistant part, and next in order follow thecorona radiata, the grey matter of the spinal cord, the pons, and, last, the medulla oblongata. Hence it is that the respiratory andcardiac centres hold out longest. _Depressed Bone as a Cause of Compression. _--It is more than doubtfulwhether a depressed portion of bone is of itself capable of inducingsymptoms of compression of the brain. When such symptoms accompanydepressed fracture, they are to be attributed either to associatedhæmorrhage, or to interference with the circulation and consequentœdema which the displaced bone produces. Fragments of bone may, however, aggravate the symptoms by irritating the cerebral tissue onwhich they impinge. _Foreign Bodies. _--The rôle of foreign bodies, such as bullets, in theproduction of compression symptoms is similar to that of depressedbone. That foreign bodies of themselves are not a cause of compressionseems evident from the fact that it is not uncommon for them to becomepermanently embedded in the brain substance without inducing anysymptoms. Not only have bullets, the points of sharp instruments, andother substances remained embedded in the brain for years withoutdoing harm, but in many cases the patients have continued to occupyimportant and responsible positions in life. _Differential Diagnosis. _--It not infrequently happens that a patientis found in an insensible condition under circumstances which give noclue to the cause of his unconsciousness. He is usually removed to thenearest hospital, and the house-surgeon under whose charge he comesmust exercise the greatest care and discretion in dealing with him. Inattempting to arrive at the cause of the condition, numerouspossibilities have to be borne in mind, but it is often impossible tomake a definite diagnosis. The chief of these causes are trauma, apoplexy or cerebral embolism, epileptic coma, alcohol and opiumpoisoning, uræmic and diabetic coma, sunstroke, and exposure to cold. The commonest error is to mistake a case of cerebral compression forone of drunkenness. It is scarcely necessary to say that a man whosmells of alcohol is not necessarily intoxicated; the drink may havebeen given with the object of reviving him. It may be that one orother 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 beadmitted to hospital. In the first instance, careful search should be made for any sign ofinjury, especially on the head. The discovery of a severe scalp woundor of a fracture of the skull, in association with the symptoms ofconcussion or compression, will in most cases raise the presumptionthat the unconsciousness is due to some traumatic intra-craniallesion. Examination of the fluid withdrawn by lumbar puncture mayfurnish useful information (p. 338). In the absence of evidence of a head injury, the stomach should bewashed out and its contents examined to see if any narcotic poison ispresent. The urine also should be drawn off and examined for albuminand sugar. In hæmorrhage due to the rupture of diseased cerebral arteries(apoplexy), or to embolism, the symptoms are essentially those ofcompression, and, in the absence of a definite history of injury tothe head, it is seldom possible to arrive at an accurate diagnosis asto the cause of the condition. The history that the patient haspreviously had "an apoplectic shock, " and the fact that he is up inyears and shows signs of arterial degeneration and of cardiachypertrophy which would favour such hæmorrhage, are presumptiveevidence that the lesion is not traumatic. If a history is forthcoming that the patient is an epileptic, there isa strong presumption that the symptoms are those of _epileptic coma_. In _alcoholic poisoning_ the examination of the stomach contents willfurnish evidence. The patient is not completely unconscious, nor is heparalysed; the pupils are usually contracted, but react; and thetemperature is often markedly subnormal. Improvement soon takes placeafter the stomach has been emptied. In _opium poisoning_ the general condition of the patient is much thesame as in poisoning by alcohol. The pupils, however, are markedlycontracted, and do not react to light. When the poison has been takenin the form of laudanum, this may be recognised by its odour. In the _coma_ of _uræmia_ or of _diabetes_ there is no true paralysis, nor is there stertor. The urine contains albumin or sugar, and theremay be œdema of the feet and legs. _Prognosis. _--The prognosis depends so much on the nature and extentof the injury to the brain that it is impossible to formulate anygeneral statements with regard to it. It may be said, however, thatthe symptoms which indicate a bad prognosis are immediate rise oftemperature, particularly if it goes above 104° F. , the early onset ofmuscular rigidity, extreme and persistent contraction of the pupils, with loss of the reflex to light, conjugate deviation of the eyes, andthe early appearance of bed-sores. In the majority of cases compression ends fatally in from two to sevendays. On the other hand, recovery may ensue after the stuporouscondition has lasted for several weeks. The _treatment_ of compression is considered with the differentlesions which cause it; the principle in all cases being to remove, ifpossible, the cause of the increased pressure within the skull. #Traumatic Œdema. #--In practice, cases are frequently met with, particularly in children, that do not conform to the classicaldescription of either concussion, cerebral irritation, or compression. The injury may be followed by a varying degree of concussion whichsoon passes off but leaves the patient in a listless, drowsy statethat may persist for days or even for weeks. The cerebration isdisturbed, so that while the patient is not unconscious, he isapathetic and has lost his bearings and fails to recognise where orwith whom he is. He complains of headache, there is tenderness onpercussion over the skull, the knee jerks are diminished or absent, but there is no motor paralysis. In some cases there are localisedjerkings, in others generalised convulsive attacks during which thepatient becomes deeply cyanosed. The condition differs fromcompression due to middle meningeal hæmorrhage in that it is lesssevere and is not steadily progressive. When the symptoms are localised, the condition is probably due toœdematous infiltration of the injured portion of brain; whengeneralised, to increased intra-cranial tension from serous effusioninto the arachno-pial space. The _treatment_ consists in diminishing the intra-cranial tension bypurgation, leeches, bleeding, or lumbar puncture, or if life isthreatened, by opening the skull over the seat of injury, or failingevidence of this, by a decompression operation in the temporal region. INTRA-CRANIAL HÆMORRHAGE Apart from the hæmorrhage that accompanies laceration of brain tissue, bleeding may occur inside the skull, either from arteries or fromveins. The effused blood may collect either between the dura mater andthe bone (_extra-dural hæmorrhage_), or inside the dura (_intra-duralhæmorrhage_). #Middle Meningeal Hæmorrhage. #--The commonest cause of extra-duralhæmorrhage is laceration of the middle meningeal artery. Thisartery--a branch of the internal maxillary--after entering the skullthrough the foramen spinosum, crosses the anterior inferior angle ofthe parietal bone, and divides into an anterior and a posterior branchwhich supply the meninges and calvaria (Fig. 186). Either branch maybe injured in association with fractures, or from incised, punctured, or gun-shot wounds. The vessel may be ruptured without the skull beingfractured, and sometimes it is the artery on the side opposite to theseat of the blow that is torn. The most common situations for ruptureare at the anterior inferior angle of the parietal bone, in which casethe anterior branch is torn (90 to 95 per cent. ); and on the inneraspect of the temporal bone, where the posterior branch is torn (5 to10 per cent. ). [Illustration: FIG. 186. --Relations of the Middle Meningeal Artery andLateral Sinus to the surface as indicated by Chiene's Lines. (After Cunningham. )] It is probable that the size of the hæmorrhage depends on the nature, extent, and severity of the injury to the head. The recoil of theskull after the blow separates the dura from the bone, and if themeningeal artery is lacerated or punctured, blood is effused into thespace thus formed (Fig. 187). A localised blow therefore results in asmall area of separation and a correspondingly small clot; while adiffuse blow is followed by more extensive lesions. It is believedthat, once the dura is partly separated, the force of the blood pouredout from the lacerated artery is--on the principle of the hydraulicpress--sufficient to continue the separation. [Illustration: FIG. 187. --Extra-Dural Clot resulting from hæmorrhagefrom the Middle Meningeal Artery. ] _Clinical Features. _--The typical characteristics of middle meningealhæmorrhage are met with only when the bleeding takes place between thedura and the bone. Under these conditions the symptoms of concussionare usually most prominent at first, and those of compression onlyensue after a varying interval, during which the patient as a ruleregains consciousness. In some cases, indeed, he is able to continuehis work, or to walk home or to hospital, before any evidence ofintra-cranial mischief manifests itself. This "lucid interval" helpsto distinguish the symptoms due to middle meningeal hæmorrhage fromthose of laceration of the brain substance, as in the latter thesymptoms of concussion merge directly into those of compression. Lumbar puncture may aid in the differential diagnosis betweenextra-and intra-dural hæmorrhage, as blood is present in the fluidwithdrawn in the latter, but not in the former. A few hours after the accident the patient experiences severe pain inthe head, and he usually vomits repeatedly. For a time he is restlessand noisy, but gradually becomes drowsy, and the stupor increasesmore or less rapidly until coma supervenes. The pulse usually becomesslow and full. The respiration is rapid (30 to 50), and becomesgreatly embarrassed and stertorous. The temperature progressivelyrises, and before death may reach 106° F. , or even higher. Monoplegia, usually beginning in the face or arm on the side opposite to thelesion, gradually comes on, and is followed by hemiplegia, frompressure on the motor areas, underlying the clot. The condition of thepupils is so variable as to have no diagnostic value; but if both arewidely dilated and irresponsive to light, the prognosis is grave. Death usually ensues in from twenty-four to forty-eight hours, unlessthe pressure within the skull is relieved by operation; even afterremoval of the clot death may ensue if the brain has been lacerated, or if there is hæmorrhage at the base. When the hæmorrhage takes place from the anterior branch, the clottends to spread towards the base, and may press upon the cavernoussinus, causing congestion and protrusion of the eye, with paralysis ofthe oculo-motor nerve and wide dilatation of the pupil. In some cases of middle meningeal hæmorrhage there is no gross injuryto the brain; the area underlying the clot is merely compressed andemptied of blood, and, on being exposed, the brain is found flattened, or even deeply indented by the blood-clot, and it does not pulsate. Ifthe clot is removed, the brain may regain its normal contour and itspulsation return. The mortality is over 50 per cent. If the fracture is compound, the blood can escape, and therefore thepressure symptoms are less evident or may be entirely absent. It is a fact of some medico-legal importance that hæmorrhage from themiddle meningeal may not take place till some days, or even weeks, after an injury, which at the time was only attended with symptoms ofconcussion. This condition is known as _traumatic apoplexy_. _Treatment. _--Immediate operation is imperatively called for, not onlyto arrest the hæmorrhage and remove the clot, but also to ward off theœdema 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 beopened is determined by the symptoms; for example, paralysis of thearm and face on one side indicates trephining over the centresgoverning these parts on the side opposite to the paralysis. If the bleeding cannot otherwise be arrested it may be necessary toligate the external carotid artery. It has been suggested by J. B. Murphy that, when the patient is seen while the symptoms ofcompression are coming on, instead of trephining, the hæmorrhage fromthe meningeal vessels should be arrested by applying a ligature to theexternal carotid, under local anæsthesia. Injury to the #internal carotid# artery within the skull may resultfrom penetrating wounds, or may be associated with a fracture of thebase. It is almost invariably fatal. In some cases a communication isestablished between the artery and the cavernous sinus, and anarterio-venous aneurysm is thus produced. Ligation of the internalcarotid in the neck or of the common carotid is the only feasibletreatment. Injuries of the #venous sinuses# may occur apart from gross lesions ofthe skull, but as a rule they accompany fractures and penetratingwounds. The transverse (lateral), superior sagittal (longitudinal), and cavernous sinuses are those most frequently damaged. On account ofthe low pressure in the sinuses, spontaneous arrest of extra-duralhæmorrhage usually takes place, and recovery ensues. In some cases, however, the amount of blood extravasated is sufficient to causecompression. If the dura mater is torn, and the blood passes into thesub-arachnoid space, it may spread over the whole surface of thebrain. Sometimes the bleeding only commences after a depressedfracture has been elevated. In the presence of an open wound, the venous source of the bleeding isrecognised by the dark colour of the blood and the continuouscharacter of the stream. It may be arrested by pressure with gauzepads or by packing a strand of catgut into the sinus (Lister), or, ifthis fails, by grasping the sinus with forceps and leaving these inposition for twenty-four or forty-eight hours. A small puncture in theouter wall of the sinus may be closed with sutures. Signs ofincreasing compression call for trephining and opening of the dura ifthis is necessary to admit of the clot being removed. #Intra-cranial Hæmorrhage in the Newly-Born. #--An extravasation ofblood into the arachno-pial space frequently occurs during birth. Theobservations of Cushing seem to show that this is usually due totearing of the delicate cerebral veins which pass from the cortex tothe superior sagittal sinus, from the strain put upon them by theoverlapping of the parietal bones, in the moulding of the head. It maysometimes be due to an excessive degree of asphyxia during birth. Theextravasation is usually most marked over the central area of thecortex near the middle line, and it is often bilateral. This condition is most frequently met with in a first-born child--andmore often in boys than in girls--the labour having been prolonged anddifficult, and the presentation abnormal. There is usually a historythat the infant was deeply cyanosed when born, and that there wasdifficulty in getting it to breathe. As a rule, there is no externalevidence of trauma. The anterior fontanelle is tense and does notpulsate, the pulse is slow, and for several days the child appears tohave difficulty in sucking and swallowing, and is abnormally still. Inthe course of a few days definite symptoms of localised pressureappear. It is noticed that one leg or arm, or one side of the body isnot moved, or both sides may be affected; when the paralysis isbilateral, the absence of movement is more liable to be overlooked. The infant may suffer from convulsions; there may be paralysis ofcertain of the ocular muscles, and inequality of the pupils; sometimesthere is blindness. Persistent rigidity of the limbs, with turning ofthe thumbs towards the palm, is present in some cases. Lumbar puncturemay reveal the presence of blood corpuscles in the cerebro-spinalfluid, and increase in the tension of the fluid. If untreated, the condition is usually followed by the development ofspastic paralysis of one or more limbs, on one or on both sides of thebody (Little's disease), by blindness, deafness, and varying degreesof mental deficiency, or by Jacksonian epilepsy. _Treatment. _--To obviate these after-effects the clot may be removedby raising an osteo-plastic flap, including nearly the whole of theparietal bone. The operation should be undertaken within the firstweek 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 onboth sides, an interval being allowed to elapse between the twooperations. For the immediate relief of increased intra-cranial tension, the dailywithdrawal of 10-12 c. C. Of cerebro-spinal fluid by lumbar puncturesmay be employed, or a sub-temporal decompression operation may beperformed. WOUNDS OF THE BRAIN #Wounds of the Brain. #--_Incised_ wounds of the brain usually resultfrom sabre-cuts, hatchet blows, or circular saws. A portion of thescalp and cranium may be raised along with a slice of brain matter, and in some cases the whole flap is severed. The extent of the injury, the conditions under which it is received, and the liability toinfection, render such wounds extremely dangerous. _Punctured wounds_ may be inflicted on the vault by stabs with a knifeor dagger, or by other sharp objects, such as the spike of a railing. More frequently a pointed instrument, such as a fencing foil, the endof an umbrella, or a knitting needle, is thrust through the orbit intothe base of the brain. Occasionally the base of the skull has beenperforated through the roof of the pharynx, for example, by the stemof a tobacco-pipe. All such wounds are of necessity compound, and therisk of infection is considerable, particularly if the penetratingobject is broken and a portion remains embedded within the skull. Theinfective complications of such injuries are described later. _Bullet wounds_ have many features in common with punctured wounds. There is more contusion of the brain substance, disintegrated brainmatter is usually found in the wound of entrance, and the bullet oftencarries in with it pieces of bone, cloth, or wad, thus adding to therisk of infection. Aseptic foreign bodies, especially bullets, may remain embedded in thebrain without producing symptoms. The _treatment_ of punctured wounds consists in enlarging the woundsin the soft parts, trephining the skull, and removing any foreign bodythat may be in it, purifying the track, and establishing drainage. AFTER-EFFECTS OF HEAD INJURIES Various after-effects may follow injuries of the head. Thus, forexample, _chronic interstitial changes_ (sclerosis) may spread from anarea of cicatrisation in the brain; or _softening_ may ensue, eitherin the form of pale areas of necrosis (white softening) or ofhæmorrhagic patches (red softening). The symptoms vary with the areaimplicated. _Adhesions_ between the brain and its membranes mayproduce severe headache and attacks of vertigo, especially on thepatient making sudden exertion. After a head injury, the patient's whole mental attitude is sometimeschanged, so that he becomes irritable, unstable, and incapacitated forbrain-work--_traumatic neurasthenia_. In some cases self-control islost, and alcoholic and drug habits are developed. #Traumatic epilepsy# may ensue as a result of some circumscribedcortical lesion, such as a spicule of bone projecting into thecortex, the presence of adhesions between the membranes and the brain, a cicatrix in the brain tissue leading to sclerosis or a hæmorrhagiccyst in the membranes or cerebral tissue. The convulsive attacks are of the Jacksonian type, beginning in oneparticular group of muscles and spreading to neighbouring groups tillall the muscles of the body may be affected. The convulsions may beginsoon after the injury, for example, when the cause is a fragment ofbone irritating the cortex; in other cases it may be several yearsbefore they make their appearance. The onset is usually sudden, andthe "signal symptom"--for example, jerking of the thumb, conjugatedeviation of the eyes, or motor aphasia--indicates the seat of thelesion. At first the attacks only recur at intervals of, it may beweeks or months, but as time goes on they become more and morefrequent, until there may be as many as forty or fifty in a day. Sometimes the patient loses consciousness during the fit; sometimes heremains partly conscious. In course of time the same degenerativechanges as occur in other forms of epilepsy ensue: certain groups ofmuscles may become paralysed; the patient may pass into a state ofidiocy, or into what is known as the "status epilepticus, " in whichthe fits succeed one another without remission, the breathing becomesstertorous, the temperature rising, the pulse becoming very rapid;finally coma supervenes, and the patient dies. _Treatment. _--The administration of bromides is only palliative. Operation is indicated only when the "signal symptom" indicates alimited and accessible portion of the brain as the seat of the lesion, or when there is a depression of the skull or other definite evidenceof cranial injury. The more recent the injury the better is theprospect, as secondary changes are less likely to have taken place, and the peculiarly irritable state of the brain--sometimes referred toas the "epileptic habit"--has not developed. The operation consists inopening the skull freely, and removing any discoverable cause ofirritation--depressed bone, thickened and adherent membranes, a cyst, or sclerosed patch of cortex; it may be necessary to interpose a layerof tissue, a flap of fascia lata, for example, between the bone andthe cortex of the brain. The point at which the skull is opened isdetermined by the seat of the injury and the focal brain symptoms. The return of fits within a few days of the operation does notnecessarily mean failure, as they often pass off again. Complete andpermanent cure is not common, but the number and severity of theattacks are usually so far diminished that life is rendered bearable. #Traumatic insanity# may follow injury to any part of the brain, andit may come on either immediately or after an interval. It may or maynot be associated with epilepsy. Any form of insanity may occur, either as a direct result of the trauma, or from the resistance of thebrain being lowered by the injury in a patient predisposed toinsanity. When insanity follows as a direct consequence of injury, theorganic lesion is usually a superficial one, and the disturbance ofbrain function is generally due to reflex irritation of the dura mater(Duret). These facts possibly explain the immediate improvement whichoccasionally follows the opening of the skull at the point of injuryand removal of the exciting cause. Cases occurring within a few daysof the injury usually recover within a month or two. The later thecondition is in developing the less obvious is the relationshipbetween the trauma and the insanity, and therefore the worse is theprognosis. _Meningitis_, _sinus thrombosis_, and _cerebral abscess_ may followupon any form of head injury attended with infection. The clinicalfeatures--save for the history of a trauma--correspond so closely withthose of the same conditions occurring apart from injury, that theyare most conveniently considered together (p. 374). CHAPTER XIII INJURIES OF THE SKULL Contusions--FRACTURES--Of the vault: _Varieties_--Of the Base: _Anterior fossa_--_Middle fossa_--_Posterior fossa_. The bones of the skull may be contused or fractured. These injuriesare not in themselves serious: their clinical importance is derivedfrom the injury to the intra-cranial contents with which they areliable to be associated. #Contusion# of the skull may result from a fall, a blow, or a gun-shotinjury. In the majority of cases the damage to soft parts--scalp, meningeal vessels, or brain--overshadows the osseous lesion, which ofitself is comparatively unimportant. FRACTURES OF THE SKULL While it is convenient to consider separately fractures of the vaultand fractures of the base of the skull, it is to be borne in mind thatit is not uncommon for a fracture to involve both the vault and thebase. Fractures in either situation may be simple or compound. FRACTURES OF THE VAULT #Mechanism. #--When the skull is broken by _direct_ violence, thefracture takes place at the seat of impact, and its extent varies withthe nature of the impinging object and the degree of violence exerted. If, for example, a pointed instrument, such as a bayonet, a foil, or aspike, is forcibly driven against the skull, the weapon simply crashesthrough the bone, disintegrating it at the point of entrance, andcracking or splintering it for a variable, but limited, distancebeyond. On the other hand, when the head is struck by a "blunt"object--for example, a batten falling from a height--the force isapplied over a wider area and the elastic skull bends before it. Ifthe limits of its elasticity are not exceeded, the bone recoils intoits normal position when the force ceases to act; but if the bone isbent beyond the point from which it can recoil, a fracture takesplace--"_fracture by bending_. " The bone gives way over a wide area, the affected portion may be comminuted, and one or more of thefragments may remain depressed below the level of the rest ofthe skull. Cracks and fissures spread widely in differentdirections--often (70 to 75 per cent. ) extending into the base. Inalmost all fractures of the vault the inner table splinters over awider area than the outer, partly because it is more brittle and isnot supported from within, but also because the diffusion of the forceas it passes inwards affects a wider area. If a bullet traverses thecranial cavity the inner table is more widely shattered at theaperture of entrance, and the outer table at the aperture of exit. VonBergmann reported thirty cases in which the inner table alone wasfractured by a blow on the head. Fractures by _indirect_ violence--that is, fractures in which the bonebreaks at a point other than the seat of impact--are almost always dueto violence inflicted with a blunt object, and acting over a widearea--such, for example, as when the head strikes the pavement. Muchdiscussion has taken place as to the method of their production. Ithas been shown that when the skull is depressed at one point by aforce impinging on it, it bulges at another, so that its whole contouris altered. But the elasticity of the bone varies at different partsof the skull, owing to differences in thickness and in structure. If, therefore, the part which is depressed--that is, the part directlystruck--happens to be less elastic than the part which bulges, itgives way, and a fracture by "bending" results; but if the bulgingpart is the less elastic, it bursts outwards--_fracture by_"_bursting_. " The term "fracture by _contre-coup_" has beenincorrectly applied to such fractures when the area of bulging happensto be opposite to the seat of impact. _Contre-coup_, properlyso-called, is only possible in a perfectly spherical body, which, ofcourse, the skull is not. When a high-velocity bullet penetrates the head, it exerts on theincompressible, semi-fluid brain an explosive (hydro-dynamic) force, which is transmitted to all points on the inner surface of the skulland leads to shattering of the bone. _Repair. _--The repair of fractures of the skull is usually attendedwith an exceedingly small amount of callus. Except in the presence ofinfection, separated fragments live and become reunited, but they mayunite in such a manner as to project towards the brain and, byirritating the cortical centres, cause traumatic epilepsy. Incomminuted fractures, the lines of fracture remain permanently visibleon the bone, but fissured fractures may leave no trace. Gaps left inthe skull by injury or operation are, after a time, filled in by afibrous membrane, which may undergo ossification from the peripherytowards the centre, but unless the aperture is a small one it isseldom completely closed by bone. The new bone which forms is derivedfrom the old bone at the margins of the opening. Permanent defects inthe skull are chiefly injurious if they are accompanied by lesions ofthe underlying dura, such as adhesions to the brain; large gaps maycause giddiness on stooping, or on forcible expiration, as in blowingthe nose or playing a wind instrument. #Varieties. #--For descriptive purposes, fractures of the vault aredivided into the fissured, the punctured, the depressed, and thecomminuted varieties. Clinically, however, these varieties are oftencombined. The practical importance of a given fracture depends uponwhether it is simple or compound, rather than upon the exact nature ofthe damage done to the bone. Compound fractures which open the duramater are the most serious. Simple fractures result, as a rule, fromdiffuse forms of violence, and are liable to spread far beyond theseat of impact. Compound fractures result from severe and localisedviolence--for example, the kick of a horse or the blow of ahammer--and tend to be limited more or less to the seat of impact. Ingun-shot injuries, however, there are usually numerous fissuresradiating from the point at which the missile enters the skull. #Fissured fractures# generally result from blows by blunt objects orfrom falls, and they usually extend far beyond the area struck, inmost cases passing into the base. The fissure may pass through thebone vertically or obliquely, and it may implicate one or both tables. So long as the fracture is simple, it can scarcely be diagnosed exceptby inference from the associated symptoms of meningeal or cerebralinjury. When compound, the crack in the bone can be seen and felt. Itis recognised by the eye as a split in the bone, filled with redblood, which, as often as it is sponged away, oozes again into thegap. In fractures by bursting a tuft of hair may be caught between theedges of the fracture, and this adds to the difficulty of purifyingthe wound. _Diagnosis. _--A normal suture may be mistaken for a fissured fracture. A suture, however, may generally be recognised by its position, theirregularity of its margins, and the absence of blood between itsedges. 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 afissured fracture to enter a suture and, after running in it for somedistance, to leave it again. The edges of a clean cut in theperiosteum may be mistaken for a fissure in the bone, especially ifreliance is placed on the probe for diagnosis. This error can beavoided by raising the edge of the periosteum from the bone, with thegloved finger. On combined auscultation and percussion a peculiar"hollow-cask" sound may be detected in some cases of fissured fractureof the vault. Fissured fractures as such call for no _treatment_. When compound, thewound must be disinfected; and intra-cranial complications, such asmeningeal hæmorrhage, laceration of the brain, or infection, are to betreated on the lines already described. #Punctured fractures# are of necessity compound, and on account of therisks of infection are to be looked upon as serious injuries. Theyresult from the localised impact of a sharp, and usually infectedobject the point of which is not infrequently left either in the boneor inside the skull. Fragments of bone are often driven into thebrain, and short fissures frequently pass in various directions fromthe central aperture. _Diagnosis. _--When the instrument impinges on the head obliquely, after piercing the scalp it may pass for some distance under it beforeperforating the skull, so that on its withdrawal a valvular wound isleft, 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 isdifficult to detect the fracture with a probe or even with the finger. In all doubtful cases the scalp wound should be sufficiently enlargedto exclude such errors. We have known of a case of a man who died ofmeningitis resulting from a punctured fracture of the vault caused bythe spoke of an umbrella, the fracture having escaped recognitionuntil the meningeal symptoms developed. _Treatment. _--The scalp wound must be purified, being opened up as faras necessary for this purpose. The infected portion of bone should beremoved to render possible the purification of the membranes andbrain, and to permit of drainage. #Depressed and Comminuted Fractures. #--As these varieties almostalways occur in combination, they are best considered together. Theterms "indentation fracture, " "gutter fracture, " "pond fracture, " havebeen applied to different forms of depressed fracture, according tothe degree of damage to the bone and the disposition of the fragments(Figs. 188, 189, 190). These fractures may be simple or compound. [Illustration: FIG. 188. --Depressed Fracture of FrontalBones--involving the air sinus on both sides--with a fissured fractureradiating from it. (From Professor Harvey Littlejohn's collection. )] [Illustration: FIG. 189. --Depressed and Comminuted Fracture of RightParietal Bone: Pond Fracture. The patient sustained the injury twentyyears before death. ] [Illustration: FIG. 190. --Pond Fracture of Left Frontal Bone, producedduring delivery. (From a photograph lent by Mr. J. H. Nicoll. )] As a rule the whole thickness of the skull is broken, and, as usual, the inner table suffers most. In infants the bones may be merelyindented, the fracture being of the greenstick variety. All degrees ofseverity are met with, from a simple, localised indentation of thebone, to complete smashing of the skull into fragments. _Diagnosis. _--When compound, the nature of these fractures is readilyrecognised on exploring the wound, but their extent is not always easyto determine, and it is not uncommon for extensive fissures to passinto the base. A hæmatoma of the scalp may readily be mistaken for a depressedfracture. The condensation of the tissues round the seat of impact andthe soft coagulum in the centre, closely simulate a depression in thebone; but if firm pressure is made with the finger, the irregular edgeof the bone can be recognised, and the depressed portion is felt to beon a lower level. On the other hand, a depression in the bone issometimes obscured by an overlying hæmatoma, and unless great care istaken the fracture may be overlooked. _Treatment. _--All are agreed that compound depressed and comminutedfractures--whether associated with cerebral symptoms or not--shouldbe operated on to enable the wound to be purified, and the normaloutline of the skull to be restored by elevating or removing depressedor separated fragments. Except in young children, in whom considerabledegrees of depression are frequently righted by nature, most surgeonsrecommend operative interference even in simple fractures with theobject of elevating the depressed bone, and to anticipate subsequentcomplications such as persistent headache, attacks of giddiness, traumatic epilepsy, or insanity. Others, including von Bergmann andTilmanns, consider that the risk of such sequelæ ensuing is notsufficient to justify a prophylactic operation of such severity astrephining. The operation is described in _Operative Surgery_, p. 93. FRACTURES OF THE BASE The base of the skull may be fractured by a pointed object, such as afencing foil, a knitting pin, or the end of an umbrella, being forcedthrough the orbit, the nasal cavities, or the pharynx. These injurieswill be referred to in describing fractures of the anterior fossa. The majority of basal fractures result from such accidents as a fallfrom a height, the patient landing on the vertex or on the side of thehead, or from a heavy object falling on the head. The violence istherefore indirect in so far as the bone breaks at a point other thanthe seat of impact. In other cases the base is broken by the patient falling from a heightand landing on his feet or buttocks, the force being transmittedthrough the spine to the occiput, and the bone giving way around theforamen magnum. Sometimes the condyle of the lower jaw is driventhrough the base of the skull by a blow or fall on the chin, andfissures radiate into the base from the glenoid cavity. It is usual todescribe these also as fractures by indirect violence, but as theskull gives way at the point where it is struck, these are reallyfractures by direct violence. Von Bergmann, Bruns, and Messerer havedone much to elucidate the mechanism of basal fractures. In the consideration of the mode of production of basal fractures byindirect violence, the irregular shape of the cavity, the varyingstrength and thickness of its different parts, and the existence ofthe foramina through the bone are to be borne in mind. The forceacting on the skull tends to increase one diameter of the cavity, andto diminish the opposite diameter. The resulting fracture, therefore, is due to bursting of the skull, and tends to take place at the partwhich has least elasticity--that is, at the base. It has been foundthat the site and direction of basal fractures bear a fairly constantrelation to the direction of the force by which they are produced. When, for example, the skull is compressed from side to side, the lineof fracture through the base is usually transverse, and it mayimplicate one or both sides (Fig. 191). On the other hand, when thepressure is antero-posterior, the fracture tends to be longitudinal;and when oblique, it tends to be diagonal. [Illustration: FIG. 191. --Transverse Fracture through Middle Fossa ofBase of Skull. ] Fractures of the base usually take the form of a single fissure, or aseries of fissures, which, as a rule, run through the foramina intheir track. Small portions of bone are sometimes completelyseparated. It is common for a fissure through the base to becontinued for a considerable distance on to the vault. The fracture may involve only one fossa, but as a rule fissuresradiate into two or all of them. Fractures of the anterior and middlefossæ are usually rendered compound by tearing of the mucous membraneof the nose, the pharynx, or the ear. Basal fractures are frequently associated with contusion andlaceration of the brain, and also with injuries of one or more of thecranial nerves. #Fracture of the anterior fossa# may result from a blow on theforehead, nose, or face; or from a punctured wound of the orbit or ofthe nasal cavity. Often the injury is at first considered trivial, andit is only when infective complications, in the form of meningitis orcerebral abscess, develop, that its true nature is suspected. Thisfossa may also be implicated in fractures of the vault, fissuresextending from the vertex to the orbital plate of the frontal bone, orto the lesser wing of the sphenoid. _Clinical Features. _--Unless the fracture is compound through openinginto the nose or pharynx, there are few symptoms by which it can berecognised. When compound, there may be bleeding from the pharynx ornose from tearing of the periosteum and mucous membrane related to thebasi-sphenoid and ethmoid respectively. When the hæmorrhage isprofuse, it is probable that the meningeal vessels or even the venoussinuses have been torn. Cerebro-spinal fluid may escape along with theblood, but it is seldom possible to recognise it. If the flow is longcontinued, the patient may be conscious of a persistent salt taste inthe mouth, due to the large proportion of sodium chloride which thefluid contains. In very severe injuries, brain matter may escapethrough the nose or mouth. Fracture of the anterior fossa is often accompanied by extravasationof blood into the orbit, pushing forward the eyeball and infiltratingthe conjunctiva (_sub-conjunctival ecchymosis_). This occursespecially when the orbital plate of the frontal bone is implicated. The blood which infiltrates the conjunctiva passes from behindforwards, appearing first at the outer angle of the eye and spreadinglike a fan towards the cornea. Later it spreads into the upper eyelid. When the orbital ridge is chipped off, without the cavity of the skullbeing opened into, the hæmorrhage shows at once both under theconjunctiva and in the upper lid. If the frontal sinus is opened, airmay infiltrate the scalp. The olfactory, optic, oculo-motor, pathetic, ophthalmic division ofthe trigeminal, and the abducens nerves are all liable to beimplicated. _Diagnosis. _--It is scarcely necessary to state that bleeding from thenose or mouth may occur after a blow on the face without theoccurrence of a fracture of the skull. It is only when it is longcontinued and profuse that the bleeding suggests a fracture. Similarlyeffusion of blood in the region of the orbit may be due to a simplecontusion of the soft parts ("black eye"), or to gravitation of bloodfrom the forehead or temple. Sub-conjunctival ecchymosis also mayoccur independently of a fracture implicating the anterior fossa--forexample, in association with an ordinary black eye, or with fractureof the orbital ridge or of the zygomatic (malar) bone. Finally, paralysis of the cranial nerves may result from pressure ofblood-clot, or from the nerves being torn without the skull beingfractured. #Fracture of the middle fossa# is usually the result of severeviolence applied to the vault, as, for example, when a man falls froma height, or is thrown from a horse and lands on his head. _Clinical features. _--The most conclusive sign of fracture of themiddle fossa is the escape of dark-coloured blood in a steady streamfrom the ear, followed by oozing of cerebro-spinal fluid. The bleedingfrom the ear may go on for days, the blood gradually becoming lighterin colour from admixture with cerebro-spinal fluid. Finally the bloodceases, but the clear fluid continues to drain away, sometimes forweeks, and in such quantity as to soak the dressings and the pillow. In our experience, the escape of cerebro-spinal fluid is much lesscommon than is generally supposed. In most cases, on examining the earwith a speculum, the tympanic membrane is found to be ruptured; whenit is intact, the blood and cerebro-spinal fluid may pass down theEustachian tube into the pharynx. The escape of brain matter from theear is exceedingly rare. Emphysema of the scalp sometimes results whenthe fracture passes through the mastoid cells. The facial and acousticnerves and the maxillary and mandibular divisions of the trigeminalare frequently implicated. Deafness is a serious and not uncommonaccompaniment of fracture of the middle fossa, as the fractureinvolves the labyrinth and is attended with hæmorrhage and theformation of new bone. _Diagnosis. _--Care must be taken not to mistake blood which has passedinto the ear from a scalp wound, or which has its origin in afracture of the wall of the external auditory meatus or a lacerationof the tympanic membrane, for blood escaping from a fracture of thebase. Under these conditions the blood is usually bright red, is notaccompanied by cerebro-spinal fluid, and the flow soon stops. It is onrecord[4] that blood and cerebro-spinal fluid may escape along thesheath of the acoustic nerve without the bone being broken. [4] Miles, _Edinburgh Medical Journal_, 1895. #Fracture of the posterior fossa# is produced by the same forms ofviolence as cause fracture of the middle fossa; it is specially liableto result if the patient falls on the feet or buttocks. _Clinical Features. _--Sometimes a comparatively limited fracture ofthe occipital bone results, and in the course of a few days bloodinfiltrates the scalp in the region of the occiput and mastoid, or maypass down in the deeper planes of the neck. As a rule, however, thereis no immediate external evidence of fracture. The patient isgenerally unconscious, and shows signs of injury to the pons andmedulla, causing interference with respiration, which soon provesfatal. The rapidly fatal issue of these cases usually prevents themanifestation of any injury to the posterior cranial nerves. _Diagnosis of Basal Fractures. _--In the diagnosis of fractures of thebase, reliance is to be placed chiefly upon: (1) the nature of theinjury; (2) the diffuse character of the cerebral symptoms; (3) theevidence of injury to individual cranial nerves; (4) the occurrence ofpersistent bleeding from the nose, mouth, or ear; (5) theextravasation of blood under the conjunctiva or behind the mastoidprocess; and (6) the presence of blood in the cerebro-spinal fluidwithdrawn by lumbar puncture. In rare cases the diagnosis is madecertain by the escape of cerebro-fluid or of brain matter from thenose, mouth, or ear. It must be admitted, however, that in a large proportion of caseswhich end in recovery, the diagnosis of fracture of the base is littlemore than a conjecture. The external evidence of damage to the bone isso slight and so liable to be misleading, that little reliance can beplaced upon it. The associated cerebral and nervous symptoms also areonly presumptive evidence of fracture of the bone. In all cases, however, in which there is reason to suspect that the base isfractured, the patient should be treated on this assumption. It isoften found that, when there are no cerebral symptoms present, it isdifficult to convince the patient of the necessity for undergoingtreatment, and of the risk involved in his leaving his bed andresuming work. _Prognosis in Basal Fractures. _--The prognosis depends upon theseverity of the cerebral lesions, and on the occurrence of traumaticœdema or infective intra-cranial complications. Many cases prove fatalwithin a few hours from the associated injury to the brain, thepatient dying from cerebral compression due to hæmorrhage. If thepatient survives two days, the prognosis is more hopeful (Wagner). Itis possible that the free escape of blood from the nose or ear may insome cases prevent compression, and to a certain extent render theprognosis more favourable. Punctured fractures are frequently fatalfrom infective complications--meningitis, sinus thrombosis, andcerebral abscess. These complications are also liable to occur infractures rendered compound by opening into the nose, pharynx, or ear, but they are less common than might be expected. _Treatment. _--The general treatment includes that for all headinjuries. In a number of cases attended with symptoms of compression, benefit has followed the relief of intra-cranial tension by adecompression operation. The withdrawal of 30 or 40 c. C. Ofcerebro-spinal fluid by lumbar puncture has also proved beneficial inthe same way; Quenú strongly recommends repeated puncture in seriouscases. In a few cases this procedure has been followed by suddendeath. Steps must be taken to prevent infection from the mucous surfacesimplicated. This is exceedingly difficult in fractures opening intothe pharynx and nose. Owing to the general condition of the patient, it is usually impossible to employ nasal douching or mouth washes, butspraying the cavities with peroxide of hydrogen or other antisepticsmay be employed with benefit. In fractures of the middle fossa, theear should be gently sponged out and the meatus plugged with gauze, retained in position by adhesive plaster or a bandage. When there is apersistent escape of blood or cerebro-spinal fluid, the dressingrequires to be changed frequently. In compound fractures of the anterior fossa due to perforation throughthe orbit, the frontal bone should be trephined to admit of theremoval of loose fragments or of any foreign body that may haveentered the skull and to provide for drainage. CHAPTER XIV DISEASES OF THE BRAIN AND MEMBRANES Pyogenic diseases--Meningitis: _Varieties_--Abscess: _Varieties_--Sinus phlebitis--Intra-cranial tuberculosis. Cephaloceles--_Meningocele_--_Encephalocele_-- _Hydrencephalocele_--Traumatic cephal-hydrocele--Hydrocephalus; _Varieties_--Micrencephaly. Cerebral tumours. Tumours of the pituitary body. Epilepsy--Hernia cerebri. Surgical affections of cranial nerves--Cervical sympathetic. PYOGENIC DISEASES The most important intra-cranial conditions that result from infectionwith pyogenic bacteria are: meningitis, abscess of the brain, andphlebitis of the venous sinuses. The organisms most frequently associated with these conditions are thestaphylococcus aureus and the streptococcus, but it is not uncommonto meet with mixed infections in which other bacteria arepresent--particularly the pneumococcus, the bacillus fœtidus, thebacillus coli, the bacillus pyocyaneus, and the diplococcusintracellularis. By far the most common source of intra-cranial infection is chronicsuppuration of the middle ear and mastoid antrum, the organismspassing from these cavities to the interior of the skull directlythrough a perforation of the tegmen tympani or of the wall of thesigmoid groove, or being carried in the blood stream by the emissaryveins. In some cases the infection travels along the sheaths of thefacial and acoustic nerves. Less frequently infective conditions of the nasal cavity and itsaccessory air sinuses, and compound fractures of the skull, particularly punctured fractures, are followed by intra-cranialcomplications; or infection is conveyed to the inside of the skull, byway of the emissary veins, from wounds of the scalp, or from suchconditions as erysipelas of the face and scalp, malignant pustule, carbuncles, or boils. At the bedside there is often difficulty in discriminating between thevarious pyogenic intra-cranial complications, because many of thesymptoms are common to all the members of this group, and becausemore than one condition is frequently present. Thus a localisedmeningitis spreading to the brain may set up a cerebral abscess; asinus phlebitis may give rise to a purulent lepto-meningitis; or acerebral abscess bursting into the sub-arachnoid space may producemeningitis. MENINGITIS #Pachymeningitis. #--This term is applied when the infection involvesthe dura mater--a condition which is usually due to the spread ofinfection from a localised osseous lesion, such as erosion of thetegmen tympani in chronic suppuration of the middle ear, of the wallof the sigmoid groove in mastoid disease, or of the posterior wall ofthe frontal sinus in suppuration of that cavity. It also occurs inrelation to septic lesions of the cranial bones such as a broken-downgumma, after operations on the cranial bones, and in cases of compoundfracture attended with a mild degree of infection and with imperfectdrainage. In contusion of the skull without an external wound, theinfection may take place through the blood stream. The layer of the dura in contact with the affected portion ofbone is inflamed, thickened, and covered with a layer ofgranulations--_external pachymeningitis_--and between it and the bonethere is an effusion of fluid. Up to this point the process is largelyprotective in its effects, and gives rise to no symptoms, beyondperhaps some pain in the head. In the majority of cases, however, suppuration occurs between the duraand the bone--_suppurative pachymeningitis_--and leads to theformation of an _extra-dural abscess_ (Fig. 192). When this happensin association with disease in the middle ear or frontal sinus, it isattended with severe headache referred to the seat of the abscess, asudden rise of temperature preceded by shivering, and other evidenceof the absorption of toxins. Over the situation of the abscess, thescalp becomes swollen and œdematous--a condition which Percival Pott, in 1760, first observed to be characteristic of extra-duralsuppuration, hence the name, _Pott's puffy tumour_, applied to it(Fig. 193). Under these circumstances the abscess is seldom ofsufficient size to cause a marked increase in the intra-cranialtension, or to give rise to localised cerebral symptoms by pressing onthe brain. [Illustration: FIG. 192. --Diagram of Extra-Dural Abscess. ] [Illustration: FIG. 193. --Pott's Puffy Tumour in case of extra-duralabscess following compound fracture of orbital margin; infected withroad-dust; operation; recovery. At the time of the photograph the manwas unconscious. ] When associated with a punctured wound implicating the skull, anextra-dural abscess may develop within a few days of the injury, ornot till after the lapse of several weeks, and it may spread over awide area and come to encroach on the cranial cavity sufficiently toraise the intra-cranial tension and cause symptoms of compression, oreven to press upon cortical centres and produce localised paralyses. As discharge can escape from the wound in the scalp, the puffy tumourdoes not necessarily form. _Treatment. _--When the abscess is secondary to middle ear disease, themastoid must be opened, the eroded bone exposed, and sufficient of itremoved with rongeur forceps to admit of free drainage. When theinfection has spread from the frontal sinus, the skull is trephined inthe frontal region, the precise site being indicated by the œdematousarea in the scalp, and the diseased bone is removed. In cases ofcompound fracture, drainage is established by enlarging the scalpwound, and removing loose, depressed, or inflamed portions of bone; ifthe bone is comparatively intact, it must be trephined, and furtherbone is removed with rongeur forceps over the entire area in which thedura has been separated. #Lepto-meningitis. #--If the infection spreads to the adjacentarachno-pia (_localised lepto-meningitis_), adhesions usually form, and shut off the infected area from the general arachno-pial space. Pus may form among these adhesions, constituting a _sub-duralabscess_, and may infiltrate the superficial layers of the cortex(_purulent encephalitis_, or _meningo-encephalitis_) (Fig. 194). Thesymptoms are similar to those of extra-dural abscess, but may be moresevere; and it is seldom possible to distinguish between them beforeexposing the parts by operation. The treatment is carried out on thesame lines. [Illustration: FIG. 194. --Diagram of Sub-Dural Abscess. ] _Acute General Lepto-Meningitis. _--In bone lesions, particularlycompound fractures, infection of the arachno-pia may take placebefore protective adhesions form, and a diffuse lepto-meningitisresults. The open structure of the arachno-pial membrane favours therapid spread of the infection, which may extend over the surface ofthe hemispheres, or downwards towards the base (_basal meningitis_), or in both directions. The process is at first attended with a copiouseffusion of cerebro-spinal fluid into the arachno-pial space and intothe ventricles (_serous lepto-meningitis_), but this fluid tends tobecome purulent, the pus forming in a thin layer over the surface ofthe brain, and in the sulci between the convolutions (_purulentlepto-meningitis_). The membranes are congested and thickened, theveins of the arachno-pia engorged, and the superficial layers of thecortical grey matter may share in the process (_encephalitis_). _Clinical features. _--The earliest and most prominent symptom isviolent pain in the head, often referred to the frontal region, or, incases starting from middle ear disease, to the temporal region. Thisis accompanied by a sudden rise of temperature, usually without anantecedent rigor; the temperature remains persistently elevated (102°to 105° F. ), and the pulse is small, rapid, and irregular both in rateand force. The patient, especially if a child, is extremely irritable, all his sensations are hyper-acute, and he periodically utters apeculiarly sharp, piercing cry. Vomiting of the cerebral type--that is, unattended with nausea and notrelated to the taking of food or to gastric disturbance--is common, and persists through the illness. The bowels are usually constipated. There is an increase in the number of leucocytes in the cerebro-spinalfluid, and organisms also are found in the fluid. As this does notoccur in cerebral abscess, examination of the cerebro-spinal fluid maybe useful in differential diagnosis. There is a higher leucocytosis inthe blood in meningitis than in cerebral abscess. When the inflammation is most marked over the cerebral hemisphere, there may be paralysis of the side of the body opposite to the seat ofthe original lesion; sometimes there is erratic rigidity of the limbs, sometimes clonic spasms of groups of muscles. The superficial reflexesdisappear early on both sides; the abdominal reflexes being lostsooner than the knee-jerks. In basal meningitis, temporary squintingdue to irritation of the ocular muscles, retraction of the head, andan excessively high temperature are usually prominent features. Thepupils at first are equally contracted; later they become dilated andfixed. Both optic discs are œdematous and swollen. Gradually the patient becomes unconscious, shows signs of increasingintra-cranial tension, slowing of the pulse, and laboured respiration, and the condition almost always proves fatal within three or fourdays. _Treatment. _--The treatment consists in removing the source ofinfection when this is possible, but as a rule little can be done toarrest the spread of the meningitis or to ward off its effects. Incases resulting from a sub-dural abscess in relation to a compoundfracture, a sinus phlebitis, or an erosion of the tegmen tympani, anattempt should be made, after exposing this, to purify and drain themeningeal spaces. Temporary relief of symptoms sometimes follows thewithdrawal of cerebro-spinal fluid by repeated lumbar puncture, bleeding by leeches or cupping, or the use of an ice-bag or Leiter'stubes. The bowels should be freely moved by purgatives or enemata. _Cerebro-spinal Meningitis. _--This form of meningitis, which is due tothe _diplococcus intracellularis_, may occur sporadically, but is morefrequently met with in an epidemic form. It is attended with theformation of a profuse sero-purulent exudate, which covers the brain, the cord, the nerves, and the membranes. The clinical features are similar to those of acute generallepto-meningitis, and in sporadic cases the diagnosis is onlycompleted by discovering the diplococcus intracellularis in the fluidwithdrawn 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 puncturefollowed by the injection of Flexner's serum has proved beneficial. Recovery may be attended with paralysis of one or other of the cranialnerves. CEREBRAL AND CEREBELLAR ABSCESS #Abscess due to Middle Ear Disease. #--The most common cause of abscessin the brain is chronic middle ear disease, and the majority ofcerebral abscesses are therefore situated in the temporal lobe. Someare due to direct spread from a collection of pus in relation to anerosion of the tegmen tympani, either inside or outside the dura, others to infection carried by the veins, and in this way theinfective material reaches the white matter; less frequently infectionfrom the middle ear takes place along the peri-vascular lymph spaces. Macewen has pointed out that cerebral abscess never occurs frompyogenic organisms passing from the middle ear by way of the internalauditory meatus, although lepto-meningitis may do so. Cerebral abscessis much more frequently met with in the white matter of the centrumovale than in the cortex, and in the majority of cases the abscess issingle. The _pus_ is often of a greenish-yellow colour, or it may be darkbrown from admixture with broken-down blood-clot; in some cases it isthin and serous and contains sloughs of brain matter, and itfrequently has a fœtid odour. In quantity it varies from a few dropsto several ounces. The _arachno-pia_ over an abscess usually has a turbid and milkyappearance. In an acute abscess the surrounding _brain tissue_ is engorged andinfiltrated with pus; in a chronic abscess it is condensed, and thepus may be encapsulated by the formation of a zone of young fibroustissue round its periphery. In this condition the abscess may remain"latent, " giving rise to no symptoms for many weeks or even months. _Clinical features. _--The _initial_ formation of pus in the cerebraltissue is associated with the sudden onset of severe pain in the head, shivering and well-marked cutis anserina, and vomiting of the cerebraltype. The discharge from the ear usually diminishes or may even cease. As a _localised abscess_ develops the patient gradually passes, into astuporous condition; he does not lose consciousness, but, hiscerebration is slow, he seems unable to sustain his attention, for anylength of time, and he answers questions "slowly, briefly, but, as arule, correctly" (Macewen). The pain in the region of the ear becomesless intense, but the mastoid and temporal areas on the affected sideare tender on percussion. The temperature falls, and, as a rule, remains subnormal. Rigors are unusual: their occurrence usuallyindicating the development of some complication such as sinusphlebitis. The pulse is full, regular, and slow (40 to 60). Vomitingfrequently occurs, and the bowels are often obstinately constipated. There is no actual paresis, but there is a "gradual diminution of theability to apply his strength. " The superficial reflexes are late ofdisappearing and the disturbance is unilateral. The optic discs aremoderately swollen. "The face is expressionless, passive, and cloudy. It may assume a meaningless smile, with which the features are notlit; it is too mechanical" (Macewen). _Differential Diagnosis. _--In the early stages it is often difficultto distinguish between meningitis and cerebral abscess. The chiefpoints on which reliance is to be placed are that in meningitis thepulse shows an irregularity, both in rate and force, which is wantingin cases of uncomplicated abscess. In meningitis the temperature israised, while in abscess it is persistently subnormal. Thesuperficial reflexes, particularly the abdominal reflexes, disappearearly in meningitis and the disturbance is bilateral; in abscess theyare slower to disappear, and one side only is affected. Retraction ofthe neck, when present, is a characteristic sign of meningitis. Inmeningitis the optic discs are highly œdematous and are more swollenthan in abscess, and the condition is equally marked on the two sides. _Localisation of Cerebral Abscess--Temporal Abscess. _--The existenceof middle ear disease is always presumptive evidence that the abscessis in the temporal lobe on the same side. A small abscess in this lobemay produce no localising symptoms; one of large size may pressindirectly on the motor cortex, on the fibres passing through theinternal capsule, or on individual cranial nerves. It is important to observe the order in which paralysis of theopposite side of the body comes on. When it begins in the face andpasses successively to the arm and leg, the pressure is on thecortical centres. When the paralysis progresses in the oppositedirection--leg, arm, face--the pressure is on the nerve fibres passingthrough the internal capsule (Fig. 195). The paralysis may be spasticin lesions of the cortex or internal capsule; if it is flaccid thelesion is almost certainly cortical. [Illustration: FIG. 195. --Diagram illustrating Sequence of Paralysis, caused by abscess in temporal lobe. (After Macewen. )] Motor aphasia may result from pressure on the left inferior frontalconvolution; auditory aphasia from abscess in the posterior part ofthe superior temporal convolution. Ptosis and lateral squint, with afixed and dilated pupil, indicates pressure on the oculo-motor nerveof the same side. Abscess in the _parietal lobe_ gives rise to paralysis of the face andlimbs on the opposite side of the body. Abscess in the _occipitallobe_ produces interference with the visual functions. An abscess inthe _frontal lobe_ may give rise to no localising symptoms, but if itis on the left side, the power of making co-ordinated movements may belost--apraxia--or the motor speech centre may be implicated. _Terminal Stage. _--If left to itself, a cerebral abscess usually endsfatally by causing gradually increasing stupor and coma, or bybursting, either into the ventricles or into the sub-arachnoid space, and setting up a diffuse purulent lepto-meningitis. When the _abscess bursts into the ventricles_, the patient suddenlybecomes much worse and dies within a few hours. "The pupils becomewidely dilated, the face livid, the respiration greatly hurried, andeither shallow or stertorous. The temperature rises within a few hourswith a bound from subnormal to 104° to 105° F. ; the pulse from 40 or50 per minute quickly reaches 120 and over. There are musculartwitchings all over the body, possibly associated with convulsions andtetanic seizures, and these are followed by coma and speedy death"(Macewen). Spontaneous evacuation of a temporal abscess may take place throughthe middle ear. #Cerebellar Abscess. #--Next to the temporal lobe, the cerebellum isthe most common seat of abscess. Cerebellar abscess is usually due tospread of infection from a thrombosed sigmoid sinus, either directlyfrom 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 thepatient may be able to go about, but as it increases in size serioussymptoms develop. There may be nystagmus, and the patient suffers fromvertigo, and is unable to co-ordinate his movements. If he attempts towalk, he reels from side to side; even when sitting up in bed, he mayfeel giddy and tend to fall, usually towards the side opposite to thaton which the abscess is situated. The head and neck are retracted, thepulse is slow and weak, and the temperature subnormal. There isfrequent yawning, and the speech is slow, syllabic, and jerky. Theremay be optic neuritis and blindness. There is sometimes unilateral oreven bilateral spastic paralysis of the limbs from pressure on themedulla oblongata. The respiration may assume the Cheyne-Stokescharacter, occasionally being interrupted for a few minutes, while theheart continues to beat vigorously. This arrest of respiration isespecially liable to occur during anæsthesia. _Treatment. _--The abscess having been localised, the skull must beopened and the pus removed. #Abscess from causes other than Middle Ear Disease. #--From the _nasalpassages_, infection may spread to the interior of the skull directlythrough the walls of the frontal, ethmoidal, or sphenoidal airsinuses, or indirectly by way of the veins, and give rise to acerebral abscess, usually in the frontal lobe. The symptoms aresimilar to those of abscess following middle ear disease, but focalsymptoms are seldom present. When the abscess is on the left side, apraxia and motor aphasia may be present. Spontaneous evacuation maytake place by the abscess bursting into the nose through thecribriform plate. The treatment consists in trephining through the frontal bone orthrough the temporal fossa, according to the site of the abscess andits seat of origin. The primary focus of infection must also be dealtwith. In _infected compound fractures_, an abscess may form in the corticalgrey matter within a few days of the injury from direct spread ofinfection from the bone and membranes. This is usually associated witha spreading lepto-meningitis, the symptoms of which predominate. Thecondition usually proves fatal, but by opening up the original wound, removing depressed fragments of bone, and establishing drainage, thepatient's life may be saved. There is evidence that an abscess may form in the brain after a simplecontusion without fracture or other external injury (Ehrenvooth). An abscess may develop in the white matter of the centrum ovale someweeks, or even months, after an injury, particularly if a fragment ofbone or a foreign body has been driven into the brain. If theinfection has spread along the track of the missile, the abscess isusually near to the seat of the brain injury, but if it is due tospread of a thrombo-phlebitis it may be a considerable distance fromit, even on the opposite side of the head. These chronic abscesses areusually in the parietal or frontal lobes, and as the pus isencapsulated they may remain latent for long periods, during whichthey may cause some degree of headache, neuralgic pains in thedistribution of the trigeminal nerve, and occasional rises oftemperature. When the abscess becomes active, general symptoms similarto those of other forms of abscess develop, and there may be localisedparalysis of the opposite side of the body, the distribution of whichdepends upon whether the cortical centres or the motor fibres areimplicated. The treatment consists in opening up the original wound, removing anydepressed bone or foreign body that may be present, and establishingdrainage. _Bronchiectasis_ and other infective diseases of the lungs are lesscommon causes of cerebral abscess, which is usually single, and mayoccur in any part of the brain. _Disease of the bones of the skull_, such as osteomyelitis orsyphilis, may be followed by cerebral abscess. Abscesses of _pyæmic_ origin are usually multiple, and may occur bothin the cerebrum and in the cerebellum; they are not amenable tosurgical treatment. SINUS PHLEBITIS Inflammation of the intra-cranial venous sinuses is due to the spreadof infection from a local focus of suppuration; by far the mostfrequent cause is chronic suppuration in the middle ear. Less commonsources of infection are erysipelas of the face or scalp, infectiveconditions of the mouth or nose, and diseases of the bones of theskull. The organisms may reach the affected sinus directly by continuity oftissue, as, for instance, when the transverse (lateral) sinus becomesinfected from a focus of suppuration in the mastoid process spreadingthrough the bone to the sigmoid groove and involving the walls of thevessel; or they may reach it by extension of thrombosis in a tributaryvein--for example, when the superior sagittal (longitudinal) sinus isinfected from an anthrax pustule of the lip, which has causedthrombosis of the emissary vein that passes through the foramen cæcum. The pathological changes are the same as occur in the suppurative formof thrombo-phlebitis in the peripheral veins (Volume I. , p. 285). Thesoft clot that forms adheres to the inflamed wall of the sinus, and, being infected with pyogenic bacteria, it soon undergoes purulentdisintegration. The infective process may spread backward along tributary vessels, andso give rise to cerebral or cerebellar abscess, or to purulentmeningitis; or it may spread into the internal jugular vein and leadto the development of a diffuse purulent cellulitis along its course. General pyæmic infection may take place from pus or bacteria gettinginto the circulation, either directly or by reversed flow throughtributary veins. Infective emboli are liable to lodge in the lung orpleura, and set up pulmonary abscess, gangrene of the lung, orempyema. _Clinical Features. _--In all cases, pain in the head, referred to theregion of the affected sinus, and so severe as to prevent sleep, is anearly and prominent feature. The patient is usually excited, hypersensitive, and irritable in the early stages, and becomes dulland even comatose towards the end. Rigors, followed by profuseperspiration, occur early and increase in frequency as the diseaseprogresses. The temperature is markedly remittent, varying from 103°to 106° F. (Fig. 196). The pulse is rapid, small, and thready. Loss ofappetite, vomiting, and diarrhœa are almost constant symptoms. [Illustration: FIG. 196. --Chart of case of Sinus Phlebitis followingmiddle ear disease in a boy æt. 13. ] #Phlebitis of Individual Sinuses. #--The _transverse_ (_lateral_ or_sigmoid sinus_), from its proximity to the middle ear and mastoid aircells, is that most commonly affected, especially in young adults. With the onset of the phlebitis the discharge from the ear stops;there is severe pain in the ear and violent headache. The temperaturerises, but shows marked remissions, and rigors are common. Vomiting isfrequently present. Turgescence of the scalp veins draining into thissinus, and œdema over the mastoid, are occasionally observed; but asthese signs may accompany various other conditions, they are of littlediagnostic value. Not infrequently phlebitis spreads to the internaljugular vein, which may then be felt as a firm, tender cord runningdown the neck, and the head is held rigid, sometimes in the positioncharacteristic of wry-neck. Three clinical types of sinus phlebitis are recognised--pulmonary, abdominal, and meningeal--but it is often impossible to relegate aparticular case to one or other of these groups. Many cases presentsymptoms characteristic of more than one of the types. In the _pulmonary type_ evidence of infection of the lungs appearstowards the end of the second week, in the form of dyspnœa, cough, andpain in the side, coarse moist râles, and dark fœtid sputum. Deathusually takes place from gangrene of the lung. The brain functions mayremain active to the end. In the _abdominal type_ the symptoms closely resemble those of typhoidfever, for which the condition may be mistaken. The absence of a rashand the coexistence of middle ear disease are important factors indiagnosis. When the disease is of the _meningeal type_, symptoms of generalpurulent lepto-meningitis assert themselves, and soon come to dominatethe clinical picture. Evidence of the presence of meningitis may beobtained by lumbar puncture. The mind at first is clear, but thepatient is irritable; later he becomes comatose. The _prognosis_ is always grave, on account of the risk of generalinfection. _Treatment. _--The primary focus of infection must first be removed, and this usually involves clearing out the middle ear and mastoidprocess. The sigmoid sinus is then exposed, and after any granulationtissue or pus that may be in the groove has been cleared away, thesinus is opened and the thrombus removed. With the object ofpreventing the dissemination of infective material, a ligature shouldbe applied to the internal jugular vein in the neck before the sinusis opened, as was first recommended by Victor Horsley. If thephlebitis is accompanied by other intra-cranial infections, these are, of course, treated at the same time. The _superior sagittal_ or _longitudinal sinus_ is liable to beinfected from pyogenic lesions of the scalp. There are no symptomsthat are pathognomonic, but œdema of the scalp with turgescence of itsveins, epistaxis, and convulsions followed by paralysis, are thosemost likely to be met with. The _cavernous sinus_ is usually implicated by spread of the processfrom other sinuses--for instance, from the petrosal or transverse(lateral) sinuses--or from the ophthalmic veins in cases of orbitalcellulitis. Although at first unilateral, the thrombosis usuallyspreads across the middle line to the sinus of the opposite side. Thespecial symptoms--exophthalmos, œdema of the eyelids, and paralysis ofthe ocular nerves--are due to pressure on the structures entering theorbit. Operative interference is seldom feasible in phlebitis of the superiorsagittal (longitudinal) or cavernous sinuses. #Intra-cranial Tuberculosis. #--_Tuberculous meningitis_ is mostfrequently met with in patients below the age of twenty, and theinfection takes place by the blood stream from some focus elsewhere inthe body or from the spinal membranes. In cases of tuberculous diseaseof the middle ear infection may spread to the membranes by way of theinternal auditory meatus (Macewen). The arachno-pia, especially at thebase, is studded over with miliary tubercles, and an excess of fluidcollects in the arachno-pial space and in the ventricles (_acutehydrocephalus_). At first the _symptoms_ of irritation of the brain predominate: severeheadache, photophobia, inequality of the pupils, stiffness of theneck, cutaneous hyperæsthesia, vomiting and convulsions. Kernig'ssign--pain on flexing the hip while the knee is extended, andinability to extend the knee while in the sitting posture--is present. There is usually obstinate constipation, and the abdomen is retracted. Later, signs of increased intra-cranial tension develop:unconsciousness deepening into coma, paralysis of ocular muscles, rapid pulse, Cheyne-Stokes respiration, and sometimes hyperpyrexia. Anexcess of mono-nuclear lymphocytes and, sometimes, tubercle bacillimay be discovered in the cerebro-spinal fluid withdrawn by lumbarpuncture. The absence of the diplococcus intracellularis helps todifferentiate the disease from cerebro-spinal meningitis, which it mayclosely simulate. The only surgical measure that is justifiable is lumbar puncture, which often affords marked relief of symptoms, although the benefit isonly temporary. _Localised tuberculous nodules_ sometimes develop in the brain andform definite tumours. They vary in size from a pea to a hen's egg, are rounded and encapsulated. Sometimes the centre is caseous, sometimes fibrinous or calcified. In children they are usuallymultiple; in adults they may be single--the so-called "solitarytubercle. " They are most common in the pons, basal ganglia, andcerebellum, but occur also in the cerebral cortex and sometimes in thecentrum ovale. They usually originate in the pia and invade the brainsubstance, but do not as a rule involve the dura. The membranes in thevicinity of the growth are often the seat of tuberculous disease. As these nodules give rise to the same symptoms as other forms ofcerebral tumour, and as their nature can be diagnosed only inexceptional cases, their clinical features and treatment are describedwith tumours of the brain. #Intra-cranial Syphilis. #--_Syphilitic meningitis_ is usuallysecondary to cario-necrosis of the bones of the vault or to alocalised gumma of the brain. When primary, it usually affects theinter-peduncular region of the base, and takes the form of a diffusegummatous infiltration of the membranes which gives rise to symptomsreferable to the parts pressed upon, and especially paralysis of oneor other of the cranial nerves. As in other intra-cranial syphiliticlesions, the symptoms show a variability in intensity which ischaracteristic. The diagnosis is made by the history, and thetreatment is carried out on the same lines as in other syphiliticlesions. _Localised gummata_ are described with tumours of the brain. CEPHALOCELES The term "cephalocele" is applied to a protrusion of a portion of thecranial contents through a congenital deficiency in the bones of theskull. This malformation is believed to be due to an irregularity indevelopment, whereby a portion of the primary cerebral vesicle remainsoutside the mesoblastic layer of the embryo. It is usually associatedwith adhesion of the membranes in the region of the fourth ventricle, and with internal hydrocephalus. Cephaloceles are covered by thescalp, and are most commonly met with in the occipital region and atthe root of the nose; less frequently at the anterior inferior angleof the parietal bone, and in the line of the sagittal suture. Veryrarely they occur at the base of the skull and project into thepharynx, the mouth, or the nose, where they are liable to be mistakenfor polypi. Cephaloceles vary greatly in size, some being so small asalmost to escape detection, while others are larger than a child'shead. In many cases the condition is incompatible with life. Several varieties are recognised. They are known as (1)_meningocele_, which consists of a protrusion of a cul-de-sac of thearachno-pial membrane, containing cerebro-spinal fluid; (2)_encephalocele_, in which a portion of the brain is protruded inaddition to the membranes; and (3) _hydrencephalocele_, in which theprotruded portion of brain includes a part of one of the ventricles. _Clinical Features. _--The _meningocele_ is commonest in the occipitalregion, where it escapes through a cleft in the bone between theforamen magnum and the occipital protuberance (Fig. 197). It forms atense, smooth, translucent globular swelling, which may be sessile orpedunculated, and is usually covered by thin, smooth skin in which thevessels are dilated and nævoid. The tumour does not pulsate, butincreases in size and tension when the child cries or coughs. It maybe diminished in size or even made to disappear by pressure, and sopermit of the opening in the bone being felt. This manipulation, however, may be followed by slowing of the pulse, vomiting, loss ofconsciousness, or convulsions. [Illustration: FIG. 197. --Occipital Meningocele. (From a photograph lent by Sir George T. Beatson. )] Small meningoceles may remain stationary for a long time, or may evenundergo spontaneous cure. Those of larger size usually progress tillthey eventually burst, and death results from the escape of thecerebro-spinal fluid or from meningitis. Infection may also occurfrom eczema or from excoriation of the overlying skin. _Encephaloceles_ are much commoner than meningoceles, and usuallyoccur in the frontal region, where they form broad-based, elastic, andpulsatile tumours, which vary greatly in size. The _hydrencephalocele_ is usually met with in the occipital region, and is generally so large and associated with such great cerebraldeformity as to be inconsistent with life. It does not as a rulepulsate (Fig. 198). [Illustration: FIG. 198. --Frontal Hydrencephalocele. (From a photograph lent by Sir George T. Beatson. )] Cephaloceles have to be diagnosed from dermoid cysts, nævi (Fig. 199), cephal-hydrocele, and cephal-hæmatoma. Their recognition is seldomattended with difficulty. If the margins of the gap in the skull canbe distinctly felt, or the gap in the bone can be shown by the X-rays, the diagnosis is greatly simplified. [Illustration: FIG. 199. --Nævus at Root of Nose, simulatingCephalocele. (From a photograph lent by Sir George T. Beatson. )] _Treatment. _--Only small cephaloceles are amenable to surgicaltreatment; those that are large and contain brain substance are bestleft alone, being merely protected from irritation and infection. While the immediate effects of operation are, on the whole, satisfactory, the ultimate results are disappointing, as the essentialcause of the intra-cranial pressure persists, and the child developshydrocephalus. The method of tapping the sac and injecting iodine hasnothing to recommend it. #Traumatic Cephal-hydrocele. #--Certain rare cases of simple fractureof the vault occurring in early childhood have been followed by thedevelopment beneath the scalp of a localised fluid swelling, whichvaries in size from time to time and is partly reducible by pressure. The swelling results from laceration of the membranes, and sometimesof the brain substance, so that the cerebro-spinal fluid of thesub-arachnoid space, or even of the lateral ventricle, escapes throughthe opening in the skull and bulges beneath the scalp. In a majoritythe swelling pulsates synchronously with the heart, and becomes tenseon exertion. A distinct opening in the skull may sometimes be felt. When associated, as it frequently is, with mental deficiency or theoccurrence of fits, the cyst may be tapped or its neck ligated(Hogarth Pringle). Otherwise it should be left alone. HYDROCEPHALUS An excess of cerebro-spinal fluid may collect in the arachno-pialspace surrounding the brain, or in the interior of the ventricles, constituting in the former case an _external_, and in the latter an_internal hydrocephalus_. Hydrocephalus may be acute or chronic. #Acute hydrocephalus# is practically synonymous with tuberculousmeningitis, although it may result from other forms of meningealinfection. The excess of fluid is found both in the arachno-pial spaceand in the ventricles. This condition only calls for mention here asattempts have been made to treat it by surgical measures, such aslumbar puncture, or drainage through the occipital fossa. The results, however, have not been encouraging. #Chronic Hydrocephalus. #--_Chronic external hydrocephalus_ is rare, and usually results from some definite intra-cranial lesion, such asmeningitis, tumour, or cerebral atrophy. It is not amenable tosurgical treatment. _Chronic internal hydrocephalus_, on the other hand, is acomparatively common condition. It may be of congenital origin, or maydevelop in young rickety children, usually as a result of some chronicinflammatory process in the membranes at the base, the choroidplexuses, or the ependyma of the ventricles, causing obstruction tothe outflow of blood through the internal cerebral veins of Galen. Inthe acquired form the communication between the ventricles and thesub-arachnoid space, by way of the foramen of Magendie, is obstructed, so that the cerebro-spinal fluid is pent up in the ventricles andgradually distends them. The pressure causes the head to enlarge, thefontanelles to bulge, and the bones to be separated from one another, the interval between the bones being occupied by a thin translucentmembrane. The cerebral tissue is greatly thinned out, but the cerebellum andcranial nerves usually remain unaffected. The appearance of the patient is characteristic (Fig. 200). Theenormous dome of the skull surmounts a puny and preternaturally oldface; the eyes are pushed downwards and forwards by the pressure onthe orbital plates, and the eyebrows are displaced upwards. The headrolls helplessly from side to side; the child moans and cries a greatdeal; and vomiting is often a prominent symptom. In most cases theintelligence is defective, and epileptic seizures and other functionaldisturbances of the brain may be present. [Illustration: FIG. 200. --Hydrocephalus in a child æt. 3-1/2. ] In mild cases, especially when associated with rickets or syphilis, recovery sometimes takes place, but in the majority the conditionprogresses, and death results either from convulsions or from someintercurrent disease. Few hydrocephalic subjects reach adult life. _Treatment. _--Hydrocephalus being a symptom rather than a disease, nomethod of treatment which does not remove the primary cause can bepermanently curative. Anti-syphilitic treatment should be tried in thehydrocephalus of infants and young children. The rachitic element, when present, must also be treated. In congenital hydrocephalus, as there is no blocking of the passagesat the fourth ventricle, the foramina being as a rule much larger thannormal, no form of drainage is beneficial. Ligation of the commoncarotids, one some weeks after the other, has been successful inrestoring the balance which normally exists between the secretion andabsorption of the cerebro-spinal fluid (H. J. Stiles). In acquiredhydrocephalus, puncture of the ventricles is sometimes followed by aremarkable improvement in the symptoms, and may even result inapparent cure. An exploring needle is introduced at the lateral angleof the anterior fontanelle, to avoid the superior sagittal(longitudinal) sinus, and from a half to one ounce of cerebro-spinalfluid withdrawn. This is repeated once a week for several weeks. Continuous drainage of the fourth ventricle through an opening made inthe occipital region (Parkin), and the establishment of acommunication between the ventricle and sub-arachnoid space(Watson-Cheyne), or between the sub-arachnoid space of the spinal cordand the peritoneal cavity, or the retro-peritoneal space (Cushing), have been tried, with little more than temporary benefit in themajority of cases. Operative treatment, if it is to do good, must beundertaken early, before permanent changes in the brain have takenplace. #Micrencephaly. #--This condition is due to defective development ofthe brain, and not to premature closure of the cranial sutures andfontanelles, and as the subjects of it are mentally deficient, andoften blind, deaf and dumb, the removal of segments of the skull witha view to enable the brain to develop have proved futile. CEREBRAL TUMOURS As a comparatively small proportion of tumours of the brain--using theterm "tumour" in its widest sense--are amenable to surgical treatment, it is only necessary here to refer to those aspects of this subjectthat have a distinctively surgical bearing. Various forms of growth occur in the brain, the most common beingtuberculous nodules, syphilitic gumma, endothelioma, glioma, andsarcoma. Less frequently fibroma, osteoma, and parasitic, hæmorrhagic, and other cysts are met with. The growth may originate in the braintissue primarily, or may spread thence from the membranes, or from theskull. In relation to operative treatment, it is an unfortunate factthat those forms that are well defined and do not tend to infiltratethe brain tissue, usually occur at the base, where they are difficultto reach; while those that develop in more accessible regions are forthe most part infiltrating growths of a gliomatous or sarcomatousnature, and are therefore irremovable. _Clinical Features. _--The presence of a tumour in the brain inevitablyresults sooner or later in an increase in the intra-cranial tension, and to this the symptoms are chiefly due. The earliest and most prominent of the _general symptoms_ are severeparoxysmal headache, optic neuritis, with choked disc and limitationof the field for blue, amounting sometimes to blue-blindness(Cushing). The relative degree of neuritis in the two eyes is areliable 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 takingof food and is usually unattended by nausea, is a characteristicsymptom when present, but it is wanting in two-thirds of the cases(Cushing). Vertigo, general convulsions, and signs of mentaldeterioration are also present in a considerable proportion of cases. In addition, certain _localising symptoms_ may be present. When, forexample, the tumour is situated in the _cortex of the Rolandic area_, attacks of Jacksonian epilepsy, preceded by an aura, which is usuallyreferable to the centre primarily implicated, are common. The group ofmuscles first involved, and the order in which other groups becomeaffected, are important localising factors. As the tumour increases insize, these irritative phenomena are replaced by localised paralyses. The tactile and muscular sensations are also disturbed, and motor andsensory aphasia may be present. In some cases localised tenderness onpercussing the skull may be of assistance in indicating the site ofthe tumour. When the tumour is _sub-cortical_, that is, in the centrum ovale, there are no Jacksonian spasms, the motor paralysis is morewidespread, and sensation also is lost on the opposite side of thebody. There is no special tenderness on percussion. It is not alwayspossible, however, to distinguish between cortical and sub-corticaltumours, and in many cases both areas are invaded. Tumours situated in the region of _the internal capsule_, and _in thedeeper parts of the brain_, are not attended with Jacksonian spasms, paralysis develops more rapidly than in cortical and sub-corticaltumours, and there is complete loss of sensation on the opposite sideof the body. The cranial nerve-trunks also are liable to be pressedupon. Tumours and cysts _in the cerebellum_ give rise to symptoms similar tothose of cerebellar abscess (p. 381). Tumours _in the cerebello-pontine angle_, in addition to the specialsymptoms associated with cerebellar lesions, give rise to symptoms ofinterference with nerve-roots of the same side. The facial andacoustic nerves are most frequently affected, resulting in facialweakness, tinnitus, loss of perception for high-pitched notes, astested by Galton's whistle, or absolute unilateral deafness. Any ofthe other cranial nerves from the fifth to the twelfth may be eitherirritated or paralysed. Pressure on the pons may produce hemiplegia ofthe opposite side, with spasticity and exaggeration of reflexes. Sudden death may occur from crowding of the cerebellum into theforamen magnum. With the growth of the tumour the symptoms become aggravated, theoptic neuritis is followed by optic atrophy and blindness, the patientgradually becomes stuporous, and finally dies in a state of coma. Theseverity of the symptoms depends to a large extent on the rapidity ofgrowth of the tumour; thus an osteoma growing slowly from the innertable of the skull and implicating the brain may reach a considerablesize without producing cerebral symptoms, while a comparatively smallsarcoma or syphilitic gumma of rapid growth may endanger life. Asudden and serious aggravation of symptoms may result from hæmorrhageinto a soft tumour, such as glioma. The _diagnosis_ of the pathological nature of a cerebral tumour isgenerally "hardly more than a guess" (Gowers). At the same time it maybe borne in mind that _syphilitic gummata_ occur in adults, from fortyto sixty years of age, who have suffered from acquired syphilis, andwho may present other evidence of the disease. They tend to increasesomewhat rapidly. A negative Wassermann reaction does not necessarilyexclude a diagnosis of brain syphilis. Severe nocturnal pain whichinterferes with sleep is often a prominent symptom. Gummata aregenerally situated on the surface of the brain; they often originatein the dura mater, and when exposed are easily enucleated. Improvementin the symptoms may follow the administration of iodides and mercury, or organic arsenical salts of the salvarsan group, but in many casesthe growth is very resistant to anti-syphilitic treatment. _Tuberculous masses_ occur most frequently in children andadolescents, and other signs of tuberculosis are usually present. Thecerebellum is a common seat of these tumours, and they are oftenmultiple. Their growth may be rapid at first, and then become arrestedfor a time. Spasmodic growth of a tumour strongly suggests itstuberculous nature, and superadded signs of basal meningitis confirmthe diagnosis. _Endothelioma_ grows from the dura mater, and in so far as it is awell-defined and non-infiltrating growth it lends itself to removal byoperation. Unfortunately, however, it is usually located at the baseof the brain and is not readily accessible. _Glioma_ is usually met with in the young; it tends to grow slowly atfirst, but may take on a rapid growth at any time, and hæmorrhage isliable to occur into the substance of the tumour, causing a suddenaggravation of the symptoms. _Sarcoma_ occurs between puberty and middle life; it grows slowly, andcompresses rather than destroys the brain tissue. It is sharplydefined from the surrounding cerebral tissue, and is therefore morefavourable for operation than glioma. The _prognosis_ is grave in all forms of brain tumour. Even insyphilitic growths, although the more urgent symptoms may beameliorated by the use of drugs, recurrence is liable to occur, andthe structural changes induced in the cerebral tissue, and thecontraction of the cicatrix which results, may permanently interferewith the functions of the brain, or may induce Jacksonian epilepsy. Tuberculous tumours also may become arrested, and may cease for a timeto cause symptoms, but permanent cure is extremely rare. We have knowna sarcoma to recur as late as five years after removal. Deathsometimes occurs suddenly from hæmorrhage, from acute œdema, or fromimplication of vital centres. _Treatment. _--It is to be borne in mind that gummatous growths in thebrain are seldom influenced to any extent by anti-syphilitic remedies, and time should not be wasted in trying this form of treatment. The question of removal by operation arises in cases in which there isreason to believe that the tumour is situated near the surface of thebrain and that it is circumscribed and of moderate size. Unfortunatelyit is only in a small proportion of cases that these conditions arepresent and can be recognised before opening the skull. In many cases in which there is no hope of being able to remove thetumour, it is advisable to relieve symptoms due to excessiveintra-cranial tension, such as blindness, severe headache, andpersistent vomiting, by performing a "decompression operation"(_Operative Surgery_, p. 108). The relief that follows such operationsis often remarkable. Lumbar puncture, frequently repeated, has also been practised for therelief of tension in inoperable cases, but it is not free of dangerand is not to be looked upon as a substitute for a decompressionoperation. When surgical treatment is contra-indicated, all that can be done isto palliate the symptoms by bromides, opium, phenacetin, caffein, andother drugs. #Tumours of the Pituitary Body# or #Hypophysis Cerebri#. --The tumoursmost frequently met with in the pituitary body are of the nature ofadenoma with hyperplasia and cystic degeneration; carcinoma andsarcoma also occur. They develop slowly and give rise to comparativelyslight increase in the intra-cranial tension. When the anterior lobeis implicated and there is a pathological increase in the functionalactivity of the gland (_hyperpituitarism_), signs of acromegaly mayensue. Diminution of function (_hypopituitarism_) is attended withinfantilism, a rapid deposition of fat in the subcutaneous tissue, anda decrease or loss of the genital functions. In women, amenorrhœa isan early and constant symptom. Intense drowsiness is a marked featurein some cases. From their position close to the back of the optic chiasma thesegrowths affect the fibres passing to the nasal half of each retina, and so give rise to bilateral temporal hemianopsia, and although thereis no choked disc, the optic nerves undergo primary atrophy frompressure, and there is failure of sight. Marked temporary benefit has followed the administration of thyreoidextract. Operative treatment has been successful in a number of cases, but as the anterior lobe is essential to life, the operation is merelydirected towards the relief of pressure on the optic chiasma with aview to preventing loss of vision. We have seen marked relief follow atemporal decompression operation. #Epilepsy. #--The surgical aspects of Jacksonian epilepsy followinghead injuries have already been considered (p. 358). For the cure ofthose forms of epilepsy in which there is no gross lesion of thebrain, numerous surgical procedures have been suggested, but from noneof these have the results been encouraging. #Hernia Cerebri. #--This term is applied to a protrusion of brainsubstance through an acquired opening in the skull and dura mater, such as may result from a compound fracture or a gun-shot wound. Theprotrusion is due to increased intra-cranial tension, and is almostinvariably associated with infection of the brain and its membranes, and with the presence of a foreign body or fragments of bone. Otherthings being equal, a hernia is more likely to occur through a smallthan through a large opening in the skull. So long as the extruded portion of brain matter is small, it pulsates, but as it increases in size and is pressed upon by the edges of theopening through which it escapes, the pulsation ceases, and theherniated portion may become strangulated and undergo necrosis. In cases of compound fracture, and in other conditions associated withnecrosis of bone, masses of redundant granulation tissue growing fromthe soft parts outside the skull may simulate a hernia cerebri. The _treatment_ consists in counteracting the septic infection bypurifying the protruding mass, and if necessary by enlarging theopening in the skull with rongeur forceps to admit of the removal offoreign bodies or bone fragments and to relieve the inter-cranialtension. Steps must also be taken to prevent meningitis, which, if itoccurs, is usually fatal. Pressure over the hernia, with the objectof returning it to the skull, is to be avoided, and the herniatedportion should not be cut away unless it is sloughing, or has becomepedunculated. 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; thisis picked off, and the formalin re-applied. After the hernia has disappeared and the wound is aseptic, stepsshould be taken to close the gap in the skull. This may be done by anosteo-plastic operation in which a flap, comprising a segment of theouter table, is raised from an adjacent part of the skull and placedin the gap; or by transplanting a portion of periosteum-covered bonefrom the scapula, tibia, or other suitable source. An alternativemethod is to implant a plate of celluloid, silver or other metal, or aportion of the fascia lata, in the gap. When a permanent hole is leftin the bone, the patient should wear over it a leather or metal shieldto protect the brain. The protrusion of brain resulting after a decompression operationdeliberately performed for the relief of intra-cranial tension, unlessit becomes infected, has nothing in common with a hernia cerebri. SURGICAL AFFECTIONS OF THE CRANIAL NERVE Irritation, or paralysis, of one or more of the cranial nerves mayresult from lesions implicating their centres or trunks. When the trunk of the nerve is affected, the paralysis is on the sameside as the lesion, and is of the lower neurone type; when thecortical centre or the upper axons are involved, it is on the oppositeside, and is of the upper neurone type (p. 334). The lesions of thecerebral centres with which nerve symptoms are most frequentlyassociated are: laceration of the brain, hæmorrhage, meningitis, tumour, and syphilitic gumma. The nerve-trunks may be contused or torn across, especially in basalfractures which traverse their foramina of exit; blood may be effusedinto their sheaths as a result of injuries not attended with fracture;or they may be pressed upon by an inflammatory effusion, a tumour, agumma, or an aneurysm invading the base of the skull. When the nerveis merely contused, or pressed upon by blood-clot, the paralysis tendsto pass off in the course of a few days. When it is torn across, orcompressed by a new growth, the paralysis is permanent. In sometraumatic cases paralysis does not come on until a few days after theinjury, and is then due either to gradually increasing pressure fromblood-clot, or more probably to the onset of meningitis or ofascending neuritis. I. The branches of the _Olfactory Nerve_ may be ruptured as they passthrough the cribriform plate in fractures implicating the anteriorfossa of the skull, and there results complete and permanent loss ofsmell (_anosmia_). Hæmorrhage into the nerve sheath or contusion ofthe nerve may cause a transitory loss of smell. The trunk of the nervemay be implicated also in tumours and meningitis in the anteriorfossa. In all cases in which anosmia results there is alsointerference with the power of recognising different flavours, thusgreatly impairing the sense of taste. II. _Optic Nerve. _--Temporary paralysis of one or both optic nerves isa comparatively common result of traumatic effusion of blood intotheir sheaths; the resulting blindness may pass off in a few days, ormay last for some weeks. When a large effusion takes place, theprolonged pressure on the nerve may result in optic atrophy andpermanent blindness. Complete severance of the nerve by a bullet, thepoint of a sharp instrument, or a fragment of bone, results in loss ofsight in the eye on the same side. In cellulitis of the orbit, intra-orbital tumour, gumma and aneurysm in the region of thecavernous sinus, also, the optic nerve may be implicated. Lesions implicating the cortical centre for sight in the occipitallobe give rise to hemianopia--that is, loss of sight in the lateralhalves of the fields of vision of both eyes--colour-blindness, subjective sensations of light and colour, and other eye symptoms. Double optic neuritis, followed by optic atrophy, is one of the mostconstant effects of the growth of a tumour within the skull, and isnot uncommon in cases of cerebral abscess and meningitis. Pressure onthe optic chiasma, for example by a tumour of the pituitary body, isassociated with bilateral temporal hemianopsia. III. _Oculo-Motor Nerve. _--One or more of the branches of this nervemay be compressed by extravasated blood, or be contused and laceratedin fractures implicating the region of the sphenoidal fissure. Fixeddilatation of one pupil may result from pressure by blood-clot, without other functional disturbance of the nerve. A tumour or ananeurysm growing in this region also may press upon the nerve. Sometimes both nerves are involved--for example, in fractureimplicating both sides of the anterior fossa, and in tumours, particularly gumma, growing in the region of the floor of the thirdventricle. In lesions of the cerebral hemispheres the third nerve isfrequently paralysed. Its cortical centre lies in close proximity tothe centre for the face (Fig. 179). The most prominent symptoms of complete paralysis are ptosis ordrooping of the upper eyelid, lateral strabismus, and slight downwardrotation of the eye with diplopia. There are also dilatation of thepupil from paralysis of the circular fibres of the iris, and loss ofaccommodation and reaction to light from paralysis of the ciliarymuscle. Paralysis of the muscle supplied by the third nerve is frequentlyassociated with paralysis of other ocular muscles. When all themuscles of the eye are paralysed, the condition is known as"opthalmoplegia externa"; it is usually due to syphilitic disease inthe floor of the third ventricle. IV. The _Trochlear_ or _Patheticus Nerve_, which supplies the superioroblique muscle, may suffer in the same way as the oculo-motor nerve. When it is paralysed, there is defective movement of the eye downwardand medially, and the patient may complain of diplopia when he looksdownward. V. _Trigeminal Nerve. _--The most important surgical affection of thisnerve is "trigeminal neuralgia, " which has already been described(Volume I. , p. 373). One or other of the divisions of the nerve may betorn in fractures of the base of the skull, and there resultsanæsthesia in the area supplied by it. In fractures crossing the apexof the petrous portion of the temporal bone, the great and smallsuperficial petrosal nerves may be ruptured, and the soft palate anduvula are paralysed and there is difficulty in swallowing; there arealso painful sensations in the ear. When the ophthalmic division isimplicated, the conjunctiva is rendered insensitive, andconjunctivitis, which may be followed by ulceration of the cornea, results from exposure to dust and other foreign bodies, which, onaccount of the anæsthetic condition of the eye, are allowed to remainand cause irritation. VI. _Abducens Nerve. _--This nerve, which supplies the lateral rectusmuscle, has the longest course within the skull of any of the cranialnerves. In spite of this fact, it is comparatively seldom torn inbasal fractures; but it is prone to be pressed upon by tumours, gummas, or aneurysms in the region of the base of the brain. When itis paralysed, medial strabismus results. VII. _Facial Nerve. _--Paralysis of the facial muscles, more or lesscomplete, is the most characteristic symptom of lesions of this nerve. _Paralysis of the Cerebral Type. _--When the fibres of the nerve areimplicated in any part of their course between the cortical centreand the nucleus in the lower part of the pons, the paralysis is of theupper neurone (cerebral) type. It affects the side of the faceopposite to that of the lesion, and the defective movement is moremarked in the lower than in the upper half of the face. This form of facial paralysis may be due to the pressure of anintra-cranial tumour, abscess, or hæmorrhage, or to degenerativeprocesses in the cerebral tissue, and as a rule other cranial nervesare also affected. Its recognition is chiefly of diagnostic andlocalising importance. _Paralysis of the Peripheral Type. _--When the trunk of the nerve isimplicated between the pontine nucleus and its peripheraldistribution, the paralysis is of the lower neurone (peripheral) type, the muscles on the same side as the lesion being flaccid andatrophied. The majority of cases are of the so-called "rheumatic" variety, andare attributed to exposure to cold. Others result from fracturesimplicating the middle fossa of the skull, or are associated withchronic suppuration in the middle ear. In fractures passing across the petrous temporal, the nerve may betorn at the time of the injury, or may become pressed upon by atraumatic effusion or by callus later, but considering the frequencyof these fractures it is comparatively seldom damaged. Suppurative disease of the middle ear is a more common cause of facialparalysis. The nerve, as it traverses the facial canal (aqueductusFallopii), may be pressed upon by inflammatory effusions orgranulations, or may be destroyed by the suppurative process, particularly in young children, as in them the osseous wall of theaqueduct is very thin. It may also be involved in tuberculous and inmalignant disease of the middle ear. The nerve may be injured also in the course of operations on themastoid or middle ear, or in the removal of tumours or glands in theparotid region. As the nerve breaks up into numerous branches soonafter it leaves the stylo-mastoid foramen, the paralysis may beconfined to one or more of its branches. Temporary paralysis may result from inflammatory conditions such asparotitis, or from blows or pressure over the nerve, for example bythe forceps in delivery. _Symptoms. _--In complete unilateral _facial paralysis_ (Bell'sparalysis) the affected side of the face is expressionless and devoidof voluntary or emotional movement. The muscles are flaccid, the cheekis flattened and smooth, all its folds and wrinkles beingobliterated. When the patient speaks or smiles, the face is drawn tothe sound side (Fig. 201). The eye on the affected side cannot beclosed, and on making the attempt the eyeball rolls upwards andoutwards. The lower lid droops, the patient cannot wink, and theconjunctiva therefore becomes dry, and is irritated by exposure tocold and dust. The tears run over the cheek. From paralysis of thebuccinator muscle there is inability to whistle or to puff out thecheeks and food collects between the cheek and the gums. Theorbicularis oris being also paralysed, the patient is unable to showhis upper teeth, and the labial consonants are pronouncedindistinctly. The sense of taste is often impaired from involvement ofthe chorda tympani nerve. [Illustration: FIG. 201. --Patient suffering from left facialParalysis. Note smoothness of left side of face, imperfect closure ofleft eye, and deviation of face to right side. (From a photograph lent by Dr. Edwin Bramwell. )] When the paralysis is bilateral, the symmetrical appearance of theface renders the condition liable to be overlooked. _Treatment. _--In addition to removing the cause, when this ispossible, recovery of function may be promoted by the administrationof drugs, such as potassium iodide, strychnin, or iron, by theapplication of blisters, or by massage and electricity. These measuresare most useful in cases due to blows or exposure to cold. When thenerve is accidentally divided in the course of an operation on theface, it should immediately be sutured. So long as the electricalreactions of the affected muscles indicate an incomplete lesion, recovery may be confidently expected (Sherren). When the reaction ofdegeneration is present and the paralysis has lasted for more than sixmonths, there is little hope of recovery, and recourse should be hadto operation, to restore the function of the nerve by grafting itsdistal end on to the trunk of the hypoglossal nerve. To preventparalysis of the tongue the lingual nerve may be divided, and itsproximal end anastomosed with the distal end of the hypoglossal. The facial may be grafted on the accessory nerve, but the associatedmovements of the face which then accompany movements of the shoulderoften prove inconvenient. _Facial Spasm. _--Clonic contraction of the facial muscles (histrionicspasm) occasionally results from irritative lesions in the cortex orpons. Sometimes all the muscles are involved, sometimes only one, forexample the orbicularis oculi (palpebrarum)--blepharospasm. Thiscondition may be induced reflexly from irrigation of the trigeminalnerve, notably of branches that supply the nasal cavities and theteeth. The _treatment_ consists in removing any source of peripheralirritation that may be present, in employing massage, and inadministering nerve tonics, bromides, and other drugs. In severecases, the facial nerve may be stretched with benefit, either at itsexit from the stylo-mastoid foramen or on the face. VIII. _Acoustic_ or _Auditory Nerve_. --The acoustic nerve is liable tobe damaged along with the facial in tumours of the cerebello-pontineangle, and in fractures which traverse the internal auditory meatus. Both nerves also may be torn across just before they enter the meatusin severe brain injuries apart from fracture. Complete and permanentdeafness results. Effusion of blood into the nerve sheath, or into theinternal or middle ear, causes transitory deafness, and the patientsuffers from noises in the ear, giddiness, and interference withequilibration. IX. The _Glosso-pharyngeal Nerve_ is comparatively seldom injured. When it is compressed by a tumour in the region of the medulla, thereis interference with speech and deglutition, ulcers form on thetongue, and œdema of the glottis may supervene. X. The _Vagus_ or _Pneumogastric Nerve_ is seldom injured within thecranial cavity. In the neck, it is liable to be divided or ligated in the course ofoperations for the removal of malignant or tuberculous glands, forgoitre, or for ligation of the common carotid. Division of the nerveon one side, or even removal of a portion of it, is not as a rulefollowed by any change in the pulse or respiration. If it isirritated, however, for example by being grasped with an arteryforceps, there is inhibition of the heart, and if it is accidentallyligated, there may be persistent vomiting. Division of the main trunk, or of its recurrent branch on one side, results in paralysis of the corresponding posterior crico-arytænoidmuscle--the muscle that opens the glottis. This condition is known asunilateral _abductor paralysis_, and is accompanied by interferencewith inspiration and phonation. If both nerves are divided, bilateralabductor paralysis results: the vocal cords flap together, producing acrowing sound on inspiration and embarrassment of breathing, andtracheotomy may be necessary to prevent asphyxia. The vagus and recurrent nerves have been successfully sutured afterhaving been divided accidentally. XI. _Accessory_ or _Spinal Accessory Nerve_. --This nerve is seldomdamaged within the skull. It supplies the sterno-mastoid andtrapezius; but as these muscles usually have an additional nervesupply from the cervical plexus, the accessory may be divided, or aconsiderable portion of it resected, as, for example, in the treatmentof spasmodic torticollis, without any serious disablement resulting. It is liable to be accidentally divided in excising malignant ortuberculous glands in the neck. When, however, the accessory is theonly source of supply to these muscles, its division is followed byconsiderable disablement, which appears to depend almost entirely onthe _paralysis of the trapezius_. The head is inclined slightlyforward, the shoulder is depressed, the arm hangs heavily by the sideand is slightly rotated forward, the scapula is drawn away from thespine and rotated on its horizontal axis, and there is slight cervicalscoliosis with the concavity towards the affected side. The trapeziusis markedly wasted, and is, therefore, less prominent in the neck thannormally, and the functions of the arm and shoulder are impaired, especially in making overhead movements. In time other musclescompensate in part for the loss of the trapezius. When divided accidentally, the nerve should be immediately sutured. Even when the paralysis has lasted for some time, secondary sutureshould be attempted; if this is impossible, the peripheral end shouldbe anastomosed with the anterior primary divisions of the third andfourth cervical nerves (Tubby). Massage, electricity, and theadministration of tonics are also indicated. XII. _Hypoglossal Nerve. _--This nerve has been ruptured in fracturespassing through the canalis hypoglossi (anterior condylar foramen). Itis also liable to be divided in wounds of the submaxillary region--forexample, in cut throat, or during the operation for ligation of thelingual artery, or the removal of diseased lymph glands. The paralysed half of the tongue undergoes atrophy. When the tongue isprotruded, it deviates towards the paralysed side, being pushed overby the active muscles of the opposite side. Speech and mastication areinterfered with, the tongue feeling too large for the mouth; in timethis disability is to a large extent overcome. #The Cervical Sympathetic. #--The cervical sympathetic cord and itsganglia may be injured in the neck by stabs or gun-shot wounds, or inthe course of deep dissections in the neck; and in injuries of thelower part of the cervical enlargement of the spinal cord (p. 417) orof the first dorsal nerve root. Paralysis of the cervical sympathetic is characterised by diminutionin the size of the pupil on the affected side. The pupil does notdilate when shaded, nor when the skin of the neck is pinched--"loss ofthe cilio-spinal reflex. " The palpebral fissure is smaller than itsfellow, and the eyeball sinks into the orbit. There is anidrosis orloss of sweating on the side of the face, neck, and upper part of thethorax, and on the whole upper extremity of the affected side. CHAPTER XV DISEASES OF THE CRANIAL BONES Suppurative periostitis and osteomyelitis--Tuberculosis-- Syphilis--Tumours. #Suppurative Periostitis and Osteomyelitis. #--These conditions may bethe result of infection through the blood stream, but as a rule theyfollow upon a breach of the surface caused by a wound, a severe burnas in epileptics, a tertiary syphilitic ulcer, or a compound fracturethat has become infected. Sometimes they follow suppuration in themiddle ear and mastoid or in the frontal sinus, and epithelioma androdent cancer that has ulcerated and become infected after spreadingfrom the face towards the vertex. They are occasionally associatedwith acute cellulitis of the scalp. When the infection is blood-bornesuppuration occurs on both aspects of the bone--a point of importancein treatment. The illness is usually ushered in by a rigor, and this is soonfollowed by other signs of suppuration--high temperature, pain andtenderness, and the formation of a fluctuating swelling in relation tothe bone. When pus forms between the bone and the dura, there is acharacteristic œdema of the overlying area of the scalp--spoken of as_Pott's puffy tumour_--which is of value as indicating the extent ofthe disease in the bone, and of the collection of pus between it andthe dura. When suppuration occurs under the pericranium, an incisiongives exit to a quantity of pus, and exposes an area of bare bone. Ifthe incision is made early, this bone may soon be covered bygranulations and recover its vitality; but if operation is delayed, itusually undergoes necrosis. The sequestrum that forms includes, as arule, only the outer table, but in some cases the whole thickness ofthe bone undergoes necrosis. In either case the separation of thesequestrum is an exceedingly slow process, and is not accompanied bythe formation of new bone. When the whole thickness of the skull islost, there may be a protrusion of the contents of the skull--herniacerebri; should the patient survive, the gap becomes filled in by adense fibrous membrane which is fused with the dura mater. Serious complications, in the form of meningitis, cerebral abscess, sinus phlebitis, and general pyæmia, are liable to develop at any timeduring the progress of the infection, and we have seen pyæmia developafter the suppuration in the skull had been recovered from. _Treatment. _--Early, free, and, if necessary, multiple incisions areindicated to admit of disinfection of the affected area, and of theestablishment of drainage. If the symptoms point to suppuration havingoccurred between the bone and the dura, the skull should be trephinedand further bone removed with the rongeur forceps as may be required. Time may be saved by separating the sequestrum with the aid of anelevator or sharp spoon, or by chiselling away the dead part tillhealthy vascular bone is reached. #Tuberculosis# of the cranial vault is usually met with in children. The disease commences in the diploë, and results in the formation of acentral sequestrum, around and beneath which the tuberculous processspreads. Granulations form between the skull and the dura, and on theouter aspect lifting up the pericranium. The sequestrum is slowlythrown off, and when separated is circular like a coin and presentsworm-eaten edges. A circumscribed, tender swelling forms, at first yielding an obscuresensation of fluctuation, but later, when the pus is no longerconfined under the pericranium, assuming the characters of a coldabscess, which gradually becomes superficial, and eventually burststhrough the scalp, forming one or more sinuses. The abscess should be laid open, all tuberculous granulations scrapedaway, and the sequestrum removed, with the aid of the chisel if it hasnot already become loose. On inserting the finger through the opening, it appears to penetrate to an alarming extent; this is due to theaccumulation of tuberculous material between the skull and the duramater, depressing the latter. After healing is completed, a depressionor gap in the bone remains. #Syphilis. #--Syphilitic affections occur during the tertiary period ofthe disease, and usually implicate the frontal and parietal bones(Fig. 202). They are described in Volume I. , p. 462. [Illustration: FIG. 202. --Skull of woman illustrating the appearancesof Tertiary Syphilis of Frontal Bone--Corona Veneris--in the healedcondition. ] #Tumours. #--_Osteoma_ of the skull has been described with diseases ofbone (Volume I. , p. 481). _Sarcoma. _--All forms of sarcoma are met with, implicating the bonesof the skull. They may originate in the pericranium, in the diploë, orin the dura mater, and usually involve the bones of the vault. Theysometimes occur in children (Fig. 203). [Illustration: FIG. 203. --Sarcoma of Orbital Plate of Frontal Bone ina child at age of 11 months, and 18 months. (Mr. D. M. Greig's case. )] The tumour grows chiefly towards the surface, but it also tends toinvade the cranial cavity, and may thus assume the shape of adumb-bell. Its growth is usually rapid, and results in the formationof a diffuse soft swelling, which sometimes pulsates, and sooner orlater fungates through the skin. On account of its rapid growth thetumour is liable to be mistaken for an abscess, and in some cases thenature of the disease is only discovered after making an exploratoryincision, and finding that the finger passes through a softened areain the bone. When the cranial cavity is encroached upon, signs of compressionensue. After the tumour has fungated, infective complications withinthe skull are liable to develop. In all cases the prognosis isextremely unfavourable. If diagnosed sufficiently early, an attempt may be made to remove thetumour, but often the operation has to be abandoned, either on accountof the hæmorrhage which attends it, or because of the extent of thedisease. The bones of the skull may become the seat of _secondary growths_ bythe direct spread of cancer from the soft parts, _e. G. _ rodent cancer(Fig. 204), or by metastasis of cancer or sarcoma from distant partsof the body, or of thyreoid tumours. Metastatic cancer would appear tobe conveyed by the blood stream; it may occur in a diffuseform--cancerous osteomalacia--softening the calvaria so that at thepost-mortem examination it may be removed with the knife instead ofthe saw; or it occurs in a discrete or scattered form, and then themacerated skull presents a number of circular and oval perforations. [Illustration: FIG. 204. --Destruction of Bones of Left Orbit, causedby Rodent Cancer. The patient died of septic meningitis. (Mr. D. M. Greig's case. )] CHAPTER XVI THE VERTEBRAL COLUMN AND SPINAL CORD Surgical Anatomy--Injuries of the spinal cord: _Concussion_; _Traumatic hæmatorrachis_; _Traumatic hæmatomyelia_; _Total transverse lesions at different levels_; _Partial lesions_; "_Railway spine_"--Injuries of the vertebral column: _Sprain_; _Isolated dislocation of articular processes_; _Isolated fracture of arches and spinous processes_; _Compression fracture of bodies_--Traumatic spondylitis--Fracture-dislocation--Penetrating wounds. #Surgical Anatomy. #--The veretebral column is the central axis of theskeleton, and affords a protecting casement for the spinal cord. The spine is movable in all directions--flexion, extension, lateralflexion, and rotation around the long axis of the column. Flexion isaccompanied by compression of the intervertebral discs, and by aslight forward movement of each vertebra on the one below it. Thisforward movement is checked by the tension of the ligamenta flavawhich stretch between the laminæ. In the infant, the spine is either straight or presents one longantero-posterior curve with its convexity backwards. With theassumption of the erect posture the normal S-shaped curve isdeveloped, the cervical and lumbar segments arching forward, while thethoracic and sacral segments arch backward. Through the skin it is often difficult to identify with certainty theindividual spinous processes. The spine of the seventh cervicalvertebra, --vertebra prominens--and that of the first thoracic, arethose most readily felt. While the arm hangs by the side, the root ofthe spine of the scapula is opposite the third thoracic spine, and thelower angle of the scapula is on the same level as the seventh. Thetwelfth thoracic vertebra may be recognised by tracing back to it thelast rib. A line joining the highest points of the iliac crestscrosses the fourth lumbar spine; and the second sacral spine is on thesame level as the posterior superior iliac spine. The bodies of theupper cervical vertebræ may be felt through the posterior wall of thepharynx. The cricoid cartilage corresponds in level to that of thelower border of the sixth cervical vertebræ and its transverseprocess. It is important for surgical purposes to bear in mind that most of thespinous processes do not lie on the same level as their correspondingbodies. The tips of the spines of the cervical and first two or threethoracic vertebræ lie, roughly speaking, opposite the lower edge oftheir respective bodies; those of the remaining thoracic vertebræ lieopposite the body of the vertebræ below; while the spines of thelumbar vertebræ lie opposite the middle of their corresponding bodies. The _vertebral canal_ contains the spinal cord so suspended within itsmembranes that it does not touch the bones, and is not disturbed bythe movements of the vertebral column. The _membranes_ of the cord are continuous with those of the brain. The arachno-pia invests the cord and furnishes a sheath to each of thespinal nerves as it passes out through the intervertebral foramen. Thearachno-pial space is filled with cerebro-spinal fluid, which forms awater-bed for the cord, continuous with that at the base of the brain. The dura mater constitutes the enveloping sheath of the cord. It hangsfrom the edge of the foramen magnum as a tubular sac, and is connectedto the bones only opposite the intervertebral foramina, where it isprolonged on to each spinal nerve as part of its sheath. Between thedura and the bony wall of the canal is a space filled with looseareolar tissue and traversed by large venous sinuses. The dura extendsas far as the upper edge of the sacrum. The _spinal cord_ extends from the foramen magnum to the level of thedisc between the first and second lumbar vertebræ. The cervicalenlargement, which includes the lower four cervical and the upper twothoracic segments, ends opposite the seventh cervical spine. Thelumbar enlargement lies opposite the last three thoracic spines. One pair of spinal nerves leaves each "segment" of the cord. Onleaving the cord the nerves incline slightly downwards towards theforamina by which they make their exit from the canal. The obliquityof the nerves gradually increases, till in the lower part of thecanal--from the second lumbar vertebra onward--they run parallel withthe filum terminale and together constitute the cauda equina. It is to be borne in mind that owing to the fact that the cord isrelatively shorter than the canal, the tips of the spinous processeslie a considerable distance lower than the segments of the cord withwhich they correspond numerically. To estimate the level of thesegment of the cord which is injured: in the cervical region add oneto the number of the vertebra counted by the spines; in the upperthoracic region add two, in the lower thoracic region add three, andthis will give the corresponding segment. The lower part of theeleventh thoracic spinous process and the space below it are oppositethe lower three lumbar segments. The twelfth thoracic spinous processand the space below it are opposite the sacral segments (Chipault). _Functions. _--The essential function of the spinal cord is to transmitmotor and sensory impulses between the brain and the rest of the body. The general course of the fibres by which these impulses travel hasalready been described (p. 331). In the grey matter there are groups of nerve-cells--"centres"--whichgovern certain reflex movements. The most important of these--thecentres for the rectal, the vesical, and the patellar reflexes--aresituated in the lumbar enlargement. In the great majority of cases of spinal disease or injury comingunder the notice of the surgeon the symptoms are bilateral, that is, are of the nature of paraplegia, and the whole of the body below thelevel of the segment affected is involved in the paralysis. Lesionsaffecting only one-half of the cord are rare and give rise to symptomswhich are exceedingly complicated. When the lesion implicates thenerve-roots only, the symptoms are confined to the area supplied bythe affected nerves. INJURIES OF THE SPINAL MEDULLA OR CORD As the clinical importance of a spinal injury depends almost entirelyon the degree of damage done to the cord, we shall consider injuriesof the cord before those of the vertebral column. They will bedescribed under the headings: Concussion of the Cord; Traumatic SpinalHæmorrhage; Total Transverse Lesions; Partial Lesions of the Cord andNerve Roots; and "Railway Spine. " #Concussion of the Spinal Cord. #--Concussion of the cord is nowregarded as a definite entity closely resembling concussion of thebrain. In some cases, the underlying lesion is of a temporarycharacter, usually in the form of a vascular disturbance such as œdemaor vascular engorgement, and possibly an arterial anæmia; in othercases there is definite evidence of injury, of the nature ofcontusion, minute hæmorrhages and blood-staining of the cerebro-spinalfluid. It must be clearly stated, that concussion of the cord may beattended with an immediate arrest of all its functions closelyresembling the condition following upon complete crushing of thecord--total transverse lesion, --and it may be impossible todifferentiate between the two conditions until two or more days haveelapsed after the accident; it is usual, however, in concussion, ascontrasted with crushing of the cord, that although motor conductionmay be completely abolished, sensation is only impaired and evidenceof sensory conduction can usually be elicited. If the lesion is merelya concussion, the functions of the cord will be restored within a dayor two, first to full sensation and then to full motor power. A classical instance is that of a late Governor-General of India, whoon being thrown in the hunting-field was found to be paralysed in allfour extremities; Paget diagnosed a total transverse lesion of thecervical cord with the necessary inference that it would inevitablyhave a fatal termination. The fact that the patient recoveredcompletely, and was later able to fill two Viceroyalties, proved thatthe lesion must have been of the nature of a concussion of the cord. The _treatment_ consists in adopting the same measures as in crushingof the cord, while careful watch is observed for the signs of recoveryof conduction. The usual order of recovery is first the reflexes, thensensation, and lastly, the motor functions. #Traumatic Spinal Hæmorrhage. #--Hæmorrhage into the vertebral canal isa common accompaniment of all forms of injury to the spine, but thelower cervical region is the common seat of the severe type ofhæmorrhage resulting from acute flexion of the spine such as occursespecially in a fall on the head from a horse or a vehicle in motion. The blood may be effused around the cord--between it and thedura--(extra-medullary), or into its substance (intra-medullary). _Extra-medullary Hæmorrhage--Hæmatorrachis. _--The symptoms associatedwith extra-medullary hæmorrhage are at first of an irritativekind--muscular cramps and jerkings, radiating pains along the courseof the nerves pressed upon, and hyperæsthesia. It is only when theblood accumulates in sufficient quantity to exert definite pressure onthe cord that symptoms of paralysis ensue, and it is characteristic ofextra-medullary hæmorrhage that the paralysis comes on gradually. Whenthe effusion is in the cervical region--the commonest situation--thearms are more affected than the legs. The paralysis of the arms is ofthe lower neurone type, and the muscles are flaccid and undergoatrophy; the legs may exhibit a more complete degree of paralysis ofthe upper neurone type, with exaggeration of the knee-jerks. Blood maytrickle down the canal and collect at a level lower than that of thelesion which causes the bleeding, and produce paralysis which slowlyspreads from below upwards--_gravitation paraplegia_ (Thorburn). Thereis blood in the cerebro-spinal fluid. The _treatment_ is on the same lines as in total transverse lesions. When there is evidence of progressive pressure on the cord, the bloodis removed by spinal puncture if possible, or by laminectomy performedat the level suggested by the symptoms; operation is, however, rarelycalled for. _Intra-medullary Hæmorrhage--Hæmatomyelia. _--Traumatic hæmorrhage intothe substance of the cord occurs almost invariably in the lowercervical region, and results from forcible stretching of the cord byacute flexion of the neck. The blood is usually effused into theanterior cornua of the grey matter and into the central canal, andthere is a varying degree of laceration of the nerve tissue, inaddition to pressure exerted by the extravasated blood. The severity of the _clinical features_ depends upon the extent of thelesion. In contrast with what results in extra-medullary hæmorrhage, the symptoms are paralytic from the outset. When the hæmorrhage is only sufficient to cause _pressure_ on thecord, the paralysis is usually most marked in the lower extremitiesbecause the conducting fibres are pressed upon. This is associatedwith evanescent anæsthesia for temperature and pain, while tactilesensibility is preserved. There is retention of urine and fæces, andin young men, priapism. As the fibres which supply the dilator pupillæare involved, the pupils are contracted. The symptoms graduallysubside as the extravasated blood is re-absorbed, sensation beingrestored before motion, and recovery may be comparatively rapid. When the blood extravasated in the cord causes disintegration of itssubstance, there is complete paralysis with atrophy, and anæsthesia inthe area supplied by the segments of the cord directly implicated. Theparalysis in the parts below the lesion assumes the spastic form. Asthe lesion is usually in the upper part of the cord, it is the armsthat are most frequently affected. In less severe degrees of damagethe paralysis of the most distant parts, _e. G. _ the feet, may betransitory. Even in cases in which the loss of function below thelevel of the lesion has been complete, recovery may take place, but itis apt to be marred by a spastic condition of the muscles concerned, due to sclerotic changes in the cord. Except that operative treatment is contra-indicated, the _treatment_is the same as for extra-medullary hæmorrhage, and at a later periodmeasures may be employed to relieve the spastic condition of themuscles. #Total Transverse Lesions. #--Total transverse lesions, that is, thosein which the cord is completely crushed or torn across, are much morecommon than partial lesions, being an almost invariable accompanimentof a complete dislocation or of a fracture-dislocation of the spine. Even when the displacement of the vertebræ is only partial andtemporary, the cord may be completely torn across. Similar lesions mayresult from stabs or bullet-wounds. From the records of cases in which the vertebræ were injured by modernrifle bullets, even although the bony walls of the spinal canal hadnot been fractured and no hæmorrhage had occurred within the spinalcanal, the cord in the vicinity was degenerated into a "custard-likematerial" incapable of any conducting power (Makins). According toStevenson, "this must have been due to the vibratory concussioncommunicated to it by the passage of the bullet at a high rate ofvelocity. " The importance of this observation lies in the fact that insuch cases no benefit can follow operative interference. The _clinical features_ vary with the level at which the cord isinjured, and the diagnosis as to the nature and site of the lesion isto be made by a careful analysis of the symptoms. By gently passingthe fingers under the patient's back as he lies recumbent, anyirregularity in the spinous processes or laminæ may be detected, butmovement of the patient to admit of a more direct examination of thespine is attended with considerable risk, and should be avoided. Skiagrams are indispensable, as they show the exact site and nature ofthe lesion. _Immediate Symptoms. _--At whatever level the cord is damaged there isimmediate and complete paralysis of motion and sensation (paraplegia)below the seat of injury, and the paralysed limbs at once becomeflaccid. On careful examination, a narrow zone of hyperæsthesia may bemapped out above the anæsthetic area, and the patient may complain ofradiating pain in the lines of the nerves derived from the segments ofthe cord directly implicated. In complete transverse lesions theparalytic symptoms are symmetrical; any marked difference on the twosides indicates an incomplete lesion. Retention of urine and retention or incontinence of fæces are constantsymptoms. In young men priapism is common--the corpus cavernosum penisis filled with blood without actual erection. There is other evidenceof vaso-motor paralysis in the form of dilatation of the subcutaneousvessels, and local elevation of temperature in the paralysed parts. The deep reflexes, including the tendon reflexes, are permanentlylost. Unless regularly emptied by the catheter, the bladder becomesdistended, and there is dribbling of urine--the overflow from the fullbladder. As the bladder is unable to empty itself, and its trophicnerve supply is interfered with, the use of the catheter involvesconsiderable risk of infection, unless the most rigid precautions areadopted. Hypostatic pneumonia is liable to develop. Great care innursing is necessary to prevent trophic sores occurring over partssubjected to pressure, such as the sacrum, the scapulæ, the heels, andthe elbows. _Later symptoms_ are the result of descending degeneration takingplace in the antero-lateral columns of the cord. There are oftenviolent and painful jerkings of the muscles of the limbs; the musclesbecome rigid and the limbs flexed. _Treatment. _--When the cord is completely divided, no benefit canfollow operative interference, and treatment is directed towards theprevention of infective complications from cystitis and bed-sores. #Injuries of the Cord at Different Levels. #--_CervicalRegion. _--Complete lesions of the _first four cervical segments_--thatis, above the level of the disc between the third and fourth cervicalvertebræ--are always rapidly, if not instantaneously, fatal, asrespiration is at once arrested by the destruction of the fibreswhich go to form the phrenic nerve. It is from this cause that deathresults in judicial hanging. In lesions between the _fifth cervical and first thoracic segmentsinclusive_, all four limbs are paralysed. Sensation is lost below thesecond intercostal space. The parts above this level retain sensation, as they are supplied by the supra-clavicular nerves which are derivedfrom the fourth cervical segment (Fig. 205). Recession of theeyeballs, narrowing of the palpebral fissures, and contraction of thepupils result from paralysis of the cervical sympathetic. Respirationis almost exclusively carried on by the diaphragm, and hiccup isoften persistent. There is at first retention of urine, followed bydribbling from overflow, and sugar is sometimes found in the urine. Priapism is common. The pulse is slow (40 to 50) and full; and thetemperature often rises very high--a symptom which is always of graveomen. [Illustration: FIG. 205. --Distribution of the Segments of the SpinalCord. (After Kocher. )] When the lesion is confined to the _sixth cervical segment_, the armsassume a characteristic attitude as a result of the contraction of themuscles supplied from the higher segments. The upper arm is abductedand rotated out, the elbow is sharply flexed, and the hand supinatedand flexed (Fig. 206). Sensation is retained along the radial side ofthe limb. [Illustration: FIG. 206. --Attitude of Upper Extremities in TraumaticLesions of the Sixth Cervical Segment. The prominence of the abdomenis due to gaseous distension of the bowel. ] Total lesions of the lower cervical segments are usually fatal in fromtwo to three days to as many weeks, from embarrassment of respirationand hypostatic pneumonia. When the lesion is confined to _the first thoracic segment_, theattitude of the arms is usually that of slight abduction at theshoulder and flexion at the elbow, the forearms lie semi-pronated onthe chest or belly, and there is slight flexion of the fingers. Thereis complete anæsthesia as high as the level of the second interspace, and along the distribution of the ulnar nerve (Fig. 205); therespiration is entirely diaphragmatic; and the ocular changesdepending on paralysis of the cervical sympathetic are present. _Thoracic Region. _--In injuries of the thoracic region--second toeleventh thoracic segments inclusive--the anæsthesia below the levelof the lesion is complete and its upper limit runs horizontally roundthe body, and not parallel with the intercostal nerves. Above theanæsthetic area there is a zone of hyperæsthesia, and the patientcomplains of a sensation as if a band were tightly tied round thebody--"girdle-pain. " The motor paralysis and the anæsthesia are co-extensive. Theintercostal muscles below the seat of the lesion and the abdominalmuscles are paralysed. The respiratory movements are thus impeded, and, as the patient is unable to cough, mucus gathers in theair-passages and there is a tendency to broncho-pneumonia. As thepatient is unable to aid defecation or to expel flatus by straining, the bowel is liable to become distended with fæces and gas, and themeteorism which results adds to the embarrassment of respiration bypressing on the diaphragm. There is retention of urine followed bydribbling from overflow. As the reflex arc is intact there may beinvoluntary and unconscious micturition whenever the bladder fills. If infection of the bladder and the formation of bed-sores areprevented, the patient may live for months or even for years. At anytime, however, infection of the bladder may occur and spread to thekidneys, setting up a pyelo-nephritis; or the patient may develop anascending myelitis, and these conditions are the most common causes ofdeath. _Lumbo-sacral Region. _--All the spinal segments representing thelumbar, sacral, and coccygeal nerves lie between the level of theeleventh thoracic and first lumbar vertebræ. Injuries of the lowerthoracic and upper lumbar vertebræ, therefore, may produce completeparalysis within the area of distribution of the lumbar and sacralplexuses. The anæsthesia reaches to about the level of the umbilicus. There is incontinence of urine and fæces from the first. Priapism isabsent. Bed-sores and other trophic changes are common, and there isthe usual risk of complications in relation to the urinary tract. _Conus Medullaris. _--A lesion confined to the conus medullaris mayresult from a fall in the sitting position. It is attended with slightweakness of the legs, anæsthesia involving a saddle-shaped area overthe buttocks and back of the thighs, the perineum, scrotum, and penis. The urethra and anal canal are insensitive, and there is paralysis ofthe levatores ani, the rectal and the vesical sphincters. The testesretain their sensation. _Cauda Equina. _--As the cord terminates opposite the lower border ofthe first lumbar vertebra, injuries below this level implicate thecauda equina. The extent of the motor and sensory paralysis varieswith the level of the lesion and with the particular nerves injured. Sometimes it is complete, sometimes, selective. As a rule all themuscles of the lower extremity are paralysed, except those supplied bythe femoral (anterior crural), obturator, and superior gluteal nerves. The perineal and penile muscles are also implicated. There isanæsthesia of the penis, scrotum, perineum, lower half of the buttock, and the entire lower extremity, except the front and lateral aspectsof the thigh, which are supplied by the lateral cutaneous nerve andthe cutaneous branches of the femoral (anterior crural). There isincontinence of urine and fæces. The prognosis is more favourable thanin lesions affecting the cord itself, and the only risk to life is theoccurrence of infective complications. #Partial Lesions of the Cord and Nerve Roots. #--Partial lesions, suchas bruises, lacerations, or incomplete ruptures, are always attendedwith hæmorrhage into the substance of the cord, and usually resultfrom distortions or incomplete fractures and dislocations of thespine, or from bullet wounds. They are comparatively rare. When the _nerve roots_ alone are injured, sensory phenomenapredominate. Formication, radiating pains, and neuralgia are presentin the area of distribution of the nerves implicated. There is motorparesis or paralysis, which may disappear either suddenly orgradually, or may persist and be followed by atrophy of the musclesconcerned. In contrast to what is observed from pressure by tumoursand inflammatory products, twitchings and cramps are rare. In _partial lesions of the cord_ the motor phenomena predominate. Paresis extends to the whole of the motor area below the seat of thelesion, but the weakness is more marked on one side of the body. Thedistal parts--feet and legs--suffer more than the proximal--arms andhands, and the extensors more than the flexors. The paresis developsslowly, varies in extent and degree, and may soon improve. Vaso-motordisturbances accompany the motor symptoms. Irritative phenomena, suchas twitchings or contractures, may come on later. The deep reflexes, particularly the knee-jerks, may be absent atfirst, but they soon return, and are usually exaggerated; awell-marked Babinski response may appear later. Abolition of thereflexes, therefore, does not necessarily indicate completedestruction of the cord, but their return is conclusive evidence thatthe lesion is a partial one. It is necessary, therefore, to deferjudgment until it is determined whether the abolition of the reflexesis temporary or permanent. Sensory disturbances may be entirely absent. When present, they areincomplete, and are chiefly irritative in character. They may notreach the same level as the motor phenomena, and the different sensoryfunctions are unequally disturbed in the areas corresponding to theseveral nerve roots. There is sometimes a combination of hyperæsthesiaon one side and anæsthesia on the other. Retention of urine is not always present even in those cases in whichthe limbs are completely paralysed, as the fibres of one side of thecord are sufficient to maintain the functions of the bladder. Thepatient may be aware that the bladder is full, although he is unableto empty it. Similarly, sensation in the rectum and anus may beretained although the control of the sphincters is lost. Priapism maybe present, but tends to disappear. In partial lesions, the difficulties of diagnosis are sometimesincreased by the occurrence of hæmorrhage into the substance of thecord, so that symptoms of generalised pressure are superadded to thoseof the partial lesion. In time the symptoms due to the intra-medullaryhæmorrhage pass off, but those due to the tearing of the cord persist. The _prognosis_ is generally favourable, but must be guarded, aspermanent organic changes in the cord may take place, causing aspastic condition of the muscles. When recovery is taking place thefirst signs are the return of the knee-jerks, and a gradual change inthe limbs from the flaccid to the spastic condition. Sensibilityreturns in the order--touch, pain, temperature, and the parts suppliedby the lowest sacral segments usually become sentient first. Voluntarypower returns earlier in the flexors than in the extensors, andflexion of the toes is almost invariably the earliest voluntarymovement possible. Infection from bed-sores or from the urinary tractis the most common cause of death in cases that terminate fatally. The _treatment_ is carried out on the same lines as for total lesions. Laminectomy, however, is indicated when there is reason to believethat the pressure is due to some cause, such as a blood-clot or adisplaced fragment of bone, which is capable of being removed. In practice when a person has lost the power of the lower extremitiesas the result of an accident, there are three conditions requiringultimate differentiation--a concussion of the cord alone, a totaltransverse lesion and a partial lesion of the cord together withconcussion. It must again be emphasised that it may not be possible todifferentiate between these immediately after the accident. Two orthree days may elapse before it is possible to give a definiteopinion. "#Railway Spine. #"--This term is employed to indicate a disturbance ofthe nervous system which may develop in persons who have been inrailway accidents, but a similar group of symptoms is met with in menengaged in laborious occupations such as coal-miners, who, after aninjury to the back, develop symptoms referable to the nervous systemon account of which they claim compensation not infrequently in thelaw-courts. It is a remarkable fact that it seldom occurs in railwayemployees, or in passengers who sustain gross injuries, such asfractures or lacerated wounds. _Clinical Features. _--The patient usually gives a history of havingbeen forcibly thrown backwards and forwards across the carriage at thetime of the accident. He is dazed for a moment and suffers from shockor, it may be, is little the worse at the time, and is able tocontinue his journey. On reaching his destination, however, he feelsweak and nervous, and complains of pain in his back and limbs. Thereis rarely any sign of local injury. For a few days he may be able toattend to business, but eventually feels unfit, and has to give it up. The symptoms that subsequently develop are for the most partsubjective, and it is difficult therefore either to corroborate or torefute them; it will be observed that while some of them are referableto the cord the greater number are referable to the brain. Theyusually include a feeling of general weakness, nervousness, andinability to concentrate the attention on work or on business matters. The patient is sleepless, or his sleep is disturbed by terrifyingdreams. His memory is defective, or rather selective, as he canusually recall the circumstances of the accident with clearness andaccuracy. He becomes irritable and emotional, complains of sensationsof weight or fullness in the head, of temporary giddiness, ishypersensitive to sounds, and sometimes complains of noises in theears. There are weakness of vision and photophobia, but there are noophthalmoscopic changes. He has pain in the back on making anymovement, and there is a diffuse tenderness or hyperæsthesia along thespine. There is weakness of the limbs, sometimes attended withnumbness, and he is easily fatigued by walking. There may be loss ofsexual power and irritability of the bladder, but there is seldom anydifficulty in passing urine. The patient tends to lose weight, and mayacquire an anxious, careworn expression, and appear prematurely aged. Special attention should be directed to the condition of the deepreflexes and to the state of the muscles, as any alteration in thereflexes or atrophy of the muscles indicates that some definiteorganic lesion is present. As the symptoms are so entirely subjective, it is often extremelydifficult to exclude the possibility of malingering; it is essentialthat the patient should be examined with scrupulous accuracy atregular intervals and careful notes made for purposes of comparison, and also that the doctor should retain an impartial attitude and notdevelop a bias either in favour of or against the patient's claim forcompensation. So long as litigation is pending the patient derives little benefitfrom treatment, but after his mind is relieved by the settlement ofhis claim--whether favourable to him or not--his health is usuallyrestored by the general tonic treatment employed for neurasthenia. INJURIES OF THE VERTEBRAL COLUMN _Partial_ lesions include twists or sprains, isolated dislocations ofarticular processes, isolated fractures of the arches and spinousprocesses, and isolated fractures of the vertebral bodies. The mostimportant _complete_ lesions are total dislocations andfracture-dislocations. In partial lesions, the continuity of the column as a whole is notbroken, and the cord sustains little damage, or may entirely escape;in complete lesions, on the other hand, the column is broken and thecord is always severely, and often irreparably, damaged. Twists and dislocations are most common in the cervical region, thatis, in the part of the spine where the forward range ofmovement--flexion--is greatest. Fractures are most common in thelumbar region, where flexion is most restricted. Fracture-dislocationsusually occur where the range of flexion is intermediate, that is, inthe thoracic region. In all lesions accompanied by displacement, the upper segment of thespine is displaced forwards. #Twists# or #sprains# are produced by movements that suddenly put theligamentous and muscular structures of the spine on the stretch--inother words, by lesser degrees of the same forms of violence asproduce dislocation. When the interspinous and muscular attachmentsalone are torn, the effects are confined to the site of thesestructures, but when the ligamenta flava are involved, blood may beextravasated and infiltrate the space between the dura and the boneand give rise to symptoms of pressure on the cord. The nerve rootsemerging in relation to the affected vertebræ may be stretched orlacerated, and as a result radiating pains may be felt in the area oftheir distribution. In the _cervical_ region, distortion usually results either fromforcible extension of the neck--for example from a violent blow orfall on the forehead forcing the head backwards--or from forcibleflexion of the neck. The patient complains of severe pain in the neck, and inability to move the head, which is often rigidly held in theposition of wry-neck. There is marked tenderness on attempting tocarry out passive movements, and on making pressure over the affectedvertebræ or on the top of the head. The maximum point of tendernessindicates the vertebra most implicated. In diagnosis, fracture anddislocation are excluded by the absence of any alteration in therelative positions of the bony points, and by the fact that passivemovements, although painful, are possible in all directions. In the _lumbar_ region sprains are usually due to over-exertion inlifting heavy weights, or to the patient having been suddenly thrownbackwards and forwards in a railway collision. The attachments of themuscles of the loins are probably the parts most affected. The back iskept rigid, and there is pain on movement, particularly on rising fromthe stooping posture. _Treatment. _--Unless carefully treated, a sprain of the spine isliable to cause prolonged disablement. The patient should be kept atrest in bed, and, when the injury is in the cervical region, extensionshould be applied to the head with the nape of the neck supported on aroller-pillow. Early recourse should be had to massage, but activemovements are forbidden till all acute symptoms have disappeared. Inpatients predisposed to tuberculosis, the period of complete restshould be materially prolonged. #Isolated Dislocation of Articular Processes. #--This injury, which ismost frequently met with in the cervical region and is nearly alwaysunilateral, is commonly produced by the patient falling from a vehiclewhich suddenly starts, and landing on the head or shoulders in such away that the neck is forcibly flexed and twisted. The articularprocess of the upper vertebra passes forward, so that it comes to liein front of the one below. The pain and tenderness are much less marked than in a simple twist, as the ligaments are completely torn and are therefore not in a stateof tension. The patient often thinks lightly of the condition at thetime of the accident, and may only apply for advice some time afteron account of the deformity. The head is flexed and the face turnedtowards the side opposite the dislocation, the attitude closelyresembling that of ordinary wry-neck, only it is the oppositesterno-mastoid that is tight. The bony displacement is best recognisedby palpating the transverse process of the dislocated vertebra. In thecase of the upper vertebræ this is done from the pharynx, in the lowerbetween the sterno-mastoid and the trachea. There is pain onattempting movement, and tenderness on pressure, particularly on theside that is not displaced, as the ligaments there are on the stretch. There are often radiating pains along the line of the nerves emergingbetween the affected vertebræ. As the bodies are not separated, damageto the cord is exceptional. The lesion can usually be recognised in aradiogram. _Treatment. _--Reduction should be attempted at once, before thevertebræ become fixed in their abnormal position. Under anæsthesiagentle extension is made on the head by an assistant, and the abnormalattitude is first slightly exaggerated to relax the ligaments and torestore mobility to the locked articular processes. The head is thenforcibly flexed towards the opposite side, after which it can berotated into its normal attitude (Kocher). Haphazard movements toeffect reduction are attended with risk of damaging the cord. Afterreduction has been effected, the treatment is the same as that of asprain. #Isolated Fractures of the Arches, Spinous and TransverseProcesses. #--Fractures of the arches and spinous processes usuallyresult from direct violence, such as a blow or a bullet wound, and areaccompanied by bruising of the overlying soft parts, irregularity inthe line of the spines, and by the ordinary signs of fracture. Skiagrams are useful in showing the exact nature of the lesion. Thesefractures are most common in the lower cervical and in the thoracicregions, where the spines are most prominent and therefore mostexposed to injury. In many cases there are no symptoms of damage to the cord or spinalnerves, but when both laminæ give way the posterior part of the archmay be driven in and cause direct pressure on the cord, or blood maybe effused between the bone and the dura. In such cases immediateoperation is indicated. When there are no cord symptoms, the treatmentconsists in securing rest, with the aid of extension, if necessary, for several weeks until the bones are reunited. The use of the X-rays has shown that one or more of the _transverseprocesses of the lumbar vertebræ_ may be chipped off by directviolence. The symptoms are pain and tenderness in the region of thefracture, and marked restriction of movement, especially in thedirection of flexion. This lesion may explain some of the cases ofpersistent pain in the back following injuries in workmen. It isimportant to remember, however, that in a radiogram an un-unitedepiphysis may simulate a fracture. #Isolated Fracture of the Bodies--"Compression Fracture. "#--The"compression fracture" consists in a crushing from above downwards ofthe bodies--and the bodies only--of one or more vertebræ. It is due tothe patient falling from a height and landing on the head, buttocks, or feet in such a way that the force is transmitted along the bodiesof the vertebræ while the spine is flexed. If the patient lands on his head, the compression fracture usuallyinvolves the lower cervical or upper thoracic vertebræ. When he landson his buttocks or feet it is usually the lumbar or the lower thoracicvertebræ that are fractured (Fig. 207). [Illustration: FIG. 207. --Compression Fracture of Bodies of Third andFourth Lumbar Vertebræ. Woman, æt. 28, who fell three storeys andlanded on the buttocks. ] As a rule, there are no external signs of injury over the spine. Thesternum, however, is often fractured, and irregularity anddiscoloration may be detected on examining the front of the chest. Therecognition of a fracture of the sternum should always raise thesuspicion of a fracture of the spine. On examination of the back amore or less marked projection of the spinous processes of the damagedvertebræ may be recognised. In the cervical and lumbar regions thisprojection may merely obliterate the normal concavity. The spinousprocess which forms the apex of the projection belongs to the vertebraabove the one that is crushed. The cord usually escapes, but thenerves emerging in relation to the damaged vertebræ may be bruised, and this gives rise to girdle-pain. Local tenderness is elicited on pressing over the affected vertebræ. As might be expected from the nature of the accident producing thislesion, it is often associated with serious injuries to the head, limbs, or internal organs which gravely affect the prognosis. The _treatment_ consists in taking the pressure off the injuredvertebræ in order that the reparative material may be laid down insuch a way as to restore the integrity of the column. In the cervicalregion, extension is applied to the head, and a roller-pillow placedbeneath the neck. In the lumbar region, the extension is appliedthrough the lower limbs, and the pillow placed under the loins. Thepatient is confined to bed for six or eight weeks, and before he getsup a poroplastic or plaster-of-Paris jacket is applied. This is wornfor a month or six weeks. #Traumatic Spondylitis. #--This condition is liable to develop inpatients who have sustained a severe injury to the back. It isbelieved to originate in a compression fracture which has not beenrecognised, and is probably due to the callus thrown out for therepair of the fracture being subjected to strain and pressure tooearly, or to a progressive softening of the injured vertebra and ofthe bodies of those adjacent to it. This leads to an alteration in theshape of the affected bones, which can be demonstrated by means of theX-rays. The usual history is that some considerable time after thepatient has resumed work he suffers from pain in the back, andradiating pains round the body and down the legs. He becomes more andmore unfit for work, and a marked projection appears in the back andmay come to involve several vertebræ. While the condition isprogressive, the prominent vertebræ are painful and tender. In courseof time the softening process is arrested, and the affected bonesbecome fused, so that the area of the spine involved becomes rigid andpermanent deformity results. So long as the condition is progressivethe patient should be kept in the recumbent and hyper-extendedposition over a roller-pillow and, when he gets up, the spine shouldbe supported by a jacket. #Dislocation and Fracture-Dislocation. #--It is seldom possible at thebedside to distinguish between a complete dislocation of the spine anda fracture-dislocation. _Fracture-dislocation_ is by far the morecommon lesion of the two, and is the injury popularly known as a"broken back. " It may occur in any part of the column, but is mostfrequently met with in the thoracic and thoracico-lumbar regions. Itusually results from forcible flexion of the spine, as, for example, when a miner at work in the stooping posture is struck on theshoulders by a heavy fall of coal. The spine is acutely bent, andbreaks at _the angle of flexion and not at the point struck_. Thelesion consists in a complete bilateral dislocation of the articularprocesses, together with a fracture through one or more of the bodies. This fracture is usually oblique, running downwards and forwards. Theupper fragment with the segment of the spine above it is displaceddownwards and forwards, and the cord is crushed between the posterioredge of the broken body and the arch of the vertebra above it (Fig. 208). In almost every case the cord is damaged beyond repair. [Illustration: FIG. 208. --Fracture--Dislocation of Ninth ThoracicVertebra, showing downward and forward displacement of upper segment, and compression of cord by upper edge of lower segment. (Anatomical Museum, University of Edinburgh. )] _Total dislocation_, in which the articular processes on both sidesare displaced and the contiguous intervertebral disc separated, israre, and is met with chiefly in the lower cervical region. _Clinical Features. _--The outstanding symptoms of total lesions arereferable to the damage inflicted on the cord. The diagnosis shouldalways be made by a consideration of the mechanism of the injury andthe condition of the nerve functions below the lesion. On no accountshould the patient be moved to enable the back to be examined, as thisis attended with risk of increasing the displacement and causingfurther damage to the cord. On passing the fingers under the back asthe patient lies recumbent, it is usually found that there is somebackward projection of the spinous processes, the most prominentbeing that of the broken vertebra. The spinous process immediatelyabove it is depressed as the upper segment has slipped forward. Pain, tenderness, swelling and discoloration may be present over the injuredvertebræ. It is usually possible to have skiagrams taken without riskof further damage to the spine. There is complete loss of motion andsensation below the seat of the lesion. The symptoms of totaltransverse lesions of the cord at different levels have already beendescribed (p. 416). _Treatment. _--An attempt may be made to reduce the displacement underanæsthesia, gentle traction being made in the long axis of the spineby assistants, while the surgeon attempts to mould the bones intoposition. No special manipulations are necessary, as the ligaments areextensively torn, and the bones are, as a rule, readily replaced. Aroller-pillow is placed under the seat of fracture to allow the weightof the body above and below to exert gentle traction, and so torelieve pressure on the cord. Operative treatment is almost never ofany avail, as the cord is not merely pressed upon, but is severelycrushed, or even completely torn across. Even when the cord is onlypartially torn, operative treatment is not likely to yield betterresults than are obtained by reduction and extension. The usualprecautions must be taken to prevent cystitis and bed-sores. Total fracture-dislocation between the _atlas_ and _epistropheus_(axis), if attended with displacement, is instantaneously fatal (Fig. 209). This is the osseous lesion that occurs in judicial hanging. Fracture of the odontoid process may occur, however, withoutdisplacement, the transverse ligament retaining the fragment inposition and protecting the cord from injury. The patient complains ofstiff neck and pain, and the lesion may be recognised in a radiogram. A number of cases are recorded in which death took place suddenlyweeks or months after such an injury, from softening of the transverseligament and displacement of the bones. [Illustration: FIG. 209. --Fracture of Odontoid Process of AxisVertebra. ] #Penetrating Wounds. #--These result from stabs or gun-shot accidents, and are practically equivalent to compound fractures of the spine;their severity depends on the extent of the damage done to the cord, and on whether or not the wound is infected. In many cases thecondition is complicated by injuries of the pleural or peritonealcavities and their contained viscera, or by injury of the trachea, œsophagus, or large vessels and nerves of the neck. When the membranesof the cord are opened, the profuse and continued escape ofcerebro-spinal fluid may prove a serious complication. _Treatment. _--The wound of the soft parts is treated on the usuallines. When the spinous processes and laminæ are driven in upon thecord, they must be elevated at once by operation. In injuriesinvolving the lumbo-sacral region it is sometimes advisable to performlaminectomy for the purpose of suturing divided nerve cords. When there is evidence that the spinal cord is completely divided, operation is contra-indicated. Attempts have been made to unite thetwo ends of the divided cord by sutures, but there is as yet noauthentic record of restoration of function following the operation. CHAPTER XVII DISEASES OF THE VERTEBRAL COLUMN AND SPINAL CORD POTT'S DISEASE: _Pathology_; _Clinical features_--Pott's disease as it affects different regions of the spine--Disease of the sacro-iliac joint; Syphilitic disease of spine; Tumours of vertebræ; Hysterical spine; Acute osteomyelitis; Rheumatic spondylitis; Arthritis deformans; Coccydynia; Tumours of cord and membranes--Spinal meningitis; Spinal myelitis--Congenital deformities: _Spina bifida_; _Congenital sacro-coccygeal tumours_. Congenital sacro-coccygeal sinuses and fistulæ. TUBERCULOUS DISEASE OF THE SPINE--POTT'S DISEASE Percival Pott, in 1779, first described a disease of the vertebralcolumn which is characterised by erosion and destruction of the bodiesof the vertebræ. It is liable to produce an angular deformity of thespine, and to be associated with abscess formation and with nervoussymptoms referable to pressure on the cord. This disease is now knownto be tuberculous. It may occur at any period of life, but in at least50 per cent. Of cases it attacks children below the age of ten andrarely commences after middle life. #Morbid Anatomy. #--The tuberculous process may affect any portion ofthe spine, and as a rule is limited to one region; several vertebræare usually simultaneously involved. The disease may begin either inthe interior of the bodies of the vertebræ--tuberculousosteomyelitis--or in the deeper layer of the periosteum on theanterior surface of the bones--tuberculous periostitis. _Osteomyelitis_ is the form most frequently met with in children. Thedisease commences as a tuberculous infiltration of the marrow, whichresults in softening of the bodies of the affected vertebræ, particularly in their anterior parts, and, as the disease progresses, caseation and suppuration ensue, and the destructive process spreadsto the adjacent intervertebral discs. In some cases a sequestrum isformed, either on the surface or in the interior of a vertebra. Thepus usually works its way towards the front and sides of the bones, and burrows under the anterior longitudinal (common) ligament. Lessfrequently it spreads towards the vertebral canal and accumulatesaround the dura, causing pressure on the cord. The compression of the diseased vertebræ by the weight of the head andtrunk above the seat of the lesion, and by the traction of the musclespassing over it, produces angling of the vertebral column. Theanterior portions of the bodies being more extensively destroyed, sinkin, while the less damaged posterior portions and the intact articularprocesses prevent complete dislocation. In this way the integrity ofthe canal is maintained, and the cord usually escapes being pressedupon. The spinous processes of the affected vertebræ project and forma prominence in the middle line of the back. When, as is usually thecase, only two or three vertebræ are implicated, this prominence takesthe form of a sharp angular projection, while if a series of vertebræare involved, the deformity is of the nature of a gentle backwardcurve (Fig. 210). [Illustration: FIG. 210. --Tuberculous Osteomyelitis affecting severalvertebræ at Thoracico-lumbar Junction. ] The _periosteal form_ of vertebral tuberculosis is that mostfrequently met with in adults. The disease begins in the deeper layerof the periosteum on the anterior aspect of the vertebræ, and extendsalong the surface of the bones, causing widespread superficial caries. It may attack the discs at their margins, and spread inwards betweenthe discs and the contiguous vertebræ. Owing to the comparativelywide area of the spine implicated, this form of the disease is notattended with angular deformity, but rather with a wide backwardcurvature which corresponds in extent to the number of vertebræaffected. The accumulation of tuberculous pus under the periosteum andanterior longitudinal ligament is the first stage in the formation ofthe large abscesses with which this form of spinal tuberculosis is socommonly associated. _Effects on the Spinal Cord and Nerve Roots. _--In some cases the cordand nerve roots are pressed upon by an œdematous swelling of themembranes; in others, the tuberculous process attacks the dura materand gives rise to the formation of granulation tissue on its outeraspect--_tuberculous pachymeningitis_. Less frequently a collection ofpus forms between the bone and the dura, and presses the cord backagainst the laminæ. The cord is rarely subjected to pressure as aresult of curving of the spine alone, but occasionally, especially inthe cervical region, a sequestrum becomes displaced backward andexerts pressure on it, and it sometimes happens, also in the cervicalregion, that the cord is nipped by sudden displacement of diseasedvertebræ--a condition comparable to a fracture-dislocation of thespine. The severity of the symptoms is aggravated by the occurrence ofinflammation of the cord--_myelitis_--which is not due to tuberculousdisease, but to interference with its blood-supply from the associatedmeningitis. _Repair. _--When the progress of the disease is arrested, the naturalcure of the condition is brought about by the bodies of the affectedvertebræ becoming fused by osseous ankylosis (Fig. 211). While thisreparative process is progressing, the cicatricial contraction rendersthe angular deformity more acute, and it may go on increasing untilthe bones are completely ankylosed; this reparative process can befollowed in successive skiagrams. An increase in the projection in theback, therefore, is not necessarily an unfavourable symptom, although, of course, it is undesirable. [Illustration: FIG. 211. --Osseous Ankylosis of Bodies (_a_) of DorsalVertebræ, (_b_) of Lumbar Vertebræ following Pott's disease. There ismarked kyphosis at the seat of the disease and compensatory lordosisabove and below. (Museum of the Royal College of Surgeons, Edinburgh. )] [Illustration: FIG. 212. --Radiogram of Museum Specimen of Pott'sdisease in a Child; the disease is located at the thoracico-lumbarjunction. (Dr. Hope Fowler. )] In rare cases the disease affects only the articular or the spinousprocesses, producing superficial caries and a localised abscess. #Clinical Features. #--The clinical features of Pott's disease vary sowidely in different regions of the spine, that it is necessary toconsider each region separately. To avoid repetition, however, certaingeneral features may be first described. _Pain. _--In the earliest stages, the patient complains of a feeling oftiredness, which prevents him walking far or standing for any lengthof time. Later, there is a constant, dull, gnawing pain in the back, increased by any form of movement, particularly such as involvesjarring or bending of the spine. If the patient is a child, it isnoticed that he ceases to play with his companions, and inclines tosit or lie about, usually assuming some attitude which tends to takethe weight off the affected segment of the spine (Figs. 214, 217). Ifhe is going about, the pain increases as the day goes on, but may passoff during the night. It is often referred along the course of thenerves emerging between the diseased vertebræ, and takes the form ofheadache, neuralgic pains in the arms or side, girdle-pain, orbelly-ache, according to the seat of the lesion. Tenderness may beelicited on pressing over the spinous or transverse processes of thediseased vertebræ, or on making pressure in the long axis of thespine. These tests, however, are not of great diagnostic value, andthey should be omitted, as they cause unnecessary suffering. It is tobe borne in mind that in some cases the disease is not attended withany pain. _Rigidity. _--The pain produced by movement of the diseased portion ofthe spine causes reflex contraction of the muscles passing over it, and the affected segment of the column is thus rendered rigid. If thepalm of the hand is placed over the painful area while the patientattempts to make movements of stooping, nodding, or turning to theside, it is found that the vertebræ implicated move _en bloc_ insteadof gliding on one another. This rigidity of the diseased portion ofthe column with "boarding" of the muscles of the back is one of theearliest and most valuable diagnostic signs of Pott's disease. _Deformity. _--The most common and characteristic deformity is anabnormal antero-posterior curvature, with its convexity backwards. Thesituation, extent, and acuteness of the bend vary with the region ofthe spine affected, the situation of the disease in the bone, and thenumber of vertebræ implicated. When the disease has destroyed thebodies of one or two vertebræ, a short, sharp, angular deformityresults; when it affects the surface of several bones, a long, widecurvature. Lateral deviation is occasionally met with in the early stages of thedisease as a result of unequal muscular contraction, and in the laterstages from excessive destruction of one side of a vertebra, or frompartial luxation between two diseased vertebræ. _Abscess Formation. _--Spinal abscesses occur with greater frequencyand at an earlier stage in adults than in children, because in adultsthe disease usually begins on the surface of the vertebræ. Pyogenicinfection of such abscesses after they have burst externallyconstitutes one of the chief risks to life in Pott's disease. _X-Ray Appearances. _--These, when considered along with the clinicalsigns, usually afford valuable information as to the exact seat andnature of the lesion and the number of vertebræ involved. It isrecommended to compare the skiagram with that of the normal spine fromthe same region and from a patient of approximately similar age. Theoutlines of the bodies are woolly or blurred; in the early stage theremay be clear areas corresponding to cheesy foci. In progressive casesthe bodies may be altered in shape and in size, and from destructionand collapse of the bones there is altered spacing, both of the bodiesand of the ribs. In the interpretation of skiagrams, help is oftenobtained from an alteration in the axis of bodies, an angulardeviation often drawing attention to the lesion which is located atthe "angle. " In children (Fig. 213) there is often a spindle-shapedshadow, outlined against the vertebral column, which is due to a coldabscess, and which extends above and below the bodies actuallyinvolved in the tuberculous process. The fusion of the bodies by newbone, which accompanies repair, can be followed in skiagrams taken atintervals. [Illustration: FIG. 213. --Radiogram of Child's Thorax, showingspindle-shaped shadow at site of Pott's disease of fourth, fifth, andsixth thoracic vertebræ. ] _Cord and Nerve Symptoms. _--When the spinal cord is pressed upon, themotor fibres are first affected as they lie superficially on theantero-lateral aspects of the cord, and are more sensitive topressure. There is at first weakness or paresis of the musclessupplied from the part of the cord below the seat of pressure. Theknee-jerks and plantar reflexes are exaggerated, and there is markedankle clonus. Later, there is paralysis of the spastic type, varyingin extent and sometimes amounting to complete paraplegia, and this maycome on gradually or quite suddenly. There is wasting of muscles fromdisuse, and later a tendency to contracture and the development ofdeformities, as a result of sclerosis or descending degeneration ofthe cord. The sensory fibres usually escape, although in some cases there ispartial anæsthesia and perversion of sensation. When there is alsomyelitis, loss of sensibility to pain (analgesia) below the level ofthe lesion is one of the most characteristic symptoms. In severe casesthere is incontinence of urine and of fæces, as the patient losescontrol of the sphincters. Acute bed-sores are not uncommon. The symptoms referable to pressure on the _nerve roots_ at theirpoints of emergence are pain and hyperæsthesia along the course of thenerves that are pressed upon, and occasionally weakness and wasting ofthe muscles supplied by them; girdle-pain is often a prominent symptomin adults. In the #diagnosis# of Pott's disease in young children, chief stressis laid on the demonstration of rigidity of the affected portion ofspine; the child is laid prone and is lifted by the legs and feet soas to hyper-extend the spine; in Pott's disease the spine is heldrigid, while in the rickety and other conditions that resemble it, themovements are normal. #Treatment of Pott's Disease. #--In addition to the general treatmentof tuberculosis, the essential factor consists in _immobilisingthe spine in the recumbent posture and in the attitude ofhyper-extension_; this must be persisted in until the diseasedvertebræ become fused together or ankylosed by new bone, a resultwhich is estimated partly by the disappearance of all symptoms andmore accurately by observing the formation of the new bone insuccessive skiagrams. Under conservative measures it is estimated that this reparativeprocess entails an immobilisation of the spine of from one to threeyears; the _operative procedures introduced by Albe and Hibbs_ bringabout a bony ankylosis of the vertebræ in as many months, and may beaccepted as reducing the period of spinal immobilisation in therecumbent posture to one year at the most. The immobilisation of the recumbent spine in the attitude ofhyper-extension is most efficiently carried out by an apparatus on thelines of the _Bradford frame_; this is made of gas-piping covered bycanvas, and is easily bent as may be required in the progress of thecase towards convalescence. The frame does not interfere with such_extension_ as may be necessary, to the head, for example, in recentcervical caries, or to the lower extremities where flexion at the hipfrom spasmodic contraction of the psoas muscle may be efficientlyrelieved by weight-extension. _Gauvain's "wheel-barrow" splint_ and the _double Thomas' splint_(Fig. 215) are efficient substitutes, but _Phelps' box_ has beendiscarded because it fails to secure immobilisation of the spine. When the stage of _convalescence_ is arrived at, and recumbency is nolonger essential, the child is allowed to sit up, stand, and goabout, with the restraint, however, of some apparatus that willprevent movement of the spine, except to a limited extent. The_plaster-of-Paris jacket_, applied over a woollen jersey, asintroduced by Sayre of New York, is probably the best; the jacket isaccurately moulded to the trunk while the child is partly suspended bymeans of a tripod and the necessary strings under the chin, occiput, and armpits. Poroplastic felt, celluloid, papier mâché, and othermaterials, reinforced by strips of metal, may be substituted for theplaster of Paris. Various forms of _jury-masts_ and _collars_ havebeen employed to diminish the weight of the head in children withcervical caries, but have been very properly discarded as failing toperform the function expected of them. _Correction of the Angular Projection. _--In cases in which the angularprojection or gibbus, as it is called by continental authors, is ofrecent origin, it may be corrected by the method so successfullyemployed by Calot of Berck-sur-Mer--a plaster jacket is accuratelymoulded to the trunk, and a diamond-shaped window is cut in the jacketopposite the gibbus; a series of layers of cotton-wool are thenapplied, one on top of the other, so as to exert firm pressure on thegibbus, a plaster or elastic webbing bandage being employed to retainthem and reinforce the pressure. The padding is renewed at intervalsof three weeks or a month; in successful cases the projection mayultimately be replaced by a hollow. _Treatment of Abscess. _--If a spinal abscess is causing symptoms or isapproaching the surface, and there appears to be a risk of mixedinfection, the abscess should be asperated and injected with iodoformemulsion. _Treatment of Cord-Complications. _--Extension is applied, in the firstinstance, to the head or to the lower limbs, or to both, while someform of pillow is inserted at the seat of the disease; if thecondition is merely one of œdema, the symptoms usually yield withremarkable rapidity; if they persist, in spite of extension, for threeto six weeks, recourse should be had to _laminectomy_; it is usual tofind evidence of mechanical pressure by granulation tissue, pus, ordisplaced bone, the relieving of which is followed by disappearance ofthe nerve symptoms. Some authors are lukewarm in their advocacy ofthis operation, but we can cite a number of cases in which, afterlaminectomy, an apparently hopeless paraplegia has been entirely gotrid of. #Prognosis. #--As regards the _survival of persons who have sufferedfrom Pott's disease_, and as having an important bearing on prognosis, it may be noted that surgical museums contain many specimensillustrating the "cured" stage of the disease, in which the bodies ofthe vertebræ, formerly the seat of tuberculous destruction or caries, are represented by a ridge-shaped mass of new bone, forming a solidunion between the segments above and below (Fig. 211), or the remainsof the original bodies may still be identifiable, although they aresurrounded and fused together by new bone. The latter condition is themore liable to a recrudescence of the tuberculous infection. Further, it may be inferred from the number of "cured" cases of Pott's diseasemet with in everyday life, that the malady is one from which recoverymay be expected. The cervical cases are recognised by the "telescoping" of the neck, the head and thorax being unduly approximated; the dorsal cases by thewell-known _hump_ or _hunch-back_, in which the spinous processes ofthe collapsed vertebræ constitute the apex of the hump; the thorax istelescoped from above downwards, the ribs are crowded together, thelower ones, it may be, inside the iliac crests, and the sternumprojected forwards. The hunch-back from Pott's disease is often aremarkably capable person, both physically and intellectually. POTT'S DISEASE AS IT AFFECTS DIFFERENT REGIONS OF THE SPINE #Upper Cervical Region, including Atlo-axoid Disease. #--When thedisease affects the first and second cervical vertebræ, the atlo-axoidarticulation becomes involved, and as a result of the destruction ofits component bones and ligaments, the atlas tends to be dislocatedforward. When this occurs suddenly, the odontoid process may impingeon the medulla and upper part of the cord and cause sudden death. Whenthe displacement occurs gradually, the atlas and axis may be separatedto a considerable extent without the cord being pressed upon, andrecovery with ankylosis may ensue. When the third, fourth, and fifthvertebræ are affected, the tendency to dislocation and compression ofthe cord is not so great, but a portion of bone may be displacedbackwards and exert pressure on the cord. The patient complains of a fixed pain in the back of the neck, and ofradiating pains along the course of the sub-occipital and othercervical nerves. The neck is held rigid, and to look to the side thepatient turns his whole body round. As the disease advances the headmay be bent to one side as in wry-neck, or it may be retracted and thechin protruded. To take the weight of the head off the diseasedvertebræ the patient often supports the chin on the hands (Fig. 214). [Illustration: FIG. 214. --Attitude of patient suffering fromTuberculous disease of the Cervical Spine. The swelling on the leftside of the neck is due to a retro-pharyngeal abscess. ] An abscess may form between the vertebræ and the wall of thepharynx--_retro-pharyngeal abscess_--the pus accumulating between thediseased bones and the prevertebral layer of the cervical fascia. Theabscess may project towards the pharynx as a soft fluctuatingswelling, and may cause difficulty in swallowing and breathing, andsnoring during sleep; if it bursts internally it may causesuffocation. The abscess may bulge towards one or both sides of theneck, and come to the surface behind the posterior border of thesterno-mastoid muscle (Fig. 214). In some cases it comes to thesurface in the sub-occipital region. If the cord is pressed upon by inflammatory products, there ismuscular weakness, beginning in the arms and extending to the legs, and sometimes followed by complete paralysis. In the early stagesthere is retention of urine and constipation; later the bladder andrectum are paralysed, and there is incontinence. Sudden death may result when dislocation of the atlo-axoid joint takesplace. Cervical caries has to be diagnosed from rheumatic torticollis, andfrom the effects of injuries, such as a sprain or twist of the spine. When a retro-pharyngeal abscess points behind the sterno-mastoid, itis apt to be mistaken for a cold abscess originating in tuberculouscervical glands. Retro-pharyngeal abscess due to other causes isdescribed with diseases of the pharynx. _Treatment. _--Extension is applied to the head, preferably by means ofan elastic band fixed to the top of the bed, and the head of the bedis raised on blocks so that the weight of the body may furnish thenecessary counter-extension. Lateral movements of the head areprevented by means of sand-bags. After the acute symptoms havesubsided, the spine should be fixed by some rigid apparatus, such as adouble Thomas' splint prolonged so as to support the occiput (Fig. 215). [Illustration: FIG. 215. --Thomas' Double Splint for Tuberculousdisease of Spine. ] When it is considered advisable to open a retro-pharyngeal abscess, this should be done from the side of the neck by an incision along theposterior border of the sterno-mastoid, as first recommended by JohnChiene. The abscess is evacuated, and the cavity filled with iodoformemulsion, and closed without drainage. An opening made through themouth is attended with the risks of pus being inhaled into theair-passages and of pyogenic infection. When the patient is allowed to get up, a poroplastic collar and jacketof the Minerva type which supports the head and controls the movementof the cervical and thoracic vertebræ must be worn until the cure iscomplete. #Cervico-thoracic Region. #--When the lower cervical and upper thoracicvertebræ are affected, in addition to the fixed pain in the diseasedbones, the patient complains of pain radiating along the distributionof the superficial cervical nerves and down the arms. There is oftenmarked angular deformity. If an abscess forms, it may come to thesurface in the lower part of the posterior triangle, or may spreadinto the posterior mediastinum or into the axilla. Sometimes the pusburrows behind the œsophagus and trachea, and it may find its way intothe pleural cavity. The cord is not often pressed upon; when it is, the cervical sympathetic is implicated. #Thoracic or Dorsal Region. #--When the disease is confined to thethoracic region, stiffness of the back and boarding of the vertebralmuscles are prominent features. On being asked to pick up an objectfrom the floor, the patient reaches it by bending his knees and hips, while he keeps his back rigid. He refuses to make any movement thatinvolves jolting of the spine, such, for example, as jumping from achair to the ground. Children often attempt to take the weight off thediseased vertebræ by placing the palms of the hands on the edge of achair so that the weight is borne by the arms. Angular deformity is often well marked, and may implicate severalvertebræ. In order to maintain the head erect, the spine above andbelow the seat of disease becomes unduly arched forward--compensatorylordosis. In advanced cases the ribs become approximated, and thelower end of the sternum is projected forward. The antero-posteriordiameter of the thorax is thus increased, while its vertical diameteris diminished. These changes, together with the telescoping of thevertebral bodies, lead to the deformity characteristic of thetuberculous hunch-back (Fig 216). The alterations in the shape of thechest may lead to functional disturbances of the heart and lungs. [Illustration: FIG. 216. --Hunch-back Deformity following Pott'sdisease of Thoracic Vertebræ. (Photograph lent by Sir George T. Beatson. )] _Dorsal Abscess. _--As already mentioned, the earliest stage of abscessis well seen in skiagrams (Fig. 213), especially in children. Whenthere is an extension of the suppurative process, the pus may passdirectly backwards along the posterior branches of the intercostalvessels and nerves, and come to the surface behind the transverseprocesses, or it may travel forward between the pleura and the ribs, and, passing along the course of the lateral cutaneous branches of theintercostals, come to the surface opposite the middle of the rib. Inthe latter case, the abscess is liable to be mistaken for oneassociated with tuberculous disease of the rib, particularly as therib is usually found to be bare. In rare cases the pus opens into thepleura, giving rise to empyema. When the disease is on the anteriorsurface of the bodies of the lower thoracic vertebræ, the pus mayspread down through the pillars of the diaphragm and reach the sheathof the psoas muscle. _Treatment_ is on the usual lines. #Thoracico-lumbar Region. #--The symptoms are similar to those ofdisease in the thoracic region. Children while standing often assume acharacteristic attitude--the hips and knees are slightly flexed, andthe hands grasp the thighs just above the knees (Fig. 217). In thisway the weight is partly taken off the affected vertebræ and borne bythe 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 tuberculousdisease may be differentiated from one due to rickets, as in thelatter case the projection disappears. [Illustration: FIG. 217. --Attitude in Pott's disease ofThoracico-lumbar Region of Spine. ] The patient often complains of pain in the abdomen--which in childrenmay be mistaken for a simple "belly-ache"--and of pain shooting downthe buttocks and into the legs. If the cord is pressed upon at thelevel of the lumbar enlargement the anal and vesical sphincters areparalysed, and the reflexes are exaggerated. _Psoas Abscess. _--When an abscess forms, it usually occupies thesheath of the psoas muscle, in which it spreads down towards the iliacfossa, and into the thigh, passing beneath Poupart's ligament, posterior and lateral to the femoral vessels. The communicationbetween the pelvis and the thigh is often very narrow, so that theabscess cavity has to some extent the shape of an hour-glass. The pusmay reach the surface in the region of the saphenous opening, or mayspread farther down the thigh under cover of the deep fascia. In somecases it is liable to be mistaken for a femoral hernia, as theswelling becomes smaller when the patient lies down, and has animpulse on coughing. _Lumbar Abscess. _--Sometimes the pus travels along the posteriorbranches of the lumbar vessels and nerves to the lateral border of thesacro-spinalis (erector spinæ) and comes to the surface in the spacebetween the edges of the latissimus dorsi and external obliquemuscles--the triangle of Petit. In rare cases it passes through the sacro-sciatic foramen and forms aswelling in the buttock (_sub-gluteal abscess_); or it may passthrough the obturator foramen and reach the adductor region of thethigh or even the perineum. #Lumbo-sacral Region. #--Pott's disease in the lumbo-sacral regionusually affects adults, and, on account of the breadth of thevertebral bodies and the limited range of movement in this segment ofthe spine, is seldom accompanied by marked symptoms or deformity. Thediagnosis, therefore, is often difficult, unless good skiagrams areavailable. The disease may be associated with pain in the distributionof the sciatic nerve, which is liable to be mistaken for sciatica. Single or double _iliac abscess_ frequently forms without the patientshowing any characteristic signs of spinal disease. When the diseasebegins in childhood it may induce a permanent deformity of thepelvis, the conjugate diameter at the brim being increased, while thetransverse diameter at the outlet is diminished--kyphotic pelvis, and, in females, this may lead to complications in parturition. #Tuberculous Disease of the Sacro-iliac Joint. #--This condition mayoccur as a primary affection, but is much more frequently secondary todisease in the ilium, sacrum, or lower lumbar vertebræ, and is mostcommon in adolescents and young adults of the male sex. It is attendedwith pain in the lumbar region, and sometimes in the buttock and alongthe course of the sciatic nerve. The pain is aggravated by movements, especially such as involve sudden and violent contraction of thelumbar and abdominal muscles, for example, coughing, sneezing, orstraining during defecation. Tenderness is elicited on making pressureover the joint, on pressing together the iliac bones, or on attemptingto abduct the limb while the pelvis is fixed. The muscles of thebuttock and thigh are wasted. As any attempt to bear weight on theaffected limb causes pain, the patient walks with a limp, and to savethe joint he assumes an attitude which is characteristic: he throwshis weight on the sound limb, leans forward, using a stick forsupport, tilts the affected side of the pelvis downwards, and flexesthe hip and knee-joints of the diseased limb. The anterior superiorspine is unduly prominent on the affected side, and the limb appearsto be lengthened. Sooner or later, in most cases, an abscess forms, and the pus may reach the surface over the posterior aspect of thejoint. When the pus forms in front of the joint, it may spreadlaterally in the iliac fossa as an _iliac abscess_ or may gravitatedownwards in the hollow of the sacrum and emerge on the buttockthrough the sacro-sciatic foramen--_sub-gluteal abscess_. Sometimes itpasses into the ischio-rectal fossa or into the perineum. The presenceof an abscess in the pelvis may sometimes be recognised on rectalexamination. The appearance of an abscess is sometimes the first thingto draw attention to the condition. As pain across the small of the back and along the course of thesciatic 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 ofthe hip-joint are not restricted. It is not always possible withoutthe aid of skiagrams to differentiate sacro-iliac disease from diseaseof the lumbar spine, and the two conditions sometimes coexist. The _prognosis_ is unfavourable, particularly in cases complicated byextensive disease of the ilium with abscess formation and mixedinfection. _Treatment. _--In early cases the patient should use crutches and weara patten on the foot of the sound side; in more advanced cases he mustbe confined to bed, and have absolute rest to the joint secured bymeans of extension applied to both legs, or by other apparatus. Inchildren a double Thomas' splint or Stiles' abduction frame is aconvenient appliance. Counter-irritation by blisters or the actualcautery may be had recourse to in dry cases in which pain is aprominent feature. If operative treatment becomes necessary, as itmay, for removal of a sequestrum, access to the seat of disease isobtained by removing the posterior portion of the iliac bone. Coldabscess is treated on the usual lines. #Syphilitic Disease of the Vertebræ. #--All the clinical features ofPott's disease may be simulated by gummatous disease of the vertebræ. This is usually met with in adults who have suffered from acquiredsyphilis; it is most common in the upper cervical vertebræ, and beginson the anterior surface of the bodies. The onset is more sudden thanthat of tuberculous caries, and the progress more rapid. The bone isearly and extensively destroyed, but abscess formation is rare. Severenocturnal pains are complained of, and some degree of angulardeformity may develop. In almost all cases other evidence of tertiarysyphilis is present, and this, together with the history and theeffects of anti-syphilitic treatment, aids in diagnosis. The localtreatment is carried out on the same lines as for tuberculous disease. #Malignant Disease of the Vertebræ. #--_Sarcoma_ is the most importantof the primary tumours met with in the vertebral column. It gives riseto symptoms which are liable to be mistaken for those of Pott'sdisease or of arthritis deformans. The pain, however, is more intense, and the disease progresses more continuously, and is uninfluenced bytreatment. The changes in the vertebræ, as seen in skiagrams, arehelpful in diagnosis. The growth may encroach upon the vertebral canaland cause pressure on the cord (p. 451). In the sacrum--the mostcommon site--the tumour implicates the sacral nerves, and causessymptoms of intractable sciatica; and the real nature of the diseaseis often only detected on making a rectal examination. _Secondary cancer_ is a common disease, particularly in cases ofadvanced scirrhus of the breast. It leads to extensive softening ofthe bodies of the vertebræ, so that they yield under the weight of thebody, as in Pott's disease. Clinically it is associated with severepain in the region of the vertebræ affected, and along the course ofthe nerves emerging in the neighbourhood. If paralysis occurs fromthe cancerous bodies pressing upon the cord (_paraplegia dolorosa_), it is of rapid development, often becoming complete in a few hours. When the cervical cord is compressed all four limbs are paralysed, andfrom interference with respiration, the condition is fatal within afew days. #Actinomycosis#, #Blastomycosis#, and #Hydatid Cysts# also occur inthe vertebræ, and are difficult to diagnose from tuberculous disease. #Typhoid Spine. #--An acute infective condition of the vertebræ, intervertebral discs, and spinal ligaments occasionally occurs duringconvalescence from typhoid fever. The lumbar region is most frequentlyaffected, and the X-rays reveal inflammatory changes in the bones, disappearance of the discs, and, in the later stages, deposits of newbone leading to synostosis of adjacent vertebræ. The onset, which maybe gradual or sudden, is attended with intense pain, and tendernessover the affected vertebræ. The temperature is raised, and other signsof an acute infective process are present. In a few cases there aresymptoms of involvement of the membranes and cord. With prolonged restand immobilisation of the spine the inflammation usually subsides, butsometimes it goes on to suppuration. #Hysterical Spine. #--This term is applied to a functional affection ofthe spine occasionally met with in neurotic females between the agesof seventeen and thirty, and liable to be mistaken for Pott's disease. The patient complains of pain in some part of the spine--usually thecervico-thoracic or thoracico-lumbar region--and there is markedhyperæsthesia on making even gentle pressure over the spinousprocesses. As the patients are usually thin, the pressure of thecorset is apt to redden the skin over the more prominent vertebræ, andgive rise to an appearance which at first sight may be mistaken for aprojection. The general condition of the patient, the freedom ofmovement of the vertebral column, and the entire absence of rigidity, are sufficient to exclude tuberculosis. The condition is treated onthe same lines as other hysterical affections. #Acute osteomyelitis# of the vertebræ is a rare affection, and is metwith in young subjects. It attacks the more mobile portions of thespine--cervical and lumbar--and may begin either in the bodies or inthe arches. It is attended with extreme sensitiveness on movement, severe localised pain in the region of the vertebræ attacked, and amarked degree of fever. Pus usually forms rapidly, but, being deeplyplaced, is not easily recognised unless it points towards thesurface. The infection is liable to spread to the meninges of the cordand give rise to meningitis, particularly when the disease begins inthe arches. A milder form occurs, in which the main incidence is onthe periosteum; the symptoms are less severe, it does not tend tosuppurate, and is usually recovered from. The treatment consists inapplying extension to the spine and in opening any abscess that may bedetected. The suppurative form usually proves fatal, and, indeed, isoften only diagnosed on post-mortem examination. #Arthritis Deformans. #--This disease usually begins between the agesof thirty-five and forty, and attacks men who follow some laboriousoccupation which involves exposure to cold and wet. It is met with, however, in women who lead a sedentary life. There is sometimes arecent history of gonorrhœa, rheumatism, or other toxic disease, andoccasionally the condition follows upon injury. The discs disappear, osteophytic outgrowths develop at the margins of the bodies and inconnection with the transverse processes, and bridge across the spacebetween neighbouring vertebræ (Fig. 218). The articulations betweenthe ribs and the vertebræ show similar changes, and the ligaments ofthe several joints tend to undergo ossification, so that the bones arefused together. [Illustration: FIG. 218. --Arthritis Deformans of Spine. The vertebræare fixed to one another by outgrowths of bone which bridge across theintervertebral spaces, and there is a slight lateral deviation to theleft in the mid-dorsal region. (Anatomical Museum, University of Edinburgh. )] In the early stage the patient complains of pain and stiffness in theback; later the spine becomes rigid, and gradually develops akyphotic curve, sometimes accompanied by lateral deviation. In somecases, the curvature of the spine assumes an extreme type, theshoulders are rounded, and the head depressed, the face approximatingthe sternum, so that to see an object such as a picture on a wall, thepatient must turn his back to it. The chest is flattened andrestricted in its movements, with the result that respiration isembarrassed and becomes almost entirely abdominal. The muscles of theback, shoulders, and hips undergo atrophy, and may exhibit tremors, and the deep reflexes become exaggerated. The nerves are liable to bepressed upon as they pass through the intervertebral foramina, andthis gives rise to pain and other disturbances of sensation in theirarea of distribution. These pains may simulate those associated withrenal or gastro-intestinal affections. The disease may simulate tuberculous caries or malignant disease. Thechanges in the bones are demonstrated by the use of the X-rays. The treatment is carried out on general principles (Volume I. , p. 530), but it is seldom possible to do more than arrest the progress ofthe disease. #Coccydynia# is the name applied to a condition in which the patientexperiences severe pain in the region of the coccyx on sitting orwalking, and during defecation. The pathology is uncertain. In somecases there is a definite history of injury, such as a kick or blow, causing fracture of the coccyx, or dislocation of the sacro-coccygealjoint. These lesions have also been produced during labour. In othercases the pain appears to be neuralgic in character, and is referableto the fifth sacral and the coccygeal nerves, or to the terminalbranches of the sacral plexus distributed in this region. Theaffection is almost entirely confined to females, and the patients areusually of a neurotic type. On rectal examination the coccyx isexceedingly tender, and it is sometimes found to be less movable thannormal, and unduly arched forward. When medicinal treatment fails togive relief, the coccyx may be excised. #Tumours of the Spinal Cord and Membranes. #--Tumours may develop inthe substance of the cord (_intra-medullary_), in the membranes(_meningeal_), or in the tissues between the dura and the bone(_extra-dural_); or the cord may be pressed upon by a tumouroriginating in the vertebræ. It is seldom possible to diagnose thenature of a tumour before operation, and it is often difficult todetermine in which of the above situations it has originated. Tumours growing _in the substance of the cord_ are nearly as commonas extra-medullary growths, and as the growth is usually sarcoma, glioma, tuberculoma, or gumma, and infiltrates the cord, it is seldomcapable of being removed by operation. The great majority of _meningeal_ tumours are primary sarcomas, and inabout 25 per cent. Of cases they are multiple. Hydatid cysts andfibromas are also met with in this situation, and they too may bemultiple. _Extra-dural_ growths are comparatively rare. The forms usually metwith are sarcoma and lipoma. These extra-medullary tumours seldom infiltrate the cord; they simplycompress it, and should be subjected to operative treatment beforesecondary changes are produced in the cord. The _symptoms_ vary according as the tumour presses on the nerveroots, on one half, or on both halves of the cord. Pressure on nerveroots is a characteristic sign in extra-medullary growths. It givesrise to pain, which, according to the level of the tumour, passesround the trunk (girdle-pain), or shoots along the nerve-trunks of theupper or lower limbs. When the cord is pressed upon, intense neuralgic pain related to thesegment first involved is one of the earliest symptoms, particularlyin extra-medullary tumours. The pain is at first unilateral, but laterbecomes bilateral--a point of importance in diagnosis. The painfulareas are anæsthetic, but the anæsthesia does not always reach to thelevel of the lesion. There may be a zone of hyperæsthesia at the upperlimit of the anæsthesia, or in the area corresponding to the roots onwhich the tumour is situated, but there is never diffuse hyperæsthesia(V. Horsley). In intra-medullary tumours the pain is less severe, itis rarely an initial symptom, and is seldom referable to individualnerve roots. The next symptom to appear is motor paresis, followed by completeparalysis, and later by contracture of the paralysed muscles--_spasticparaplegia_. In intra-medullary tumours the paraplegia is usually lesscomplete than in those that are extra-medullary. When only one lateralhalf of the cord is pressed upon, the motor paralysis and loss ofordinary sensation are on the same side as the tumour, and the loss ofthe sense of pain and of the temperature sense is on the oppositeside. Retention of urine accompanies the onset of paralysis, and latergives place to incontinence. The rectum becomes paralysed, andcystitis and pressure sores develop. Anti-syphilitic treatment should be employed in the first instance toexclude the possibility of the lesion being of the nature of a gumma. Radical operative treatment is contra-indicated in intra-medullaryand in metastatic growths, but decompressive measures may be employedfor the relief of pain. In meningeal and extra-dural tumours, however, in view of the hopeless prognosis if the condition is allowed to takeits 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 segmentshigher than the complete anæsthesia would appear to indicate; thevertebral canal, therefore, should be opened about four inches abovethe level of the anæsthesia. When the tumour is not removable, the patient's suffering maysometimes be alleviated by resecting the posterior roots of the nervesemerging in the vicinity of the lesion. #Chronic Spinal Meningitis. #--Victor Horsley (1909) described by thisname a condition which gives rise to symptoms closely simulating thoseof a tumour of the cord. He believes it to consist in apachymeningitis combined with a certain degree of sclero-gliosis ofthe periphery of the cord. The theca is greatly distended over avariable extent of the cord; the cerebro-spinal fluid is increased inquantity and is under considerable tension; and the cord itselfpresents a shrunken appearance. Sometimes there is thickening of thearachno-pia and matting of the nerve roots. The condition appears tobegin in the lower part of the cord, and to spread up, usually as faras the mid-thoracic region. There is frequently a history of syphilis, sometimes of recent gonorrhœa, but in some cases no cause can beassigned for the lesion. _Clinical Features. _--This affection is almost always met with inadults, 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 theother; 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 asensation of tightness in the limbs. There is never absoluteanæsthesia, but there is relative anæsthesia for all forms ofsensation, which extends as a rule as far as the sixth or eighththoracic root. There are no vaso-motor phenomena, and no tendency to the formation ofpressure sores. Sometimes the patient complains of pain in the spine, but this is not aggravated by movement. _Treatment. _--The treatment recommended by Horsley consists inperforming laminectomy, opening the theca, and washing it out with 1in 1000 mercurial lotion. After the wound has healed, mercurialinunction over the spine is employed to hasten the absorption ofinflammatory products. The administration of anti-syphilitic drugs hasnot proved beneficial. #Acute Spinal Meningitis. #--The spinal membranes may become implicatedby direct spread in cases of acute intra-cranial lepto-meningitis, orthey may be infected from without--for example, in gun-shot injuriesor in cases of spina bifida. When the infection spreads from the cranial cavity, the cerebralsymptoms dominate the clinical picture, but evidence of involvement ofthe membranes of the cord may be present in the form of rigidity ofthe cervical muscles with retraction of the neck; deep-seated pain inthe back, shooting round the body (girdle-pain) and down the limbs;painful cramp-like spasms in the muscles of the back and limbs, withincreased reflex excitability, sometimes so marked as to simulate thespasms of tetanus. When the theca of the cord is directly infected the spinal symptomspredominate at first, but as the condition progresses it involves thecerebral membranes, and symptoms of acute general lepto-meningitisensue. Once the condition has started little can be done to arrest itsprogress, but the symptoms may be relieved by repeated lumbarpuncture. #Spinal Myelitis. #--The term "myelitis" is applied to certain changeswhich occur in the spinal cord as a result, for example, of hæmorrhageinto its substance (_hæmorrhagic myelitis_); or of pressure exerted onit by fragments of bone, blood-clot, tuberculous material, or newgrowths (_compression myelitis_). In another group of cases myelitis is a result of the action oforganisms or their toxins. Syphilis is a common cause, but thecondition may follow on infections with ordinary pyogenic cocci, pneumococci, the influenza bacillus or the bacillus coli. In addition to the use of anti-syphilitic remedies, or of seradirected to neutralise the toxins of the causative organism, attentionmust be directed to the bladder, and steps taken to prevent cystitisand the formation of bed-sores. CONGENITAL DEFORMITIES OF THE SPINE #Spina Bifida. #--Spina bifida is a congenital defect in certain of thevertebral arches, which permits of a protrusion of the contents of thevertebral canal. It is due to an arrest of development, whereby theclosure of the primary medullary groove and the ingrowth of themesoblast to form the spines and laminæ fail to take place. The cleftmay implicate only the spinous processes, but as a rule the laminæalso are deficient. The defect usually extends over several vertebræ(Fig. 219). While the protrusion varies much in size, there is noconstant ratio between the dimensions of the swelling and the extentof the defect in the neural arches. [Illustration: FIG. 219. --Meningo-myelocele of Thoracico-lumbarRegion. ] The condition is comparatively common, being met with in about one outof every thousand births. It is most frequent in the lumbar and sacralregions (Fig. 219), but occurs also in the cervical (Fig. 220) andthoracic regions. It is not uncommon to find spina bifida associatedwith other congenital deformities such as hydrocephalus, club-foot, and extroversion of the bladder. [Illustration: FIG. 220. --Meningo-myelocele of Cervical Spine. ] _Varieties. _--Four varieties are usually described according to thecharacter of the protrusion. They are analogous, to a certain extent, to the varieties of cephalocele (p. 387). (1) _Spinal meningocele_, inwhich only the membranes, filled with cerebro-spinal fluid, areprotruded. (2) _Meningo-myelocele_, the form most commonly met withclinically, in which the cord and some of the spinal nerves areprotruded, and spread out over the inner aspect of the sac (Figs. 219, 220). (3) _Syringo-myelocele_, in which there is a dilatation of thecentral canal in the protruded part of the cord. In these three formsthe 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 thecerebro-spinal fluid to drain away. (4) In the _myelocele_, this skin, as well as the vertebral arches and membranes, is absent, and the cordlies exposed on the surface. This form is comparatively common, but asthe infants are either dead born or die within a few days of birth, itseldom comes under the notice of the surgeon. _Clinical Features. _--The presence of a swelling in the middle line ofthe back, which has existed since birth, and which contains fluid andincreases in size and tenseness when the child cries, renders thediagnosis of spina bifida easy. The defect in the bone may be seen inskiagrams. 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 inyoung children this may cause a bulging of the fontanelles. This test, however, must be employed with caution, as it is liable to induceconvulsions. A meningocele, as it contains no nerve elements, may betranslucent. In a meningo-myelocele the shadows of the cord and nervesstretched out in the sac may be recognised. The presence of the cordis sometimes indicated by a median furrow, and after withdrawal ofsome of the fluid the cord can sometimes be palpated. It is, however, often difficult to distinguish between a meningocele andmeningo-myelocele. [Illustration: FIG. 221. --Meningo-myelocele in Thoracic Region. ] Sometimes there are no nervous disturbances, and this is especiallythe case when the defect is in the lower lumbar and sacral regionsbelow the termination of the cord. In most cases, however, there areparalytic symptoms referable to the lower extremities, the bladder, and the rectum, and there may also be trophic disturbances in theparts below. Paralytic symptoms may be absent during infancy, anddevelop during childhood or adolescence. _Prognosis. _--Comparatively few children born with spina bifidasurvive longer than four or five years. The great majority die withina few weeks of birth, death being due to the escape of cerebro-spinalfluid, or to spinal meningitis following on infection. The conditionin some cases remains stationary for years, but spontaneousdisappearance is rare. _Treatment. _--The more severe forms of spina bifida only call forpalliative treatment, which consists in protecting the protrusionagainst infection and applying a sterilised dressing and a supportingbandage. A meningocele may be tapped with a fine needle passed throughhealthy skin, and the empty sac compressed by a pad of wool and anelastic bandage. Operative treatment is seldom to be recommended in a young childunless it is otherwise viable and the swelling is increasing rapidlyand threatening to burst, and there is reason to believe that theparalysis is due to pressure. The immediate results of operation areusually satisfactory, but in a large proportion of cases the childsubsequently develops hydrocephalus, from which it ultimatelysuccumbs. The hope of improvement in the motor symptoms afteroperation depends on the site of the spina bifida; above the twelfththoracic vertebra there is no prospect of improvement; below thislevel, inasmuch as it is the tip of the conus or the cauda equina thatis involved, there may be regeneration of nerve fibres and return ofpower in the lower extremities, and control of the sphincters may beregained. Murphy has practised resection of cicatricial or atrophiedportions of the cauda, with end-to-end suture. The term #spina bifida occulta# is applied to a condition in whichthere is no protrusion of the contents of the vertebral canal, although the vertebral arches are deficient. The skin over the gap isoften puckered and adherent, and is frequently covered with a growthof coarse hair. A mass of fat may project towards the surface, and when situated inthe lumbo-sacral region may suggest a caudal appendage or tail (Fig. 222). [Illustration: FIG. 222. --Tail-like Appendage over Spina BifidaOcculta in a boy æt. 5, and associated with incontinence of urine. Operation was followed by temporary retention. ] The clinical importance of spina bifida occulta lies in the fact thatit is sometimes associated with congenital club-foot, and with nervesymptoms, in the form of sensory, motor, and trophic disturbancesreferable to the lower limbs, such as perforating ulcer, and to thesphincters. These nerve symptoms usually result from the presence of atough cord composed of connective tissue, fat, and muscle, stretchingfrom the skin through the vertebral canal to the lower end of thespinal cord. As this strand of tissue does not grow in proportionwith the body, in the course of years it drags the cord against thelower border of the membrana reuniens, which closes in the vertebralcanal posteriorly. These symptoms may be relieved by the removal ofthis strand of tissue from the gap in the vertebral arches, or byincising the membrana reuniens. #Congenital Sacro-coccygeal Tumours--Teratoma. #--Many varieties ofcongenital tumours are met with in the region of the sacrum andcoccyx. The majority are developed in relation to the communicationwhich exists in the embryo between the neural canal and the alimentarytract--the post-anal gut or neurenteric canal. Some are evidently ofbigerminal origin, and contain parts of organs, such as limbs, partlyor wholly formed, nerves, parts of eyes, mammary, renal, and othertissues. Among other tumours met with in this region may be mentioned: thecongenital _lipoma_--a small, rounded, fatty tumour which oftensuggests a caudal appendage (Fig. 222); the _sacral hygroma_, whichforms a sessile cystic tumour growing over the back of the sacrum, andis believed to be a meningocele which has become cut off _in utero_ bythe continued growth of the vertebral arch; dermoids, sarcoma, andlymphangioma. [Illustration: FIG. 223. --Congenital Sacro-coccygeal Tumour. (Photograph lent by Sir George T. Beatson. )] The _treatment_ consists in removing the tumour, as from its situationit is exposed to injury, and this is liable to be followed byinfection. From the position of the wound, and the fact that many ofthese tumours extend into the hollow of the sacrum and thereforenecessitate an extensive dissection, there is considerable risk frominfection, especially in young children. The risk is increased whenthe tumour communicates with the vertebral canal. #Congenital Sacro-coccygeal Sinuses and Fistulæ. #--The _post-analdimple_, a shallow depression frequently observed over the tip of thecoccyx, may be due to traction exerted on the skin at this spot by theremains of the neurenteric canal, or by the caudal ligament ofLuschka. Sometimes the integument is retracted to such an extent thatone or more _sinuses_ are formed, lined with skin which is furnishedwith hairs, sweat, and sebaceous glands. The bursting of a dermoid, orits being incised in mistake for an abscess, may result in theformation of such a sinus, which fails to heal and may persist foryears. In some cases the depression communicates with the vertebral canal, constituting a complete _sacro-coccygeal fistula_, which may be linedwith cylindrical or ciliated epithelium. From the accumulation of secretions and subsequent infection, theseconditions may be associated with a persistent offensive discharge, and they are liable to be mistaken for ano-rectal fistulæ. They arebest dealt with by complete excision, and as primary union cannot beexpected, the wound should be treated by the open method. CHAPTER XVIII DEVIATIONS OF THE VERTEBRAL COLUMN LORDOSIS--KYPHOSIS--SCOLIOSIS Three main deviations of the vertebral column are described:_Lordosis_, in which it is unduly arched forwards; _Kyphosis_, inwhich it is unduly arched backwards; and _Scoliosis_ or lateraldeviations, in which the spine deviates to one side of the middleline. #Lordosis# or _anterior curvature of the spine_ with the convexityforwards, is chiefly met with in the lumbar region as an exaggerationof the natural curvature. A minor degree of lordosis sometimes occursas a peculiarity in the conformation of the individual and may bepresent in several members of the same family; also in street-hawkersand others who carry weights suspended in front of them; in very obesepersons; in those who suffer from large abdominal tumours, such asfibroids; and in pregnant women. In its more marked and typical formsit is met with as a compensatory deviation when the pelvis is tiltedforwards in association with flexion of one or of both hip-joints. Illustrations of this association are found in congenital dislocationof the hip, particularly when this is bilateral, in tuberculousdisease of the hip when recovery has occurred with ankylosis in theflexed position, and in Charcot's disease of the hip. The resuming ofthe erect position with tilting of the pelvis from flexion at the hipis necessarily attended by an exaggeration of the forward curvature ofthe lumbar spine. Its relationship to the erect posture is readilydemonstrated by noting its partial or complete disappearance when thepatient is sitting and the tilting of the pelvis is thus eliminated. Lordosis elsewhere than in the lumbar segment is met with as acompensatory deviation to kyphotic or backward curvature of the spine:in Fig. 211, for example, a kyphotic projection in the mid-thoracicregion has led to a lordosis in the cervico-thoracic segment above, and in the thoracico-lumbar segment below, the forward curve beingagain a necessary outcome of the resuming of the erect posture. Theabsence of a compensatory lordosis in such a condition would warrantthe inference that the patient had been bed-ridden. #Kyphosis# or _posterior curvature of the spine_ with the convexitybackwards, is met with at all periods of life, and results from a widerange of conditions. In infancy it is a common result of _general debility_. The child neednot 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 tohold itself erect in the sitting posture. It is to be noted that aconsiderable degree of kyphosis may exist without interference withthe normal outlook in the erect posture, and, therefore, the questionof compensatory curvature does not arise. In the adolescent a degreeof kyphosis in the cervico-thoracic region is common, and is spoken ofas "round shoulders"; it is largely a matter of habit that requirescorrection by the governess or nurse. Among agricultural labourers andgardeners after middle life, and in the aged, this type of curvatureis of common occurrence and is evidently associated with theiroccupation. An exaggerated form of the same cervico-thoracic kyphosisis met with in patients suffering from progressive muscular atrophy, poliomyelitis, osteitis deformans of Paget, acromegaly, and manyallied conditions in which either the muscular or the mental vigour isdeficient, and the patient adopts the cervico-thoracic kyphosis as theattitude of rest. Another type of diffuse kyphosis without compensatory curvature is metwith in _arthritis deformans_, in which the kyphosis is associatedwith the disappearance of the intervertebral discs and ankylosis ofthe vertebral bodies by bridges of new bone in the position of theanterior common ligament. _Partial or localised kyphosis_, on the other hand, is the result oforganic changes in the bodies of the vertebræ of the segment of spineaffected. It is most often met with in Pott's disease in which theextent of the curve depends on the number of bodies affected, and itsdegree on the amount of destruction that the bodies have undergone. With the resumption of the erect posture, and in order that the eyesshould look directly forwards, a compensatory lordosis is acquiredabove and below the segment that is the seat of kyphosis (Fig. 211). Asimilar but less marked type of kyphosis may follow upon compressionfracture of the spine--in the condition known as traumaticspondylitis; and as a result of other lesions, such as osteomalacia, or malignant disease, in which the bodies undergo softening and yield, so that the spinous processes project posteriorly. SCOLIOSIS #Scoliosis# or _lateral curvature_ is by far the commonest and mostimportant deviation of the spine. The student will obtain a clearerconception of the nature of this deformity if we consider in the firstplace those types for which an obvious explanation is available. _Static scoliosis_, for example, when one leg is shorter than theother, the pelvis is tilted down on the short side, thethoracico-lumbar spine deviates laterally to the normal side, and torestore the equilibrium of the trunk the cervico-thoracic spinedeviates again in the opposite direction. The causes of one leg beingshorter than the other are numerous and varied; they include suchconditions as unilateral congenital dislocation of the hip, fracturesunited with overriding of the fragments, diseases of the joints, _e. G. _, hip disease, or of the bones, especially such as interferewith the function of ossifying junctions; and acquired deformitiessuch as unilateral flat-foot, knock-knee, or bow-leg. Clinically, this type of scoliosis is identified by observing that when thepatient sits down the deviation of the spine disappears; it isrelieved or got rid of by raising the sole and the heel of the boot onthe short side, and, if required, by inserting an "elevator" insidethe boot. When there is _shortening of the muscles on one side of the trunk_there develops a lateral curvature of the spine with its convexity tothe normal side; a good example of this is afforded in cases ofinfantile hemiplegia (Fig. 224) in which the deviation affects theentire column: a localised form is seen in congenital wry-neck, inwhich the convexity of the cervico-dorsal curve is on the side of thenormal sterno-mastoid with a compensatory deviation to the oppositeside in the spine below (Fig. 272). _Unilateral paralysis_ of_muscles_ acting on the trunk may also cause a lateral deviation ofthe spine, as is well seen in paralysis of the trapezius, whichresults in a cervical scoliosis with the convexity to thenon-paralysed side. [Illustration: FIG. 224. --Scoliosis following upon Poliomyelitisaffecting right arm and leg. (Mr. D. M. Greig's case. )] _Asymmetry of the thorax_, such as may follow on empyema withdefective expansion of the lung, causes a lateral deviation of thedorsal spine with the convexity towards the normal side. _Attitudes_ adopted to relieve pain, such as that caused by sciatica, sacro-iliac or hip disease, in which the weight of the body istransferred to the normal side, cause a scoliosis similar to that dueto irregularity in the length of the lower extremities, and issimilarly made to disappear when the patient sits upon a flat surface. _Malformation_ or _disease of the vertebræ_ themselves is a wellrecognised cause of scoliosis; the best known, as it may be also themost severe and the most intractable, is that due to rickets, underwhich heading it has already been described (Fig. 225). In a few casesa rudimentary wedge-shaped vertebra has been revealed by the X-rays. [Illustration: FIG. 225. --Rickety Scoliosis in a child æt. 2. ] In all of these forms or types of scoliosis the primary cause must besearched for and when found is made the first object of treatment; thetreatment of the scoliosis as such is on the same lines as in thepostural variety that now falls to be described. #Habitual or Postural Scoliosis. #--These names have been given to thetype of scoliosis that develops in young girls and for which there isno mechanical explanation. It is most frequently met with in rapidly growing girls of poorphysique who are overworked at school or lessons, or on commencing anapprenticeship for which they are physically unfit. In some casesthere is nasal obstruction from adenoids, in others the developmentand free play of the chest are interfered with by tight andill-fitting garments; in all of them the muscular system is weak andthe muscles of the trunk do not take their proper share in maintainingthe erect posture. The most important determining factor would appearto be the habitual or repeated assumption of faulty attitudes, partlyfrom carelessness, largely from fatigue, in order to relieve thefeeling of tiredness in the back. So far as is known, the conditiondoes not occur in communities living under aboriginal conditions. Insome cases there is a hereditary tendency to scoliosis; we have seenit, for example, in a father and his daughters. The excessive use of one arm in the carrying of weights, the habit ofresting on one leg more than the other, or the assumption of a faultyattitude in writing or in playing the piano or violin, doubtless, determine the seat and direction of the curvature, and, when it hasonce commenced, tend to aggravate and to perpetuate it. It is probable that the greater frequency of the primary curvaturetowards the right is associated with the more general use of the righthand and arm, although primary curvatures towards the left are notconfined to left-handed persons. _Morbid Anatomy. _--The original deviation or "primary curve" isusually in the thoracic region, and has its convexity directed towardsthe right side. To re-establish the equilibrium of the column, "secondary" or "compensatory" curves, with their convexities to theleft, develop in the regions above and below the primary curve. It hasbeen proved experimentally that lateral deviation of the spine isinevitably accompanied by rotation of the vertebræ around a verticalaxis, in such a way that their bodies look towards the convexity ofthe curve, while their spines, laminæ, and articular processes aredirected towards the concavity (Fig. 226). [Illustration: FIG. 226. --Vertebræ from case of Scoliosis, showingalteration in shape of bones. ] As the deformity increases, the individual vertebræ are distorted, thebodies becoming wedge-shaped from side to side, the base of the wedgelooking towards the convexity of the curve, while the narrow end lookstowards the concavity (Fig. 228). As the spine, laminæ, and articularprocesses also undergo alterations in shape, a line uniting the tipsof the spinous processes does not furnish an accurate index of thedegree of lateral deviation but minimises it considerably. The musclesand ligaments are altered in length in accordance with the changes inthe shape and position of the bones. In the thoracic region, the ribs necessarily accompany the transverseprocesses, so that on the side of the convexity they form an undueprominence behind--the "rib-hump" (Fig. 227), while on the side of theconcavity the chest is flattened and the ribs crowded together so thatthe intercostal spaces are diminished or even obliterated. Theconverse--flattening on the side of the concavity--is seen on thefront of the chest. [Illustration: FIG. 227. --Adolescent Scoliosis in a girl æt. 23. ] The general shape of the thorax is altered: on the side of theconvexity it is longer and narrower than normal and its capacitydiminished, while on the side of the concavity it is shorter andbroader and its capacity is increased. The viscera are distorted and displaced in accordance with the alteredshape of the thoracic and abdominal cavities. The twisting of thespine causes the patient to lose in stature, and the limbs appear tobe disproportionately long. In advanced cases the pelvis becomesobliquely contracted--a deformity known as the _scoliotic pelvis_. [Illustration: FIG. 228. --Scoliosis with primary curve in ThoracicRegion. ] In spite of the marked deformity the spinal cord is never compressed. _Clinical features. _--The development of scoliosis is always slow andinsidious. As a rule, attention is first attracted to the deformityabout the age of puberty, but in most cases it has existed for aconsiderable time before it is observed. The patient--usually a girl, although it also occurs in boys--is easily fatigued, has difficulty inkeeping herself erect, and often complains of pain in the back andshoulders and along the intercostal spaces on the side of theconvexity. To relieve the muscles of the back she is inclined tolounge in easy and ungainly attitudes. The most common form of scoliosis met with in adolescents is a_primary thoracic curvature_ with its convexity to the right (Fig. 227), and with more or less marked compensatory curves towards theleft in the lumbar and cervical regions. The thoracic spines lietowards the right of the middle line. On account of the prominence ofthe ribs, the right scapula is projected backwards, and its inferiorangle is on a higher level and farther from the middle line than thatof the left scapula. The right shoulder seems higher than the left, and is popularly said to be "growing out"--a point which is oftenfirst observed by the dressmaker. The right side of the back is undulyprominent, while the left side is flattened. A deep sulcus forms inthe left flank below the costal margin, and the space between the armand the chest wall--the "brachio-thoracic triangle"--on the left sideis much more marked than on the right; and the left iliac crestusually projects upwards and backwards. As seen from the front, theright side of the chest is flattened, while the left side isabnormally prominent, the breasts are asymmetrical, and the rightnipple is on a higher level than the left. [Illustration: FIG. 229. --Scoliosis showing rotation of bodies ofvertebræ, and widening of intercostal spaces on side of convexity. ] In aggravated cases, the patient may suffer from shortness of breathon exertion, and the respiratory difficulty may react on the heart, causing dilatation of the right side, palpitation, and precordialpain. Sometimes, and particularly in males, the primary curvature is in thelumbar region, and the convexity is to the left. The deviation of thelumbar vertebræ produces a prominence in the left flank which masksthe outline of the iliac crest on that side, while the right flankshows a deep furrow and the right half of the pelvis is undulyprominent. There is a slight compensatory curve to the right in thethoracic region, and the right side of the chest projects backwards. The brachio-thoracic triangle is much more marked on the right than onthe left side. _Diagnosis of Adolescent Scoliosis. _--In many cases the patient isbrought to the surgeon on account of pain and weakness in the backbefore any distinct deviation has developed, and, unless a carefulexamination is made, the real cause of the symptoms is liable to beoverlooked. The patient should be stripped and examined in a good light in variousattitudes; for example, standing in an easy position, standing asstraight as she can, and sitting on a flat stool. She should also beasked to read from a book and to write, in order to exhibit her usualattitudes. In early cases, an inequality in the level of the angles ofthe scapulæ is often the only physical sign to be detected. It shouldalso be observed whether the line of the spines is altered when thepatient hangs from a horizontal bar or trapeze. Any backwardprojection of the ribs on one side is rendered more obvious if thepatient folds the arms across the chest and bends well forward, whilethe surgeon looks along the back from behind. Pott's disease may be excluded by the absence of rigidity. Anymechanical cause of deviation of the spine, such, for example, asinequality in the length of the limbs or contraction of the chestafter empyema, must be sought for. Scoliosis that depends uponinequality in the length of the limbs or tilting of the pelvis, disappears on sitting. _Treatment. _--The treatment of postural scoliosis implies acomprehensive 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 ofyears. The object of the treatment is to correct the deformity beforethe position has become fixed by rotation of the vertebræ andalteration in their shape. The child must not be allowed to assumeawkward attitudes while reading, writing, or playing the piano; shemust sit on a low chair, the seat of which slopes slightly downwardsand backwards, and the back rest of which reaches as high as theshoulders, and is at an angle of 100°-110° with the seat. The feetshould rest on a sloping stool, and when the child is reading orwriting, a desk sloping at an angle of 45° should be used. In weaklygirls approaching the period of puberty, special care should be takento avoid compression of the trunk by tight corsets. Adenoids or othersources of respiratory obstruction must be removed; and if the patientis myopic she should be provided with suitable glasses. Standingshould be avoided, as there is a great tendency to throw the weight onto one leg; but walking, running, and other exercises which bring bothsides of the body into action equally are permitted under supervision. Horse-riding is a suitable form of exercise, but girls must rideastride; cycling is not to be recommended. In mild cases--that is, those in which the curvature is obliteratedwhen the patient is suspended--the prophylactic measures abovementioned must be rigidly enforced, and gymnastic exercises should beprescribed. The exercises should not be commenced, however, until, after a period of rest in bed, all pain and feeling of tiredness inthe back have disappeared. In cases in which the curvature is not affected by suspension, thedeformity is usually permanent, but by suitable exercises it may beprevented from becoming worse, and the patient may be educated todisguise it to a considerable extent. Training is also directedtowards _regaining the muscular sense_; with the eyes shut before amirror, the child should endeavour to assume the correct posture; onopening the eyes, the faulty attitude is seen and corrected. Forciblecorrection by means of successive plaster jackets, applied in _theflexed position_, somewhat on the lines employed by Calot in Pott'sdisease, has yielded results which may be described as encouraging. Only in very advanced cases should the patient be allowed to wear asupporting jacket; such appliances have no curative effect, and canonly be expected to relieve symptoms. * * * * * _Exercises for Lateral Curvature. _--The particular exercises givenmust be carefully selected to meet the indications present in eachcase, the movements prescribed being designed to strengthen the weakmuscles and ligaments, to increase the mobility of the spine as awhole, and to correct the deviation that exists. The exercises shouldbe taken twice daily, preferably in the morning and afternoon, andafter each spell the patient should rest for an hour, lying flat onthe back. During the exercises the breathing should be carefullyregulated, and at the end of each movement one or two deep breathsshould be taken. Each movement should be carried out slowly, thenumber of times it is repeated varying from four to twelve or more, according to the nature of the exercise and the strength of thepatient. The exercises should be stopped if the patient feelsfatigued. Hot-air baths and massage are useful adjuvants to all formsof exercise. #Special Exercises for Thoracic Curvature with convexity toright. #--1. _Stand_ with arms by side; palms directed forward;shoulders braced back. This is referred to as the "_best standingposition_" or _original position_. 2. Slowly raise arms from sidesuntil level with shoulders, with palms directed forward; carry leftarm straight upward--"_the keynote position_. " Then slowly lower leftarm to level of shoulder; lower both arms into original position. 3. _Assume keynote position_: slowly bend body forwards at hips untilstooping position is reached, with legs kept quite straight, head bentslightly backwards, and eyes directed forward. Gradually return tokeynote and original positions. 4. _Keynote position_: slowly bendwhole spine to right; resume keynote and original positions. 5. _Keynote position_: turn body forward sideways. 6. _Keynote position_:rise on to balls of toes. 7. _Keynote position_: rise on to balls oftoes; bend knees; back to original position in reverse order. 8. _Patient suspended from bar or rings, the left end of the bar or leftring being three inches higher than the right. _ (_a_) Draw right kneeupwards and forwards against resistance. (_b_) Draw legs apart againstresistance. (_c_) Draw legs together against resistance. 9. _Patientlying on back. _ (_a_) Bend right knee- and hip-joints againstresistance. (_b_) Extend right knee and hip against resistance. (_c_)Rotate right hip against resistance. 10. _Patient lying on face withpillow under chest_; slowly raise arms to keynote position. Whilelimbs are firmly held by a nurse, raise the body backwards and to theright. 11. _Same position_: make swimming movements. 12. _Patientastride a narrow table or chair, without a back. _ (_a_) Repeatexercises 3, 4, 5, and 11. (_b_) Bend body forwards, backwards; androtate to right and left against slight resistance made by nursegrasping patient's shoulders. _Klapp's "four-footed" Exercises. _--Rudolf Klapp has devised a seriesof exercises designed to strengthen the muscles and ligaments of thespine, and to increase the mobility of the column. To take the weightof the body off the spine, and to render both ends of the columnmobile, these exercises are carried out in the "all-fours" attitude, the patient crawling in imitation of a quadruped, that is, in such away that the hand and knee of one side are approximated, while thoseof the other side are separated; in other words, the hand and knee ofone side should not move forward simultaneously (Fig. 230). With eachstep the spine is curved laterally, the concavity of the curve beingtowards the side on which the hand and knee are approximated. Theexercises, for a case of dorsal curvature with the convexity to theright, for example, are graduated as follows: (1) The child crawls ina straight line till he has acquired the "quadruped gait"; (2) witheach step forward the head is inclined towards the side on which thehand and knee are approximated; (3) at each step the hand and kneewhich are wide apart are brought over and cross the limbs on the otherside; (4) to open out the concave left side, he crawls in a circletowards the right. The exercises are practised morning and afternoonfor from fifteen to sixty minutes at a time. If there is a marked_double_ curve, it is best neutralised by imitating the "pacing"action of a quadruped, _i. E. _, the limbs of the same side movingforward together. The hands, knees, and toes should be protected bysuitable gloves and leather pads. Hot-air baths and massage are usefuladjuvants to the exercises. [Illustration: FIG. 230. --Diagram of attitudes in Klapp's four-footedexercises for Scoliosis. ] Abbott has introduced a method of treatment applicable to cases inwhich the deformity has become permanent. Under general anæsthesia, the patient being slung in a bracket-frame with the spine flexed, thecurvature is over-corrected and a plaster-case is then applied tomaintain the attitude; the plaster-case is renewed at intervals of twoor three months. CHAPTER XIX THE FACE, ORBIT, AND LIPS FACE--Congenital malformations: _Hare-lip and cleft palate_; _Macrostoma_; _Microstoma_; _Facial cleft_; _Mandibular cleft_--Injuries of soft parts: _Wounds_; _Burns_--Bacterial diseases: _Boils_; _Anthrax_; _Glanders, etc. _; _Lupus_; _Syphilis_. Tumours: _Epithelioma_. ORBIT--Injuries: _Contusion_; _Wounds_; _Fractures_--Injuries of eyeball--Orbital cellulitis--Tumours. LIPS--_Cracks_; _Chronic induration_; _Tuberculous ulcers_; _Syphilitic lesions_--Tumours: _Nævi_; _Lymphangioma_; _Cysts_; _Epithelioma_. THE FACE CONGENITAL MALFORMATIONS. --The description of the various congenitalmalformations of the face will be simplified by a brief considerationof its development. _Development. _--About the middle of the first month of intra-uterinelife the prosencephalon bends acutely forward over the end of thenotochord and sends out from its base a series of processes, whichultimately blend to form the face (Fig. 231). These processes surrounda stellate depression, the primitive buccal cavity or stomatodæum, from which the mouth and nasal cavities are developed. The buccalcavity is bounded above by the fronto-nasal process, which is dividedby a fissure--the nasal cleft or olfactory pit--into a lateral nasalprocess, and a mesial nasal process, at the outer angle of which aspheroidal elevation appears--the globular process. [Illustration: FIG. 231. --Head of human embryo about 29 days old, showing the division of the lower part of the mesial frontal processinto the two globular processes, the intervention of the nasal cleftsbetween the mesial and lateral nasal processes, and the approximationof the maxillary and lateral nasal processes, which, however, areseparated by the nasal-orbital cleft. (After His. )] From the mesial nasal and globular processes the septum of the nose, the mesial segment of the premaxillary bone, and the middle portion ofthe upper lip are developed; while the lateral nasal process forms theroof of the nasal cavity, the ala nasi and adjacent portion of thecheek, and the lateral segment of the os incisivum or premaxillarybone. Each segment of the os incisivum carries one of the incisorteeth, and each of the mesial segments may contain in addition anaccessory tooth. The nasal cleft ultimately becomes the anteriornares. The primitive buccal cavity is bounded below by the mandibular arch, which contains Meckel's cartilage, and from which are developed themandible, the lower lip, and the floor of the mouth. From the lateral and back part of the mandibular arch springs themaxillary process, which grows upwards and blends with the lateralnasal process across the naso-orbital cleft--the deeper portion ofwhich persists as the nasal duct. From the maxillary process aredeveloped the cheeks, certain of the facial bones, the lateralportions of the upper lip, the soft and hard palate (with theexception of the os incisivum). The development of the face iscompleted about the end of the second month of intra-uterine life. HARE-LIP AND CLEFT PALATE Hare-lip is a congenital notch or fissure in the substance of theupper lip, and cleft palate a congenital defect in the roof of themouth. Either of these conditions may exist alone, but they occur sofrequently in combination that it is convenient to consider themtogether. In hare-lip the cleft may be median or lateral, and it may or may notbe associated with a cleft in the palate. The resemblance to theY-shaped cleft in the upper lip of the hare, suggested by the name, isin most cases only superficial. #Median hare-lip# is extremely rare. It occurs in two forms: one inwhich there is a simple cleft in the middle of the lip, the result ofnon-union of the two globular processes; another in which there is awide gap due to entire absence of the parts developed from the mesialnasal process--the central portion of the lip, the mesial segment ofthe os incisivum, and the septum of the nose. The second form isusually associated with cleft palate. #Lateral hare-lip# is much more common. It is due to imperfect fusionof the globular process with the labial plates of the maxillaryprocess. There may be a cleft only on one side of the lip, or thecondition may be bilateral. In some cases the cleft merely extendsinto the soft parts of the lip--_simple hare-lip_ (Fig. 232) forming anotch with rounded margins on which the red edge of the lip showsalmost to the apex. In other cases the cleft passes into the alveolusof the jaw--_alveolar hare-lip_--partly or completely separating themesial and lateral segments of the premaxillary bone (Fig. 233). Thesecases are usually combined with cleft palate (Fig. 236). [Illustration: FIG. 232. --Simple Hare-lip. ] [Illustration: FIG. 233. --Unilateral Hare-lip with Cleft Alveolus. ] When the hare-lip is _bilateral_, the two clefts may be unequal, oneforming a simple notch in the lip, the other passing into the nostril. In most cases, however, both clefts are complete, and the mesialportion of the lip is entirely separated from the lateral portions. The central portion or prolabium is usually smaller than normal, andis closely adherent to the os incisivum. This bone may retain itsnormal position in line with the alveolar processes of the maxilla(Fig. 234), or it may be tilted forward so that the incisor teeth, when present, project beyond the level of the prolabium (Fig. 235). Inaggravated cases, the os incisivum and prolabium are adherent to theend of the nose. In these cases there is a Y-shaped cleft in thepalate. [Illustration: FIG. 234. --Double Hare-lip in a girl æt. 17. ] [Illustration: FIG. 235. --Double Hare-lip with Projection of OsIncisivum, in an infant before first dentition. ] #Cleft Palate. #--It has already been mentioned that the palate isformed by the blending of the two palatal plates of the maxillaryprocesses with the four segments of the os incisivum, derived from thenasal processes. The foramen incisivum (anterior palatine foramen)marks the point at which these elements of the palate unite. Theprocess of fusion begins in front and spreads backwards, the twohalves of the uvula being the last part to unite. As development may be arrested at any point, several varieties ofcleft palate are met with. The uvula, for example, may be bifid, orthe cleft may extend throughout the soft palate. In more severe cases, it extends into the hard palate as far forward as the foramenincisivum. In these varieties the whole cleft is mesial. In still moreaggravated cases, the cleft passes farther forward, deviating to oneor to both sides in the fissures between the mesial and lateralsegments of the os incisivum or between the lateral segments and themaxillæ. These cases are combined with double hare-lip. The cleft varies considerably in width. It may be so wide that theimperfectly developed nasal septum is seen between its edges, andgives to the cleft the appearance of being double, or the septum isadherent to one edge of the palate--usually the right--and the cleftappears to be to the left of the middle line. In most cases the roofof the mouth is unduly arched, and is narrower than normal (Fig. 236). [Illustration: FIG. 236. --Asymmetrical Cleft Palate extending throughalveolar process on left side. ] _Clinical Features. _--_Single hare-lip_ is about twice as common onthe left as on the right side, and it occurs more frequently in boysthan in girls. In a considerable proportion of cases there is awell-marked hereditary tendency to these deformities, and theyfrequently occur in several members of a family. The nose is characteristically broad and flattened, the ala beingbound down to the alveolar margin of the maxilla by fibrous tissue. The margins of the cleft in the lip are also attached to the alveolusby firm reflections of the mucous membrane. The orbicularis oris andother muscles of expression about the mouth being defective, thedeformity is exaggerated when the child cries or laughs. In simplehare-lip the child may have difficulty in sucking, but this canusually be overcome by some mechanical contrivance to occlude thecleft. When the _hare-lip is double and combined with cleft palate_, thechild is unable to suck, and food introduced into the mouth tends toregurgitate through the nose. The nutrition can only be maintained byhaving recourse to spoon-feeding, and in feeding the child it isnecessary to throw the head well back and to introduce the fooddirectly into the back of the pharynx. Many of these infants are ofsuch low vitality, however, that in spite of the most careful feedingthey emaciate and die. In those who survive, the voice has a peculiar nasal twang, as inphonation the air is expelled through the nose instead of through themouth, and the articulation, especially of certain consonants, is veryindistinct. Taste and smell are deficient. The constant exposure ofthe nasal and pharyngeal mucous membrane renders it liable tocatarrhal inflammation and granular pharyngitis. _Treatment. _--The only means of correcting these deformities is byoperation, and, speaking generally, it may be said that the earlierthe operation is performed the better, provided the general conditionof the child is equal to the strain. In simple hare-lip the best timeis between the sixth and the twelfth weeks. When cleft palate coexistswith hare-lip, the lip should be operated on first, as the closure ofthe lip often exerts a beneficial influence on the cleft in thepalate, causing it to become narrower. Considerable difference of opinion exists as to when the cleft in thepalate should be dealt with. Some surgeons, notably Arbuthnot Lane, recommend that it should be done in early infancy, as soon as theviability of the child is assured. We agree with R. W. Murray, JamesBerry, and others in preferring to wait until the child is between twoand a half and three years old. It should not be delayed longer, because, even if the cleft in the palate is repaired, the nasalcharacter of the voice persists, as the patient cannot overcome thehabit of expelling the air through the nose. Before the operation is undertaken, the child must be got into thebest possible condition; and arrangements must be made for itsconstant supervision by a competent nurse. Success depends largely onthe avoidance of infective complications, and on absence of tensionbetween the rawed surfaces that are brought into apposition. More thanone operation is sometimes required to effect complete closure of thecleft. _Voice Training. _--The treatment of cleft palate does not cease with asuccessful operation; the importance of voice training must beexplained to the parents. The child must be taught, in speaking, tosend the stream of air through the mouth, instead of through the nose. If the soft palate is not sufficiently large and mobile to shut offthe mouth from the nasal cavity, little improvement in speaking can belooked for. In _adolescents_ and _adults_, if the cleft is wide and the softtissues of the palate are thin and atrophied, better physiologicalresults may be obtained by the use of an artificial obturator orvelum. With the aid of the dentist a plate of vulcanite or gold isfitted to the teeth and kept in position by suction. #Other Congenital Deformities of the Face. #--_Macrostoma_ is anabnormal enlargement of the mouth in its transverse diameter, due toimperfect fusion of the maxillary and mandibular processes. _Microstoma_ is due to excessive fusion of the maxillary andmandibular processes. In some cases the buccal orifice is so small asonly to admit a probe. _Facial cleft_ is due to non-closure of the fissure between the nasaland maxillary processes. It passes upwards through the lip and cheekto the lateral angular process of the frontal bone. _Mandibular cleft_ occurs in the middle line of the lower lip, and mayextend to, or even beyond, the chin; it is due to non-union of the twolateral halves of the mandibular arch. These various deformities are treated by plastic operations carriedout on the same principles as for hare-lip. _Fistulæ of the Lower Lip. _--Two small openings, about the size of apin's head, are occasionally met with on the free border of the lowerlip, near the middle line. On passing a probe, each is found to leadinto a narrow cul-de-sac, which runs for about an inch laterally andbackwards under the mucous membrane. Watery, saliva-like fluid exudesthrough the openings. These fistulæ frequently occur in severalmembers of the same family, and are usually associated with hare-lip. The treatment consists in dissecting them out. #Injuries of the Soft Parts of the Face. #--Owing to its free bloodsupply, the skin of the face has great vitality, and even whenseverely lacerated it not only survives, but shows such resistance tobacterial infection that primary union frequently takes place. Inplastic operations, also, even extensive flaps seldom become infected, and they heal so rapidly that the sutures can be removed in two orthree days. In _incised_ wounds the bleeding is usually free at first, but unlessone of the larger arteries, such as the external maxillary (facial) ortemporal, is injured, it soon ceases. Paralysis of the muscles ofexpression may follow if the facial nerve is injured; and loss ofsensation may result from injury to the supra-orbital or infra-orbitalnerves. If the parotid gland is implicated, saliva may escape from thewound, but it usually ceases in a few days; if the duct is involved, apersistent salivary fistula may form. _Punctured_ wounds may perforate the orbit, the cranial cavity, or themaxillary sinus, and be followed by infective complications, particularly if the point of the instrument breaks off and is left inthe wound. _Contused and lacerated_ wounds result from explosions and injuries byfirearms, and foreign bodies, such as particles of stone or coal, orgrains of gunpowder and small shot, may lodge in the tissues. Everyeffort should be made to remove such foreign bodies, as if leftembedded they cause unsightly pigmentation of the skin. Ligatures areseldom necessary for the arrest of hæmorrhage unless the largerbranches are injured, as the bleeding from smaller twigs is arrestedby the sutures. The edges of the wound are approximated by means ofMichel's clips, or by a series of interrupted horse-hair stitches, andfor this purpose a fine Hagedorn needle is to be preferred, as itleaves less mark than the ordinary bayonet-shaped needle. If themucous membrane of the mouth or of the eyelid is implicated, its edgesshould be approximated by a separate row of catgut stitches. _Cicatricial contraction_ after severe burns may lead to markeddeformities of the eyelids (ectropion), mouth, and nose. When the burnhas implicated the neck, the chin may be drawn towards the chest, andthe movements of the lower jaw and head seriously impeded. #Bacterial Disease. #--_Boils_, _carbuncles_, and _anthrax pustules_frequently occur on the face, and when situated near the middle line, and particularly on the upper lip, are liable to give rise to generalinfection and to intra-cranial complications which may prove fatal. The primary infection of _glanders_ and of _actinomycosis_ may alsooccur on the face. The various forms of _tuberculous lupus_ are met with more frequentlyon the face than in any other situation (Fig. 237). _Tuberculousdisease of the facial bones_, particularly of the lateral half of theorbital margin at the junction of the zygomatic (malar) bone with themaxilla, is not uncommon in children. [Illustration: FIG. 237. --Illustrating the deformities caused by LupusVulgaris, which dated from adolescence. (Mr. D. M. Greig's case. )] The primary lesion of _syphilis_, and the various forms of secondaryand tertiary syphilides, may simulate tuberculous lupus, cancer, andother ulcerative conditions. #Tumours. #--The simple tumours met with on the face include sebaceousand dermoid cysts, nævus, plexiform neuroma and adenoma; the malignantforms include the squamous epithelioma, and rodent, paraffin, andmelanotic cancers. _Epithelioma_ occurs most frequently in men beyond the age of forty. The affection usually begins at the margin of the lip, the edge of thenostril, or the angle of the eye. There is generally a history ofprolonged or repeated irritation, or the condition may develop inconnection with a scar, a wart, a cutaneous horn, or an ulceratingsebaceous cyst. It may begin as a hard nodule, or as a papillarygrowth which breaks down on the surface, leaving a deep ulcer with acharacteristically indurated base--the _crateriform ulcer_. Theneighbouring lymph glands are infected early, but metastases to otherorgans are not common. The treatment consists in excising the growthand the associated lymph glands as early and as freely as possible. When excision is impracticable, benefit may be derived from the use ofradium or of the X-rays. The face is the commonest seat of _rodent cancer_ (Volume I. , p. 395). THE ORBIT #Injuries. #--_Wounds of the eyelids_ are liable to be complicated bydamage to the lachrymal apparatus, leading to stenosis of thecanaliculus and persistent watering of the eye. If the wall of thelachrymal sac or nasal duct is torn, the patient should be warned notto blow his nose for some days lest air be forced into the tissues andproduce emphysema. In suturing wounds of the lids care must be takento secure accurate apposition at the free margins, and to avoidconstricting the canaliculi. _Contusion_ of the eyelids and circum-orbital region--the ordinary"black eye"--is associated with extravasation of blood into the loosecellular tissue of these parts, and is followed within a few hours ofthe injury by marked ecchymosis. The lids may swell to such an extentthat the eye is completely closed. In some cases the impinging objectlacerates the vessels of the conjunctiva and produces asub-conjunctival ecchymosis, which may be situated under the palpebralconjunctiva of the lower lid, or close to the corneal margin on thefront of the globe. The blood effused under the conjunctiva remainsbright red as it is aerated from the atmospheric air. Thecharacteristic play of colours which attends the disappearance ofeffused blood is observed within a week or ten days of the injury. Firm pressure applied by means of a pad of cotton wadding and anelastic bandage, if employed early, may limit the effusion of blood;and massage is useful in hastening its absorption. A black eye is to be distinguished from the effusion which sometimesfollows such injuries as fracture of the anterior fossa of the skull, fracture of the orbital ridges, or a bruise of the frontal region ofthe scalp, chiefly by the facts that in the former the discolorationcomes on within a very short time of the injury, the swelling appearssimultaneously in both lids, and the sub-conjunctival ecchymosis, whenpresent, is coeval with the ecchymosis of the lids. In fractures ofthe orbital plate and bruises of the forehead, on the other hand, theecchymosis does not appear in the eyelids for several days, and thatunder the conjunctiva is usually disposed on the globe as a triangularpatch towards the lateral canthus. _Wounds_ of the orbit result from the introduction of pointed objects, such as knitting pins, pencils, or fencing foils, or from chips ofstone or metal, or small shot. They are attended with considerableextravasation of blood, which may be diffused throughout the cellulartissue of the orbit, or may form a defined hæmatoma. In either casethe eyeball is protruded, and the cornea is exposed to irritation andmay become inflamed and ulcerated. The optic nerve may be lacerated, and complete and permanent loss of vision result. Sometimes the ocularmuscles and nerves are damaged, and deviation of the eye or loss ofmotion in one or other direction results. The globe itself may beinjured. Foreign bodies lodged in the orbit, so long as they areaseptic, may give rise to little or no disturbance, and are liable tobe overlooked. The Röntgen rays are useful in determining the presenceand position of a foreign body. Infective complications are liable to follow injuries by bullets orfragments of shell, and they not only endanger the eyeball, but areliable to be associated with suppurative conditions in the adjacentair sinuses--frontal, maxillary, and ethmoidal--or in the cranialcavity. In purifying wounds of the orbit, and in extracting foreignbodies, great care is necessary to avoid injury of the eyeball or ofits muscles or nerves. _Fracture of the margin_ of the orbit results from a direct blow, andis followed by circum-orbital and sub-conjunctival ecchymosis, andsometimes is associated with paralysis of the optic nerve, or of theother ocular nerves. Implication of the frontal sinus may be followedby emphysema of the orbit and lids, and if there is infection bysuppurative complications. The _roof_ of the orbit is implicated in many fractures of theanterior fossa of the skull produced by indirect violence. It is alsoliable to be fractured by pointed instruments thrust through theorbit, in which case intra-cranial complications are prone to ensue, and these in a large proportion of cases prove fatal. When the medialwall is fractured and the nasal fossa opened into, epistaxis andemphysema of the orbit are constant symptoms. Sub-conjunctivalecchymosis, and some degree of exophthalmos, are almost alwayspresent. Treatment is directed towards the complications. When thenasal fossæ or the air sinuses are opened into, the patient should bewarned against blowing his nose, as this is liable to induce orincrease emphysema of the orbit or lids. #Injuries of the Eyeball. #--These injuries may be divided into twogroups--(1) those in which the globe is contused without its outercoat being ruptured, and (2) those in which the outer coat isruptured. In cases belonging to the first group, while the sclerotic coat andcornea remain intact, the iris may be partly torn from its ciliaryorigin, and the blood effused collects in the lower portion of theanterior chamber; or the pupillary margin of the iris may be rupturedat several points, causing apparent dilatation of the pupil. The lensmay be partly or completely dislocated, and in the latter case it maypass forward into the anterior chamber or backward into the vitreous. Among other injuries resulting from contusion of the eye may bementioned hæmorrhage into the vitreous, rupture of the choroid, anddetachment of the retina. Injuries in which the outer coat of the eyeball is ruptured may befurther subdivided into two groups according to whether or not aforeign body is lodged in the globe. Rupture of the outer coat, especially when it results from a puncturedwound, adds greatly to the risk of the injury, by opening up a paththrough which infective material may enter the globe, and this risk ismaterially increased when a foreign body is retained in the cavity ofthe eyeball. When the globe is burst by a blow with a blunt object, the scleroticusually gives way, and as the rupture takes place from within outward, there is less risk of infection than in punctured wounds. The lens maybe extruded through the wound, and the iris prolapsed. If the ruptureis large, the conjunctiva torn, and the globe collapsed from loss ofvitreous, the eye should be removed without delay. If sight is notentirely lost and there is no marked collapse of the globe, an attemptshould be made to save the eye. Wounds produced by stabs or punctures are liable to be followed byinfective complications ending in panophthalmitis. When this isthreatened, removal of the eye is indicated, not only because theaffected eye is destroyed beyond hope of recovery, but to avoid therisk of "sympathetic ophthalmia" affecting the other eye. #Orbital Cellulitis. #--Infection of the cellular tissue of the orbitby pyogenic bacteria is specially liable to follow punctured woundsand compound fractures, if a foreign body has lodged in the orbitalcavity. It may also result from the spread of a suppurative processfrom the globe of the eye, the conjunctiva, or the nasal fossæ ortheir accessory air sinuses. Both orbits may be affectedsimultaneously. _Clinical Features. _--The disease is ushered in by rigors, hightemperature, and severe pain, which radiates all over the affectedside of the head. There is exophthalmos and fixation of the globe, with redness, swelling and tenderness of the eyelids, and congestionand ecchymosis of the conjunctiva. The pupil is usually dilated, thecornea becomes opaque and may ulcerate, and there is photophobia andsometimes diplopia. Suppuration usually ensues, and the pus burrows inevery direction, and may ultimately point through the eyelids orconjunctiva. Sometimes the infection spreads to the meninges, and tothe ophthalmic vein, and the phlebitis may then extend to thecavernous sinus. The eyeball may be infected and destructivepanophthalmitis result. The prognosis therefore is always grave. The _treatment_ consists in making one or more incisions into thecellular tissue for the purpose of removing the pus and establishingdrainage. A narrow bistoury is passed in parallel to the wall of theorbit, 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 establishedby incising through the lid. When the eye is destroyed bypanophthalmitis, the propriety of eviscerating or enucleating it willhave to be considered. #Tumours of the Orbit. #--Tumours may originate in the orbit or mayinvade it by spreading from adjacent cavities. Those which originatein the orbit may be solid or cystic. Of the solid tumours the gliomaand the sarcoma are the most common, and when they originate in thepigmented structures of the globe they present the characters ofmelanotic growths. Primary carcinoma begins in the lachrymal gland. Osteoma--usually the ivory variety--may originate in the wall of theorbit, or may spread from the adjacent sinuses. _Clinical Features. _--In children, the tumour is usually a glioma, andit is frequently bilateral. It generally occurs before the age offour, is associated with increased intra-ocular tension, protrusion ofthe eyeball, and dilatation of the pupil, and soon produces blindness. The tumour fungates and bleeds, and rapidly invades adjacentstructures and spreads along the optic nerve to the brain. It ishighly malignant, and recurrence usually takes place, even when thetumour is removed early. In adults melanotic sarcoma is most common. It occurs between the agesof forty and sixty, and is almost always unilateral; and while itshows little tendency to invade the brain, the adjacent lymph glandsare early infected, and death usually results from dissemination. In all varieties of intra-orbital tumour exophthalmos is a prominentfeature (Figs. 238, 239), and when the protrusion of the eyeball ismarked the lids become swollen, œdematous, and dusky. The eye isseldom pushed directly forward except when the tumour is growing inthe optic nerve or its sheath. When the tumour is solid, the eyecannot be pressed back into the orbit, but in cystic tumours it may tosome extent. The movements of the eyeball are restricted in a varyingdegree, and ptosis often results from paralysis of the levatorpalpebræ superioris. In almost all cases there is also more or lessvisual disturbance. The cornea being unduly exposed is liable tobecome inflamed, or even ulcerated. Pain is a variable symptom; whenpresent, it usually radiates along the branches of the first andsecond divisions of the trigeminal nerve. Tenderness on pressure isnot always present. It is comparatively uncommon for a tumour of theorbit to invade the globe directly. [Illustration: FIG. 238. --Sarcoma of Orbit, causing exophthalmos anddownward displacement of the eye, and projecting in temporal region. ] [Illustration: FIG. 239. --Sarcoma of Eyelid in a child. (Mr. D. M. Greig's case. )] _Treatment. _--When practicable, removal of the tumour is the onlymethod of treatment, and in malignant tumours it is often necessary tosacrifice the eye to ensure complete removal. When the tumour hasinvaded the orbit secondarily, its removal may be impossible, but itmay be necessary to remove the eye for the relief of pain. The _orbital dermoid_ usually occurs at the lateral end of thesupra-orbital ridge (Fig. 240). A less common situation is theanterior part of the orbit, near the nasal wall, and this variety, from its position and from the fact that it is usually met with inchildren, is liable to be confused with orbital meningocele orencephalocele. Treatment consists in its removal by carefuldissection, and this can usually be done under local anæsthesia. [Illustration: FIG. 240. --Dermoid Cyst at outer angle of orbitalmargin. ] _Orbital aneurysms_ have already been described, Volume I. , p. 317. THE LIPS _Herpes_ of the lips, due to a mild staphylococcal infection, iscommon in delicate children and in the early stages of pneumonia. Acrop of vesicles forms and, after bursting, these leave dry scabs. A more severe staphylococcal infection may give rise to a carbuncularswelling with great œdema, and lead to infective phlebitis of thefacial vein and general septicæmia. Excision of the focus isindicated. The lip is sometimes the seat of the malignant pustule of anthrax. Painful _cracks and fissures_ are frequently met with in the middleline of the lip and at the angle of the mouth in young subjects. Theyusually develop during frosty weather, and as they are constantlybeing torn open by the movements of the mouth, they are difficult toheal. If local applications fail, it may be necessary to cocainise thefissure and scrape it with a sharp spoon. _Chronic Induration of the Lips (Strumous Lip). _--A chronic œdematousinfiltration, probably of the nature of a lymphangitis, sometimesaffects the submucous tissue of the lips of delicate children. It ismost common on the upper lip, and may be associated with a fissure orwith chronic coryza. The lip is everted, and its mucous membraneunduly prominent. The cervical glands are frequently enlarged. The _treatment_ consists in removing the cause and in improving thegeneral condition. In cases of long standing it may be necessary toremove from the inner aspect of the lip a horizontal strip of tissuehaving the shape of a segment of an orange. The term "_double lip_" is applied to a condition occasionally metwith in young men, in which there is a hypertrophy of the labialglands in the mucous membrane of the upper lip. It is of slow growth, and forms an elongated swelling on each side of the frenum, coveringthe teeth, and projecting the lip. It is shotty to the feel, and theonly complaint is of disfigurement. The treatment consists in excisingthe redundant fold of mucous membrane, including the enlarged mucousglands. _Tuberculous disease_ may occur in the form of lupus or of ulcers. The_ulcers_ generally occur in patients suffering from advanced pulmonaryor laryngeal phthisis. They are usually superficial, may be single ormultiple, and are exceedingly painful. _Syphilitic Lesions. _--The upper lip is the most frequent seat ofextra-genital chancre. The _chancre of the lip_ begins on the mucoussurface as a small crack or blister, which becomes the seat of arounded, indurated swelling, about a quarter of an inch in diameter. The surface is smooth, of a greyish colour, and exudes a smallquantity of sero-purulent fluid. The lip is swollen and everted, andthere is a considerable area of induration around. The submental andsubmaxillary lymph glands on one or on both sides soon becomeenlarged, and may reach the size of a pigeon's egg. At first they arefirm, but they may subsequently soften and become painful. In somecases the sore is much less characteristic, resembling an ordinarycrack or fissure, and its true nature is only revealed when thesecondary manifestations of syphilis appear. _Mucous patches_ and _superficial ulcers_ are frequently met with onthe mucous surface of the lips and at the angles of the mouth duringthe secondary stage of syphilis. In the inherited form of the diseasedeep cracks and fissures form, and often leave characteristic scarswhich radiate from the angles of the mouth. Gummatous lesions occur on the lips, and are liable to be mistaken forepithelioma. _Tumours. _--_Nævi_ are not uncommon on the lips. When confined to themucous surface they may be dissected out, but when they invade theskin they are best treated by electrolysis. _Lymphangioma. _--The term _macrocheilia_ is applied to a congenitalhypertrophy of the lip (Fig. 241), which is probably of the nature ofa lymphangioma (Middeldorpf). One or both lips may be affected. Thelip is protruded, the mucous membrane everted, and, when the lower lipis implicated, it becomes pendulous and is liable to ulcerate. Thesubstance of the lip is uniformly firm and rigid, so that it moves inone piece, and sucking, mastication, and phonation are interferedwith. [Illustration: FIG. 241. --Macrocheilia. (From a photograph lent by Sir H. J. Stiles. )] The _treatment_ consists in removing a wedge-shaped portion of theswelling on the same lines as for "strumous lip, " or in employingelectrolysis. _Mucous cysts_ occur as small rounded tumours, projecting from theinner surface of the lip. They are of a bluish colour, and contain aglairy fluid. They are treated by removal of the cyst wall, togetherwith the overlying portion of mucous membrane. #Epithelioma of the lip# is of the squamous-celled variety, and is metwith either as a fungating wart-like projection, or as an induratedulcer. It almost exclusively occurs on the lower lip of men over fortyyears of age. The growth begins about midway between the middle lineand the angle of the mouth, either as a horny epidermal thickening, oras a warty excrescence, which bleeds readily and soon ulcerates. Theaffection is said to be especially common in those who smoke shortclay pipes, and it is a suggestive fact that, while epithelioma of thelip is rare in women, the majority of those who do suffer aresmokers. The ulceration spreads along the lip, chiefly towards the angle of themouth, and downwards towards the chin, and the substance of the lipbecomes swollen and indurated (Figs. 242, 243). The edges arecharacteristically raised and hard, and the raw surface is extremelypainful, especially when irritated by hot food or fluids. The growthis liable to spread to the mucous membrane and gum, and to invade themandible. The disease spreads early to the submental and submaxillaryglands, which are best felt with one finger inside the mouth, underthe tongue, and another outside, behind the mandible. The infectedglands tend to become fixed to the bone, and while at first extremelyhard, so much so that they simulate a bony tumour of the jaw, theylater soften, liquefy, and fungate (Fig. 244). Metastasis to internalorgans is rare. Unless removed by operation, the disease usuallyproves fatal in from three to three and a half years. [Illustration: FIG. 242. --Squamous Epithelioma of Lower Lip in a manæt. 55. (Mr. D. M. Greig's case. )] [Illustration: FIG. 243. --Advanced Epithelioma of Lower Lip. ] [Illustration: FIG. 244. --Recurrent Epithelioma in Glands of Neckadherent to mandible. ] The _treatment_ consists in early and free removal of the affectedportion of lip and of all the lymphatic connections in thesubmaxillary region and neck. Recurrence in the scar is rare; it isnearly always located in the glands. The operation of cleaning out the glands below the mandible on bothsides in men who are advanced in years is not free from risk to life, especially from respiratory complications which may or may not betraceable to the anæsthetic. In inoperable cases benefit may follow the use of the X-rays, or ofradium. _Epithelioma of the upper lip_ is less common. It occurs with equalfrequency in the two sexes, progresses more slowly, and is, on thewhole, less malignant. It sometimes appears to be due to contactinfection from the lower lip. It is treated on the same lines ascancer of the lower lip. CHAPTER XX THE MOUTH, FAUCES, AND PHARYNX Stomatitis--Roof of mouth: _Abscess_; _Gumma_; _Tuberculous disease_; _Tumours_--Elongation of uvula--Epithelioma of floor of mouth--Tonsillitis: _Varieties_--Hypertrophy of tonsils--Calculus--Syphilis and Tuberculosis--Tumours--Retro-pharyngeal abscess. THE MOUTH #Stomatitis. #--The term stomatitis is applied to any inflammation ofthe buccal mucous membrane. The _catarrhal_ form is often associatedwith the presence of carious teeth or an infected wound; the mucousmembrane is hyperæmic and swollen, and exudes an excessive amount ofviscid mucous secretion, and the epithelium desquamates in patches, leaving small superficial erosions or ulcers, which are verysensitive. The _aphthous_ form, met with in unhealthy, underfedchildren, is characterised by the occurrence of patches of fibrinousexudate into the superficial layers of the mucous membrane; theepithelium is shed, leaving a series of whitish spots surrounded by ared hyperæmic zone, which may become confluent and form small ulcers. The condition known as _thrush_, which closely resembles aphthousstomatitis, is met with in infants during the period of teething, andis due to the _oïdium albicans_, a fungus met with in sour milk. Thespots, which are most numerous on the lips, tongue, and throat, havethe appearance of curdled milk. The _treatment_ of these forms consists in improving the generalcondition of the patient, and in employing a mouth-wash, such asperoxide of hydrogen, Condy's fluid, chlorate of potash, orboro-glyceride. The superficial ulcers may be touched with silvernitrate or with a 1 per cent. Solution of chromic acid. _Ulcerative stomatitis_ is frequently met with in debilitated subjectswith decayed teeth, and is specially liable to occur during the courseof acute febrile diseases in which sordes accumulate about the teethand gums. It also occurs in syphilitic subjects while under treatmentby mercury--_mercurial stomatitis_. Some patients show a specialsusceptibility to mercury, and one of the first signs of intoleranceof the drug is some degree of stomatitis, which may ensue after acomparatively small quantity has been administered. It begins in thegums, which become swollen and spongy, growing on to the teeth andinto the interstices. The gums assume a bluish-red colour and bleedreadily, and the teeth may become loose and fall out. The tongue mayshare in the swelling--mercurial glossitis. There is also profusesalivation, and the breath has a characteristically offensive odour. In severe cases the alveolar margin of the jaw undergoes necrosis. Asimilar condition occurs in lead and in phosphorus poisoning, and inpatients suffering from scurvy. The _treatment_ consists in removing the cause, and in employingantiseptic and astringent mouth-washes. The internal administration ofchlorate of potash is also indicated, as this drug is excreted in thesaliva. Loose teeth should not be removed as they become fixed againwhen the stomatitis subsides. _Gangrenous stomatitis_, or cancrum oris (Fig. 245), has already beendescribed (Volume I. , p. 102). [Illustration: FIG. 245. --Cancrum Oris. (Mr. D. M. Greig's case. )] #Roof of the Mouth. #--_Suppuration_ in the muco-periosteum of thepalate is usually secondary to suppuration at the root of a carioustooth. It may also arise in excoriations caused by an ill-fittingtooth-plate, or from the impaction of a foreign body, such as a fishor game bone, in the mucous membrane. The inflammation begins close tothe alveolus, and may spread back along the palate. Themuco-periosteum becomes swollen, red, and exceedingly tender, and, aspus forms, is raised from the bone, forming a prominent, firm, elongated swelling, which on bursting or being incised gives exit tofoul-smelling pus. The _syphilitic gumma_, which begins as a rounded indolent swelling, is usually situated in the middle line near the posterior edge of thehard palate. The swelling gradually softens and ulcerates, and asequestrum may separate and leave a perforation in the palate (Fig. 246). The treatment consists in employing the usual remedies fortertiary syphilis. If the perforation persists and causes trouble byallowing food to pass into the nose, or by giving a nasal tone to thevoice, it may be closed by an operation on the same principle as thatperformed for cleft palate, or an obturator may be fitted to occludethe opening. [Illustration: FIG. 246. --Perforation of Palate, the result ofSyphilis, and Gumma of Right Frontal Bone. (From Dr. Byrom Bramwell's _Atlas of Clinical Medicine_. )] _Tuberculous_ disease is chiefly met with in the form of lupus whichhas spread from the nose or lips, and it may lead to widespreaddestruction of the soft tissues, or even to perforation of the bonypalate. Mucous cysts, dermoids, adenomas, lipomas, and fibromas areoccasionally met with. _Papillomatous thickening_ of the mucousmembrane sometimes occurs in association with leucoplakia. It resistsanti-syphilitic treatment, but yields to scraping with the sharpspoon. _Endotheliomas_, or _mixed tumours_, similar to those met within the parotid gland, also occur in young subjects, and grow in thesubmucous tissue of the soft palate, usually to one side of the middleline. In their early stages they are of slow growth, and give rise tono inconvenience save from their size, are easily removed, and show notendency to recur. Later, they grow more rapidly, tend to infiltratetheir surroundings and to assume malignant characters, so thatcomplete removal becomes difficult or impossible. _Epithelioma_ may originate in the hard palate as a result of localirritation, or may spread from adjacent parts. When it is confined tothe palate it is treated by removal of the palatal and alveolarportions of the maxilla. #Elongation of the uvula# is usually due to a chronic inflammatoryengorgement combined with glandular hypertrophy of the mucousmembrane. It often occurs in children, and is associated with aconstant hacking cough, which is usually worst when the patient islying down. By tickling the back of the tongue and pharynx it mayinduce vomiting after meals. The treatment consists in snipping offthe redundant portion with scissors. #Epithelioma of the floor of the mouth# frequently originates in themucous membrane between the frenum of the tongue and the inner aspectof the gum. It develops insidiously, grows slowly, and graduallyspreads to the mandible and to the substance of the tongue, tacking itdown so that it cannot be protruded. The glands are early involved, and their enlargement not infrequently first draws attention to thecondition. It is to be regarded as a particularly unfavourable site, as local recurrence is frequent. For the complete removal of thedisease it is necessary to excise the tissues in the floor of themouth, and a variable portion of the tongue and mandible, and to clearout the glands and fat from the submaxillary and submental regions. THE TONSILS AND PHARYNX #Infective Conditions. #--The majority of the infective conditionsincluded under the popular term "sore throat" originate in thetonsils, and are due to the action of bacteria which under normalconditions are present in the crypts of the tonsils and of the mucousmembrane of the naso-pharynx. The most important of these organismsare streptococci, various forms of staphylococci and ofpneumo-bacteria, and diphtheritic and pseudo-diphtheritic bacilli. Solong as the health is good these organisms are harmless, but whenthere is any lowering of the vitality they become virulent and giverise to various forms of infection. _Catarrhal tonsillitis_--usually attributed by the laity to "catchingcold"--is characterised by hyperæmia and congestion of the tonsils andmucous membrane of the pharynx, soft palate, and uvula. It is oftenmet with in those who are much exposed to air contaminated withorganisms--for example, patients who have been long in hospital, orthe resident staff of hospitals (_septic_ or _hospital throat_), andparticularly in persons of a "rheumatic" tendency. There is slightpain on swallowing, and a tickling sensation passes along theEustachian tube to the ear; the throat feels dry, and the patient hasa constant desire to clear it, and there is usually a rise oftemperature to 101°-102° F. As a rule the symptoms pass off in threeor four days, but the condition may spread along the Eustachian tubeto the ear, and interfere with hearing, or it may set up chronicsuppuration of the middle ear. A similar condition of the pharynx is frequently one of the initialsymptoms in acute febrile diseases, such as scarlet fever, measles, influenza, or acute rheumatism. The _treatment_ of the throat affection consists in employingantiseptic and soothing gargles, inhalations of chloride of ammonium, or a spray of peroxide of hydrogen, menthol, or eucalyptol. Lozengesor pastilles containing chloride of ammonium, chlorate of potash, andcubebs may be employed. In rheumatic cases, salicin, aspirin, andsalicylate of soda are indicated. In _follicular tonsillitis_, the infection first implicates thelymphoid follicles. The crypts are distended with yellowish-whiteplugs, composed of inflammatory exudate, leucocytes, and desquamatedepithelium, and these may project from the openings, giving the tonsila spotted appearance. Sometimes the exudate accumulates on the surfaceof the tonsils and pharynx, forming a thin, greyish-white film, whichis liable to be mistaken for the false membrane of diphtheria. It can, however, usually be wiped off, and when examined microscopically doesnot contain the typical Löffler's bacillus. The tonsils are enlarged, and project so that they obstruct theisthmus of the fauces, sometimes even meeting in the middle line. There is pain on swallowing, and the respiration is impeded and noisyduring sleep. There is usually some degree of fever, and the glandsbehind the angle of the jaw are enlarged and tender and may suppurateand set up cellulitis. The acute symptoms usually subside in four orfive days, but if the deeper crypts are filled with plugs of exudatethe condition may prove obstinate. The patient is liable to periodicattacks, particularly if the tonsils are chronically enlarged. The _treatment_ is carried out on the same lines as for the catarrhalform. In recurrent cases the tonsils should be removed. #Acute Suppurative Tonsillitis and Peri-tonsillitis--Quinsy. #--This isan acute suppurative inflammation of the tonsils and peritonsillartissue, due to infection with pyogenic bacteria. It affects the wholesubstance of the tonsils, and the cellular tissue of the pillars ofthe fauces, the soft palate, and the pharynx. _Clinical Features. _--The onset is usually sudden, and the affectionis ushered in by a rigor, high fever, and a feeling of malaise. Thereis persistent thirst and dryness of the throat, and the patient hasthe sensation of a foreign body being in the pharynx, with a constantdesire to swallow. Swallowing is extremely painful, the pain shootingup to the ears, and the patient has difficulty in taking nourishment. The saliva accumulates in the mouth; the voice is thick and nasal; andthe respiration impeded and noisy. If the patient can open the mouthsufficiently to afford a view of the back of the throat (which, however, is seldom the case), the inflamed parts are seen to be of adull reddish-violet colour. One tonsil is often more swollen than theother, and the corresponding anterior pillar of the fauces moreprominent. The uvula is swollen and œdematous, and is deviated towardsthe side on which there is least swelling. Suppuration occurs in fromthree to seven days; in adults it is usually in the peritonsillartissue of the anterior pillar of the fauces, and extends into the softpalate. In children the pus sometimes forms in the substance of thetonsil. If left to burst, the abscess discharges itself into themouth, and the patient experiences instant relief. The pus is alwaysoffensive, and if the abscess bursts during sleep, it may enter theair-passages and cause septic pneumonia. The lymph glands in the neckare usually enlarged and tender, and sometimes they suppurate and giverise to a diffuse cellulitis. General infection of the blood mayfollow, leading to metastatic invasion of different tissues andorgans, particularly one or other of the large joints. _Treatment. _--In the early stages soothing antiseptic gargles areindicated. Later, when the patient is unable to gargle, the inhalationof steam impregnated with the vapour of carbolic acid or friar'sbalsam, and the application of hot fomentations or a large linseedpoultice to the neck may afford relief. When an abscess is formed, itshould be opened by means of a fine-pointed pair of sinus forceps, thrust through the soft palate at a point opposite the base of theuvula, and in the line of the anterior pillar of the fauces. As thosewho suffer from quinsy are liable to have attacks coming onperiodically, if the tonsils remain permanently enlarged they shouldbe removed between attacks. #Hypertrophy of the tonsils# is most commonly met with in childrenbetween five and ten years of age, and is often associated withadenoid vegetations in the naso-pharynx and chronic thickening of thepharyngeal mucous membrane. The whole tonsil is enlarged, the mucous membrane thickened, and theconnective tissue more or less sclerosed. The crypts appear on thesurface as deep clefts or fissures, and the lymph follicles areenlarged and prominent. Secretion accumulates in the crypts, and acalculus may form from the deposit of lime salts. Sometimes foodparticles lodge in the crypts, and they may collect and formaccumulations of considerable size, requiring the use of a scoop todislodge them. _Clinical Features. _--The hypertrophy is bilateral, but not alwayssymmetrical. Sometimes the tonsils project to such an extent as almostto meet in the middle line; sometimes they scarcely pass beyond thelevel of the pillars of the fauces. They are usually sessile, butsometimes the base is so narrow as almost to form a pedicle. Duringchildhood they are usually soft and spongy, but when they persist intoadolescence or adult life they become firm and indurated. Thissclerotic change is due to the repeated attacks of catarrhal orsuppurative tonsillitis to which the patient is subject. The lymphglands behind the angle of the jaw are frequently enlarged. Swallowingis sometimes interfered with, and the patient is liable to attacks ofnausea and vomiting. Respiration is always more or less impeded; thepatient breathes through the open mouth, and snores loudly duringsleep; and the hindrance to respiration interferes with thedevelopment of the chest. In some cases alarming suffocative attacksoccasionally supervene during sleep, but the difficulty in breathingdisappears as soon as the child is wakened. The voice ischaracteristically thick and nasal, especially when adenoids arepresent, and in many cases the patient has a vacant and stupidexpression. Hearing is often impaired from obstruction of theEustachian tube. _Treatment. _--In early and mild cases, the tonsils should be paintedwith glycerine of tannic acid, or some other astringent, and anantiseptic mouth-wash, or spray of hydrogen peroxide, should be usedseveral times a day. When the condition is interfering with thegeneral health or with the development of the chest, or when there isdeafness or disturbance of sleep, the tonsils should be removed. #Calculi# composed of phosphate or carbonate of lime are sometimesformed in the crypts of enlarged tonsils; as a rule they are about thesize of a pea, but they may be much larger. They cause a sharpstabbing pain on swallowing, and sometimes a persistent hacking cough. They are easily shelled out through a small incision into the tonsil. #Syphilis. #--The fauces and tonsils are occasionally the seat of ahard chancre, and the condition may simulate malignant disease. Thesubmaxillary glands, however, become enlarged sooner and increase morerapidly than in cancer, and they are tender. The secondarymanifestations of the disease usually appear before the chancre hashealed. Early in secondary syphilis, mucous patches and superficial ulcers arefrequently met with. Later, severe phagedænic ulceration sometimesoccurs, especially in alcoholic subjects, and may rapidly eat throughthe soft palate, leading to marked deformity from contraction whencicatrisation takes place. In the tertiary stage, a diffuse gummatous infiltration occurs, and isliable to be followed by ulceration, which spreads to the pharyngealwall and soft palate, and, by causing cicatricial contraction andadhesions, may lead to narrowing or even complete occlusion of thecommunication between the pharynx and the naso-pharynx. #Tuberculous# lesions of the fauces and tonsils are almost invariablysecondary to tubercle of the larynx or lungs, or to lupus of the faceor naso-pharynx. They are attended with more pain than syphiliticlesions; are less prone to spread to the palate and cause perforation;but, when cicatrisation takes place, they are equally liable toproduce contraction and deformity. #Tumours. #--_Innocent tumours_--fibroma, lipoma, myoma--arecomparatively rare. When sessile they cause inconvenience only bytheir bulk; when pedunculated they may hang down into the pharynx andinterfere with swallowing and breathing. They may be shelled out, orligated at the base and cut off, according to circumstances. _Malignant Disease. _--The _tonsil_ is frequently the primary seat of_lympho-sarcoma_, a very malignant form of round-celled sarcoma. Thetumour is at first confined to the tonsil, which differs in appearancefrom simple hypertrophy only in being paler and more nodular. Thegrowth rapidly infiltrates the peritonsillar connective tissue andadjacent palatal mucous membrane, which becomes pale and œdematous, and the condition at this stage may simulate a suppurativetonsillitis. As it increases, the tumour encroaches upon the cavity ofthe pharynx, causing interference with swallowing and breathing; themucous membrane soon gives way, and widespread ulceration andsloughing of the tumour substance occurs, sometimes leading to seriousand even fatal hæmorrhage. The patient emaciates rapidly. The adjacentlymph glands are early infected. Removal by operation is seldom practicable, but the introduction of atube containing radium for several days has in some cases provedbeneficial. _Carcinoma_ is more common than sarcoma. It may take the form of_squamous epithelioma_ or of _medullary cancer_, and may originate inthe tonsil, in the groove between the tonsil and the tongue, or in thesoft palate. By the time the patient seeks advice it has usuallyimplicated the fauces, soft palate, and pharyngeal wall as well as thetonsil. Males suffer more frequently than females. The disease may exist for aconsiderable time before giving rise to marked symptoms, and attentionmay first be drawn to it by pain and difficulty in swallowing, or bypain shooting towards the ear. In some cases enlargement of the glandsbehind the angle of the jaw is the first thing to attract thepatient's attention. The other symptoms are very like those of cancerof the tongue--pain during eating or drinking, salivation and fœtidbreath. Sometimes fluids regurgitate through the nose, and the voicemay become nasal and indistinct. As the patient is usually unable toopen the mouth widely, it is seldom possible to learn much byinspection, but a digital examination may reveal an irregular, hard, and ulcerated growth. The swelling is sometimes palpable from theoutside, filling up the hollow behind the angle of the jaw, and inthis situation also the enlarged lymph glands may be felt. These areoften enlarged out of all proportion to the size of the primarygrowth. The disease tends to spread locally, causing increasingdifficulty in swallowing and breathing. The patient gradually losesstrength, and may die from exhaustion induced by pain and insomnia, from hæmorrhage, or from septic pneumonia. In early cases an attempt may be made to remove the disease byoperation. In our experience radium has proved less efficacious incancer than in sarcoma. In advanced cases, it is only possible to relieve the patient'ssuffering by palliative measures. Antiseptic mouth-washes are used todiminish the fœtor of the breath and the risk of pneumonia, and heroinor morphin to relieve pain. The use of the nasal tube, or even agastrostomy, may be necessary to enable the patient to take sufficientfood, and tracheotomy may be called for to relieve dyspnœa. #Retro-pharyngeal Abscess. #--The _chronic_ retro-pharyngeal abscessassociated with tuberculous disease of the cervical vertebræ, in whichthe pus accumulates behind the prevertebral fascia, has already beendescribed (p. 441). The _acute_ abscess occurs in the space between the prevertebralfascia and the wall of the pharynx. The infection usually begins inone of the lymph glands that occupy this space, and rapidly ends insuppuration, which spreads to the surrounding cellular tissue. It ismost common in children during the first and second years, and thepatient may be convalescent after one of the eruptive fevers attendedwith inflammation of the bucco-pharyngeal mucous membrane--such asscarlet fever, measles, or chicken-pox--or may suffer from nasalexcoriations or coryza. In some cases the irritation of dentition isthe only discoverable cause. In infants, the condition is usually very acute, and is attended withfever, rigors, vomiting, and often with convulsions. The head is heldrigid, and usually twisted to one side, and there is pain onattempting to move it. The child has great pain on swallowing, thereis regurgitation of food, and the saliva dribbles from the mouth. There is marked dyspnœa and a short, dry cough. The back of the throatis red and swollen, and a localised projection, which is soft andfluctuating, and is usually asymmetrical, may be recognised by digitalexamination. Sometimes the voice is lost, and the patient has severeattacks of choking--symptoms which have led to the disease beingmistaken for membranous laryngitis. In some cases a soft swelling ispalpable on one or on both sides of the neck. Unless the abscess ispromptly opened the condition usually proves fatal. The mouth isopened by means of a gag, the head allowed to hang over the end of thetable, and the abscess incised, with a guarded bistoury, through thewall of the pharynx. The dangers associated with opening the abscessfrom the mouth appear to have been exaggerated. A _less acute_ form of retro-pharyngeal abscess sometimes develops inthe course of chronic middle ear disease, the inflammatory processspreading along the Eustachian tube, in the wall of which an abscessforms and burrows into the retro-pharyngeal space. CHAPTER XXI THE JAWS, INCLUDING THE TEETH AND GUMS TEETH: Dental caries--Impacted wisdom tooth. GUMS: Gingivitis; Pyorrhœa alveolaris; Hypertrophy; Epithelioma. JAWS: Pyogenic affections: _Periostitis_; _Osteomyelitis_; Tuberculosis; Syphilis; Actinomycosis--Tumours: _Of alveolar process_; _Of maxilla_; _Of mandible_--Fracture of maxilla--Fracture of mandible--Affections of the temporo-mandibular articulation: _Dislocation of the mandible_; _Acute arthritis_; _Tuberculous arthritis_; _Arthritis deformans_; _Closure of the jaws_. #Dental caries# is a process of disintegration which begins in theenamel of a tooth--usually in the region of its neck--and graduallyextends through the dentine till the pulp cavity is reached. Infection of the exposed pulp cavity may set up an acute purulent_pulpitis_. This is associated with severe pain, which is not confinedto the diseased tooth, but may spread to adjacent teeth, and sometimesto all the branches of the trigeminal nerve on the same side of theface. The infection may spread from the tooth to the alveolo-dentalperiosteum, and set up a _periodontitis_. In the affected tooth thereis at first a feeling of uneasiness, which is relieved by the patientbiting against it. Later there is severe lancinating or throbbingpain. The affected tooth usually projects beyond its neighbours, andis excessively tender when the opposing tooth comes in contact with itin mastication. The gum becomes red and swollen, and the cheek isœdematous. Periodontitis is usually followed by the formation of an _alveolarabscess_. The pus, which forms at the root of the tooth, in most casesworks its way through the bone and into the gum, constituting a"gum-boil. " The pus may then burst through the gum, or may spreadunderneath the external periosteum of the jaw and lead to necrosis. In some cases the cheek becomes adherent to the gum and to the jawbefore the abscess bursts, and the pus escapes through the skin, leaving a sinus which leads down to the defaulting tooth, and which isslow to heal, usually because there is a small sequestrum at thebottom of it. The opening of the sinus is most commonly situated atthe under margin of the mandible a little in front of the massetermuscle. An alveolar abscess deeply seated in the maxilla may open intothe maxillary antrum and set up suppuration in that cavity. To avoid ascar on the face, the abscess should be opened from the mouth. Aperiodontal abscess of one of the upper central incisors spreadsbackwards between the muco-periosteum and the bony palate, causing anelongated swelling in the roof of the mouth. In all cases the extraction of the carious tooth is necessary beforethe abscess will cease discharging and the sinus heal. If a sequestrumis present it must be removed, and the bone scraped with a sharpspoon. Among the other effects of dental caries may be mentionedlocalised necrosis of the alveolar margin, cellulitis of the neck, andenlargement of the cervical lymph glands. A _cyst_ is frequently found attached to the root of a decayed tooth. It is lined with epithelium, and is probably derived from a belatedportion of the enamel organ which has been stimulated to active growthby infective processes in the pulp cavity. It is seldom larger than apea, and contains a pultaceous mass like inspissated pus. It givesrise to no symptoms, and is only recognised after extraction of theroot. _Odontomas_ have already been described (Volume I. , p. 192). A localised swelling of the mandible, associated with pain referred tothe ear and neck, and in some cases with spasmodic contraction of themuscles of mastication, may be due to _impaction of the wisdom tooth_(lower third molar). If the tooth is merely embedded in the gum, incision may allow of its eruption; if the X-rays show that it iswedged under the second molar it must be extracted, and this may provea difficult dental operation. #Affections of the Gums. #--Inflammation of thegums--_gingivitis_--usually occurs in association with a generalstomatitis. The gums are swollen and spongy, and may show superficialulceration, associated with bleeding and extreme fœtor of the breath. The teeth become loose, project from the alveoli, and sometimes fallout. These symptoms are prominent in cases of scurvy, and of chronicmercurial poisoning. In chronic lead-poisoning a characteristic blueline is seen on the gums near the dental margin. The _treatment_consists in removing the cause, improving the hygienic and dieteticconditions of the patient, and administering lime-juice, iodide ofpotash, quinine, or cod-liver oil, according to the cause. Antisepticmouth-washes and dentifrices are also indicated. Chlorate of potash, being excreted in the saliva, is particularly useful. _Pyorrhœa alveolaris_ is a chronic form of gingivitis, met with aftermiddle life, which begins in relation to the necks of the teeth andthe alveolo-dental periosteum. It is due to bacterial infection, andis associated with an accumulation of tartar between the gums and theteeth. A muco-purulent discharge escapes from within the free edge ofthe gum and alveolus. The alveolar borders and the gum subsequentlyundergo atrophy, so that the roots are exposed, and the teeth areliable to become loose and eventually to fall out. The condition mayonly affect a few teeth, or it may spread to them all, in which casethe patient may in the course of some years become edentulous. Gastro-intestinal disturbances, chronic joint affections of the natureof arthritis deformans, a form of pernicious anæmia, and other generalconditions have been attributed to the absorption of toxic products. The _treatment_ consists in removing the tartar from the teeth, applying strong antiseptics to the groove between the teeth and thegums, and employing mouth-washes and dentifrices. Massage of the gumsnight and morning, and rubbing in a paste of chlorate of potash andmenthol, is often of great value. Good results have followed the useof vaccines and improvement of the general health. _Hypertrophy of the gums_ is occasionally met with in children andyoung adults who are mentally defective, and the teeth appear earlyand are abnormally large. The gum almost buries the teeth, and largepolypoid masses form which tend to fungate. The treatment consists inremoving not only the hypertrophied gums, but also the affectedalveolus (Heath). A localised hypertrophy--_polypus of the gum_--sometimes results fromthe irritation of a carious tooth, or from the pressure of anartificial denture, and may simulate an epulis (p. 513). The swellingis usually pedunculated, and if cut away close to the alveolar margindoes not tend to recur. _Epithelioma_ sometimes originates in the gum in relation to a carioustooth or to an artificial tooth-plate. The growth tends to invade thebone and to spread to the cheek or buccal mucous membrane, or to themaxillary antrum, and its malignant nature is suggested by itspersisting after the removal of the irritation. The only treatment isearly and complete removal of the growth and the adjacent segment ofbone. Other tumours of the gums, such as angioma and papilloma, are rare. THE JAWS #Pyogenic Infections. #--The jaws may be infected in fracturescommunicating with the mouth or as a result of the unskilfulextraction of teeth, but the majority of pyogenic infections originatein relation to carious teeth, beginning as a periodontitis which isfollowed by diffuse periostitis that may lead to necrosis ofconsiderable portions of bone. In workers exposed to the fumes ofyellow phosphorus, the bone may be so devitalised that it readilybecomes infected with pyogenic organisms and undergoes a process ofcario-necrosis--the _phosphorus necrosis_ of the older writers. [Illustration: FIG. 247. --Cario-necrosis of Mandible. ] _Acute osteomyelitis_ occasionally attacks the mandible, lessfrequently the maxilla. Pus rapidly forms under the periosteum, and aconsiderable area of bone may undergo necrosis. In _cancrum oris_, also, the bones are frequently attacked and mayundergo necrosis. The _treatment_ is to let out the pus, and, whenever possible, thisshould be done from the mouth to avoid a cicatrix on the face. Whenthe angle or the ascending ramus of the mandible or the facial portionof the maxilla is involved, it is not possible to avoid making anexternal opening. Drainage is secured, and the mouth kept sweet by thefrequent use of antiseptic washes. When the condition is due to acarious stump or to an unerupted tooth, this should be extracted atthe same time as the abscess is opened. The separation of a sequestrum is usually slow, taking from two tofour months according to the acuteness of the infection and the extentof the necrosis. In the mandible the sequestrum becomes surrounded bya sheath of new periosteal bone, so that, even if the greater part ofthe jaw undergoes necrosis, the arch is reproduced, and after removalof the sequestrum little or no deformity results. The sequestrum canusually be removed after dividing the mucous membrane and gouging awaya portion of the outer aspect of the new sheath. The cavity is packedwith iodoform or bismuth gauze. When the ascending ramus is involved, precautions must be taken to prevent fixation of the jaw taking placeduring the healing process. In the maxilla no new case is formed, anddeformity results from sinking in of the cheek, unless this isprevented by wearing a plate made by the dentist. #Tuberculous disease# is comparatively rare. It is occasionally metwith on the orbital margin of the maxilla and in the region of thezygomatic (malar) bone. In the mandible it usually occurs near theangle. Stockman isolated the tubercle bacillus from a series of casesof "phosphorus necrosis" investigated by him. The sinuses that formwhen a cold abscess bursts on the surface are peculiarly intractableand only heal after the diseased bone has been removed, leaving acharacteristically depressed scar, which is adherent to the bone. #Syphilitic# affections are also rare. A localised gumma may developin the neighbourhood of the angle of the mandible, or the whole of thebody of that bone may be the seat of a diffuse gummatous infiltration(Fig. 248). In either case the clinical importance of the conditionlies in the fact that it is liable to be mistaken for a new growth, such as an osteo-sarcoma, or for actinomycosis. [Illustration: FIG. 248. --Diffuse Syphilitic Disease of Mandible. ] #Actinomycosis. #--This condition is met with in the jaws morefrequently than in any other part, and the mandible is attackedoftener than the maxilla. The actinomyces gain access to the bonethrough a carious tooth or through the gum. At the outset the patient complains of pain and tenderness referred toone or more carious teeth. Within a few weeks a swelling forms--in themandible near the angle as a rule, and in the maxilla in some part ofthe cheek. The swelling, which varies in consistence, implicates thebone and cannot be moved apart from it. The skin over it becomes red, suppuration occurs, and sinuses form and give exit to a sero-purulentfluid in which the characteristic yellow "sulphur grains" may bedetected. The surrounding soft tissues are infiltrated, and the partbecomes riddled with sinuses, which lead down to bare bone. Thedisease usually runs a chronic course, lasting for one or two years, and, unless pyogenic infection is superadded, is not attended withfever. In the absence of the characteristic yellow granules, actinomycosismay readily be mistaken for tuberculous or syphilitic disease, or forsarcoma. The _treatment_ consists in removing the diseased tissue with theknife or sharp spoon, and in the administration of large doses ofpotassium iodide. The insertion of tubes of radium has a beneficialeffect. #Tumours of the Alveolar Process. --Epulis. #--The tumours that growfrom the alveolar processes of the jaws appear at first sight tospring from the gums, hence the term _epulis_, generally applied tothem. They really originate in the periosteum of the alveolus or inthe periodontal membrane, and are essentially of the nature offibro-sarcoma. In some, the fibrous element predominates, but thefrequency with which they recur after removal, unless the segment ofbone from which they spring is also excised, indicates their malignanttendency. In most cases the tumour is of the myeloid type--myeloma; inothers new bone is formed in its substance--osteo-sarcoma. An epulis usually begins in the gap between two teeth, and growsslowly, either towards the cavity of the mouth, or more frequentlytowards the lip or cheek, where it appears as a bright red, smooth, firm, rounded swelling, which is adherent to the jaw, and may besessile or pedunculated (Fig. 249). It causes little pain, but isliable to interfere with mastication. As it increases in size itspreads over the alveoli of several teeth, becomes softer, and assumesa dark violet colour, and if subjected to pressure or irritation mayulcerate and bleed. [Illustration: FIG. 249. --Epulis of Mandible. (Anatomical Museum, University of Edinburgh. )] The true alveolar tumour is to be diagnosed from a mass of redundantgranulations such as may form in relation to a carious tooth, from apolypus or an epithelioma of the gum, a tumour of the body of the jaw, or an angioma. The _treatment_ consists in removing the tumour together with awedge-shaped or quadrilateral portion of the alveolar process fromwhich it grows. A dental plate should be fitted to fill up the gap inthe alveolus. After such free removal these tumours show littletendency to recur and metastases are rare. #Malignant Tumours of the Maxilla. #--All varieties of _sarcoma_ and_carcinoma_ are met with; of the former, the round and spindle-celledare the most common. Carcinoma occurs chiefly in two forms, lesscommonly a columnar epithelioma arising from glandular epithelium, much more commonly a squamous epithelioma either originating withinthe antrum and causing its expansion, or spreading to the maxilla fromthe mucous membrane of the nose or mouth. Clinically it is practicallyimpossible to differentiate sarcoma from carcinoma; in the laterstages the infection of the glands below the mandible is more markedin carcinoma. An important point to determine is whether the growtharises 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 theX-rays are helpful. Their malignancy is evidenced by the rapidity oftheir growth, the manner in which they infiltrate adjacent parts, andthe frequency with which they recur after removal. They occur at allages, and have been met with even in children. The _clinical features_ vary according to whether the tumouroriginates on the anterior aspect of the bone, in the maxillaryantrum, or on the posterior aspect. When the tumour originates in the periosteum covering the front of thebone, it forms a swelling under the cheek, usually in the vicinity ofthe zygomatic (malar) bone, and grows towards the mouth as well astowards the surface. The cheek is gradually invaded, and in some casesthe growth extends into the maxillary sinus. The typical malignant tumour of the upper jaw originates in the liningmembrane of the antrum; it first fills the cavity and then bulges itswalls in every direction, so that, on pressure being made over theswelling, the osseous shell of the sinus dimples and crackles underthe finger. The sinus is dark on trans-illumination. The tumour mayobstruct the nostril on the same side, and, by pressing on the tearduct, may cause the tears to flow over the cheek. It may be seenthrough the anterior nares, and may be attended with a saniousdischarge from the nose. The eyeball is liable to be displacedupward, and if the ethmoid cells are invaded, it is also pushedoutward; the palate may be depressed and the cheek projected (Figs. 250, 251). [Illustration: FIG. 250. --Sarcoma of the Maxilla. ] [Illustration: FIG. 251. --Malignant Disease of Left Maxilla, whichdisplaced the eyeball and caused double vision. ] When the tumour grows from the periosteum of the posterior aspect ofthe bone, and extends into the spheno-maxillary or pterygo-maxillaryfossa, the eyeball is usually protruded by the invasion of the orbitfrom behind, and a swelling appears in the temporal region. If thesinus is invaded, the tumour spreads in the various directions alreadyindicated. Not infrequently a tumour, which appears to have its seatin the maxilla, is really a downward prolongation of a growthoriginating in the base of the skull, a point on which the X-rays mayyield valuable information. In all cases the tumour tends to infiltrate the surrounding tissuesindiscriminately. There is severe pain referred to the distributionof the maxillary division of the trigeminal nerve. Hæmorrhage isliable to occur when exposed portions of the tumour ulcerate--forexample in the nasal fossæ. Sarcoma is to be distinguished from thesolid and cystic forms of odontoma, which also may distend the bone, bulging the hard palate and projecting on the face. _Treatment of Malignant Disease. _--Without the help of radiation theresults of operative treatment of malignant disease of the maxilla arefar from encouraging. Probably the best line to follow is to embedseveral tubes of radium in different parts of the tumour for severaldays, and when the resulting shrinkage of the growth appears to haveattained its limits, the maxilla should be excised. If on microscopicexamination it is found to be a carcinoma, the glands on the same sideof the neck should be removed at a second operation on lines similarto those in Butlin's operation in cancer of the tongue. The aid of thedentist is required to fit a denture which will at least restore thehard palate and alveolar margin. The operation of excising theupper jaw is not a dangerous one, especially if the risk ofbroncho-pneumonia is minimised by the intra-tracheal administration ofether. The final illness in cases of malignant disease of the upperjaw left to nature, or when it has recurred after operation, is aterrible one; the growth displaces and destroys the globe, blocks thenose and fungating on the face, causes hideous disfigurement. #Simple tumours# are rare. _Fibroma_ may originate in the periosteumor in the lining membrane of the maxillary sinus. It usually tends toassume the characters of sarcoma. _Chondroma_ usually begins either onthe nasal surface of the bone or in the maxillary sinus. _Osteoma_occurs in two forms: the exostosis, which may be composed ofcancellated or of compact tissue, and the diffuse osteoma orleontiasis ossea (Volume I. , p. 485). All intermediate forms are metwith, and when confined to the maxilla, the resulting disfigurementmay be improved or remedied by operation; the cheek is raised orreflected and the bone shaved away with a strong knife or osteotome. #Tumours of the Mandible. #--The same varieties are met with as in themaxilla. The non-malignant forms--osteoma, chondroma, and fibroma--arerare. A _dentigerous cyst_ appears as a smooth, rounded, and painlessswelling, usually in the region of the molar teeth. The bone graduallybecomes expanded and crackles on pressure. The cyst is filled with aglairy mucoid fluid, and may contain one or more unerupted teeth (Fig. 252). The X-ray appearances are characteristic. The treatment consistsin removing the anterior wall of the cyst, scraping the interior, andpacking the cavity with iodoform or bismuth gauze. [Illustration: FIG. 252. --Dentigerous Cyst of Mandible containingrudimentary tooth. (From Sir Patrick Heron Watson's collection. )] The myeloid tumour or _myeloma_ is comparatively common. It developsin the interior of the bone and expands the affected segment (Fig. 253). It grows slowly, is more or less encapsulated, and thereforedoes not infiltrate the surrounding tissues. Sometimes it so weakensthe bone that pathological fracture occurs. There is no glandularinvolvement, and the tumour shows little evidence of malignancy. [Illustration: FIG. 253. --Osseous Shell of Myeloma of Mandible. (From Professor Annandale's collection. )] The _periosteal sarcoma_ is the most malignant form. It grows rapidly, and infiltrates the surrounding tissues. The submaxillary salivaryglands and the cervical lymph glands are usually implicated, and thedisease tends to spread by metastasis to distant parts. _Epithelioma_ is the commonest new growth affecting the mandible; itusually involves the central portion of the bone, being a directspread from the lower lip, tongue, or floor of the mouth. When itoriginates in the pillars of the fauces it implicates the ascendingramus. In all cases the infection of the cervical lymph glands is aserious factor both in prognosis and treatment. _Treatment. _--_Partial removal_ of the mandible may be undertaken formyeloma, and in cases of sarcoma and epithelioma in which the tumouris limited to a small area of the bone--for example, to the alveolarprocess, the angle, the horizontal ramus, or the symphysis; in othercases, the whole bone must be removed. INJURIES OF THE JAWS #Fracture of the Maxilla. #--Fractures of the maxilla are nearly alwaysdue to direct violence, such as a blow on the face, a stab, or agun-shot wound. They are often rendered compound by opening into themouth, into the maxillary sinus, or on to the skin of the cheek. Thealveolar process, in whole or in part, may be separated from the bodyof the bone by a severe blow, such as the kick of a horse, and whenthe whole alveolus is detached, it may carry with it the hard palate. Limited portions of the alveolus are frequently broken in theextraction of teeth. The main trouble after severe alveolar fracturesis that the upper teeth do not accurately oppose the lower ones, andmastication is thereby interfered with. When the frontal (nasal) portion of the maxilla is broken, thelachrymal sac and nasal duct may be damaged and the flow of the tearsobstructed. In such cases emphysema is also liable to develop. Fractures of the facial portion are frequently complicated byhæmorrhage from the infra-orbital vessels, and anæsthesia of the areasupplied by the infra-orbital nerve. Suppuration may occur in themaxillary sinus. In some cases the maxilla is driven in as a whole, and in others the fracture radiates to the base of the skull andcerebral symptoms develop. The _treatment_ consists in reducing any deformity that may bepresent, ensuring efficient drainage, and keeping the mouth as asepticas possible. Union takes place rapidly, and owing to the vascularityof the parts necrosis is rare, even when suppuration ensues. When thealveolar portion is comminuted, the fragments may be kept in positionby fixing the mandible against the maxilla by means of a four-tailedbandage (Fig. 255), or by adjusting a moulded lead or gutta-perchasplint to the alveolus and palate. The _zygomatic (malar) bone_ is sometimes fractured by directviolence, along with the adjacent portion of the maxilla. It may bepossible to manipulate the displaced fragments into position with thefingers introduced between the cheek and the gum; if this fails, asmall incision should be made in the mucous membrane anterior to themasseter, and the bone levered into position with an elevator. The _zygomatic arch_ is occasionally fractured by a direct blow. Asthe depressed fragments are liable to interfere with the movement ofthe mandible, they should be elevated either by manipulation orthrough an incision. #Fractures of the Mandible. #--The most common situation for fractureof the mandible is through the _body_ of the bone in the vicinity ofthe canine tooth (Fig. 254). The depth of the socket of this tooth, and the comparative narrowness of the jaw at this level, render it theweakest part of the arch. The fracture is usually due to directviolence, such as a blow with the fist, the kick of a horse, or a fallfrom a height. It is sometimes bilateral, the bone giving way at thecanine fossa on one side and just in front of the masseter on theother; or both fractures may be at the canine fossæ. The fracture isusually oblique from above downwards and outwards, and is nearlyalways rendered compound by tearing of the mucous membrane of themouth. [Illustration: FIG. 254. --Multiple Fracture of Mandible. (From Sir Patrick Heron Watson's collection. )] When only one side is broken, the smaller fragment is usuallydisplaced outwards and forwards by the masseter and temporal muscles, so that it overlaps the larger fragment. In bilateral fractures thecentral loose segment is driven downwards and backwards towards thehyoid bone by the force causing the fracture, and is held in thisposition by the muscles attached to the chin, while both lateralfragments are tilted outwards and forwards by the masseters andtemporals. The amount of displacement is best recognised by observingthe degree of irregularity in the line of the teeth. Abnormal mobilityand crepitus are readily elicited, and there is severe pain, particularly if the inferior dental nerve is stretched or crushed. Thepatient's attitude is characteristic; he supports the broken jaw withhis hands, and keeps it as steady as possible when he attempts tospeak or swallow. Saliva dribbles from the open mouth, and the speechis indistinct. In adults, the bone may be broken at the _symphysis_ as a result oflateral compression of the jaw--for example, pressing together of theangles. The general characters of the fracture are the same as thoseof fracture of the body, but the displacement is inconsiderable. Fractures of the _angle_ and through the _ramus_ are less common, andare not attended with deformity, as the fragments are retained inposition by the masseter and internal pterygoid muscles. Fracture ofthe _coronoid process_ is rare. The _condyle_ is usually fractured just below the insertion of theexternal pterygoid muscle (Fig. 254) by a fall on the chin or by asevere blow on the side of the face. When the fracture is unilateral, the broken condyle is tilted inwards and forwards by the externalpterygoid, and can be palpated from the mouth, while the rest of thejaw is displaced _towards_ the affected side, and not away from it, ashappens in unilateral dislocation. When the fracture is bilateral, themandible falls backwards, so that the lower teeth lie behind those ofthe maxilla. In a few cases the condyle has been driven through the floor of theglenoid cavity, causing fracture of the base of the skull. Thediagnosis may be established by means of the X-rays. _Complications. _--As the majority of these fractures are compound, suppuration is comparatively common during the process of repair, butif means are taken to keep the mouth clean it can usually be kept incheck, and seldom leads to necrosis. The teeth adjacent to thefracture are liable to be loosened or displaced. If merely loosenedthey should be left in place, as they usually become firmly fixed inthe course of a few days. Care must be taken that a displaced toothdoes not pass between the fragments, as this has been the cause ofdifficulty in reducing a fracture and of its failure to unite. Irregular union, by destroying the alignment of the teeth, leads tointerference with mastication. The bone usually unites in from four tosix weeks. Want of union is a rare event. _Treatment. _--In the majority of cases of unilateral fracture afterreduction, the fragments can be kept in apposition by closing themouth and keeping the lower jaw fixed against the upper by means of afour-tailed bandage (Fig. 255). Care must be taken that the posteriortails of the bandage do not pull the mandible backward. Additionalsecurity may be given by a light poroplastic or gutta-percha splintfitted to the chin, the vertical portion passing well up the ramus ofthe jaw. After a few days the apparatus is removed, the patient isencouraged to move the jaw, and massage is employed. The mouth must beregularly cleansed by an antiseptic mouth-wash, or by a spray ofhydrogen peroxide. [Illustration: FIG. 255. --Four-tailed Bandage applied for Fracture ofMandible. ] In certain fractures implicating the body of the jaw, and particularlywhen bilateral, the co-operation of the dentist is necessary to obtainthe best results. After the fragments have been coapted, a plasterimpression is taken of the jaw and teeth, and from this a silver frameis cast which surrounds but does not envelop the teeth. This frame isthen applied to the fractured jaw, and restrains movement of thefragments without interfering with the action of the jaw (W. Guy). The use of an intra-oral frame obviates the necessity of wiring thefragments. Even in badly united fractures the original contour of the bone iseventually restored by the movements of the tongue moulding it intoshape. AFFECTIONS OF THE TEMPORO-MANDIBULAR ARTICULATION #Dislocation of the Mandible. #--Dislocation of the lower jaw may beunilateral or bilateral. The bilateral form is the more common, and ismet with most frequently in middle life, and in females. The liabilityto dislocation is greatest when the mouth is widely open--for example, in yawning, laughing, or vomiting--as under these conditions thecondyle, accompanied by the meniscus, passes forwards out of theglenoid cavity and rests on the summit of the articular eminence. If, while the bone is in this position, the external pterygoid muscle isthrown into contraction, it pulls the condyle forward over theeminence into the hollow beneath the root of the zygoma, and thecontraction of the masseter and temporal muscles retains it there. Muscular contraction is therefore an important factor in itsproduction. Dislocation may be produced also by a downward blow on the chin, bythe unskilful introduction of a mouth gag, particularly while thepatient is anæsthetised, or even in the attempt to take a bigbite--say, of an apple. The dislocation that results from such causesis usually unilateral. In some persons the ligaments of the joint are unnaturally lax, anddislocation is liable to occur repeatedly from comparatively slightcauses--_recurrent dislocation_. _Clinical Features. _--The appearance of a patient suffering from_bilateral_ dislocation is characteristic. The mouth is open, the jawfixed, and the chin protruded so that the lower teeth project beyondthe upper. The patient has difficulty in swallowing, and the salivadribbles from the mouth. As the lips cannot be approximated, thespeech is indistinct and guttural. Just in front of the auditorymeatus a deep hollow can be felt, and in front of this the condyleforms an undue projection. The coronoid process is displaced below andbehind the zygomatic (malar) bone, and may be felt through the mouth. The contracted temporal muscle forms a prominence above the zygoma. In _unilateral_ dislocation the deformity is the same in character, but is less marked, and in mild cases its cause is liable to beoverlooked. In most cases the chin deviates towards the sound side. _Treatment. _--In recent cases, reduction is usually easily effected. The patient should be seated on a low chair or stool, an assistantsupporting the head from behind. The surgeon, standing in front, places his thumbs, well protected by a roll of lint, far back on themolar teeth, and with his other fingers grasps the body of the jaw. Pressure is now made downwards and backwards to free the condyles fromthe articular eminence, and to overcome the tension of the temporaland masseter muscles, and as this is effected the tip of the chin iscarried upward, while the whole jaw is pushed directly backward. Thecondyle slips into position, sometimes with a distinct snap. Whendifficulty is experienced in levering the condyle from its abnormalposition, a cork may be placed between the molar teeth on each side toact as a fulcrum. After reduction the jaw is fixed by means of afour-tailed bandage for a few days. The patient is warned to avoid forsome weeks opening the mouth widely. _Old-standing Dislocation. _--It sometimes happens that, from havingbeen overlooked or neglected, the dislocation remains unreduced. Insuch cases the movement of the jaw is in time partly restored, and thepatient acquires sufficient control of the lips to be able toarticulate intelligibly and to prevent dribbling of saliva. The powerof masticating the food, however, remains impaired. The hollow behindthe condyle and the projection of the chin persist. Reduction bymanipulation is seldom possible after the dislocation has existed formore than three months, but it has been effected as long as ten monthsafter the accident. Several attempts at reduction should be made atintervals of two or three days, and if these fail recourse may be hadto operation. As the masseter and internal pterygoid muscles haveassumed a vertical position and become shortened, they form anobstacle to reduction, and to overcome their action it is necessary toseparate them from their insertion to the ascending ramus of the bonethrough an incision carried round the angle. If the adhesions aboutthe dislocated condyle are then separated, reduction can be effected(Samter). In some cases it is necessary to excise the condyle torestore movement. _Internal Derangements of the Temporo-mandibular Joint. _--Theintra-articular cartilage is liable to be displaced by excessivetraction exerted on it by the external pterygoid muscle during somesudden movement of the joint, particularly in closing the mouth. There is acute pain in the region of the joint, the teeth on theaffected side cannot be brought into apposition, so that masticationis interfered with, and the patient is conscious of something lockinginside the joint. The joint is tender to the touch, but there is noexternal swelling. Replacement is effected by keeping up firm pressureat the back of the condyle with the mouth open, and slowly closing thejaw. If recurrence takes place repeatedly, the disc may be sutured tothe periosteum (Annandale), or excised (Hogarth Pringle). #Arthritis# of the temporo-mandibular joint occurs in two forms, non-suppurative and suppurative. The _non-suppurative_ form is usually due to gonorrhœal infection, andas a rule is bilateral. The patient complains of neuralgic painsshooting towards the ears and temples, and of pain in the joint onmovement. The jaw is therefore kept fixed, usually with the mouthslightly open and the chin protruded. Mastication is impossible, andthe speech is indistinct. There is effusion into the joint, and aswelling may be detected in front of the ear. The inflammation maysubside and movement restored, or fibrous ankylosis may ensue. The _suppurative_ form may be due either to direct spread of infectionfrom adjacent parts, as, for example, in middle ear disease, suppurative parotitis, or pyogenic affections of the mandible, or itmay be part of a general pyæmic infection, as sometimes occurs afterexanthematous fevers and in gonorrhœa. The clinical features aresimilar to those of the non-suppurative form, but the signs referableto the joint are often masked by those of the primary lesion. When thepus originates in the joint, it may point either towards the skin orinto the external auditory meatus through the petro-tympanic(Glaserian) fissure. The joint is usually completely disorganised andankylosis results. #Tuberculous arthritis# is rare, and is usually secondary to diseaseof the mandible, the temporal bone, or the middle ear. It leads todestruction of the joint and ankylosis. It is treated by incision andscraping, or by excision of the condyle. #Arthritis deformans# is a comparatively common affection, and isgenerally bilateral. In the earlier stages the condyle is usuallyhypertrophied and distorted, and the glenoid cavity is correspondinglybroadened and flattened, and in time may be filled up by new bone. Osteophytic outgrowths form around the joint and lead to fixation orlocking. The enlarged condyle may be felt in front of the ear, andthere is pain and cracking on movement; the pain is worst at night andin wet weather. The jaw is usually depressed and the chin protruded. The disease runs a chronic course, with occasional acuteexacerbations. Excision of the condyle may be advisable whennon-operative measures have failed to give relief. In the laterstages, the condyle, together with the meniscus, may be worn away andcompletely disappear. #Closure or Fixation of the Mandible. #--_Temporary fixation_ is due tospasmodic contraction of the muscles of mastication, particularly themasseter. This may be symptomatic of some inflammatory condition inthe vicinity, such as a pyogenic affection of the lower jaw--forexample, that associated with a carious root or an unerupted wisdomtooth, or with parotitis or tonsillitis. In such cases the spasmpasses off on the removal of the cause. It is occasionally amanifestation of hysteria. The administration of a general anæstheticand the introduction of a wedge or separator is usually necessary toconfirm the diagnosis and, it may be, to permit of operative measures, such as the extraction of a wisdom tooth. Muscular fixation may be due to rheumatic or syphilitic myositis, andthis is sometimes followed by fibroid degeneration of the muscles, rendering the fixation permanent. _Permanent fixation_ may be due to a variety of causes. Fibroiddegeneration of muscles following myositis has already been mentioned. Much more frequently it results from cicatricial contraction of thesoft parts of the face or mouth following such conditions as cancrumoris, ulceration, or burns. Fixation following upon prolongedimmobilisation after fracture or dislocation, or any of the forms ofarthritis or suppurative or tuberculous disease of the adjacentportions of the mandible, is also met with. The ankylosis may befibrous or osseous, and may be intra- or extra-articular. The _clinical features_ vary with the degree of separation of thejaws. There is always some deformity, and more or less interferencewith mastication and speech. The patient usually feeds himself bypushing small portions of bread or meat with the fingers through somegap between the badly opposed and badly formed and preserved teeth. Asthe patient is unable to keep the mouth clean, particles of food lodgeand decompose there, causing irritation of the mucous membrane, cariesof the teeth, and fœtor of the saliva and breath. When osseousankylosis occurs in childhood, it leads to _arrest of development ofthe mandible_, which is small and markedly receding, so that the teethdo not oppose those of the maxilla (Fig. 256). [Illustration: FIG. 256. --Defective development of Mandible fromfixation of jaw due to tuberculous osteomyelitis in infancy. ] _Treatment. _--When the cause of the fixation is in the joint itself, the best treatment is to resect one or both condyles. When the fixation is due to cicatricial contraction of the soft parts, mobility is best restored by forming an artificial joint well in frontof the cicatricial tissue, as suggested by Esmarch. CHAPTER XXII THE TONGUE Surgical Anatomy--Wounds--Dental ulcer--Inflammatory affections: _Acute parenchymatous glossitis and hemi-glossitis_; _Mercurial glossitis_; _Chronic superficial glossitis_; _Leucoplakia_; _Smoker's patch_--_Tuberculous disease_; _Syphilitic affections_; _Sclerosing glossitis_; _Gummas_; _Ulcers and fissures_--Tumours: _Carcinoma_; _Sarcoma_; _Innocent tumours_; _Cysts_--Thyreo-glossal tumours and cysts--Malformations: _Absence_; _bifid tongue_; _Tongue-tie_; _Excessive length of frenum_; _Macroglossia_; _Atrophy_--Nervous affections. #Surgical Anatomy. #--The tongue is composed of interlaced, stripedmuscle fibres, partly consisting of the terminations of the extrinsicmuscles, and partly of the intrinsic muscles. A median fibrous septumdivides it into two lateral halves so completely that but littlecommunication takes place between the blood vessels and lymphatics ofthe two sides. It is covered by stratified squamous epithelium. Forpractical purposes it is described as consisting of an _anterior_ or_oral_ part, and a _posterior_ or _pharyngeal_ part. The _oral part_, which includes the anterior two-thirds of the organ, is mobile, and the epithelium on its dorsal aspect is modified so asto form several varieties of papillæ. A slight median depression isrecognisable on the dorsum as far back as the vallate (circumvallate)papillæ, which mark the boundary between the oral and pharyngealparts. A double fold of mucous membrane--the _frenum_--connects theunder 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, aremucous glands--_apical glands_--in which cysts sometimes form. On thelateral border of the tongue, just in front of the anterior palatinearch, are several vertical folds of mucous membrane--the _folialinguæ_, or _foliate papillæ_. The _pharyngeal_ part, or base of the tongue, forms the anterior wallof the pharynx, and is attached to the hyoid bone. Its mucous membraneis devoid of papillæ, but contains numerous lymphoid follicles--the_lingual tonsil_. The _foramen cæcum_ lies just behind the apex of thevallate papillæ in the middle line. The chief artery, the _lingual_, a branch of the external carotid, passes forward beneath the hyoglossus muscle, and is continued to theapex as the ranine, lying nearer the under than the upper aspect ofthe tongue. The pharyngeal part is supplied by the dorsalis linguæbranch. The blood is returned to the internal jugular by the raninevein, which can be seen under the mucous membrane on the inferioraspect near the frenum, and by the venæ comites of the lingual arteryand its branches. The _hypoglossal_ is the motor nerve of the tongue. The _lingual_branch of the mandibular (inferior maxillary) supplies the anteriortwo-thirds with common sensation. It is accompanied by the _chordatympani_ branch of the facial, which probably carries the tastefibres. The _glosso-pharyngeal_ supplies the posterior third of thetongue with both common and gustatory sensation. The _lymph vessels_ of the anterior two-thirds of the tongue draininto the submental and submaxillary glands, and these in turn into thedeep cervical group which accompany the internal jugular vein. Thevessels of the base converge into several large trunks which pass outbehind the tonsils and drain directly into the deep cervical glands. One of these, which lies in the angle between the internal jugular andcommon facial veins, is frequently infected in cancer of the tongue. #Wounds# are commonly produced by the teeth, as, for instance, when achild falls on the chin with the tongue protruded, or when anepileptic bites his tongue during a fit. Less frequently a foreignbody, such as a pipe-stem, a bullet, or a displaced tooth, is driveninto the tongue. The immediate risk is hæmorrhage, particularly whenthe posterior part of the tongue is implicated and the woundpenetrates deeply. Of the later complications, infections andsecondary hæmorrhage are the most serious, and they are most liable tooccur when a foreign body is embedded in the tongue. _Treatment. _--In superficial wounds near the tip the oozing isefficiently arrested by sutures, but in deeper wounds a ligature mustbe applied to the bleeding vessel. Secondary hæmorrhage is much moredifficult to arrest on account of the friable state of the tissues, and it may be necessary to ligate the lingual or even the externalcarotid in the neck. To prevent infective complications any foreign body must be removedand an antiseptic mouth-wash regularly employed. Cases have been recorded in which such a foreign body as a bullet, aneedle, or a piece of a pipe-stem, has remained embedded in thesubstance of the tongue for a long period, and caused a firm, indolentswelling liable to be mistaken for a new growth. #Dental Ulcer. #--The continuous friction of a jagged tooth, or of anill-fitting dental plate, is liable to cause swelling and excoriationof the side of the tongue. A painful superficial ulcer forms, and ifthe irritation continues and infection occurs, the surrounding partsbecome indurated, the ulcer assumes a crater-like appearance, notunlike that of a commencing epithelioma. If such an ulcer does notpromptly heal on the removal of the irritant, a portion of the marginshould be removed and submitted to microscopic examination to makesure that it is not cancerous. #Inflammatory Affections. #--_Acute Parenchymatous Glossitis_ isusually due to the action of streptococci. Although it affects mainlythe mucous membrane and submucous tissue, it causes a diffuseœdematous swelling of the whole organ, and this may extend to theary-epiglottic folds and give rise to œdema of the glottis. As a ruleit does not go on to suppuration. The onset is sudden, and is marked by pain and stiffness of thetongue, particularly when the patient attempts to masticate or tospeak. The tongue rapidly swells, and in the course of twenty-four orforty-eight hours may fill the mouth and protrude beyond the teeth. There is profuse salivation, and in addition to difficulty inswallowing and speaking there may be considerable interference withrespiration. The salivary and lymph glands in the submaxillary spaceare enlarged and tender. The symptoms begin to subside in three orfour days, unless suppuration occurs. The _treatment_ consists in administering a sharp purge and employinga mouth-wash; leeches may be applied to the submaxillary region withbenefit. When the swelling is excessive, it may be necessary to makelongitudinal incisions into the substance of the tongue, and dyspnœamay call for laryngotomy. If an abscess forms it must be opened. A similar condition has been met with in patients who have contractedthe "_foot and mouth disease_" of cattle. Vesicles form on the mucousmembrane, and after bursting, ulcerate, and a mixed infection withstreptococci occurs, leading to diffuse œdema. Portions of the tonguemay become gangrenous, and the infection may spread to the tissues ofthe neck and set up one form of angina Ludovici. The condition isusually fatal. _Acute Hemi-glossitis. _--An acute transitory swelling, confined to onehalf of the tongue, in the distribution of the lingual nerve, isoccasionally met with. It is attended with great pain and hightemperature, and is believed to be analogous to herpes zoster(Güterbock). _Mercurial Glossitis_ may accompany mercurial stomatitis (p. 496). _Chronic Superficial Glossitis. _--Several forms of chronic superficialglossitis are met with. The most important, as it is frequentlyfollowed by the development of epithelioma, is that known as_leucoplakia_ or _leucokeratosis_. The tongue is studded over with white patches, which result fromovergrowth and cornification of the surface epithelium, whereby itbecomes thickened and raised above the surface, and at the same timethere is small-celled infiltration of the submucous tissue. Thepatches are irregularly lozenge-shaped, and when crowded together theypresent the appearance of a mosaic (Fig. 257). Similar patches areoften present on the mucous membrane lining the cheek. [Illustration: FIG. 257. --Leucoplakia of the Tongue. ] The disease is met with almost invariably in men between the ages offorty and fifty. Syphilis appears to be a predisposing factor, and anyform of irritation--for example, the chewing or smoking of tobacco, the drinking of raw spirits, friction by a rough tooth ortooth-plate--plays an important part in inducing or in aggravating thecondition. The milder forms give rise to no discomfort, but when the condition isadvanced the patient complains of dryness and hardness of the tongue, with impairment of the sense of taste and persistent thirst. Whencracks, fissures, or warts develop, there is pain on chewing orspeaking, or on taking hot or irritating food. The glands below thejaw may be enlarged. The disease is most intractable and persistent, and even afterdisappearing for a time is liable to recur. After a variable numberof years epithelioma is prone to develop, usually in one or other ofthe fissures which accompany the condition. The _treatment_ consists in removing all sources of irritation, particularly smoking, and in employing mouth-washes. Butlin recommendsantiseptic ointments applied before going to bed. In some casespainting the patches with chromic acid (10 grains to the ounce) orlactic acid (20 per cent. ) is useful in removing the excess ofepithelium, but stronger caustics are to be avoided. Constitutionaltreatment is of little use even when the patient has suffered fromsyphilis. The best results have been attained by the use of radium. The "_smoker's patch_" consists of a small oval area on the front ofthe tongue from which the papillæ have disappeared. It is slightlyraised, smooth and red, and may be covered with a yellowish-brown oryellowish-white crust. It causes no discomfort unless the crust isremoved, when a raw, sensitive surface is exposed. The condition isliable to spread over the tongue if the patient persists in smoking. It may eventually assume the characters of leucoplakia. The_treatment_ consists in stopping the use of tobacco, and painting thepatches with chromic acid, tannic acid, or alum, and employing achlorate of potash mouth-wash. #Tuberculous Disease. #--The tongue is rarely the primary seat oftuberculosis. The majority of cases occur in adult males, who sufferfrom advanced pulmonary or laryngeal phthisis, the tongue beinginfected by bacilli from the sputum or through the blood stream. Inother cases the infection is due to direct spread of lupus from theface or nose. The condition may begin as a firm, painless lump, seldom larger than ahazel-nut, on one side of the tongue, or near its tip. At first theswelling is covered by epithelium; in time caseation takes place, theepithelium gives way, and an open sore is formed. The _tuberculous ulcer_ is the form most frequently met with. Thesurface of the ulcer is uneven, pale and flabby, and is covered with ayellowish-grey discharge, with here and there feeble granulationsshowing through. The edges are shreddy, sinuous in outline, and thereis little or no induration. The surrounding parts are slightlyswollen, and may be studded with small tuberculous foci. The ulcer maybe quite superficial, or it may extend into the muscular substance, and the tip of the tongue may be completely eaten away so that itlooks as if it had been cut off with a knife. As the disease advancesthere is severe pain and usually profuse salivation. The submaxillaryglands may be, but are not always, enlarged. The ulcer may heal, buttends to break down again. Unless there is advanced pulmonary disease or other contraindicationto operation, the ulcer should be excised under local anæsthesia. Caremust be taken to avoid reinfecting the raw surface. When excision isimpracticable, it is only possible to palliate the symptoms by dustingwith orthoform, or applying local anæsthetics, and by attending to thehygiene of the mouth and removing all sources of irritation. #Syphilitic Affections. #--A _primary lesion_ on the tongue isaccompanied by marked enlargement and tenderness of the submaxillarylymph glands on one or on both sides. It is most common in men, infection usually taking place through the medium of tobacco pipes, orimplements such as the blow-pipes of glass-blowers. During the _secondary stage_--particularly in the laterperiods--mucous patches and ulcers are common, and they may assume acondylomatous or warty appearance. The _tertiary_ manifestations in the tongue are sclerosing glossitis, gummas, and gummatous ulcers. _Sclerosing glossitis_ is the term applied by Fournier to a conditionin which there is an abundant new formation of granulation tissue inthe substance of the tongue, leading to the appearance of tuberousmasses on the dorsum. These tend to be oval in outline, are elevatedabove the normal mucous membrane, and present a dull red mammilated orlobulated surface, comparable to the surface of a cirrhotic liver. They are firm, elastic, and insensitive. A _gumma_ is usually situated on the dorsum and more often towards thecentre than at the edges. As it seldom implicates the floor of themouth or the base of the tongue, the tongue can usually be protrudedfreely. It forms an indolent swelling, which tends to break downslowly and to ulcerate. So long as it remains unbroken it does notcause pain, and there is no enlargement of the adjacent lymph glands. Two forms are met with--the superficial, and the deep orparenchymatous. A _superficial_ gumma appears as a small hard nodule under the mucousmembrane, varying in size from a pin's head to a pea. The mucousmembrane over it is redder than normal, and in the early stagesretains its papillæ but later becomes smooth. It tends to break downearly, forming a superficial ulcer. Superficial gummas are oftenmultiple. The _deep_ or parenchymatous form varies in size from a hazel-nut to awalnut, and feels like a hard body in the substance of the tongue. The mucous membrane over the swelling is of normal colour, but isusually devoid of papillæ. The gumma may remain for months unchanged, or may approach the surface, soften, and break down, leaving a deep, ragged ulcer. _Syphilitic ulcers and fissures_ are nearly always due to thesoftening and breaking down of gummas. The ulcers have seldom thetypically rounded or serpiginous outline of gummatous ulcers on otherparts of the body. The base is ragged and unhealthy, and on it ayellowish-grey slough resembling wash-leather may be seen. The edgesare steep, ragged, and often undermined, and the surrounding partsthickened and indurated. The neighbouring glands are not usuallyenlarged. The ulcer is extremely painful when irritated by food, hotfluids, or spirits. If untreated, the sore may remain indolent and formonths show no sign either of spreading or healing, but at any time itmay become the seat of cancer. Syphilitic fissures are met with as long, narrow, deep clefts, or asstellate or sinous cracks in the substance of the tongue. After thehealing of these ulcers and fissures permanent furrows and depressedscars remain. _Treatment. _--The tertiary manifestations of syphilis in the tongueare treated on the same lines as other tertiary lesions. Locally, theuse of mouth-washes, such as chlorate of potash or black wash dilutedwith lime-water, the insufflation of powdered iodoform and borax witha small quantity of morphin, or the application of mercurial ointmentis useful. The sore must be thoroughly cleansed before these remediesare applied. NEW GROWTHS #Carcinoma# is by far the most common form of new growth met with inthe tongue, and it is almost invariably a squamous epithelioma. Epithelioma generally occurs between the ages of forty and sixty, andattacks males oftener than females, in the proportion of about six toone. Its development is favoured by any long-continued irritation, such as the rubbing of the tongue against a carious tooth, anill-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, andsyphilitic fissures, ulcers, or scars, also act as predisposingfactors. The repeated application of strong caustics to chronicinflammatory conditions is, according to Butlin, a determining causeof cancer. The degree of malignancy appears to vary in differentcases, and is probably lowest when the disease originates in a patchof leucoplakia or other pre-cancerous lesion. The disease is usually situated in the anterior half of the tongue, and more commonly on the edge than on the dorsum. It may begin as anexcoriation, ulcer, or fissure, or as a warty growth, particularly inassociation with a patch of leucoplakia. In all cases ulcerationbegins early, and the base of the ulcer and the surrounding partsbecome indurated. The lymph glands are, as a rule, early infected. _Clinical Features. _--The clinical appearances vary widely. Sometimesthe surface presents a warty growth; sometimes it is excavated, forming a deep ulcer with raised nodular edges; in other cases theulcer is smooth, and its edges even and rounded. Extreme hardness ofthe edges and base of the ulcer is always a characteristic feature. The tongue tends to become fixed, especially when the disease spreadsto the floor of the mouth, so that it cannot be protruded, and therestriction of its movement produces a characteristic interferencewith articulation, certain words being slurred, and when the fixationis extreme it may interfere with mastication and swallowing. Thepatient complains of a constant gnawing pain in the tongue, and ofsevere pain shooting along the branches of the trigeminal nerve, andespecially towards the ear. In the advanced stages there is salivationand fœtor of the breath. When the disease is situated on the edge of the tongue it tends tospread to the floor of the mouth and the muco-periosteum of themandible. If situated far back on the dorsum, it spreads on to theepiglottis, the pillars of the fauces, and the tonsil. The neighbouring lymph glands--particularly those under the jaw andalong the line of the carotid vessels--soon become infected and arepalpable. The submaxillary and sublingual salivary glands are alsoliable to be affected. The enlarged cervical glands later undergosoftening, or suppurate and burst on the skin surface, formingfungating ulcers. Metastasis to the liver, lungs, and other viscera isexceptional. If the disease is allowed to run its course, the patientusually dies in from twelve to eighteen months from repeated smallhæmorrhages, toxin absorption, or septic broncho-pneumonia. _Differential Diagnosis. _--Cancer of the tongue has to be diagnosedfrom syphilitic and tuberculous affections, from papilloma, and fromsimple ulcer and fissure. It is to be borne in mind that any of theseconditions may take on malignant characters and develop intoepithelioma. The microscopic examination of a portion of the growthremoved under local anæsthesia from the base of the ulcer at somedistance from its epithelial core is often the only certain means ofestablishing the diagnosis, and should be had recourse to as early aspossible. When there is still doubt as to the nature of the growth, itshould be treated as if it were cancerous. An unbroken gumma is liable to be confused only with the uncommon formof epithelioma which begins as a nodule under the mucous membrane. Gumma, however, are often multiple, and the tongue shows old scars orother evidence of syphilis. Gummatous ulcers are usually situated on the dorsum, are frequentlymultiple, and have sloughy, undermined edges; the surrounding parts, although indurated, are not so densely hard as in cancer; there is notnecessarily any involvement of lymph glands. The cancerous ulcer isusually single and situated on the margin of the tongue; its edges arehard, raised, and nodular; and the glands are usually enlarged andhard. Little reliance is to be placed on the therapeutic effects ofanti-syphilitic drugs in the differential diagnosis, as they are ofteninconclusive, and their use results in loss of time. Tuberculous ulcers usually occur in association with other andunmistakable evidences of tuberculosis. A papilloma, when sessile, maysimulate cancer; these tumours show a marked tendency to becomemalignant. Simple ulcers and fissures are usually recognised by thehistory of the condition, the absence of induration and of glandularinvolvement, and by the fact that they heal quickly on removal of thecause. _Treatment. _--The only treatment that offers any hope of cure is freeremoval of the disease, and experience has proved that unless this isdone early the prospect of the cure being a radical one is remote. Notonly must the segment of the tongue on which the growth is situated bewidely excised, but all the lymphatic connections must also be removedwhether the glands are palpably enlarged or not. The chief risk after operation is pneumonia resulting from theinhaling of blood and products of infection: hence the importance ofrendering the mouth as dry and as sweet as possible before operation, special attention being paid to the teeth, and precautions being takenat the operation to prevent the passage of blood down the trachea. Thepatient is usually able to be out of bed on the second or third day, and is well in a fortnight or three weeks. The operation, even whenfollowed by recurrence, usually prolongs life by six or eight months, and renders the patient more comfortable by removing the foul ulcerfrom the mouth. The speech, although impaired by the removal ofone-half or even more of the tongue, is distinct enough for ordinarypurposes. When recurrence takes place it is usually in the glands, andmay be attended with great suffering. _Treatment of Inoperable Cases. _--The mouth must be kept as sweet aspossible. The pain may be relieved to some extent by cocain ororthoform, but as a rule the free administration of morphin is calledfor. Pain shooting up to the ear may be relieved by resection of thelingual nerve, or the injection of alcohol into its substance. Ifhæmorrhage takes place from the ulcerated surface and cannot becontrolled by adrenalin, or other local styptics, it may be necessaryto ligate the lingual, or even the external carotid artery. Interference with respiration may necessitate tracheotomy. When thepatient has difficulty in taking food, recourse should be had to theuse of the stomach-tube or to gastrostomy. The use of radium or of theX-rays appears to have a restraining influence on the disease in theglands, but has not proved curative. #Sarcoma# of the tongue is rare, and is sometimes met with inchildren. The round-cell type is the most common; it grows rapidly, and tends to ulcerate and fungate, pain becoming severe when thegrowth has broken down. The diagnosis is always difficult, and isseldom made until a portion of the growth has been removed andexamined microscopically. The more slowly growing forms, if removedbefore ulceration has taken place, show little tendency to recur, butthose which grow rapidly and break down, not only recur locally, butare liable to give rise to metastases. The treatment is the same asfor cancer; the use of radium is more likely to be beneficial than inepithelioma. #Innocent Tumour and Cysts. #--_Lipoma_, _fibroma_, and various formsof _angioma_ (Fig. 258) are occasionally met with. They are all ofslow growth, and give rise to inconvenience chiefly by their bulk, andshould be removed. [Illustration: FIG. 258. --Papillomatous Angioma of left side of tonguein a woman aged 26. ] _Papilloma_ may occur on any part of the tongue, and at any age. Itmay be single or multiple, pedunculated or sessile, and is liable tobecome malignant, especially when associated with leucoplakia. Itshould be freely removed by excising a wedge-shaped portion of thetongue. _Dermoid_ cyst is met with beneath the tongue, lying in the middleline, between the genio-glossi (genio-hyoglossi), and on the uppersurface of the mylo-hyoid muscles. It may be noticed soon afterbirth, or may only attract attention during adult life. The cystusually projects under the chin, forming a soft swelling of putty-likeconsistence, which varies in size from a pigeon's to a turkey's egg(Fig. 259). When it bulges towards the mouth it is liable to bemistaken for a retention cyst of one of the salivary glands. It isdistinguished by its medial position, its yellow colour, and itsopacity, the retention cyst being to one side of the middle line, purplish in colour, translucent and fluctuating. The cyst should bedissected out, either from the mouth or from under the chin, accordingto circumstances. [Illustration: FIG. 259. --Dermoid Cyst in middle line of neck. (Mr. J. W. Struthers' case. )] A _sebaceous cyst_ may reach such dimensions as to simulate a dermoidor thyreo-glossal cyst. _Hydatid and cysticercus cysts_ have also been met with in the tongue. #Thyreo-glossal Tumours and Cysts. #--Tumours may develop in theembryonic tract which passes from the isthmus of the thyreoid glandto the foramen cæcum at the base of the tongue--the thyreo-glossaltract of His. They have the same structure as the thyreoid gland, andoccupy the dorsum of the tongue, extending from the foramen cæcumbackwards towards the epiglottis, in some cases attaining considerablesize. They are of a bluish-brown or dark red colour, and are liable torepeated attacks of hæmorrhage. These tumours sometimes become cystic, the cysts being lined with ciliated epithelium and containing colloidmaterial. Bleeding may take place into a cyst, causing it to becomesuddenly enlarged, or the cyst may burst and the blood escape into themouth. These variations in size and repeated attacks of bleeding helpto distinguish thyreo-glossal cysts from other swellings of thetongue. Treatment is only called for when the swelling causesinterference with speech or swallowing; it consists in removing thetumour by dissection. When the lower end of the tract becomes cystic it forms a swelling inthe neck (p. 583). #Malformations. #--Complete or partial _absence_ of the tongue isexceedingly rare. Occasionally the fore part of the tongue is _bifid_. The function ofthe organ is not interfered with, and the operation of paring andsuturing the two halves is only called for on account of thedisfigurement. _Congenital tongue-tie_ is a condition in which the tip of the tongueis bound down to the floor of the mouth by an abnormally short andnarrow frenum, or by folds of mucous membrane on each side of thefrenum, so that the tongue cannot be protruded. Although thisdeformity is rare, it is common for parents to blame an imaginarytongue-tie when a child is slow in learning to speak, or when hespeaks indistinctly or stammers, and the doctor is frequentlyrequested to divide the frenum under such circumstances. In the vastmajority of cases nothing is found to be wrong with the frenum. In therare cases of true tongue-tie the edges of the shortened bands shouldbe snipped with scissors close behind the incisor teeth, and then tornwith the finger-nail. _Excessive length_ of the frenum is occasionally met with, and inchildren may allow of the tongue falling back into the throat andcausing sudden suffocative attacks, one of which may prove fatal. Insome cases the patient is able voluntarily to fold the tongue backbehind the soft palate. _Macroglossia_ is the term applied to a variety of conditions in whichthe tongue becomes unduly large, so that it tends to be protruded fromthe mouth, and to become scored by the teeth. The typicalform--lymphangiomatous macroglossia--is due to a dilatation of thelymph spaces of the tongue. It is often congenital, and may affect thewhole or only a part of the tongue. The enlargement may be progressivefrom the first, or may remain stationary for years, and then begin todevelop somewhat suddenly, sometimes after an injury or as a result ofsome infective condition. The treatment consists in removing awedge-shaped portion of the tongue. In certain cases of macroglossia in children, the lesion has beenfound to be a fibromatosis of the nerves of the tongue, analogous tothe plexiform neuroma. _Atrophy_ of the tongue is rare as a congenital condition. Hemi-atrophy occurs in various diseases of the central nervous system, as well as after injuries and diseases implicating the hypoglossalnerve. #Nervous Affections of the Tongue. #--_Neuralgia_ confined to thedistribution of the lingual nerve is comparatively rare. It usuallyyields to medical treatment, but in inveterate cases it is sometimesnecessary to resect the nerve. It is more common to meet with a condition in which the patientcomplains of severe burning or aching pain in the region of thefoliate papilla, which is situated on the edge of the tongue just infront of the anterior pillar of the fauces. The patient is usually amiddle-aged, neurotic woman, and often with a gouty or rheumatictendency. The pain, for which it is seldom possible to discover anycause, is usually worst at night, and may last for months, or evenyears. The practical importance of the condition is that, as thefoliate papilla is prominent and red, it is liable to be mistaken onsuperficial examination for a commencing epithelioma. An inspection ofthe opposite side of the tongue, however, will reveal an exactlysimilar condition, which is not painful. The first and most importantstep in treatment is to assure the patient that the condition is notcancerous. Caustics and other irritating applications are to beavoided. _Spasm_ of the tongue sometimes occurs after injuries of the headimplicating either the centre or the trunk of the hypoglossal nerve. It may also appear as a reflex condition in infective affections ofthe teeth and gums, or as a manifestation of some general disease ofthe central nervous system. _Paralysis_ of the tongue--unilateral or bilateral--may be due toinjury or disease of the nerve centres of the hypoglossal nerve, morefrequently to injury of or pressure on the nerve-trunk. The nerve maybe bruised or divided in operations for the removal of tuberculousglands or other tumours in the neck. When the tongue is protruded itdeviates towards the paralysed side, being pushed over by the activemuscles of the opposite side (Fig. 260), and speech and masticationmay be interfered with. The paralysed half of the tongue subsequentlyundergoes atrophy, but the functional disability largely disappears. [Illustration: FIG. 260. --Temporary Unilateral Paralysis of Tongue, from bruising of hypoglossal nerve during operation for tuberculouscervical glands. ] CHAPTER XXIII THE SALIVARY GLANDS Surgical Anatomy--Injuries--Salivary fistulæ--Salivary calculi--Infective conditions: _Parotitis_; _Inflammation of submaxillary gland_; _Angina Ludovici_; _Inflammation of sublingual gland_; _Tuberculous disease_--Tumours: _Ranula_; _Mixed tumours of parotid_; _Sarcoma_; _Carcinoma_; _Tumours of submaxillary and sublingual glands_. #Surgical Anatomy. #--_The parotid gland_ lies on the side of the facebelow and in front of the ear, and extends deeply behind the mandiblereaching almost to the side wall of the pharynx. Its deeper part liesin close relation with the internal carotid artery, the internaljugular vein, and the vagus, glosso-pharyngeal, accessory, andhypoglossal nerves. The external carotid artery passes through thesubstance of the parotid, and bifurcates opposite the neck of thecondyle into the temporal and internal maxillary arteries. It isaccompanied by the venous trunk formed by the junction of the temporaland internal maxillary veins. The facial nerve and its branchestraverse the lower third of the gland from behind forwards. The facialportion of the gland lies on the surface of the masseter muscle, andthe _parotid duct (Stenson's duct)_ emerges from its anterior border. After crossing the masseter, the duct pierces the buccinator muscleand the mucous membrane obliquely, and opens into the mouth oppositethe second upper molar tooth. Its course is indicated by a linepassing from the upper part of the lobule of the ear to a point midwaybetween the ala of the nose and the margin of the upper lip--thatis, at a higher level than the facial nerve. Several lymphglands--pre-auricular--lie inside the capsule of the parotid just infront of the ear. The _submaxillary gland_ lies under the integument and fascia in thetriangle formed by the lower jaw and the two bellies of the digastricmuscle. Its anterior part is crossed by the facial vessels, andseveral lymph glands lie inside its capsule. The _submaxillary duct(Wharton's duct)_ opens into the mouth by the side of the frenum ofthe tongue. The _sublingual gland_ lies in the floor of the mouth just beneath themucous membrane. It has numerous ducts, some of which open directlyinto the mouth, others into the submaxillary duct. #Injuries. #--The _parotid_ is frequently injured by accidental woundsand in the course of operations. If the blood vessels traversing thegland are divided, such wounds are liable to bleed freely, and if thefacial and auriculo-temporal nerves are damaged, motor and sensoryparalysis of the parts supplied by them ensues. Wounds of the parotidheal rapidly and without complications so long as infection isprevented, but if suppuration takes place they are liable to befollowed by the escape of saliva, which may go on for weeks; in somecases a salivary fistula is thus established. _The parotid duct_ may be divided and a salivary fistula result. Ifthe external wound heals rapidly, a salivary cyst may develop in thesubstance of the cheek, forming a swelling, which fills up at meals, and may be emptied by external pressure, the saliva escaping into themouth. In a wound implicating the whole thickness of the cheek the skinshould be accurately sutured, care being taken that the stitches donot include the duct, but in order that the saliva may readily reachthe mouth, the mucous membrane should not be stitched. #Salivary Fistulæ. #--A salivary fistula may occur in relation to theglandular substance of the parotid or in relation to the duct. Fistulain connection with the glandular substance--_parotid fistula_--seldomresults from a wound, made, for example, in the removal of a tumour orin an operation on the ramus of the jaw, so long as it is aseptic; butas a sequel of suppuration in the gland, and particularly of anabscess developing around a concretion, it is not uncommon. Thefistulous opening is usually small, and may occur at any point overthe gland. The fistula may be dry between meals, or the saliva mayescape in small transparent drops, but the quantity is always greatlyincreased when food is taken. A parotid fistula, although it maycontinue to discharge for weeks, or even for months, usually closesspontaneously. In persistent cases, the edges of the fistula may be pared and broughttogether with sutures, or the actual cautery may be applied to inducecicatricial contraction. _Fistula of the parotid duct_ is more serious. It is usually due to awound, less frequently to abscess or impacted calculus. From theminute opening, which is most frequently situated over the buccinatormuscle, there is an almost continuous flow of clear limpid saliva, which is greatly increased in quantity while the patient is eating. These fistulæ show little tendency to close spontaneously. Attempts toclose the opening by the external application of collodion, bycauterising the edges, or even by paring the edges and introducingsutures, usually fail. It is necessary to establish an opening intothe mouth, either by opening up the original duct or by making aninternal fistula in place of the external one. #Salivary Calculi. #--Salivary calculi are most commonly met with _inthe submaxillary gland or its duct_. They consist of phosphate andcarbonate of lime with a small proportion of organic matter, andresult from the chemical action of bacteria on the saliva. In rarecases a foreign body, such as a piece of straw, a fruit-seed, or afish-bone, forms the nucleus of the concretion. They vary in size froma pea to a walnut, and are hard, of a whitish or grey colour, andrough on the surface. Those that form in the gland itself are usuallyirregular, while those met with in the duct are rounded orspindle-shaped (Fig. 261). [Illustration: FIG. 261. --Series of Salivary Calculi. ] A calculus in the duct gives rise to sharp lancinating pain, which isaggravated when the patient takes food. The duct is seldom completelyobstructed, but the flow of saliva is usually so much impeded that thegland becomes greatly swollen during meals. The swelling graduallysubsides between meals, or can be made to disappear by externalpressure. The calculus can usually be felt by means of a probe passedalong the duct, or by puncturing the swelling with a needle; or, withone finger inside the mouth and another under the jaw, a hard lump canbe detected under the mucous membrane of the floor of the mouth. Itmay be revealed by the X-rays. When the obstruction is complete, aretention cyst forms in which suppuration is liable to occur, causingmarked aggravation of the symptoms. In some cases the wall of the ductand the surrounding tissues become thickened and indurated, forming aswelling which is liable to be mistaken for a malignant growth. Thetreatment consists in making an incision through the mucous membraneover the calculus and extracting it with a scoop or forceps. INFECTIVE CONDITIONS. --#Parotitis. #--Inflammation of the parotid glandmay be non-suppurative or suppurative. Of the _non-suppurative_ varieties the most common is the epidemicform known as _mumps_. This is an acute infective condition, whichusually attacks young children, and implicates both glands, eithersimultaneously or consecutively. It runs a definite course, whichlasts for from one to two weeks, and almost invariably ends inresolution. The parotid gland is swollen and tender, there is pain onattempting to open the mouth, difficulty in swallowing, and dribblingof saliva. The surgical interest of this disease lies in the fact thatit is frequently complicated by pain and swelling of the testis, œdemaof the scrotum, and occasionally by a urethral discharge, and atrophyof the testis has been observed after such an attack. In females thereis sometimes pain in the ovary, tenderness and swelling of the mamma, and a vaginal discharge. [Illustration: FIG. 262. --Acute Suppurative Parotitis. ] The parotid on one or both sides may suddenly become swollen andtender in patients who are taking large doses of mercury, in goutysubjects, or in patients suffering from infective conditions of thegenito-urinary organs, such as orchitis, ovaritis, urethritis, orcystitis. The condition is usually transient and leads to nocomplications. _Recurrent enlargement_ of the parotid and submaxillary glands, aswell as of the lachrymal glands, is occasionally met with in adults, and was first described by Mikulicz. It may be associated withsalivary lithiasis, xerostomia, or organic narrowing of the ducts, butin the majority of cases no such cause can be discovered (D. M. Greig). When the parotid is affected the condition tends to bebilateral and there is some constitutional disturbance. Thesubmaxillary form is usually unilateral and the symptoms are entirelylocal. The affected gland rapidly becomes swollen, painful and tenderto the touch, and the swelling increases markedly while the patient iseating. Each attack lasts for a few hours to one or two weeks, andthen subsides spontaneously. The intervals between attacks vary from afew weeks to a year or more. In the course of a few years there isconsiderable deformity, and sometimes deficiency in the glandularsecretion, but the disease is not attended by other inconvenience. Benefit has followed the administration of arsenic and iodides, andthe use of radium and X-rays. The treatment of these non-suppurative forms of parotitis consists inrelieving the symptoms. _Suppurative parotitis_ may be due to direct spread of infection fromthe mouth along the parotid duct, or to extension of suppurativeprocesses from the temporo-mandibular joint, the jaw, or a lymphgland. It is liable to occur also in the course of any disease inwhich there is an infection of the blood with pyogenic bacteria, andhas been met with in diphtheria, typhoid fever, scarlet fever, measles, and other eruptive fevers. The _post-operative_ form of parotitis is most frequently met withafter laparotomy for such conditions as suppurative appendicitis, perforated gastric ulcer, ovarian cyst, and pyosalpinx. These secondary forms are probably due to infection from the mouthunder conditions in which the secretion of saliva is arrested or itsescape from the gland interfered with. The early symptoms are apt to be overshadowed by those of the generaldisease from which the patient suffers. At first the gland is swollen, hard, and tender, and the seat of constant, dull, boring pain; laterthere is redness, œdema, and fluctuation. The movements of the jaware restricted and painful, the patient is unable to open the mouth, and has difficulty in swallowing. The inflammation reaches its heighton the third or fourth day, and usually ends in suppuration. The pusis scattered in numerous foci throughout the gland, and sometimeslarge sloughs form. The dense capsule of the gland prevents the pusreaching the surface and causes it to burrow among the tissues of theneck, giving rise to dyspnœa and dysphagia. It may find its waydownwards towards the mediastinum, inwards towards the pharynx--whereit constitutes one form of retro-pharyngeal abscess--or upwardstowards the base of the skull. Not infrequently it burrows into thetemporo-mandibular joint, or escapes by bursting into the externalauditory meatus. Serious hæmorrhage may result from erosion of thevessels traversing the gland or of the internal jugular vein, orvenous thrombosis may ensue. Persistent paralysis may followdestruction of the facial nerve; and salivary fistulæ may form. Deathmay take place from toxæmia even before pus forms. _Treatment. _--During the first two or three days hyperæmia is inducedby means of poultices, hot fomentations, or Klapp's suction bells, andthe mouth is frequently washed out with an antiseptic. As soon asthere is reason to believe that pus has formed an incision is madebehind the angle of the jaw, parallel to the branches of the facialnerve, the abscess opened by Hilton's method, a finger passed into thegland, and all septa broken down and drainage secured. Acute infection of the #submaxillary gland# is met with under the sameconditions as that of the parotid. Both glands are occasionallyattacked at the same time. The acute phlegmonous peri-adenitis of the submaxillary gland, knownas _angina Ludovici_, is referred to at p. 597. The _treatment_ consists in making incisions through the deep fasciain order to relieve the tension, or to let out pus if it has formed. Acute suppurative inflammation of the #sublingual gland# may occurunder the same conditions as in the parotid, and is associated withthe formation of an exceedingly painful and tender swelling under thetongue. The tongue is gradually pushed against the roof of the mouth, so that swallowing is difficult and respiration may be seriouslyimpeded. There is marked constitutional disturbance. An incision intothe swelling is immediately followed by relief of the symptoms. #Tuberculous disease# of the salivary glands is rare. It usuallybegins in the lymph glands within the capsule of the parotid orsubmaxillary, and spreads thence to the salivary gland tissue. TUMOURS. --#Cystic Tumours--Ranula. #--The term ranula is applied to anycystic tumour formed in connection with the glands in the floor of themouth. Formerly these tumours were believed to be retention cysts dueto blocking of the salivary ducts. They are now known to be the resultof a cystic degeneration of one or other of the secreting glands inthe floor of the mouth. They contain a thick glairy fluid, whichdiffers from saliva in containing a considerable quantity of mucin andalbumin, while it is free from any amylolytic ferment orsulpho-cyanide of potassium. Numerous degenerated epithelial cells arefound in the fluid. The _sublingual ranula_ is the most common variety. It appears as apainless, smooth, tense, globular swelling of a bluish colour. Itusually lies on one side of the frenum, and over it the mucousmembrane moves freely. As it increases in size it gradually pushes thetongue towards the roof of the mouth, and so causes interference withspeech, mastication, and swallowing. It is to be differentiated from aretention cyst of the submaxillary gland by the fact that a probe canusually be passed down the submaxillary duct alongside of theswelling, and from sublingual dermoid (p. 539). The _treatment_ consists in making an incision through the mucousmembrane over the swelling, dissecting away the whole of the cyst wallif possible, and, if any portion cannot be removed, swabbing it with asolution of chloride of zinc (40 grains to the ounce), after which thecavity is stuffed with bismuth gauze and allowed to close bygranulation. It is sometimes found more satisfactory to dissect outthe cyst through an incision below the jaw, and in the event ofrecurrence this should be undertaken. Cystic tumours, similar to the sublingual ranula, form in the otherglands in the floor of the mouth--for example, the incisive gland, which lies just behind the symphysis menti, as well as in the apicalgland on the under aspect of the tip of the tongue. The latter isdistinguished by the fact that it moves with the tongue. In rare caseschildren are born with a cystic swelling in the floor of themouth--the so-called _congenital ranula_. It is usually due to animperfect development of the duct of the submaxillary or sublingualgland. #Solid Tumours--Mixed Tumours of the Parotid. #--The most important ofthe solid tumours met with in the salivary glands is the so-called"mixed tumour of the parotid. " This was formerly believed to be anendothelioma derived from a proliferation of the endothelial cellslining the lymph spaces and blood vessels of the gland. A moreprobable view is that it develops from rests derived from the firstbranchial arch an not from the parotid. The matrix of the tumour ismade up of cartilaginous, myxomatous, sarcomatous, or angiomatoustissue, the proportion of these different elements varying inindividual specimens, and it may include some portions that areadenomatous. A gelatinous substance forms in the intercellular spacesof the tumour, and may accumulate in sufficient quantity to give riseto cysts of various sizes. There is reason to believe that the tumoursof the parotid previously described as adenoma, chondroma, angioma, myxoma, and many of the cases of sarcoma, were really mixed tumours inwhich one or other of these tissues predominated. The tumour usually develops in the vicinity of the parotid, andpresses on the salivary tissue, thinning it out and causing it toundergo atrophy. _Clinical Features. _--The mixed tumour is usually first observedbetween the ages of twenty and thirty. It is of slow growth andpainless, and forms a rounded, nodular swelling, the consistence ofwhich varies with its structure. The skin over the swelling is normalin appearance and is not attached to the tumour (Figs. 263, 264). Onlyin rare cases does paralysis result from pressure on the facial nerve. [Illustration: FIG. 263. --Mixed Tumour of Parotid. ] [Illustration: FIG. 264. --Mixed Tumour of the Parotid of over twentyyears' duration. ] Although usually benign, these tumours may, after lasting for years, take on malignant characters, growing rapidly, implicating adjacentlymph glands, and showing a marked tendency to recur after removal. The _treatment_ consists in shelling out the tumour, care being takento avoid injuring the facial nerve or the parotid duct by making theincision and the subsequent cuts in the dissection run parallel tothem. If the tumour is removed early and completely, recurrence is theexception. #Sarcoma and carcinoma# are rare. They are very malignant, growrapidly, infiltrate surrounding parts, including the skin, and infectthe adjacent lymph glands. There is severe neuralgic pain, andparalysis from involvement of the facial nerve is an early symptom. The _treatment_ consists in excising the whole of the parotid glandwith the tumour, no attempt being made to conserve the facial nerve orother structures traversing it. Recourse should be had to the use ofradium both before and after operation, otherwise recurrence is allbut inevitable. The _submaxillary and sublingual glands_ may be the seat of the samevarieties of tumour as the parotid. These glands are particularlyliable to become invaded along with the adjacent lymph glands inepithelioma of the tongue and floor of the mouth. CHAPTER XXIV THE EAR[5] Surgical Anatomy--CARDINAL SYMPTOMS OF EAR DISEASE: _Impairment of hearing_; _Tinnitus aurium_; _Earache_; _Giddiness_; _Discharge_--Hearing tests--Inspection of ear--Inflation of middle ear. AFFECTIONS OF EXTERNAL EAR: _Deformities_; _Hæmatoma auris_; _Epithelioma and Rodent cancer_; _Impaction of wax_; _Eczema_; _Boils_; _Foreign bodies_. AFFECTIONS OF TYMPANIC MEMBRANE AND MIDDLE EAR: _Rupture of membrane_; _Acute inflammation of middle ear_; _Chronic suppuration_; _Suppuration in the mastoid antrum and cells_. [5] We desire here to acknowledge our indebtedness to Dr. Logan Turnerfor again revising this chapter. #Surgical Anatomy. #--The anatomical subdivision of the ear into threeparts--the external, middle, and internal ear--forms a satisfactorybasis for the study of ear lesions. The outer ear consists of theauricle and external auditory meatus, the latter being made up of anouter cartilaginous portion half an inch in length, and a deeperosseous portion three-quarters of an inch long. The canal forms acurved tube, which can be straightened to a considerable extent forpurposes of examination by pulling the auricle upwards and backwards. It is closed internally by the tympanic membrane, which separates itfrom the tympanic cavity or middle ear. The middle ear includes thetympanum proper, which is crossed by the chain of ossicles--malleus, incus, and stapes--the Eustachian tube, which communicates with thenaso-pharynx, and the tympanic antrum and mastoid cells. As thesecavities lie in close relation to the middle and posterior cranialfossæ, infective conditions in the tympanum and mastoid cells areliable to spread to the interior of the skull. The internal ear orlabyrinth lies in the petrous part of the temporal bone, its outerboundary being the inner wall of the middle ear. Physiologically the different parts of the auditory mechanism may bedivided into (1) the _sound-conducting apparatus_, which includes theouter and middle ears; and (2) the _sound-perceiving apparatus_--theinternal ear and central nerve tracts. Impairment of hearing may bedue to causes existing in one or other or both of these subdivisions. The condition of the sound-conducting apparatus can be investigated bydirect inspection through the speculum, and by inflation of theEustachian tube and tympanum, while that of the sound-perceivingapparatus is ascertained partly by testing the hearing, and partly byexcluding affections of the outer and middle ear. When thesound-conducting apparatus is at fault, the resulting deafness isspoken of as "obstructive"; when the sound-perceiving apparatus isaffected, the term "nerve deafness" is used. The semicircular canals, which are peripheral organs concerned in the maintenance ofequilibration, form part of the inner ear apparatus. CARDINAL SYMPTOMS OF EAR DISEASE. --The most important symptom of eardisease is _impairment of hearing_, which varies in degree, and may bedue to lesions either in the sound-conducting or in thesound-perceiving apparatus. The sudden onset of deafness may be due toimpaction of wax in the external meatus or to hæmorrhage or effusioninto the labyrinth. A gradual onset is more common. In children thereis a great tendency for acute inflammatory conditions of the middleear to arise in connection with the exanthemata and in associationwith adenoids. In adult life chronic catarrhal processes are morecommon causes of gradually increasing deafness, while in advanced agethere is a tendency to acoustic nerve impairment. Certain anomalousconditions of hearing are occasionally met with, such as the"paracusis of Willis"--a condition in which the patient hears betterin a noise; "diplacusis, " or double hearing; and "hyperæsthesiaacustica, " or painful impressions of sound. _Tinnitus aurium_, or subjective noises in the ear, may constitute avery annoying and persistent symptom. These sounds vary in theircharacter, and may be described by the patient as ringing, hissing, orsinging, or may be compared to the sound of running water or of atrain. They are usually compared to some sound which, from hisoccupation or otherwise, the patient is accustomed to hear. They maybe purely aural in origin, being due, for example, to increasedpressure on the acoustic nerve endings from causes in the labyrinthitself or in the middle or external ear; or they may be due to certainreflex causes, such as naso-pharyngeal catarrh or gastric irritation. Vascular changes such as occur in anæmia, Bright's disease, and heartdisease may also be concerned in their production. _Pain_, or _earache_, varies in degree from a mere sense of discomfortto acute agony. The pain associated with a boil in the external meatusis usually aggravated by movements of the jaw, by pulling the auricle, and by pressure upon the tragus. The pain of acute middle-earinflammation is deep-seated, intermittent in character, and worse atnight, and is aggravated by blowing the nose, coughing, andsneezing--acts which increase middle-ear tension by forcing air alongthe Eustachian tube. Mastoid pain and tenderness are indicative ofinflammation in the antrum or cells, and when these symptoms supervenein the course of a chronic middle-ear suppuration, they should alwaysbe regarded as of grave import. Severe neuralgia of the ear maysimulate the pain of acute mastoiditis, and it must not be forgottenthat earache may be traced to a diseased tooth. A careful examination, not only of the ear, but also of the throat and teeth, shouldtherefore be made in all cases of earache. _Vertigo_, or _giddiness_, may be produced by causes which alter thetension of the labyrinthine fluid, such, for example, as the pressureof wax upon the tympanic membrane, or exudation into the middle ear orinto the labyrinth. Giddiness occurring in the course of chronicmiddle-ear suppuration may be significant of labyrinthine or ofintra-cranial mischief, but is not necessarily so. Giddiness precededby nausea suggests a gastric origin; if followed by nausea it pointsto an aural origin. In cases of suspected aural vertigo, the patient's"static sense" should be carefully tested. He should be asked (1) tostand with both feet together with the eyes closed, (2) to stand onone or other foot with eyes closed, (3) to walk in a straight line, (4) to hop backwards and forwards off both feet. His incapacity forperforming such movements should be noted. As nystagmus may beassociated with disturbance of equilibrium due to ear disease, themovements of the eyeballs must be carefully tested. Labyrinthine _nystagmus_ is of a rhythmic character, and consists of aslow and a rapid movement. Physiological nystagmus can be induced bystimulating the movement of the endolymph in the semicircular canals, by syringing the ear with hot and cold water (caloric test), byrotating 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 thesemicircular canals. _Discharge from the ear_, or _otorrhœa_, is occasionally due to aneczematous condition of the skin lining the external meatus. It isthen usually of a thin, watery character, and contains epithelialflakes and débris. An aural discharge is, however, most commonly ofmiddle-ear origin. It may be muco-purulent and stringy, or purulentand of thicker consistence. A peculiar, offensive odour ischaracteristic of chronic middle-ear suppuration. The surgeon shouldsmell the speculum in suspicious cases. He should never accept thepatient's statement as regards the absence of discharge, but shouldsatisfy himself by inspection and by the introduction of a cotton-woolwick. #The Hearing Tests. #--In testing the hearing, a definite routinemethod should be adopted, the watch, whisper, voice, and tuning-forktests being systematically employed. Although the patient onlycomplains of one ear, both must be examined. Each ear should be testedseparately, and the patient should be so placed that he cannot see thelips of the examiner. While one ear is being tested, the other shouldbe closed with the finger, and each test should be commenced outsidethe probable normal range of hearing. All the results should bewritten down at once, and the date of the test recorded, as this isessential for following the progress of the case. _Tuning-fork Tests. _--To differentiate between deafness due to alesion in the sound-conducting apparatus and that due to labyrinthinecauses, it is necessary to enter into a little more detail. The toneproduced by a vibrating tuning-fork is conducted to the nerveterminations in the labyrinth both through the air column in theexternal meatus (air-conduction), and through the cranial bones(bone-conduction). When, in a deaf ear, the vibrations of atuning-fork placed in contact with the mastoid process are heardbetter than when the fork is held opposite the meatus, the lesion isin the sound-conducting apparatus. When, on the other hand, thevibrations are heard better by air-conduction, the lesion is in thesound-perceiving apparatus. In addition to these facts, we find alsothat in obstructive deafness low tones tend to be lost first, while innerve deafness the higher notes are the first to go. This may beinvestigated by tuning-forks of different pitch or with the aid of aGalton's whistle. Again, in middle-ear deafness, hearing may be betterin a noisy place, and be improved by inflation of the tympanum; whilein labyrinthine deafness, hearing may be better in a quiet room, andbe rendered worse by inflation. #Inspection of the Ear. #--This should be carried out by the aid ofreflected light, the ear to be examined being turned away from thewindow, lamp, or other source of light that may be employed. A smallear reflector, either held in the hand or attached to a forehead band, and a set of aural specula are required. Before introducing thespeculum, the outer ear and adjacent parts should be examined, and thepresence of redness, swelling, sinuses or cicatrices over the mastoid, displacement of the auricle, or any inflammatory condition of theouter ear observed. To inspect the tympanic membrane, a medium-sizedspeculum held between the thumb and index finger is insinuated intothe cartilaginous meatus, the auricle being at the same time pulledupwards and backwards by the middle and ring fingers, so as tostraighten the canal. The tympanic membrane is then sought for and itsappearance noted. The _normal membrane_ is concave as a whole on its meatal aspect; itoccupies a doubly oblique plane, being so placed that its superior andposterior parts are nearer the eye of the examiner than the anteriorand inferior parts. While varying to some extent in colour, polish, and transparency, it presents a bluish-grey appearance. The handle ofthe malleus traverses the membrane as a whitish-yellow ridge, whichappears to pass from its upper and anterior parts downwards andbackwards to a point a little below the centre. At the lower end ofthe handle of the malleus a bright triangular cone of light passesdownwards and forwards to the periphery of the membrane. At the upperend of the handle is a white knob-like projection, the short processof the malleus. Passing forwards and backwards from this are theanterior and posterior folds. The portion of the membrane situatedabove the short process is known as the membrana flaccida orShrapnell's membrane. Behind the malleus the long process of the incusmay be visible through the membrane. The mobility of the membranatympani should be tested by inflating the tympanum or by means ofSiegle's pneumatic speculum. Various departures from the normal may be observed. _Atrophy_ of themembrane is characterised by extreme transparency of the whole disc. Circumscribed atrophic patches appear as dark transparent areas, whichshow considerable mobility and bulge prominently on inflation. A_cicatrix_ in the membrane is evidence of a healed perforation, and isalso transparent, but differs from an atrophic patch in being moresharply defined from the surrounding membrane. A _thickened membrane_presents an opaque white appearance. _Calcareous_ or _chalky patches_are markedly white, and when probed are hard to the touch; they areoften evidence of past suppuration. An _indrawn_ or retractedmembrane, resulting from Eustachian obstruction, is characterised byincreased concavity, undue prominence of the lateral short process ofthe malleus and of the anterior and posterior folds, and by the handleof the malleus assuming a more horizontal position. An _inflamed_membrane, showing congestion of the vessels about the malleus or ageneral diffuse redness, is evidence of middle-ear inflammation. Ayellow appearance of the lower part of the membrane, limited above bya dark line stretching across the drum-head, is indicative ofsero-purulent exudation into the tympanum. The membrane may be bulgedoutwards into the meatus by the fluid, and thus lie nearer theobserver's eye than normally. A _perforation_ is usually single, andvaries in size from a small pinhead to complete destruction of themembrane. The labyrinthine (inner) wall of the tympanum may be visiblethrough the perforation, and is recognised by being on a deeper planethan the membrane, and by its hard bony consistence when touched withthe probe. The diagnosis of a perforation associated with middle-eardischarge may be further assisted by inspection during inflation, whenbubbles of air and secretion are visible. When the perforation isinvisible, its existence may be inferred if a small pulsating spot oflight can be recognised through the speculum. _Granulations_ in thetympanum appear as red fleshy masses of different sizes. When largethey constitute _aural polypi_, which are recognised by theirproximity to the outer end of the meatus, their soft consistence andmobility, and the fact that the probe may be passed round them. Granulations and polypi usually indicate the presence of middle-earsuppuration. #Inflation of the Middle Ear. #--Before proceeding to inflate themiddle ear, the examiner should inspect the nose, naso-pharynx, andpharynx. This should be made a routine part of the examination in allcases of ear disease. As inflation is not only an aid in diagnosis, but is also of great assistance in prognosis, it is necessary that thehearing should be tested and noted before the ear is inflated. Thereare three methods of inflating the tympanum: Valsalva's method, Politzer's method, and by means of the Eustachian catheter. In _Valsalva's inflation_ the patient himself forces air into hisEustachian tubes, by holding his nose, closing his mouth, and forciblyexpiring. This method of inflation has only a limited application andis of little therapeutic value. _Politzer's Method. _--For this a Politzer's air-bag and anauscultating tube, one end of which is inserted into the patient's earand the other into the ear of the examiner, are required. The nasalend of the bag should be protected with a piece of rubber tubing or beprovided with a nozzle. The patient retains a small quantity of waterin his mouth until directed to swallow. The nozzle of the bag isinserted into one nostril, and the other is occluded by the fingers ofthe surgeon. The signal to swallow is then given, and, simultaneouslywith the movement of the larynx during this act, the bag is sharplyand forcibly compressed. Holt's modification of this method consistsin directing the patient to puff out his cheeks while the lips arekept firmly closed. _Inflation through the Eustachian Catheter. _--For this method, inaddition to the Politzer's bag and the auscultating tube, a silver orvulcanite Eustachian catheter is required. The silver instrument hasthe advantage that it can be sterilised by boiling. The patient isseated facing the light, while the surgeon stands in front of him, and, having placed the auscultating tube in position, with his leftthumb he tilts up the tip of the patient's nose. The beak of thecatheter is now inserted into the inferior meatus, point downwards, and carried horizontally backwards along the floor of the nose untilthe convexity of the curve touches the posterior wall of thenaso-pharynx. When the posterior pharyngeal wall is felt, the point ofthe instrument is rotated inwards through a quarter of a circle; theposition of the point is indicated by the metal ring upon the outerend of the catheter. The finger and thumb of the left hand should nowgrasp the stem of the catheter just beyond the tip of the nose so asto steady it. It is now gently withdrawn until the concavity of thebeak is brought against the posterior edge of the septum nasi. Withthe right hand the point of the instrument is then rotated downwardsand outwards through a little more than half a circle, so that thepoint slips into the Eustachian orifice and the metal ring looksoutwards and upwards towards the external canthus of the eye of thesame side. While the instrument is maintained in this position by theleft hand, the nozzle of the Politzer's bag is inserted into thefunnel-shaped outer extremity of the catheter, and inflation is gentlycarried out with the least possible jerking. Before withdrawing thecatheter its point must be disengaged from the Eustachian opening byturning it slightly downwards. Difficulties in introducing thecatheter may arise from the presence of spines and ridges upon, anddeviations of, the septum, and it may be necessary to pass theinstrument under the guidance of the mirror and speculum. More accurate information is gained from the use of the catheter thanfrom Politzer's inflation, and it is the safer method to employ when acicatrix or atrophied patch exists in the tympanic membrane, as by thelatter method rupture of these areas might occur. Further, thecatheter has the advantage of only inflating one ear, and thuspreventing any undue strain being put upon the other. In children thecatheter can seldom be employed, on account of the difficulty inpassing it. Considerable information may be derived from inflation. If theEustachian tube is patent, a full clear sound is heard close to theexaminer's ear through the auscultating tube. If the Eustachian tubeis obstructed, the sound is fainter and more distant. If there isfluid in the tympanum, a fine moist sound may be detected, which mustnot be confounded with the coarser and more distant gurgling soundassociated with moisture at the pharyngeal opening of the tube. If asmall dry perforation exists in the tympanic membrane, the air may beheard whistling through it, while if the perforation is large, asensation which is almost painful may be produced in the examiner'sear. If there is fluid associated with the perforation, these soundsmay be accompanied by a bubbling noise. The effect of inflation uponthe hearing must be carefully tested and recorded. AFFECTIONS OF THE EXTERNAL EAR #Deformities. #--The auricle, together with the external auditorymeatus, may be _congenitally absent_ on one or on both sides. Thecondition is not amenable to surgical treatment. _Double auricles_ areoccasionally met with; more frequently rudimentary _auricularappendages_ about the size of a pea, consisting of skin, subcutaneousconnective tissue and nodules of cartilage occur in front of thetragus, on the lobule or in the neck. These appendages should besnipped off with scissors. These congenital deformities are due toerrors in development of the mandibular arch, and are frequentlyassociated with macrostoma, facial clefts, and other malformations ofthe face. _Outstanding ears_ may be treated by excising a triangular orelliptical portion of skin and cartilage from the posterior surface ofthe pinna and uniting the cut edges with sutures. Abnormally _largeears_ may be diminished in size by the removal of a V-shaped portionfrom the upper part of the auricle. The term #hæmatoma auris# is applied to a sub-perichondrial effusionof blood, which may occur either as the result of injury to theauricle, for example in football players, or as a result of trophicchanges in the cartilage and perichondrium. The latter form is notuncommon among the insane. A more or less tense fluctuating swellingforms on the anterior surface of the auricle, presenting in some casesa distinctly bluish coloration. Inflammation may ensue, and in somecases suppuration and even necrosis of cartilage may follow. The _treatment_ in a recent case consists in applying cold or elasticcompression with cotton-wool and a bandage, or in withdrawing theeffused blood by means of a hollow needle. In the event of suppurationsupervening, incision and drainage must be carried out. #Epithelioma# may attack the auricle and extend along the externalauditory meatus. It begins as a small abrasion which refuses to heal, and is attended with a constant fœtid discharge and intense pain. Thedisease may spread to the middle ear and invade the temporal bone, andfacial paralysis then ensues. The adjacent lymph glands are earlyinfected. The treatment consists in removing the growth freely, andexcising the associated lymph glands at an early stage of the disease. In inoperable cases radium or the X-rays may be employed. #Rodent cancer# also may attack the outer ear. #Impaction of Wax or Cerumen. #--Hyper-secretion may result fromunknown causes, or it may accompany or be induced by the dischargefrom a chronic middle-ear suppuration. The association of these twoconditions should be borne in mind. An accumulation of wax may becaused by the too zealous attempts of the patient to keep the earclean, the wax being forced into the narrow deeper part of the meatus. The chief _symptom_ of impacted wax is deafness, which is often ofsudden onset. Impaction of wax causes deafness only when the lumen ofthe auditory canal becomes completely occluded by the plug. Tinnitusaurium and vertigo are sometimes present, and may be troublesome ifthe wax rests upon the tympanic membrane. Pain is occasionallycomplained of, and is usually due to the pressure of the plug upon aninflamed area of skin. Certain reflex symptoms, such as coughing andsneezing, have been met with. It is only by an objective examination of the ear that the diagnosiscan be made. The plug varies in colour and consistence, and may beyellow, brown, or black in appearance. Sometimes from the admixture ofa quantity of epithelium it is almost white in colour. _Treatment. _--The ear should be syringed with a warm antiseptic orsterilised solution. The lotion is at a suitable temperature if thefinger can be comfortably held in it. The ear should be turned to thelight, a towel placed over the patient's dress, and a kidney basinheld under the auricle and close to the cheek. A syringe provided withmetal rings for the fingers and armed with a fine ear nozzle should beheld with the point inserted just within the aperture of the externalmeatus and in contact with the roof of the canal. Care must be takenthat all the air is first removed from the syringe. To straighten thecanal, the pinna should be pulled upwards and backwards by the lefthand. It may be necessary to exert some considerable degree of forcebefore the plug becomes dislodged, but this must be done with caution. The ear should then be dried out with cotton-wool, and a small plugof wool inserted for a few hours. If pain is complained of, or if thewax is hard and cannot be readily removed, the syringing should bestopped, and means taken to soften it by the instillation of a fewdrops of a solution of bicarbonate of soda (10 grains to the ounce ofwater or glycerine), or of peroxide of hydrogen, several times daily. #Eczema of the external meatus# is often associated with eczema of theauricle and of the surrounding parts. Not infrequently there alsoexists a chronic middle-ear suppuration, which may be the cause of theeczema. Intense itchiness is the most characteristic symptom, and awatery discharge may also be complained of. Deafness and tinnitus aredependent upon the accumulation of epithelium and débris. After theear is syringed the skin may present a dry, scaly appearance, whilesometimes fissures and an indurated condition of the outer end of themeatus may be noted. Rarely is the outer surface of the tympanicmembrane itself involved. _Treatment_ consists in keeping the ear clean by syringing and carefuldrying. Probably the best local application is nitrate of silver (10grains to the ounce of spiritus ætheris nitrosi). This is applied bymeans 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 uponthe cheek, otherwise staining of the skin occurs. A plug ofcotton-wool is inserted, and the solution is re-applied at the end ofa week. Sometimes the condition is very intractable. Occasionally the vegetable parasite _aspergillus_ is present in theexternal meatus, and produces a condition that is liable to bemistaken for eczema. Strong antiseptic lotions are required to killthe fungus. #Furunculosis# or #Boils#. --Boils in the ear may arise singly or incrops, and may be associated with eczema of the meatus or with chronicsuppuration of the middle ear. Pain is the chief symptom complainedof, and it may be very acute. Deafness ensues when the meatus becomescompletely blocked by the swelling. The boil occurs in thecartilaginous meatus, and it is to be borne in mind that the skin maypresent a normal appearance even when suppuration has occurred. Palpation of the affected area with the probe causes intense pain. Sometimes œdema over the mastoid with displacement forwards of thepinna supervenes, and simulates acute inflammation of the mastoid. _Treatment. _--If seen in the earliest stages, an attempt may be madeto relieve the pain by the application of a 20 per cent. Menthol andparolein solution, or by the use of carbolic acid and cocain, 5 grainsof each to a dram of glycerine. When suppuration has occurred, thebest treatment is by early incision, transfixing the base of theswelling with a narrow knife and cutting into the meatus. If thetendency to boils persists, a staphylococcal vaccine will be found ofvalue. #Foreign Bodies. #--It is unnecessary to enumerate all the varieties offoreign bodies that may be met with in the ear. They may beconveniently classified into the animate--for example maggots, larvæ, and insects; and the inanimate--for example beads, buttons, and peas. Pain, deafness, tinnitus, and giddiness may be produced, and suchreflex symptoms as coughing and vomiting have resulted. The main practical point consists in identifying the body byinspection. The mere history of its introduction should not be takenas proof of its presence. In children it is advisable to give ageneral anæsthetic so that a thorough examination may be made with theaid of good illumination. If previous attempts to remove the body havecaused œdema of the meatal walls, and if the symptoms are not urgent, no further attempt should be made until the swelling has been allayedby syringing with warm boracic lotion, and by applying one or moreleeches to the tragus. An attempt should always be made in the firstinstance to remove the body by syringing. It is rare to find thismethod fail. Should it do so, a small hook should be used, sharp orblunt according to the consistence of the body. Maggots, larvæ, andinsects should first be killed by instillations of alcohol and thensyringed out. AFFECTIONS OF THE TYMPANIC MEMBRANE AND MIDDLE EAR #Traumatic Rupture of the Tympanic Membrane. #--Perforating wounds mayresult from direct violence caused by the patient--for example, inattempts to remove wax or foreign bodies, or by clumsiness on the partof the surgeon. It is also a comparatively common complication offracture of the middle fossa of the base of the skull. More commonly, perhaps, the membrane is ruptured from indirect violence due to greatcondensation of the air in the external auditory meatus, followingblows upon the ear, heavy artillery reports, or diving from a height. The injury is followed by pain in the ear, often by considerabledeafness and tinnitus, and bleeding is frequently observed. If earlyexamination of the ear is made, coagulated blood may be found in themeatus or upon the membrane, or ecchymosis may be visible on thelatter. A rupture in the membrane following indirect violence isusually lozenge-shaped. During inflation by Valsalva's method the airmay be heard to whistle through the perforation. In all such injuriesthe hearing should be carefully tested, and the possibility of aninjury to the labyrinth investigated by means of the tuning-fork test. Prognosis as regards hearing should be guarded at first. As a rule therupture heals rapidly, and no treatment is necessary save theintroduction of a piece of cotton-wool into the meatus. Syringingshould be avoided unless suppuration has already occurred, in whichcase treatment for this condition must be adopted. As these injuriesfrequently have a medico-legal bearing, careful notes should be made. #Acute Infection of the Middle Ear. #--This usually arises inconnection with infective conditions of the throat and naso-pharynx. It varies considerably in its severity, and may run a mild or a severecourse. It is characterised by pain in the ear, deafness, and acertain degree of fever. In children the symptoms may simulate thoseof meningitis. When the tympanic membrane is examined in the mildforms of the affection or in the early stages of the more severe type, the vessels about the handle of the malleus and periphery of themembrane are injected, and possibly a number of injected vessels maybe seen coursing across the surface of the membrane. In the laterstages the whole membrane presents a red surface, the anatomicallandmarks being indistinguishable, the membrane bulges outwards intothe meatus, and, if an abscess is pointing, a yellowish area may bevisible upon it. The sudden cessation of pain and the appearance of adischarge from the meatus indicate perforation of the membranatympani. The _treatment_ of acute otitis media varies with the severity of theattack. The patient should be confined to the house or to bed, alcoholand tobacco should be forbidden, and the bowels must be freely opened. Pain may be allayed by repeated instillations of cocain and carbolicacid (5 grains of each to a dram of glycerine). A few drops oflaudanum, hot boracic instillations, or the application of a dry hotsponge, may prove soothing. Two or three leeches may be applied overthe mastoid, but should the pain persist or should rupture of themembrane appear imminent, paracentesis must be carried out. Afterspontaneous perforation or puncture, the meatus must be kept clean. Itis probably safer not to inflate through the Eustachian tube in theacute stage. Attention must be paid to any affection of the nose orthroat that may be present. #Chronic Suppuration in the Middle Ear. #--Acute suppuration may passinto the chronic variety, which is characterised by a perforation ofthe tympanic membrane, a persistent purulent or muco-purulentdischarge from the middle ear, and a certain amount of deafness. _Various complications_ may arise in the course of chronic middle-eardisease, and so long as a person is the subject of a chronic otorrhœa, he is liable to one or more of these. The complications may beextra-cranial or intra-cranial. Those affecting the middle ear itselfinclude granulations, polypi, cholesteatoma, caries and necrosis ofthe temporal bone, destruction and loss of one or more of theossicles, facial paralysis, hæmorrhage from the carotid artery orjugular vein, and malignant disease. As mastoid complications may bementioned: suppurative mastoiditis, leading to destruction of thebone, mastoid fistula, and sub-periosteal mastoid abscess. Theintra-cranial complications that may arise are: extra-dural abscess, sub-dural abscess, meningitis, cerebral and cerebellar abscess, andlateral sinus phlebitis with general septicæmia and pyæmia. The _treatment_ of chronic middle-ear suppuration consists in keepingthe parts clean by syringing with antiseptic lotions. The installationof hydrogen peroxide, followed by syringing with boiled water orboracic lotion, and inflation through the Eustachian tube once, twice, or thrice daily, according to the requirements of the case, constitutea routine method. Packing the meatus with antiseptic gauze afterwashing out may be practised. #Suppuration in the Tympanic Antrum and Mastoid Cells#, or _AcuteSuppurative Mastoiditis_. --Acute suppuration may occur in the mastoidcells in the course of an attack of acute otitis media, or as a resultof interference with drainage in chronic suppuration of the antrum andmiddle ear. As the outer wall of the mastoid is liable to beperforated by cario-necrosis, the pus may find its way externally andform an abscess over the mastoid process behind the ear. In some casesthe pus escapes into the external auditory meatus by perforating itsposterior wall; in others a sinus forms on the inner side of the apexof the mastoid, and the pus burrows in the digastric fossa under thesterno-mastoid--_Bezold's mastoiditis_. If the posterior wall or roofof the antrum is destroyed, intra-cranial complications are liable toensue. The _clinical features_ are pain behind the ear, tenderness onpressure or percussion over the mastoid, redness and œdematousswelling of the skin, and, when pus forms under the periosteum, theœdema may be so great as to displace the auricle downwards andforwards (Fig. 265). The deeper part of the posterior osseous wall ofthe meatus may be swollen so that it conceals the upper and back partof the membrane. [Illustration: FIG. 265. --Acute Mastoid Disease, showing œdema andprojection of auricle. ] _Treatment. _--When arising in connection with acute otitis, theapplication of several leeches behind the ear, free incision of themembrane, and syringing with hot boracic lotion may be sufficient. Asa rule, however, it is necessary to expose the interior of the antrumby opening through the mastoid cells--_Schwartze's operation_. Whenmastoid suppuration is associated with chronic middle-ear disease, it is usually necessary to perform the complete radicaloperation--_Stacke-Schwartze operation_. The operations are describedin _Operative Surgery_, p. 98. CHAPTER XXV THE NOSE AND NASO-PHARYNX[6] Fracture of nasal bones--Deformities of nose: _Saddle nose_; _Partial and complete destruction of nose_; _Restoration of nose_; _Rhinophyma_--Intra-nasal affections--Examination of the nasal cavities: _Anterior rhinoscopy_; _Posterior rhinoscopy_; _Digital examination_. CARDINAL SYMPTOMS OF NASAL AFFECTIONS: Nasal obstruction: _Erectile swelling of inferior turbinals_; _Nasal polypi_; _Malignant tumours_; _Deviations, spines, and ridges of septum_; _Hæmatoma of septum_--Nasal discharge: _Foreign bodies_; _Rhinoliths_; _Ozæna_; _Epistaxis_; _Suppuration in accessory sinuses_--Anomalies of smell and taste: _Anosmia_; _Parosmia_--Reflex symptoms of nasal origin--Post-nasal obstruction: _Adenoids_--Tumours of naso-pharynx. [6] Revised by Dr. Logan Turner. #Fracture of the Nasal Bones and Displacement of theCartilages. #--These injuries are always the result of direct violence, such as a blow or a fall against a projecting object, and in spite ofthe fact that the fracture is usually compound through tearing of themucous membrane, infective complications are rare. The fractureusually runs transversely across both nasal bones near their loweredge, but sometimes it is comminuted and involves also the frontalprocesses of the maxillæ. In nearly all cases the cartilage of theseptum is bent or displaced so that it bulges into one or othernostril, and not infrequently a hæmatoma forms in the septum (p. 573). Sometimes the perpendicular plate of the ethmoid is implicated, andthe fracture in this way comes to involve the base of the skull. Thenasal ducts may be injured, obstructing the flow of the tears, and alachrymal abscess and fistula may eventually form. The _clinical features_ are pain, bleeding from the nose, discoloration, and swelling. Crepitus can usually be elicited onpressing over the nasal bones. The deformity sometimes consists in alateral deviation of the nose, but more frequently in flattening ofthe bridge--_traumatic saddle nose_. Within a few hours of the injurythe swelling is often so great as to obscure the nature of thedeformity and to render the diagnosis difficult. Subcutaneousemphysema is not a common symptom; when it occurs, it is usually dueto the patient forcing air into the connective tissue while blowinghis nose. The lateral cartilages may be separated from the nasal bonesand give rise to clinical appearances which simulate those offracture. Sometimes the septum is displaced laterally without the bonebeing broken, and this causes symptoms of nasal obstruction. _Treatment. _--As the bones unite rapidly, it is of great importancethat any displacement should be reduced without delay, and tofacilitate this a general anæsthetic should be administered, or thenasal cavity sprayed with cocain. The bones can usually be leveredinto position with the aid of a pair of dressing forceps passed intothe nostrils, the blades being protected with rubber tubing. After thefragments have been replaced and moulded into position, it is seldomnecessary to employ any retaining apparatus, but the patient must bewarned against blowing or otherwise handling the nose. When the septumis damaged and the bridge of the nose tends to fall in, rubber tubesmay be placed in the nostrils to give support, or, if this is notsufficient, a soft lead or gutta-percha splint should be moulded overthe nose, and the splint and the fragments transfixed with one or morehare-lip pins. These may be removed on the fourth or fifth day. Rigidappliances introduced into the nostrils are to be avoided if possible, as they are uncomfortable and interfere with proper cleansing anddrainage of the nose. The inside of the nose should be smeared withvaseline to prevent crusting of blood, and the nasal cavities shouldbe frequently irrigated. #Deformities of the Nose. #--The most common deformity is that known asthe _sunken-bridge_ or _saddle nose_ (Volume I. , p. 174). It is mostfrequently a result of inherited syphilis, the nasal bones beingimperfectly developed, and the cartilages sinking in so that the tipof the nose is turned up and the nostrils look directly forward. Thebridge of the nose may sink in also as a result of necrosis of thenasal bones, particularly in tertiary syphilis, and less frequentlyfrom tuberculous disease. A similar, but as a rule less markeddeformity may result from fracture of the nasal bones or fromdisplacement of the cartilages. When the condition is due to mal-union of a fracture, the contour ofthe nose may be restored by operation. A narrow knife is passed in atthe nostril and the skin freely separated from the bone; the bone isthen broken into several pieces with necrosis forceps, and thefragments moulded into shape. A rubber drainage tube introduced intoeach nostril maintains the contour of the nose till union has takenplace. When it results from disease, it is much less amenable to treatment. The present-day tendency is to discard the use of subcutaneousparaffin injection and to employ grafts of cartilage or bone. Anartificial bridge has been made by turning down from the forehead aflap, including the periosteum and a shaving of the outer table of theskull, or by implanting portions of bone or plates of gold, aluminium, or celluloid. Portions of the alæ nasi may be lost from injury, or from lupus, syphilis, or rodent cancer. After the destructive process has beenarrested, the gap may be filled in by a flap taken from the cheek oradjacent part of the nose. When the tip of the nose is lost, it may bereplaced by Syme's operation, which consists in raising flaps from thecheeks and bringing them together in the middle line. The whole of the nose, including the cartilages and bones, may bedestroyed by syphilitic ulceration or by lupus. In parts of India thenose is sometimes cut off maliciously or as a punishment for certaincrimes. In reconstructing the nose it is necessary to provide skin, asupporting structure in the form of cartilage or bone, and anepithelial lining. In the "Indian operation" a racket-shaped flap, including skin and periosteum, is turned down from the forehead andfixed in position, the edges of the flap being inturned to provide alining for the passage. An implant of free cartilage may be necessaryto support the skin flaps and to prevent subsequent contraction. Flaps of skin may be formed by Gillies' tube-pedicle method from thecheek, the forehead, or the neck, and utilised to form the covering ofthe nose. When the deformity cannot be corrected by operation, theappearance may be greatly improved by wearing an artificial nose heldin position by spectacles. The term #Rhinophyma# has been applied by Hebra to a condition inwhich the skin of the tip and alæ of the nose becomes thick andcoarse, and presents large, irregular, tuberous masses on which theorifices of the sebaceous follicles are unduly evident--_potato_ or_hammer nose_ (Fig. 266). The capillaries of the skin are dilated andtortuous, and the nose assumes a bluish-red colour, and its surface issoft and greasy. The condition is met with in elderly men, and themasses appear to be chiefly composed of sebaceous adenomas. The term_lipoma nasi_, formerly employed, is therefore misleading. [Illustration: FIG. 266. --Rhinophyma or Lipoma Nasi in man æt. 65. ] The treatment consists in paring away the protuberant masses until thenormal size and contour of the nose are restored, care being taken notto encroach on the cartilages or on the orifices of the nostrils. There is comparatively little bleeding, and the raw surface rapidlybecomes covered with epidermis. #Examination of the Nasal Cavities. #--For the examination of theinterior of the nose the following appliances are necessary: Areflector, such as is used in laryngoscopy, attached to a foreheadband or spectacle frame; one of the various forms of nasal speculum; along, pliable probe; a tongue depressor; and a small-sized mirror. Asadditional aids, a 10 per cent. Solution of cocain, a grooved probe asa cotton-wool holder, and a palate retractor should be in readiness. Good illumination is important, and may be obtained from an electriclight, or from a Welsbach or Argand burner. The light should be placedclose to, and on a level with, the patient's left ear. Both theanterior and posterior nares should be examined. _Anterior Rhinoscopy. _--Before the introduction of the speculum thetip of the nose should be tilted up and the interior of the vestibuleand the anterior part of the septum examined. In this way theexistence of eczema or small furuncules, the presence of dilated orbleeding vessels upon, or a perforation of, the anterior part of theseptum may be noted, and the general appearances observed. Afterinserting the speculum into the vestibule and dilating it, thefollowing parts should be sought for and examined:--Close to thefloor, and attached to the outer wall of the nasal cavity, is theanterior end of the inferior concha or turbinated body (Fig. 267), which overhangs the inferior meatus. It presents a pink appearance, and its size varies in different persons. At a higher level and on aposterior plane is the anterior end of the middle concha or turbinatedbody, which is of a paler colour than the inferior, and is onlyvisible when the head is tilted backwards. Between it and the inferiorturbinated body is the middle meatus, with which communicate theopenings of the maxillary sinus, the frontal sinus, and the anteriorethmoidal cells. A considerable area of the anterior part of the nasalseptum is also visible by anterior rhinoscopy, and between it and themiddle turbinal is a narrow chink--the olfactory sulcus. [Illustration: FIG. 267. --The outer wall of Left Nasal Chamber, afterremoval of the middle turbinated body. (After Logan Turner. )] _Posterior Rhinoscopy. _--Examination of the posterior nares andnaso-pharynx is frequently attended with difficulty. The patient isdirected to breathe through the nose, the tongue is depressed with aspatula, and a small-sized laryngeal mirror, comfortably warmed andwith its reflecting surface turned upwards, is introduced behind thesoft palate. When a good examination of the naso-pharynx is obtained, the following parts may be seen reflected in the mirror: the posteriorsurface of the uvula and soft palate, and above them, in the mesialplane, the posterior free edge of the septum nasi; on each side of theseptum the apertures of the posterior nares, in which may be seen theupper part of the posterior end of the inferior turbinal, the middlemeatus, the posterior end of the middle turbinal, the superior meatus, and occasionally a portion of the superior turbinal. On the lateralwall of the naso-pharynx the Eustachian opening and cushion can beseen, while by tilting the mirror backwards the vault of thenaso-pharynx can be inspected. _Digital examination_ of the naso-pharynx may be required, especiallyin children. The examiner passes his left arm and hand round the backof the child's head, and with one of his fingers presses the cheekinwards, between the jaws. His right forefinger is carried along thedorsum of the tongue, passed up behind the soft palate and a rapidexamination made of the post-nasal space. CARDINAL SYMPTOMS OF NASAL AFFECTIONS. --The chief symptoms of nasaldisease are: nasal obstruction, nasal discharge, anomalies of smelland taste, and certain reflex phenomena. #Nasal Obstruction. #--This may be partial or complete, intermittent orconstant, and may be the cause of such symptoms as alteration in thetone of the voice, catarrh of the respiratory passages, snoring, cough, headache, inability to concentrate the attention, alteration inthe physiognomy, or deformity of the chest. The half-open mouth, drooping jaw, lengthened appearance of the face, narrow nostrils, andvacant expression are characteristic signs of nasal obstruction. Nasal obstruction may be due to _intra-nasal_ or to _post-nasal_(naso-pharyngeal) causes. Amongst the former may be noted as the morecommon, erectile swelling and hypertrophy of the mucous membranecovering the inferior turbinated bones, and nasal polypi growing fromthe middle turbinal and middle meatal region. Causes originating inthe septum include deviations, spines, and ridges, and septal hæmatomaand abscess. Obstruction may also be due to the presence of a foreignbody in the nasal cavity, to a rhinolith, and to imperfect developmentof the nasal chambers. Further, tumours, both simple and malignant, and such conditions as tubercle, lupus, syphilis, and glanders mayinterfere more or less with nasal respiration. The most common causeof post-nasal obstruction is the presence of adenoids; more rarelyfibro-mucous polypi, fibrous tumours, malignant disease, andcicatricial contractions and adhesions resulting from syphilis are metwith. _Erectile swelling_ of the inferior turbinated bodies is due toengorgement of the venous spaces contained in the mucous membrane. Obstruction from this cause is usually intermittent in character, andmay be unilateral or bilateral. It is influenced by posture, beingworse when the patient is in the horizontal position, and also bychanges in atmospheric conditions and temperature. It is characterisedobjectively by a swelling of the mucous membrane, which is pink or redin appearance and of a soft consistence, pitting when touched with theprobe, and shrinking on the application of a 5 per cent. Solution ofcocain. Its soft consistence and the fact that it becomes smaller whenpainted with cocain differentiate it from true hypertrophy of themucous membrane. Its situation and immobility, its pink colour, andthe shrinkage under cocain, distinguish it from the mucous polypus ofthe nose. The turgescence may involve the whole extent of the mucosaof the inferior turbinated bodies, including their posterior ends. After anæsthetising with cocain, the electric cautery, or fusedchromic acid applied on a probe, may be employed for the relief of thecondition. If a true hypertrophy exists, it is better to remove itwith a nasal snare. _Nasal polypi_ spring from the mucous membrane covering the middleturbinated bone and from the adjacent parts of the middle meatus, butrarely from the septum. They consist of œdematous masses of mucousmembrane, and are as a rule multiple. They are usually pedunculated, and as they increase in size they become pendulous in the nasalcavity. They are smooth, rounded in outline, of a translucentbluish-grey colour, soft in consistence, and freely movable. Thesecharacters, and the fact that the probe can be passed round thegreater part of the polypus, serve to differentiate this affectionfrom the erectile swelling. It must not be forgotten that nasal polypimay be associated with suppuration in one or more of the accessorysinuses. They are frequently present also in malignant disease, and inthese cases they bleed readily. They are best removed by means of thecold snare, with the aid of the speculum and a good light. Severalsittings are usually necessary. _Carcinoma_ and _sarcoma_ sometimes grow from the muco-periosteum inthe region of the ethmoid. They tend to invade adjacent parts, givingrise to hæmorrhage and symptoms of nasal obstruction, and as theyincrease in size they may cause considerable deformity of the face. Ifdiagnosed early, an attempt should be made to remove the growth. _Deviations, spines, and ridges of the septum_ may produce partial orcomplete occlusion of the anterior nares. In deviation of the septum, the obstructed nostril is more or less occluded by a smooth roundedswelling of cartilaginous or bony hardness, which is covered withnormal mucous membrane, while the opposite nostril shows acorresponding concavity or hollowing of the septum. Sometimes theconvex side is thickened in the form of a ridge. A simple spine of theseptum is usually situated anteriorly, and presents an acuminateappearance, often pressing against the inferior turbinated body; it ishard to the touch. Ridges and spines may be cut or sawn off, orremoved with the chisel. Many methods of dealing with a deviatedseptum have been suggested, such as forcible fracture or excision of aportion of the cartilage. A submucous resection of the deflectedportion is to be preferred. _Hæmatoma of the septum_ is usually traumatic in origin. As the resultof a blow, an extravasation of blood takes place beneath theperichondrium on each side of the septum, and a bilateral, symmetricalswelling, smooth in outline and covered with mucous membrane, isvisible immediately within the anterior nares. The blood is usuallyabsorbed and should not be interfered with. If suppuration occurs, however, the swelling becomes soft, fluctuation can be detected, andthe patient's discomfort increases. The abscess must then be incisedand the cavity drained. It is sometimes found that a portion of thecartilage undergoes necrosis, leading to perforation of the septum. #Nasal discharge# may be mucous, muco-purulent, or purulent incharacter. When it is of a clear, watery nature, it is usuallyassociated with erectile swelling of the inferior turbinated bodies. Apurulent discharge may be complained of from one or both nostrils. Ifunilateral, it should suggest, in the case of children, the presenceof a foreign body; in adults, the possibility of suppuration in one ormore of the accessory sinuses. In infants, a purulent discharge fromboth nostrils may be due to gonorrhœal infection or to inheritedsyphilis. Nasal discharge may be constant or intermittent. It issometimes influenced by changes in posture; for example, it may bechiefly complained of at the back of the nose and in the throat whenthe patient occupies the horizontal position, or it may flow from thenostril when he bends his head forward or to one side. The dischargemay be intra-nasal in origin, or due altogether to naso-pharyngealcatarrh. It varies somewhat in colour and consistence, and may beassociated with such intra-nasal conditions as purulent rhinitisfollowing scarlet fever and other exanthemata or ulcerationaccompanying malignant disease, syphilis, or tuberculosis. Sometimesit contains shreds of false membrane, for example in nasal diphtheria;or white cheesy masses as in coryza cascosa. The formation of crustsis significant of fœtid atrophic rhinitis (ozæna) and syphilis, and inthese conditions the discharge is associated with a most objectionableand distinctive fœtor. Pus from the maxillary sinus is often fœtid, and the odour is noticed by the patient; while the odour of ozæna isnot recognised by the patient, although very obvious to others. #Foreign bodies# of various descriptions have been met with in thenasal cavities, particularly of children. They set up suppuration andgive rise to a unilateral discharge, which is often offensive incharacter. The surgeon must not be satisfied with the history given bythe parents, but, with the aid of good illumination, and, in youngchildren, under general anæsthesia, the nose should be carefullyinspected and probed. If there is much swelling, the introduction of a5 per cent. Solution of cocain will facilitate the examination bydiminishing the congestion of the mucous membrane. No attempt shouldbe made to remove a foreign body from the nose by syringing. If fluidis injected into the obstructed nostril, it is liable to force thebody farther back, while, if injected into the free nostril, it is aptto accumulate in the naso-pharnyx and to pass into the Eustachiantubes. A fine hook should be passed behind the body and traction madeupon it, or sinus forceps or a snare may be employed. Care must betaken that the body is not pushed still deeper into the cavity. Fungiand parasites should first be killed with injections of chloroformwater, or by making the patient inhale chloroform vapour. #Rhinoliths. #--Concretions having a plug of inspissated mucus or asmall foreign body as a nucleus sometimes form in the nose. They arecomposed of phosphate and carbonate of lime, and have a covering ofthickened nasal secretion. They are rough on the surface, dark incolour, and usually lie in the inferior meatus. They give rise to thesame symptoms as a foreign body, and are treated in the same way. Thestone, which is usually single, may be so large and so hard that it isnecessary to crush it before it can be removed. #Ozæna#, or #fœtid atrophic rhinitis#, is characterised by atrophy ofthe nasal mucous membrane, and sometimes even of the turbinated bones, and is accompanied by a muco-purulent discharge and the formation ofcrusts having a characteristic offensive odour, which is notrecognised by the patient. It is usually bilateral, and the nasalchambers, owing to the atrophy, are very roomy. It may bedifferentiated from a tertiary syphilitic condition by the absence ofulceration and necrosis of bone, by the odour, and by the fact that itis not influenced by anti-syphilitic treatment. Various methods of treatment are in vogue, but thorough cleanliness isthe most essential factor, and this is best secured by regularsyringing. Plugging of the nostrils with cotton-wool for half an hourbefore washing out the nose greatly facilitates the detachment of thecrusts. A pint of lukewarm solution containing a teaspoonful ofbicarbonate of soda or of common salt, is then used with a Higginson'ssyringe, the patient leaning over a basin and breathing in and outquickly through the open mouth. The patient should then forcibly blowdown each nostril in turn, the other being occluded with the finger, so that the infective material may thus be blown out without risk ofit entering the Eustachian tubes, as may happen when the handkerchiefis used in the ordinary way. Antiseptic sprays, such as peroxide ofhydrogen, and ointments may be applied to the mucous membrane aftercleansing. #Epistaxis. #--Bleeding from the nose may be due either to local or togeneral causes. Among the former may be cited injuries such as resultfrom the introduction of foreign bodies, blows on the face, andfractures of the anterior fossa of the skull, and the ulceration ofsyphilitic, tuberculous, or malignant disease. Amongst the generalconditions in which nasal hæmorrhage may occur are typhoid fever, anæmia, and purpura cardiac and renal disease, cirrhosis of the liver, and whooping-cough. Prolonged oozing of blood may be an evidence ofhæmophilia. Nasal hæmorrhage usually takes place from one or moredilated capillaries situated at the anterior inferior part of theseptum close to the vestibule, and in such cases the bleeding point isreadily detected. Occasionally bleeding occurs from one of theanterior ethmoidal veins, and under these circumstances the bloodflows downwards between the middle turbinal and the septum. Beforesteps are taken to arrest the bleeding, the interior of the noseshould, if possible, be inspected and the bleeding point sought for. As a preliminary to the use of local applications, the nose should bewashed out with boracic lotion or salt solution to remove all clotsfrom the cavity. In many cases this is all that is necessary to stopthe bleeding. If the bleeding is not very copious, it may be stoppedby grasping the alæ nasi between the finger and thumb, or by sprayingthe nasal cavity with adrenalin. If the blood is evidently flowingfrom the olfactory sulcus, a strip of gauze soaked in adrenalin, turpentine, or other styptic should be packed between the septum andmiddle turbinated body. If recurrent hæmorrhage takes place from theanterior and lower part of the septum, the application of the electriccautery at a dull red heat, or of the chromic acid bead fused on aprobe, is the best method of treatment. Plugging of the posteriornares is rarely necessary, as, in the majority of cases, an anteriorplug suffices. In bleeders, the administration of sheep serum by themouth has proved efficacious. #Suppuration in the Accessory Nasal Sinuses. #--As already stated, thepresence of pus in the nose should always direct attention to itspossible origin in one or more of the accessory sinuses, especially ifthe discharge is unilateral. The condition is usually a chronic one, and may be present for months, or even years, without the patientsuffering much inconvenience save from the presence of the discharge. If on examination by anterior rhinoscopy, pus is seen in the middlemeatus, suspicion should be aroused of its origin in the maxillarysinus, frontal sinus, or anterior ethmoidal cells, as all thesecavities communicate with that channel. If, on the other hand, the pusis detected in the olfactory sulcus, attention must be directed tothe posterior ethmoidal cells and sphenoidal sinus (Fig. 267). Furtherevidence of its source in the last-named cavities may be gained byfinding pus in the superior meatus above the middle turbinal onexamination by posterior rhinoscopy. As the anterior group of sinuses is most frequently affected, and ofthese most commonly the _maxillary sinus_, attention should first beturned to this cavity. Pain, tenderness on pressing over the caninefossa or on tapping the teeth of the upper jaw, and swelling of thecheek are rarely met with save in acute inflammation. The complaint ofa bad odour or taste, the reappearance of pus in the middle meatusafter mopping it away and directing the patient to bend his head wellforwards, 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 theinferior meatus of the nose with a fine trocar and cannula willestablish the diagnosis. The _treatment_ consists in opening and draining the sinus. If theinfection is due to a carious tooth, this should be extracted, thesocket opened up and drainage established through it in recent cases. If the teeth are sound, and the case is of long duration, the sinus isopened through the canine fossa and its walls curetted. To avoid therisk of reinfecting the cavity from the mouth, an opening may be madeinto the nose by removing a portion of the nasal wall of the sinus andpart of the inferior turbinated bone, after which the incision in thebuccal mucous membrane is closed with sutures. Suppuration in the _frontal sinus_ is attended with frontal headache, vertigo, especially on stooping, and tenderness on pressure, particularly over the internal orbital angle, or on percussion overthe 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 fewminutes. After removal of the anterior end of the middle turbinatedbone, it may be possible to catheterise the sinus and wash out pusfrom its interior. The diseased sinus may present a darker shadow thanthe healthy one on trans-illumination, or in an X-ray photograph. The _treatment_ consists in exposing the anterior wall of the sinus, chiselling away sufficient bone to admit of free removal of allinfected tissue, and establishing efficient drainage through theinfundibulum (Fig. 267) into the nose. The _anterior ethmoidal cells_ (Fig. 267) are frequently affected inconjunction with the frontal, and sometimes with the maxillary sinus. The presence of polypi and granulations, with pus oozing out frombetween them, and increasing after withdrawal of the probe, and thedetection of carious bone are significant of ethmoidal suppuration. The _treatment_ consists in extending the operation for the frontal ormaxillary sinus so as to ensure drainage of the ethmoidal cells. _Suppuration in the sphenoidal sinus_ (Fig. 267) is characterised inmany cases by the presence of eye symptoms. Pus in the olfactorysulcus, on the upper surface of the middle turbinal posteriorly, andon the vault of the naso-pharynx, is suggestive of sphenoidalsuppuration. The removal of the middle turbinated bone permits ofinspection of the ostium sphenoidale by anterior rhinoscopy, and pusmay be seen escaping from the orifice. A probe is then passed into theostium, and the anterior wall of the sinus is removed with a curetteor rongeur forceps. The _posterior ethmoidal cells_ (Fig. 267) are frequently affectedalong with the sphenoidal sinus. The nasal appearances just noted arepresent, and if the sphenoidal sinus can be washed out and its ostiumtemporarily plugged, and pus rapidly reappears, its origin from thesecells is probable. The operation for draining the sphenoidal sinus isextended by removing the inner wall of the posterior ethmoidal cells. #Anomalies of Smell and Taste. #--_Anosmia_ or loss of smell andimpairment or loss of the sense of recognising flavours may followfracture of the anterior fossa attended with injury of the olfactorynerves, and is a common sequel of influenza. Any lesion that preventsthe passage of the odoriferous particles to the olfactory region ofthe nose interferes with the sense of smell. In ozæna also the senseof smell is lost. _Parosmia_, or the sensation of a bad odour, may beof functional origin; it sometimes occurs after influenza. It may alsobe associated with maxillary suppuration. #Reflex Symptoms of Nasal Origin. #--It is only necessary here to drawattention to the relation that exists between affections of the noseand asthma. When present in asthmatic subjects, nasal polypi, erectileswelling of the inferior turbinated bodies, spines of the septum incontact with the inferior turbinal, or areas on the mucous membranewhich, when probed, produce coughing, call for treatment with theobject of modifying the asthma. #Post-nasal Obstruction--Adenoid Vegetations. #--The most common causeof post-nasal obstruction is hypertrophy of the normal lymphoidtissue which constitutes the naso-pharyngeal or Luschka's tonsil. _Adenoids_ form a soft, velvety mass, which projects from the vault ofthe naso-pharynx and extends down its posterior and lateral walls, insome cases filling up the fossæ of Rosenmüller behind the Eustachiancushions. They do not grow from the margins of the posterior nares. Adenoids are frequently associated with hypertrophy of the faucialtonsils, and the patient often suffers from granular pharyngitis andchronic nasal catarrh. These growths are sometimes met with in infants, but are most commonbetween the ages of five and fifteen, after which they tend to undergoatrophy. They may, however, persist into adult life. _Clinical Features. _--The most prominent symptom in most cases isinterference with nasal respiration, so that the patient is compelledto breathe through the mouth. The facies of adenoids ischaracteristic: the mouth is kept partly open, the face appearslengthened, the nose is flattened by the falling in of the alæ nasi, the inner angles of the eyes are drawn down, and the eyelids droop, while the whole facial expression is dull and stupid. As therespiratory difficulty is increased during sleep, the patient snoresloudly, 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'snutrition is interfered with, and he becomes languid and backward athis lessons. When the adenoids encroach upon the Eustachian cushions, the patientsuffers from deafness, frequent attacks of earache, and sometimes fromsuppurative otitis media with a discharge from the ear. Among the rarer conditions attributed to adenoids are asthma, inspiratory laryngeal stridor, persistent cough, chorea, and nocturnalenuresis. A _diagnosis_ should never be made from the symptoms alone; an attemptmust be made to examine the naso-pharynx by posterior rhinoscopy andby digital examination. The interior of the nose must always beexamined and any further cause of obstruction excluded. _Treatment. _--Thorough removal is the only satisfactory line oftreatment, and this should be done under general anæsthesia. Thefollowing instruments are necessary: two Gottstein's adenoid curettes, one provided with a cradle and hooks, the other without, a Hartmann'slateral ring knife, and one pair of adenoid forceps--Kuhn's orLœwenberg's--a tongue depressor, a gag, and one or two throat spongeson holders. The patient having been anæsthetised, his head should bedrawn over the end of the table. An assistant standing on the leftside inserts the gag and maintains it in position. The operator, beingon the patient's right, depresses the tongue and insinuates thecurette provided with the hooks behind the soft palate, carrying it tothe roof of the naso-pharynx between the growth and the posterior freeedge of the nasal septum. Firm pressure is then made against the vaultof the naso-pharynx, and the curette is carried backwards anddownwards in the mesial plane and withdrawn with the main mass of theadenoids caught in the hooks. The unguarded curette is then introducedand several strokes are made with it, the instrument being carried oneither side of the mesial plane. With Hartmann's lateral ring knifethe posterior naso-pharyngeal wall and fossæ of Rosenmüller arecuretted. The curette should not be used on the lateral pharyngealwall in case the Eustachian orifices and cushions are damaged. Bleeding soon ceases when the head is again elevated, and the patientshould be at once laid well over upon his side so that the blood mayescape from the mouth. No local after-treatment is required, and spraying or syringing mayprove harmful. The patient should remain in the house for five or sixdays. If nasal obstruction has been the outstanding symptom, respiratory exercises through the nose should be carried out for someconsiderable time; on the other hand, if Eustachian obstruction anddeafness have been the main features of the case, a course of Politzerinflation should be conducted after the wound has healed. #Tumours of the Naso-Pharynx. #--Tumours are occasionally metwith growing from the muco-periosteum of the basi-sphenoidand basi-occipital, and projecting from the vault of thenaso-pharynx--_naso-pharyngeal tumour_ or retro-pharyngeal polypus. This usually occurs between the ages of fifteen and twenty, and whileit may originally be a fibroma, it tends to assume the characters of afibro-sarcoma and to exhibit malignant tendencies. At first the tumouris firm, rounded, and of slow growth, but later it becomes softer, more vascular, and grows more rapidly, spreading forwards towards thenasal cavity and downwards towards the pharynx. _Clinical Features. _--In its growth the tumour blocks the nostrils, and so interferes with nasal respiration and causes the patient tosnore loudly, especially during sleep. It may also bulge the softpalate towards the mouth and interfere with deglutition. In some casesthe face becomes flattened and expanded and the eyes are pushedoutwards, giving rise to the deformity known as _frog-face_. Deafnessmay result from obstruction of the Eustachian tube. The patientsuffers from intense frontal headache, and there is a persistent andoffensive mucous discharge from the nose. Profuse recurrent bleedingfrom the nose is a common symptom, and the patient becomes profoundlyanæmic. The tumour can usually be seen on examination with the nasalspeculum or by posterior rhinoscopy, and its size and limits may berecognised by digital examination. Unless removed by operation these tumours prove fatal from hæmorrhage, interference with respiration, or by perforating the base of the skulland giving rise to intra-cranial complications. _Treatment. _--These growths are seldom recognised before they haveattained considerable dimensions, and owing to the fact that they arepermeated by numerous large, thin-walled venous sinuses, their removalis attended with formidable hæmorrhage. Attempts to remove them by thegalvanic snare are seldom satisfactory, because the base of the tumouris left behind and recurrence is liable to take place. The operativetreatment is described in _Operative Surgery_, p. 153. CHAPTER XXVI THE NECK Surgical Anatomy--Malformations: _Cervical auricles_; _Thyreo-glossal cysts and fistulæ_; _Lateral fistula_--Cervical ribs--Wry-neck: _Varieties_; _Cicatricial contraction_--Injuries: _Contusions_--_Fractures of hyoid, larynx, etc. _: _Cut-throat_--Infective conditions: _Diffuse cellulitis_; _Actinomycosis_; _Boils and Carbuncles_--Tumours: _Cystic_: _Branchial cysts_; _Cystic lymphangioma_; _Blood cysts_; _Bursal cysts_--_Solid_: _Lipoma_; _Fibroma_; _Osteoma_; _Sarcoma_; _Carcinoma_--The thymus gland--The carotid gland. #Surgical Anatomy. #--In the middle line the following structures maybe recognised on palpation: (1) the _hyoid bone_, lying below andbehind the body of the lower jaw, on a level with the fourth cervicalvertebra; (2) the _hyo-thyreoid membrane_, behind which lies the baseof the epiglottis and the upper opening of the larynx; (3) the_thyreoid cartilage_, to the angle of which the vocal cords areattached about its middle; (4) the _crico-thyreoid_ membrane, acrosswhich run transversely the crico-thyreoid branches of the superiorthyreoid arteries; (5) the _cricoid cartilage_, one of the mostimportant landmarks in the neck. It lies opposite the disc between thefifth and sixth cervical vertebræ, and at this level the commoncarotid artery may be compressed against the _carotid tubercle_ on thetransverse process of the sixth cervical vertebra. The cricoid alsomarks the junction of the larynx with the trachea, and of the pharynxwith the œsophagus; at this point there is a constriction in the foodpassage, and foreign bodies are frequently impacted here. At the levelof the cricoid cartilage the omo-hyoid crosses the carotid artery--apoint of importance in connection with ligation of that vessel. Themiddle cervical ganglion of the sympathetic lies opposite the level ofthe cricoid. (6) Seven or eight rings of the _trachea_ lie above thelevel of the sternum, but they cannot be palpated individually. The_isthmus_ of the thyreoid gland covers the second, third, and fourthtracheal rings. As the trachea passes down the neck, it graduallyrecedes from the surface, till at the level of the sternum it liesabout an inch and a half from the skin. The _thyreoidea ima_artery--an inconstant branch of the anonyma (innominate) or of theaorta--runs in front of the trachea as far up as the thyreoid isthmus. The inferior thyreoid plexus of veins also lies in front of thetrachea. In the superficial fascia, cross branches between theanterior jugular veins cross the middle line. In children under two years of age the _thymus gland_ may extend forsome distance into the neck in front of the trachea and carotidvessels, under cover of the depressors of the hyoid bone. _Cervical Fascia. _--This fascia completely envelops the neck, and fromits deep aspect two strong processes--the prevertebral and pretracheallayers--pass transversely across the neck, dividing it into three maincompartments. The posterior or _vertebral compartment_ contains themuscles of the back of the neck, the vertebral column and itscontents, and the prevertebral muscles. This compartment is limitedabove by the base of the skull, and below is continued into theposterior mediastinum. The middle or _visceral compartment_ containsthe pharynx and œsophagus, the larynx and trachea with the thyreoidgland, and the carotid sheath and its contents. These differentstructures derive their special fascial coverings from the processesthat bound this compartment. The middle compartment extends to thebase of the skull and passes into the anterior mediastinum as far asthe pericardium. The connective tissue space around the subclavianvessels is continued into the axilla. The anterior or _muscularcompartment_ contains the sterno-mastoid muscle and the depressormuscles of the hyoid bone. It extends upwards as far as the hyoid boneand base of the mandible, and downwards as far as the sternum andclavicle. The arrangement and limits of the different layers of thecervical fascia explain the course taken by inflammatory products andby new growths in the neck. #Malformations of the Neck. #--Various congenital deformities resultfrom interference with the developmental processes which take place inand around the fore-gut. These malformations are associated chieflywith imperfect development of the visceral or branchial arches andclefts, or of the hypoblastic diverticula from which the thyreoid andthymus glands are formed. The term _cervical auricles_ is applied to small outgrowths, composedof skin, connective tissue, and yellow elastic cartilage, foundusually along the anterior border of the sterno-mastoid. Theseappendages are usually unilateral, and are derived from the secondvisceral arch. Sometimes they are situated near the orifice of alateral fistula. When, on account of their size, or their situation onan exposed part of the neck, they give rise to disfigurement, theyshould be removed. _Thyreo-glossal Cysts and Fistulæ. _--The thyreo-glossal _cyst_ isdeveloped in relation to the thyreo-glossal tract of His, which inearly embryonic life extends from the foramen cæcum at the base of thetongue to the isthmus of the thyreoid. Those that form in the upperpart of the tract, in relation to the base of the tongue, have alreadybeen described (p. 538). Those arising from the lower part form aswelling in the middle line of the neck, usually above, but sometimesbelow the hyoid bone. They have to be diagnosed from other forms ofcyst occurring in the middle line of the neck--sebaceous and dermoidcysts--and when giving rise to disfigurement they should be excised. Such a cyst may rupture on the surface, usually as a result ofsuperadded infection, and give rise to a _thyreo-glossal_ or _medianfistula of the neck_. As a rule the external opening of the fistula isabove the hyoid bone, only the upper part of the duct having remainedpervious. When the whole length of the duct has persisted, the fistulaextends from the skin to the foramen cæcum, passing usually in frontof, but sometimes through the substance of, the hyoid bone. Occasionally the fistula only extends as high as the hyoid. [Illustration: FIG. 268. --Congenital Branchial Cyst in a woman æt. 33. (Microscopically the cyst was lined with squamous epithelium and thewall contained rudimentary salivary-gland tissue. )] The part of the tract near the tongue is lined by squamousepithelium; the lower part by columnar epithelium, which, below thelevel of the hyoid, is usually ciliated. Lymphoid tissue and mucousglands are found in its wall. The _treatment_ consists in excising the duct and the connections, andit is usually necessary to resect the central portion of the hyoidbone to ensure complete removal. The _lateral fistula of the neck_--formerly described as a branchialfistula--according to Weglowski, usually takes origin from the remainsof the hypoblastic diverticulum, which arises from the pharyngeal partof the third visceral cleft and extends downwards to form the thymusgland. The internal opening is situated in the lateral wall of thepharynx in the region of the posterior palatine arch close to thetonsil, and the fistula passes out above the hypoglossal nerve, andruns downwards and laterally between the carotids and along the medialborder of the sterno-mastoid muscle. When the fistula is complete, theexternal opening is situated a short distance above thesterno-clavicular joint. As the lower part of the thymus canal mostoften persists, an incomplete external fistula is the form mostfrequently met with. It is lined with ciliated columnar epithelium. The fistula may be present at birth, or may result from the rupture ofa cystic swelling, which has become infected. Clear viscous fluidexudes from it, and, when the fistula is complete and the lumensufficiently wide, particles of food may escape. As the track istortuous, it is seldom possible to pass a probe along it, but itsextent and course may be recognised by injecting an emulsion ofbismuth and taking an X-ray photograph. The _treatment_ consists in excising the fistula in its whole length, but, owing to its long and tortuous course, and its relations toimportant structures, the operation is a tedious and difficult one. Less radical measures, such as scraping with the sharp spoon, cauterising, or packing, are seldom successful. #Cervical Ribs. #--Supernumerary ribs are not infrequently met with inconnection with the seventh cervical vertebra, and in the majority ofcases the condition is bilateral. The extra rib may be thin andpointed, and project straight out from the transverse processterminating in a free end, in which case, as it passes above thesubclavian artery and the brachial plexus, it gives rise to notrouble. In other cases it arches downwards and forwards, and isattached by dense fibrous tissue to the first thoracic rib about thelevel of the scalene tubercle, or to the sternum by cartilage like anordinary rib. When it encroaches upon the posterior triangle thescalene muscles are attached to it, and the subclavian artery and thelower trunk and medial cord of the brachial plexus pass over it in agroove behind the scalenus anterior. The pleura may reach as high asthe medial border of the rib. _Clinical Features. _--The condition, which is more common in womenthan in men, is seldom recognised before the age of twenty, and isoften discovered accidentally, for example after some emaciatingillness, or by a tight collar causing pain. The diagnosis isestablished by the X-rays. [Illustration: FIG. 269. --Bilateral Cervical Ribs; the left one is thebetter developed. ] When symptoms arise, they may be referable either to pressure on theartery or on the nerve roots. When the subclavian artery is displacedupwards it may be recognisable as a prominent pulsatile swelling, andas the part of the vessel distal to the rib is sometimes dilated andyields a systolic bruit, it may simulate an aneurysm (Sir WilliamTurner). The pulse beyond is weakened while the arm hangs by the side, but may be restored by raising the hand above the head. Gangrene ofthe tips of the fingers has been observed in rare instances, but it isprobably nervous rather than vascular in origin. Symptoms referable to pressure on the nerve roots usually affect theright arm, and may be either neuralgic or paralytic in character (Wm. Thorburn). In the neuralgic group there is tingling pain, a feeling ofnumbness, and sensations of cold in the limb, most marked along theulnar border of the forearm; the arm is weak, and susceptible to cold. This condition may be mistaken for brachial neuritis; it is relieved, however, by holding the arm above the head, for example, during sleep. In the paralytic group, the pressure symptoms are referred to thefirst dorsal, or first dorsal and eighth cervical roots. The paralysisis most marked in the muscles of the thumb, and becomes less towardsthe ulnar side; the affected muscles atrophy, especially those formingthe thenar eminence, and the finer movements of the thumb and fingersare impaired. When pressure symptoms are present, the extra rib should be removedthrough an incision which exposes the posterior triangle sufficientlyto admit of the bone and its periosteum being excised, without damagebeing inflicted on the brachial plexus, the subclavian artery, or thepleura. Similar clinical features to those of cervical rib may be caused by aprominent transverse process of the first thoracic vertebra andsimilarly got rid of by its removal. _Branchial cysts and branchial tumours_ are described with tumours ofthe neck (p. 598). WRY-NECK OR TORTICOLLIS. --The term wry-neck or torticollis is appliedto a condition in which the head assumes an abnormal attitude, whichis usually one of combined lateral flexion and rotation. The most important form is due to faulty action of the cervicalmuscles, and three varieties of muscular wry-neck are recognised--(1)the acute or transient; (2) the chronic or permanent; and (3) thespasmodic. #Acute# or #transient wry-neck#--so-called "rheumatictorticollis"--comes on suddenly, usually after the patient has beenexposed to a draught of cold air or to damp. The condition ispopularly known as "stiff neck, " and is probably associated withfibrositis of the affected muscles. The sterno-mastoid, and often thetrapezius, are contracted, and pull the head to one side, twistingthe face slightly towards the opposite side (Fig. 270). There istenderness on pressing over the affected muscles, and sometimes overthe vertebral spines, and in the lines of the cervical nerves, andsevere pain on attempting to move the head. Usually in the course of afew days the condition passes off as suddenly as it came on, but insome cases a certain amount of wasting of the affected muscles ensues. [Illustration: FIG. 270. --Transient Wry-neck, which came on suddenlyafter sitting in a draught, and passed off completely in a few days. ] In the _diagnosis_ of this form of wry-neck it is necessary to excludesuch conditions as cellulitis, inflammation of the cervical glands, and disease of the cervical spine, in which the head may assume anabnormal attitude, the position being that which gives the patientgreatest comfort. The _treatment_ consists in ensuring free action of the bowels andkidneys, in inducing hyperæmia by means of heat, and applying gentlemassage. Salicylates and similar drugs are useful in relieving thepain. #Permanent# or #true wry-neck# is due to an organic shortening of thesterno-mastoid muscle. The trapezius, the splenius, the scaleni, andthe levator scapulæ muscle may also undergo shortening, along withtheir investing sheaths derived from the cervical fascia. The sternal head of the sterno-mastoid is always markedly shortened, and stands out as a tight cord; sometimes the clavicular head is alsoprominent. There is evidence that in the majority of cases the deformity resultsfrom some interference with the development of the muscles duringintra-uterine life. This is probably the effect of undue pressure onthe fœtus diminishing the arterial supply to the central part of themuscle, with the result that the muscle fibres undergo degenerationwith subsequent sclerosis and contraction. It may result also fromcicatricial contraction of the muscle following rupture of its fibresduring delivery. In such cases there is a history that the birth was adifficult one, the presentation having been abnormal; and that aswelling was observed in the sterno-mastoid shortly after birth. Thisswelling--_a hæmatoma of the sterno-mastoid_--is at first soft, laterbecomes smaller, and eventually disappears. In course of time, sometimes months, sometimes years after the disappearance of theswelling, shortening of the muscle takes place, and the deformity isestablished. _Clinical Features. _--Although the condition is usually described as"congenital, " it is the common experience in practice that the childhas reached the age of from seven to ten years before advice issought. The appearance of the patient is characteristic (Fig. 271). The shortening of the sterno-mastoid pulls the head towards theaffected side, usually the right, so that the ear is approximated tothe shoulder. At the same time the head is rotated towards theopposite side and slightly tilted backwards, with the result that thechin is directed towards the opposite side, and is somewhat raised. The shortened sterno-mastoid stands out prominently, and, on anyattempt to straighten the head, can be felt as a firm, fibrous band. The skin of the affected side of the neck may be thrown intotransverse folds. The patient is unable to correct the deformity, butit is usually possible to diminish it by manipulation. [Illustration: FIG. 271. --Congenital Wry-neck in a boy æt. 14. ] If the condition is not corrected, all the structures on the affectedside of the neck undergo organic shortening, with the result that thedeformity becomes accentuated. In advanced cases a lateral curvature, with the convexity towards the normal side, occurs in the cervicalregion, the vertebræ becoming wedge-shaped from side to side, and acompensatory curve may develop in the thoracic region (Fig. 272). [Illustration: FIG. 272. --Congenital Wry-neck seen from behind to showscoliosis. ] There is also asymmetry of the head and face, the affected side beingthe smaller. The eye on this side lies on a lower level, and is moreoblique than its neighbour, the cheek is flattened, and the mouthasymmetrical. Instead of the eyebrows and the lips forming parallellines, their axes converge towards the side of the contracted musclesand fasciæ. _Treatment. _--While it may be possible when the condition isrecognised during infancy to counteract the tendency to contractionand deformity by manipulations, massage, and exercises alone, it isusually necessary to divide the shortened structures as a preliminaryto orthopædic measures. Subcutaneous tenotomy--at one time the favourite method oftreatment--has been entirely replaced by the _open operation_, whichadmits of all the structures at fault, including the cervical fascia, being thoroughly divided, without risk of injuring other structures inthe neck. The result of division of the shortened tissues isseen at once in a marked increase in the interval between thesterno-clavicular joint and the mastoid process. As in otherdeformities, the operation is only a preliminary, although anessential one, to the treatment by massage, movement, and exerciseswhich must be persevered with for months, and it may be for years. When the torticollis attitude has been corrected in childhood, theasymmetry of the skull disappears. #Spasmodic wry-neck# is the term applied to a condition in whichclonic contractions of certain muscles produce jerkings of the head. The muscles most frequently at fault are the sterno-mastoid andtrapezius of one side, and the posterior rotators of the oppositeside. 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 constantnodding or jerking of the head. The condition is usually met with in adults of a neurotic dispositionwho are in a depressed state of health, and is due to some lesion, asyet undiscovered, in the nerve mechanism of the affected muscles--mostprobably in their cortical centres. It would appear that in some casesthe spasmodic jerkings are originated by certain movements habituallymade by the patient in the course of his work. In others, as a resultof astigmatism and other errors of refraction, the patient hasacquired the habit of repeatedly tilting his head to enable him to seeclearly, and these movements have become continuous anduncontrollable. The affection tends to become progressively worse until the patient isincapacitated for work or enjoyment. Sleep even may be interferedwith. _Treatment. _--In well-marked cases the use of drugs, electricity, orrestraining apparatus is never curative, but these measures combinedwith massage have been temporarily beneficial in milder cases. Of the operative procedures, resection of portions of the accessorynerve on one side, and of the posterior primary divisions of the firstfive cervical nerves on the opposite side, seems to offer the bestprospect of recovery. Simple division of these nerves or resection ofthe accessory alone has not proved permanently curative. Open divisionof the offending muscles without interfering with the nerves has givengood results, and is a much simpler operation (Kocher). Spasmodic wry-neck must be distinguished from the #hysterical#variety, which after lasting for weeks, or even months, may pass offcompletely, but, like other hysterical affections, is liable to recur. Deviations of the neck simulating torticollis may occur in cervicalcaries, and in unilateral dislocation of the spine. The #cicatricial contraction# of the integument of the neck thatresults from extensive burns, abscesses, or ulcers, may causeunsightly deformity and fixation of the head in an abnormal attitude, and call for surgical treatment. The contraction which follows thedisappearance of a gumma of the sterno-mastoid may also produce adeformity resembling wry-neck. INJURIES #Contusion# of the neck may result from a blow or crush, as, forexample, the passage of a wheel over the neck, or from throttling, strangling, or hanging. In medico-legal cases the distribution of thediscoloration should be carefully noted. When due to throttling, themarks of the fingers may be recognisable, and nail-prints may bepresent. In cases of strangling, the mark of the cord passes straightround the neck, while in suicidal hanging it is more or less obliqueand is higher behind than in front. When due to a direct blow, forexample by a fist, the discoloration is limited, while it is usuallydiffused over the neck when due to the passage of a wheel over thepart. The clinical importance of these injuries depends on the complicationsthat may ensue; for example, extravasation of blood under thecervical fascia may press upon the air-passage and œsophagus to suchan extent as to cause interference with breathing and swallowing; thelarynx or the trachea may be so grossly damaged that death resultsimmediately from suffocation, or later from gradually increasing œdemacausing obstruction of the glottis. If the mucous membrane of theair-passage or the apex of the lung and its investing pleura is torn, emphysema of the connective tissue may develop and spread widely overthe body. In contusions of the lower part of the neck the cords of thebrachial plexus may be injured. #Fractures of the Hyoid, Larynx, and Trachea. #--The _hyoid bone_, onaccount of its mobility and the protection it receives from the bodyof the mandible, is seldom fractured, except in old people in whom thegreat cornu has become ossified to the body of the bone. It is usuallybroken either by a direct blow, or by transverse pressure as ingarrotting. The fracture is almost always at the junction of the greatcornu with the body, and there is marked displacement of thefragments, which may injure the pharyngeal mucous membrane. The _thyreoid and cricoid cartilages_ are also liable to be fracturedin run-over accidents, particularly in old people after calcificationor ossification has taken place. The _trachea_ may be lacerated, or even completely torn from thelarynx, by the same forms of injury as produce fracture of thelaryngeal cartilages. The _clinical features_ common to all these injuries are swelling anddiscoloration; and if the mucous membrane is torn, air may escape intothe tissues and produce emphysema. There is always more or lessdifficulty in breathing, which may amount to actual suffocation, andthis may come on immediately, or in the course of a few hours fromœdema of the glottis. Blood may pass into the lungs and be coughed up. Swallowing is usually difficult and painful, especially in fracture ofthe hyoid bone. There is also pain on speaking, the voice is husky andindistinct, and spasmodic coughing is common. When blood has enteredthe air-passages there is considerable risk of septic pneumonia. _Treatment. _--As the immediate risk to life is from suffocation, it isusually necessary to perform tracheotomy at once. In fracture of thehyoid the fragments may be replaced by manipulation through the mouth, after which the head and neck are immobilised by a poroplastic collar. #Wounds--Cut-throat. #--The most important variety of wound of the neckmet with in civil practice is that known as "cut-throat"--an injuryusually inflicted with suicidal, less frequently with homicidalintent. Suicidal wounds are usually directed from left to right (if thepatient is right-handed), and they run more or less obliquely frombelow upwards across the neck; the wound being deepest towards itsleft end, that is where the weapon enters, and gradually tailing offtowards the right. In most cases the would-be suicide throws his headso far back at the moment of inflicting the wound, that the mainvessels are carried backward under cover of the tense sterno-mastoidmuscles, and so escape injury. The knife may even reach the vertebralcolumn without damaging the contents of the carotid sheath. Homicidal wounds are usually more directly transverse, and are ofequal depth throughout. The main vessels are generally divided, theœsophagus and trachea opened into, and in some cases the vertebralcanal is opened and the cord and its membranes injured. _Clinical Features. _--The clinical features vary with the level of thewound and with its depth. In all cases the contraction of the platysmacauses the wound to gape widely, and its edges tend to be turned in. In a large proportion of suicidal attempts the patient only succeedsin inflicting one or more comparatively superficial wounds across thefront of the neck. In many cases the hæmorrhage from these istrifling, but if the external jugular and other large superficialveins are divided, it may be fairly profuse, although it is seldomimmediately fatal, unless the blood is sucked in to the woundedair-passage. Occasionally, but rarely, the wound is made _above the hyoid bone_, and opens directly into the mouth. There may then be sharp hæmorrhagefrom the base of the tongue or from the lingual and external maxillary(facial) arteries or their branches in the submaxillary region, andasphyxia may result from the base of the tongue and the epiglottisfalling back and obstructing the larynx. The _hyo-thyreoid membrane_ is frequently divided, and the pharynxthus opened. As the depressor muscles of the hyoid are divided, thereis interference with deglutition and phonation, but respiration is notaffected. In such cases the upper portion of the epiglottis is oftencut off, and the base of the tongue, the tonsil or the soft palate maybe injured. The lingual, external maxillary and superior thyreoidarteries, and the hypoglossal nerve are also liable to be divided atthis level, but the main vessels of the neck usually escape. There ispain and difficulty in swallowing, and food and saliva tend to escapethrough the wound. Particles of food may pass into the air-passagesand cause violent fits of coughing. In more severe cases the knife enters the _larynx_ or the _trachea_. Sometimes the thyreoid cartilage is divided--as a rule onlypartly--and the vocal cords are injured; in other cases the trachea isopened, or it may be completely cut across. The bleeding is serious, as the superior thyreoid arteries are usually damaged. If the commoncarotid and the internal jugular vein also are wounded, the hæmorrhageusually proves fatal. The fatal issue may be contributed to by bloodentering the air-passages and causing asphyxia, or by air being suckedinto the open veins and causing air embolism. The laryngeal branchesof the vagus may be divided and paralysis of the larynx ensue. In all cases there is more or less dyspnœa and persistent coughing. The voice is husky, and the patient can only express himself in ahoarse whisper. There is difficulty in swallowing, and the food mayenter the trachea. When the external wound is small, there may be aconsiderable degree of emphysema of the cellular tissue. The _prognosis_ depends largely on the general condition of thepatient. The majority of those who attempt to take their own lives arein a low state of health from alcoholic excess, mental worry, privation or other causes, and many succumb even when the wound in theneck is comparatively slight. Shock, loss of blood, asphyxia fromblood entering the air-passages, and œdema of the glottis are the mostfrequent causes of death soon after the injury. Cellulitis, inhalation, pneumonia, and delirium tremens are later complicationsthat may prove fatal. _Treatment. _--The first indication is to arrest hæmorrhage, and thismay be done by applying digital compression over the bleeding points. The bleeding vessels are then sought for and ligated, the wound beingenlarged if necessary. If the food and air-passages are intact, any muscles that have beendivided should be sutured. When the epiglottis is cut across in wounds opening into the pharynx, it should be united, preferably with fine silk sutures, as catgut isabsorbed before healing has time to take place. The wall of thepharynx and the muscles should then be sutured layer by layer. When the air-passage is opened, it is usually advisable to introduce atracheotomy tube (Fig. 273), and pack gauze round it to avoid therisk of œdema of the glottis and to prevent blood entering the lungs. The soft tissues may then be brought together layer by layer. [Illustration: FIG. 273. --Recovery from Suicidal Cut-throat after lowtracheotomy and gastrostomy. (Mr. J. M. Graham's case. )] In all cases the superficial part of the wound should be drained, andin applying the bandage the head should be flexed on the chest to takeall tension off the stitches. The patient must be kept under constantsupervision lest he should interfere with the dressings, or make afurther attempt on his life. In some cases it is necessary to feed himthrough a tube passed into the stomach either through the mouth orthrough the nose; when this is not feasible, nourishment must be givenby the rectum, or by a gastrostomy tube (Fig. 273). _Wounds of the thoracic duct_ have been described with affections ofthe lymphatics (Volume I. , p. 324), and _wounds of the brachialplexus_ with injuries of individual nerves (Volume I. , p. 360). INFECTIVE CONDITIONS #Cellulitis# may occur in any of the cellular planes in the neck, themost important form being that which occurs under the cervical fascia, for example in the course of acute infective diseases, such as scarletfever, measles, or pyæmia. The pus tends to spread widely throughoutthe neck, infiltrating the connective-tissue spaces around the bloodvessels, the air-passages, and the œsophagus. The density and tensionof the cervical fascia cause the pus to burrow downwards towards themediastinal spaces of the thorax, where it may give rise to suchcomplications as empyema, infective pericarditis, or gangrene of thelung. The pus may also reach the axilla by spread of the infectionalong the subclavian vessels. An acute phlegmonous peri-adenitis sometimes occurs in the loosecellular tissue around the submaxillary gland, and spreads with greatrapidity through the cellular planes of the neck. The condition--whichgoes by the name of _angina Ludovici_--is usually met with in adults, and appears to originate in some infective focus in the mouth. _Clinical Features. _--In all forms the process spreads rapidly, andthe neck becomes swollen, brawny, and of a dusky red colour. The headis flexed towards the affected side, and there is pain on movement andon palpating the swelling. Pus forms early, but, as it is under greattension, fluctuation can seldom be detected. Respiration may beinterfered with by pressure on the air-passages, or by the onset ofœdema of the glottis, and tracheotomy may be urgently called for. Swallowing may also be affected by pressure on the pharynx andœsophagus. Pressure on the important nerves traversing the neck maygive rise to irritative or paralytic symptoms. The main vessels maybecome thrombosed or eroded--particularly when the cellulitis isassociated with scarlet fever--and in the latter case copioushæmorrhage may follow incision of the abscess. There is always marked constitutional disturbance, as evidenced byrigors, high temperature, a small, rapid pulse, and delirium; anddeath may result within a few days from toxæmia. _Treatment. _--In the earliest stages hot fomentations or ichthyol andglycerine should be applied, but if the process does not begin toabate within twenty-four hours, and if the swelling becomes brawny incharacter, one or more incisions should be made through the deepfascia where the signs of inflammation are most intense, and thedeeper planes of the neck opened up by dissection. Drainage is securedby tubes or strips of rubber tissue. If profuse hæmorrhage occurs itmay be necessary to ligate the main artery lower in the neck. #Actinomycosis# manifests itself in the neck as a diffuse, painlessswelling, which slowly infiltrates the superficial structures, becoming brawny at some places, and at others breaking down andforming sinuses from which the ray fungus escapes in the discharge. #Boils and carbuncles# frequently occur on the back of the neck, wherethe skin is thick and coarse and is rubbed by the collar. The affections of the _cervical lymph glands_ have already beendescribed (Volume I. , p. 330). TUMOURS #Cystic Tumours. #--A great variety of cystic tumours is met with inthe neck. #Branchial cysts# are formed by the distension of an isolated andunobliterated portion of one of the branchial clefts. They usuallyform in connection with the third cleft, and are met with in theregion of the great cornu of the hyoid bone, to which the wall of thecyst is almost always attached. Less frequently they take origin inthe second cleft, and lie below the mastoid process, in which case thecyst is adherent either to the mastoid or to the styloid process. Insome cases these cysts project towards the floor of the mouth. Whennear the skin they are of the nature of _dermoid cysts_, being linedwith squamous epithelium and filled with sebaceous material. Whendeeply placed, they are lined by cylindrical or ciliated epitheliumand contain a glairy mucoid fluid. Although of congenital origin, these cysts do not usually attractattention till about the age of puberty, when they are noticed assmall, soft, fluctuating tumours over which the skin moves freely. They grow slowly, but may attain great dimensions. The only treatmentthat yields satisfactory results is complete excision. The _cystic lymphangioma_, _hygroma_, or _hydrocele of the neck_ (Fig. 274), has been described with affections of lymphatics (Volume I. , p. 327); and _thyreo-glossal cysts in the neck_ at p. 583. [Illustration: FIG. 274. --Hygroma of Neck. (Photograph lent by Mr. J. W. Dowden. )] _Blood Cysts. _--These may originate in a diverticulum of a vein thathas become isolated, or in a cavernous angioma; or they may be due tohæmorrhage taking place into a branchial or thyreo-glossal cyst. Thediagnosis is often only possible by exploratory puncture; and thetreatment consists in complete excision. _Cystic Bursæ. _--Cystic degeneration may occur in the supra-hyoid andthyreo-hyoid bursæ, and give rise to a rounded swelling which moveswith the thyreoid on swallowing, and is only troublesome from thedisfigurement it causes. It is treated by excision. #Solid Tumours#, apart from the common enlargements of lymph glands, and the various forms of goitre, are not often met with in the neck. The _circumscribed lipoma_ usually occurs over the nape of the neck orin the supra-clavicular region. It may attain considerable size, andfrom its weight become pedunculated and hang down over the back orshoulder. _Diffuse lipomatosis_ usually begins over the nape and spreads more orless symmetrically till it completely surrounds the neck. As thenew-formed fat is not encapsulated, extirpation of the mass isdifficult and is seldom called for. [Illustration: FIG. 275. --Lympho-sarcoma of Neck. (Mr. D. M. Greig's case. )] _Fibroma_ originating in the ligamentum nuchæ, or the periosteum ofthe vertebral processes, is of slow growth, but it may attainconsiderable size, and on account of its deep attachments theoperation for its removal may be difficult. _Mixed tumours_ like that described as occurring in the vicinity ofthe parotid, and taking origin from branchial rests, are sometimes metwith in the upper part of the anterior triangle. _Osseous_ and _cartilaginous tumours_ occasionally grow in connectionwith the transverse processes of the lower cervical vertebræ. _Sarcoma_ and _fibro-sarcoma_ of the slowly growing type may developfrom any of the fascial structures in the neck, or from the connectivetissue surrounding the blood vessels. In those taking origin beneaththe sterno-mastoid, there is difficulty in removing them completely onaccount of their deep attachments, and when they are found toinfiltrate the surrounding tissues the attempt should be abandoned. This rule may be relaxed in view of the aid that may be afforded bythe insertion of a tube of radium, which is capable of rendering inertsuch portions of the growth as are not capable of being removed. Sacrifice of the common carotid artery is attended with the risk ofhemiplegia and cerebral softening, especially in persons over fifty;resection of a portion of the vagus is less dangerous to life thanstimulation by irritation of its fibres; resection of the internaljugular vein and of the cervical sympathetic cord are factors whichadd to the shock of the operation but do not carry with them anyspecial risk. _Carcinoma. _--The commonest form of primary cancer is the _branchialcarcinoma_, a squamous epithelioma which originates in connection withthe second visceral cleft (Fig. 276). It appears as a rule under thesterno-mastoid at the level of the hyoid bone, and extends towards thesubmaxillary region, infiltrating the muscles and the sheath of thevessels. [Illustration: FIG. 276. --Branchial Carcinoma--subsequently removed byoperation. ] It is more common in men than in women, and there is often a historyof a small swelling having been present for many years, or even sincebirth. About middle life more active growth begins, the swellingbecomes more fixed and is painful, and once it begins to grow, itincreases rapidly and within a month or two may reach the size of achild's head. In spite of its size, however, it seldom causesinterference with breathing or swallowing, and it has comparativelylittle effect on the general health. Clinically, the induration andfixation of the tumour suggest its epitheliomatous character, but theabsence of a primary growth in the mouth or pharynx excludes its beinga metastasis in the lymph glands. Unless completely removed at an early stage, recurrence inevitablytakes place. Primary carcinoma may also occur in a supernumerary thyreoid, and inthe para-thyreoid glands. We have met with a case of _paraffin epithelioma_ on the neck, and asimilar type of epithelioma may be met with in a lupus or a burn oflong standing. #The Thymus Gland. #--The thymus gland begins to diminish in sizetowards the end of the second year, and by the time puberty is reachedit has entirely disappeared. In some cases, however, the process ofinvolution fails to take place, and the gland may even undergohyperplasia and exert pressure on the trachea, the great bloodvessels, or the left vagus nerve and its recurrent branch. Theenlargement of the thymus may be part of a general lymphatichyperplasia--known as the _status lymphaticus_. The pressure effects may be entirely referable to the trachea--_thymusstenosis of the trachea_--giving rise to progressive dyspnœaaccompanied by stridor, with paroxysmal exacerbations during which thechild becomes asphyxiated. It is only expiration that is interferedwith, as with each inspiratory effort the gland is sucked in towardsthe mediastinum and so frees the air-passages, while with expirationit rises again, and, becoming jammed in the upper opening of thethorax, exerts pressure on the trachea, and during expiration a softswelling is sometimes recognisable in the episternal notch. Theparoxysms occur at irregular intervals, and any one of them may provefatal. In some cases the symptoms seem to be associated with pressureon the blood vessels and nerves rather than on the air-passages, andin these there is distension of the veins and a tendency to syncopalattacks. The only way to afford relief is to expose the gland and withdraw itfrom behind the sternum by making traction on its capsule. If thebreathing is not thereby improved, the capsule should be opened andthe gland shelled out. The term _thymic asthma_ has been applied to another form of disturbedrespiration due to a large thymus, which comes on suddenly in infantsotherwise apparently healthy. Without warning, the child seems tochoke, has great difficulty in breathing, with inspiratory stridor andindrawing of the epigastrium; he rapidly becomes cyanosed, and in themajority of cases dies in a few minutes--_thymus death_. Nosatisfactory explanation of the sudden onset of the symptoms isforthcoming, but it appears to be associated with something whichsuddenly narrows the mediastinal space, such as backward bending ofthe head, or venous engorgement of the thymus gland. Cases arerecorded in which an attack has come on during the administration of ageneral anæsthetic; in some instances the patient has suffered fromthe generalised status lymphaticus. #Tumours of the Carotid Gland or Glomus Carotica# (_Potato-like tumourof the neck_). --The carotid gland under normal conditions is about thesize of a grain of corn, and lies to the posterior aspect of thebifurcation of the carotid. It is sometimes the seat of_endothelioma_. The tumour has a definite capsule, is moderately firmand elastic, increases in size slowly and gradually for a time, andthen may grow more rapidly. Its relation to the vessels ischaracteristic: as it grows it envelops the common carotid and itsbranches, and becomes adherent to the internal jugular vein; and itmay come to implicate the nerves in the neck, particularly the vagusand its recurrent branch, and the cervical sympathetic. It gives rise to few symptoms, and in the majority of cases thesurgeon is consulted on account of the disfigurement resulting fromthe presence of the swelling in the neck. This swelling is ovoid, smooth or slightly lobulated; it lies at the level of the bifurcationof the carotid, and tends to grow upwards rather than downwards; it ismovable from side to side, but not up and down; it lies under thesterno-mastoid, and the skin is not implicated. There is transmittedpulsation in the tumour, but no expansion. The diagnosis has to be made from lymphoma, adenoma, tuberculousglands, sarcoma, and carcinoma. In a large proportion of the cases operated upon it has been necessaryto ligate the carotids and to excise portions of the internal jugularvein, and as severe cerebral symptoms are liable to ensue themortality has hitherto been high. Operation is therefore only to berecommended when the growth is rapid, or the symptoms have becomeurgent. CHAPTER XXVII THE THYREOID GLAND Surgical Anatomy--Physiological hyperæmia--Acute thyreoiditis--GOITRE--Varieties: _Parenchymatous_; _Adenomatous_; _Cystic_; _Malignant_; _Toxic_. #Surgical Anatomy. #--The _thyreoid gland_ consists of two laterallobes connected by an isthmus. The lateral lobes lie in contact withthe side of the larynx up to the middle of the thyreoid cartilage, andwith the sides of the first five or six rings of the trachea. Theisthmus lies in front of the second, third and fourth rings of thetrachea, and from it a process of gland tissue--the _pyramidallobe_--passes up in the middle line towards the hyoid bone. The gland lies under cover of the superficial muscles of the neck, andis surrounded by a process of the cervical fascia--the externalthyreoid capsule of Kocher--which connects it with the larynx, trachea, and œsophagus, so that it moves with these structures onswallowing. In this capsule are numerous veins; and in the groovebetween the œsophagus and trachea the recurrent (laryngeal) nerveruns. Enclosing the gland substance is the capsule proper, which sendsin processes to form its fibrous stroma. The arteries of supply--thesuperior and inferior thyreoids--are very large for the size of thegland, and enter it at its four corners. The thyreoidea ima, whenpresent, goes to the isthmus. Isolated nodules of thyreoidtissue--_accessory thyreoids_--are sometimes met with in differentparts of the neck; they are liable to the same diseases as the maingland. The secretion of the gland is absorbed into the general circulationthrough the veins; it consists of a complex colloid substance whichcontains an iodine-albumin--iodothyrin--and plays an important part inmaintaining the normal metabolism of the body, particularly of thecentral nervous and cutaneous tissues in adults, and of the bones inchildren. Disturbance of the function of the thyreoid gland plays apart in producing the symptoms characteristic of myxœdema, cretinism, and goitre. The _para-thyreoid glands_--usually two on each side--lie in theexternal capsule along the posterior edge of the lobes of thethyreoid. They are flattened, elliptical bodies, averaging a quarterof an inch in length and an eighth of an inch in width, of a lightbrown colour, smooth and glistening on the surface, and of a soft, flabby consistence (W. G. MacCallum). When tetany follows operationsfor goitre it is due to the removal of these glands. #Physiological Hyperæmia. #--The thyreoid varies greatly in size evenwithin normal limits, and may become engorged and swollen fromphysiological causes, particularly in the female. Before the onset ofmenstruation at puberty, for example, the thyreoid frequently becomesengorged, and the enlargement may recur with each period for months oreven years. During pregnancy also the gland may become swollen. #Acute Thyreoiditis# may occur in a healthy thyreoid or in one that isthe seat of goitre, and may end within a few days in resolution, or goon to suppuration. It is due to infection with pyogenic bacteria, which usually gain access to the gland by the blood stream, as, forexample, in typhoid fever, pyæmia, influenza, and other acuteinfective diseases. Direct infection sometimes occurs from an abscess, a cellulitis, or an infected wound in the neck; it has also occurredfrom a foreign body impacted in the œsophagus ulcerating through andperforating the gland. One lobe is usually more involved than the other, but the conditionmay be diffused. When pus forms it may infiltrate the stroma of thegland, or may be collected into several small foci. _Clinical Features. _--The usual signs of inflammation are present;there is severe headache of a congestive nature, and sometimesvertigo. The swelling takes the shape of the thyreoid, and althoughthe skin may not be red, the subcutaneous veins are dilated. In severecases there is pain and difficulty in swallowing and dyspnœa. When suppuration ensues, all the symptoms are aggravated, and repeatedrigors occur. The pus may burst into the cellular tissue of the neck, or into the air-passage or the œsophagus. _Treatment. _--In the non-suppurative stage the ordinary treatment ofacute inflammatory conditions is employed; if pus forms, the abscessshould be opened and drained. #Tuberculous and syphilitic affections# of the thyreoid are very rare. PARENCHYMATOUS GOITRE OR BRONCHOCELE The term goitre is applied clinically to any non-inflammatoryenlargement of the thyreoid gland. _Etiology. _--Parenchymatous goitre, sometimes called also simple, ornon-toxic goitre, is endemic in certain hilly districts inEngland--particularly Derbyshire and Gloucestershire--and in variousparts of Scotland. It is exceedingly common in certain valleys inSwitzerland. It is met with less frequently in men than in women, andit occurs chiefly during the child-bearing period of life. The toxicagent that causes goitre has been traced to certain mountain springsin goitrous districts; it has been observed that a patient with goitremay, through fæcal contamination apparently, infect the water supply, and that conscripts in order to avoid military service have drunk fromgoitrous springs with success. Children born in a goitrous districtare liable to be cretins, while if goitrous parents move to a healthydistrict, the children are born healthy. If the water supply of agoitrous valley be changed to a healthy spring, goitre and cretinismdisappear. Thorough boiling of the water rids it of its toxicproperties. [Illustration: FIG. 277. --Parenchymatous Goitre in a girl æt. 15. (Mr. D. M. Greig's case. )] _Morbid Anatomy. _--Both the secreting and the fibrous elements sharein the hyperplasia, and the gland as a whole becomes enlarged andforms a horseshoe-shaped swelling of moderate size in the neck. Thisswelling is soft and smooth on the surface, and is seldom quitesymmetrical. In some cases the hypertrophy involves chiefly theisthmus. In others an outlying accessory lobule of thyreoid tissueconstitutes the bulk of the swelling, and this may extend aconsiderable distance from the position of the normal thyreoid, reaching even behind the sternum into the thorax--_infra-thoracic_ or_retro-sternal goitre_. [Illustration: FIG. 278. --Larynx and Trachea surrounded by Goitre. ] [Illustration: FIG. 279. --Section of Goitre shown in Fig. 278, toillustrate compression of Trachea. ] When the secreting elements increase out of proportion to the stroma, numerous rounded or irregular spaces filled with a thick yellowcolloid material are formed in the substance of the goitre--_colloidgoitre_. The majority of these spaces are not larger than a pea, butone or more may enlarge and form cysts of considerable size--_cysticgoitre_. These varieties, especially the cystic form, attain greaterdimensions than any other form of goitre. When the fibrous stroma is greatly in excess--_fibrous goitre_--theswelling is smaller, firmer, and shows a greater tendency to contractand compress the trachea. If the sclerosis is extreme and thesecretory tissue undergoes atrophy, myxœdema may result. In some cases the hyperplasia affects chiefly the blood vessels ofthe thyreoid--_vascular goitre_. The capillaries, veins, and arteriesare increased in size and number; the swelling pulsates and increasesin size when the patient makes any muscular effort. Hæmorrhagic cystsmay also develop in the substance of these goitres. * * * * * _Effects on the Trachea. _--The trachea may be _displaced laterally_when the enlargement of the gland affects one lobe more than theother; or it may be _compressed and narrowed_ from side to side--the_scabbard trachea_--when both lobes are about equally affected and theenlargement extends posteriorly so as almost to surround theair-passage (Figs. 278, 279). The third effect is that of _softeningof the cartilaginous rings_ of the trachea so that the air-tube, instead of having a considerable degree of elastic resiliency, is softand flaccid and readily yields to pressure. Under these conditions analteration in the attitude of the patient, from the erect or sittingto the recumbent position, would appear to be sufficient to permit ofa compression of the trachea. Further changes in the trachea consist in catarrh and engorgement ofthe blood vessels of its mucous membrane, attended with an abundantsecretion of mucus, which, if it accumulates behind a narrowed segmentof the trachea, may still further encroach on the lumen. _Pressure on other Structures. _--The _recurrent nerve_ may be pressedupon intermittently causing spasms and choking, or continuouslycausing abductor paralysis and hoarseness. The gullet is rarely compressed; if marked difficulty in swallowingdevelops, some additional factor should be suspected, notablycarcinoma at the junction of the pharynx with the œsophagus. Thecarotid arteries are displaced laterally beneath the sterno-mastoidswithout detriment; the superficial veins--anterior and externaljugular--are greatly distended in those cases in which the goitregrows downwards behind the sternum. _Clinical Features. _--The symptoms vary widely in different cases, andtheir severity is not proportionate to the size of the goitre. Thedisfigurement produced by the swelling is often the only cause ofcomplaint. In some cases the symptoms are due to the pressure of theenlarged thyreoid on surrounding structures. In others toxic effects, in the form of cardiac, nervous, muscular, and general metabolicdisturbances, predominate, and are due to absorption of excessive orabnormal thyreoid secretion. This thyreoid toxæmia varies in degree;in the milder cases it merely amounts to a nervousness orexcitability that may unfit the patient for occupation; it reachesits maximum in the condition of hyperthyreoidism characteristic ofexophthalmic goitre or Graves' disease (p. 614). The skin over the goitre is freely movable, and the tumour itself canbe moved transversely, carrying the larynx and trachea with it, but itcannot be moved vertically. It moves up and down with the larynx onswallowing--a point of great diagnostic value. Of the mechanicalsymptoms dyspnœa is the most constant. It may only amount to shortnessof breath on exertion, or the patient may suffer from sudden andsevere dyspnœic attacks, especially when lying on the back duringsleep, and such an attack may prove fatal. This may be due to theweight of the tumour pressing on the trachea, which has been softenedand distorted by the goitre, or to temporary congestion andengorgement of the mucous membrane of the air-passages. In these casesthere is marked stridor both on inspiration and expiration, but noaphonia. In rare cases the goitre presses upon the recurrent nerve, causing spasmodic dyspnœa, hoarseness, and aphonia from impairedmovement of the vocal cords, and these symptoms, especially ifaccompanied by pain, raise the suspicion of malignancy. Disturbance ofthe heart's action may cause palpitation and sudden attacks ofsyncope; and pressure on the blood vessels may give rise to a feelingof fullness in the head, and giddiness. The occurrence of hæmorrhage into the substance of the goitre or intoa cyst, produces a sudden aggravation of the symptoms. In _intra-thoracic_ or _retro-sternal goitre_ the tumour displaces andcompresses the trachea and causes dyspnœa, and there are occasionalparoxysmal attacks of breathlessness, which may be mistaken forasthma, particularly as the patient is usually the subject also ofbronchitis and emphysema. In some cases the patient can, by a violentexpiratory effort, such as coughing, project the goitre upwards intothe neck. When the goitre is fixed in the thorax, the clinicalfeatures are those of a mediastinal tumour with lateral displacementof the trachea, and engorgement of the veins of the neck. _Treatment. _--The patient should change his residence to anon-goitrous district. The evidence regarding the benefit derived fromthe internal administration of thyreoid extract, or of preparations ofphosphorus or of iodine, is conflicting. Operative treatment is indicated when there are symptoms referable topressure on the air-passage, and in goitres which are steadilyincreasing in size. Kocher considers it advisable to operate if thepatient becomes breathless on making pressure on the goitre from sideto side. The suspicion of a goitre becoming malignant is also a reasonfor removing it by operation. The operation--_thyreoidectomy_--consists in excising that portion ofthe thyreoid which is causing pressure symptoms, and this usuallyinvolves removal of one-half of the gland. The chief danger inoperations for goitre is cardiac insufficiency, as evidenced bydisturbed rhythm of the heart-beats, lowering of the blood pressure, or dilatation of the cavities of the heart (Kocher). It is sometimes advisable to perform the operation under localanæsthesia. A general anæsthetic is, however, preferred in thiscountry. The injection of 1/6th grain of morphin and 1/120th grain ofatropin half an hour before the operation, and the administration ofether by the open method, or by intra-tracheal insufflation, is safeand satisfactory. There is reason to believe that the absorption of thyreoid secretionsqueezed from the divided surfaces gives rise to a condition known as_acute thyreodism_ during the first few hours after operation; itssymptoms are elevation of temperature, increase in the pulse-rate(150-200), rapid respiration with dyspnœa, flushing of the face, muscular twitchings, and mental excitement. The gentle handling of thetumour and the employment of a drainage tube for the first forty-eighthours diminishes this risk. _Tetany_, as evidenced by the occurrence of cramp-like contractions ofthe thumb and fingers, may supervene within a few days of theoperation if one or more of the para-thyreoids have been inadvertentlyremoved. It may be controlled by large doses of calcium lactate. On noaccount may the whole of the thyreoid gland be removed, as this isfollowed by the development of symptoms closely resembling those ofmyxœdema--_operative myxœdema_ or _cachexia strumipriva_. _Treatment of Sudden Dyspnœa. _--When dyspnœa suddenly supervenes andthreatens life, it is sometimes possible to relieve the pressure onthe trachea by open division of the skin, superficial fascia, platysmaand deep fascia in the middle line of the neck, so as to relax thetension on the goitre. If this is insufficient, the isthmus may bedivided. Should relief not follow, tracheotomy must be performed, anda long tube or a large-sized gum-elastic catheter with a terminalaperture be passed along the trachea beyond the seat of obstruction. #Adenoma of the Thyreoid. #--In this condition the swelling of thethyreoid is due to the growth within its substance of one or moreadenomas of variable size and surrounded by a capsule. The rest ofthe gland may be normal, or may show some degree of hyperplasia. Someare solid, others undergo cystic degeneration, the glandular tissuebeing replaced by a quantity of clear or yellowish fluid, sometimesmixed with blood. The cysts thus formed may be unilocular ormultilocular, and intra-cystic papillary vegetations frequently growfrom their walls. The walls of the cysts may be thin, soft, andflaccid, or thick and firm, or they may even be calcified. The thyreoid is enlarged, but instead of the uniform enlargement whichcharacterises the parenchymatous goitre, it tends to be uneven, withhillocky projections corresponding to the individual cysts (Fig. 280), and in these fluctuation may be detected. It is to be noted thatthere are no toxic symptoms in cystic adenoma. [Illustration: FIG. 280. --Multiple Adenomata of Thyreoid in a womanæt. 50. (Mr. D. M. Greig's case. )] [Illustration: FIG. 281. --Cyst of Left Lobe of Thyreoid. (Mr. D. M. Greig's case. )] The treatment is necessarily operative; cystic tumours may be tappedand injected with iodine, but the more satisfactory procedure, bothwith the solid and cystic forms, is to incise freely the overlyingthyreoid tissue and enucleate the tumour. #Malignant Disease of the Thyreoid. #--This, whether in the form of_carcinoma_ or _sarcoma_, usually develops in a gland that has beenthe seat of goitre for several years, although it may begin in apreviously healthy gland. _Clinical Features. _--Both sexes, above the age of fifty, are affectedin about equal proportion. The characteristic features are that thetumour undergoes a progressive increase in size, that it becomes fixedto its surroundings, that its surface tends to be uneven and nodular, and its consistence densely hard. The voice often becomes hoarse fromabductor paralysis due to infiltration by the growth, usually of theleft recurrent nerve. The effects upon the trachea are more decidedand more progressive than in parenchymatous goitre; it displaces andcompresses the trachea and frequently overlaps it, so as to bury theair-passage completely. If the tumour tissue has actually penetratedthe trachea, the expectoration is tinged with blood. Dysphagia israrely a prominent symptom. The lymph glands become enlarged after thetumour bursts through the capsule; and metastases to the lungs andbones, particularly the skull, sternum, and mandible, are common. Whenthe goitre extends behind the sternum--the _malignant form ofretro-sternal goitre_--the pressure symptoms are due to theencroachment upon the limited accommodation of the upper opening ofthe thorax; the trachea especially suffers, and the pressure on theveins causes distension of the anterior and external jugulars andtheir tributaries. The patient is unable to lie down; there areviolent paroxysms of coughing, and an abundant frothy expectoration. Death may take place suddenly from asphyxia, from heart failure, orfrom displacement of a thrombus from one of the veins in the neck. _Treatment. _--It is only in the earliest stages that a malignantgoitre can be successfully removed. In the later stages completeextirpation is not to be attempted, as it usually involves the removalof a portion of the trachea or œsophagus, and the operation isattended with grave risk to life. Operative interference is often called for, however, for the relief ofrespiratory embarrassment. _Tracheotomy_ may prove a difficult anddangerous procedure, owing to the trachea being buried under thegoitre and displaced or narrowed by it, so that it is not easy toreach it or to introduce an efficient tube beyond the point ofobstruction. A more certain method consists in exposing the goitre byan incision as for thyreoidectomy, rapidly removing sufficient of thegrowth to expose the trachea and admit of a tube being introduced. Ifthere is a retro-sternal prolongation compressing the trachea withinthe thorax, a long flexible tube may have to be passed beyond the siteof the compression before the dyspnœa is relieved. The benefit isimmediate and decided; the accumulated secretion is coughed up, andafter a few deep breaths the patient is able to lie down, and usuallyfalls asleep. The stridor disappears. Unfortunately the relief isonly temporary, and the patient soon succumbs to a broncho-pneumonia, or to secondary hæmorrhage from the trachea. #Toxic Goitre#--#Exophthalmic Goitre#--#Graves'# or #Basedow'sDisease#. --These terms are applied to a variety of goitrein which the symptoms due to absorption of thyreoidsecretion--_thyreotoxicosis_--predominate. The name "exophthalmicgoitre" is misleading, as in some cases the enlargement of thethyreoid, and in others the eye symptoms, are scarcely appreciable, while the general symptoms are well marked. The term toxic goitre or_hyperthyreoidism_, suggested by C. H. Mayo, is preferable, as themanifestations of the disease depend upon excessive or abnormal actionof the thyreoid tissue. [Illustration: FIG. 282. --Exophthalmic Goitre. ] The condition is chiefly met with in young adult women, and maydevelop suddenly after a shock to the nervous system. The intoxicationaffects the higher cerebral functions and causes nervousness, irritability, and tremor; the cardiac and vaso-motor centres, causingtachycardia and pallor of the skin; the sympathetic fibres to the eye, causing protrusion of the eyeballs, staring of the eyes withoutwinking, narrowing of the palpebral fissure, dilatation of the pupil, and lagging behind of the upper lid, and sometimes also of the lowerlid--von Graefe's symptom. There may be diarrhœa and vomiting, loss ofweight, and in the worst cases there is delirium at night. In courseof time there develops cardiac insufficiency with fibroid degenerationof the myocardium. Coagulation of the blood is retarded, and there isa marked diminution in the number of leucocytes, especially theneutrophils, and an increase in the lymphocytes (Kocher). In the early stages the thyreoid is enlarged and pulsatile, and bruitsmay be heard over it; later, these vascular symptoms disappear, andonly a firm, diffuse, uniform swelling implicating all parts of thegland remains. _Prognosis. _--The tenure of life is uncertain as the patient offerslittle resistance to intercurrent affections such as influenza andpneumonia. If the average course of the disease is represented by acurve, the greatest height is reached during the second half of thefirst year and then descends. For the next two to four years itfluctuates with occasional exacerbations of symptoms due to fright orworry. _Treatment. _--Medical measures, along with the external application ofradium, the strict observance of rest in bed with the exclusion of allforms of excitement and worry, the administration of bromides, heroinor other sedatives, and of digitalis or other cardiac tonics, are tobe prescribed in the first instance, and in any case, as a desirablepreparation for operation. _Operative measures_ consist in the _ligation_ of the vessels andnerves at one or other pole of the gland--usually the superior on oneside--followed by, if necessary, a partial _thyreoidectomy_. Crile of Cleveland has organised his clinic in the direction ofarranging that the operation shall be performed without the patientknowing that it is to take place--what he calls "stealing thegoitre"--the thorough preparation of the patient for the operation, the minimising the risk from the anæsthetic by the combination ofnovocain locally and of nitrous oxide and oxygen; and of diminishingthe risk of absorption of thyreoid secretion by packing the (open)wound with gauze wrung out of a solution of flavin. Operations on the cervical sympathetic cord have been abandoned. The presence of toxic goitre may influence the question of operationin the treatment of other surgical conditions, and may determine theselection of one or other form of anæsthesia. CHAPTER XXVIII THE ŒSOPHAGUS Surgical Anatomy--Methods of examination--Wounds--Rupture--Swallowing of caustics--Impaction of foreign bodies--Infective conditions: _Œsophagitis_; _Peri-œsophagitis_; _Tuberculosis_; _Syphilis_--Varix--Conditions causing difficulty in swallowing: _Impaction of foreign bodies_; _Compression of the gullet from without_; _Spasm of the muscular coat_; _Cardiospasm_; _Paralysis of the gullet_; _Diverticula_ or _pouches of the gullet_; _Innocent stricture_; _Malignant stricture, including cancer at the junction of pharynx and gullet and cancer at the lower end of the gullet_. #Surgical Anatomy. #--The œsophagus extends from the level of thecricoid cartilage to about the level of the lower end of the sternum. The distance from the upper incisor teeth to the commencement of theœsophagus is about 5 or 6 inches, and the œsophagus measures from 9 to10 inches. The whole distance, therefore, from the teeth to thestomach is from 14 to 16 inches. The cervical portion of the œsophagus, extending from the cricoidcartilage to the upper edge of the sternum, measures about 2 inches. It lies behind and to the left of the trachea, and in the groovebetween them on each side runs the recurrent nerve. The thoracicportion is about 7 inches long, and traverses the posteriormediastinum lying slightly to the left of the middle line. It iscrossed by the left bronchus, and below this level has the pericardiumimmediately in front of it. The left pleura is closely related to theanterior surface of the œsophagus throughout, while the right pleurapasses behind it in its lower part. This accounts for the frequencywith which growths in the œsophagus invade the pleura. The œsophaguspasses through the diaphragm about an inch above the cardiac openingof the stomach. There are three points at which the œsophagus shows narrowing of thelumen: (1) at the lower border of the cricoid--the "mouth of theœsophagus"; (2) where it is crossed by the left bronchus; and (3)where it passes through the diaphragm. It is at these points thatforeign bodies tend to become impacted. The mucous membrane of theœsophagus is insensitive to tactile and painful stimuli, but issensitive to heat and cold and to exaggerated peristalticcontractions. #Methods of Examination. #--It is sometimes possible to detect animpacted foreign body, a distended diverticulum, or a new growth inthe cervical portion of the œsophagus by _palpation_. _Auscultation_ while the patient is drinking sometimes aids in thediagnosis of stricture; the stethoscope is placed at various pointsalong the left side of the dorsal spine, and abnormal sounds may beheard as the fluid impinges against the stricture or trickles throughit. _Introduction of Bougies. _--Œsophageal bougies or probangs are usedfor diagnostic purposes in cases of suspected stricture, and to aid inthe detection of foreign bodies. Various forms are employed, of whichthe most generally useful are the round-pointed gum-elastic orsilk-web bougie, and the olive-headed metal bougie, consisting of aflexible whalebone stem, to which one of a graduated series ofaluminium or steel bulbs is screwed. For some purposes, such aspushing onward an impacted bolus of food, the sponge probang--whichconsists of a small round sponge fixed on a whalebone stem--is to bepreferred. Before passing bougies, it is necessary to make certain that thesymptoms are not due to the pressure of an aneurysm on the œsophagus, as cases have been recorded in which a thin-walled aneurysm has beenperforated by a bougie. The existence of ulceration or of an abscesspressing on the gullet also contra-indicates the use of bougies. For the passage of a bougie the patient should be seated on a chairwith 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 guidedwith the left forefinger. As soon as the instrument engages in theopening of the œsophagus, the chin is brought down towards the chest, and if the patient is now directed to swallow, the instrument may becarried down the œsophagus, or can be passed on by gentle pressure. Great gentleness must be exercised, and no attempt should be made toforce the instrument past any obstruction. The instrument may catchagainst the hyoid bone, and this may be mistaken for an obstruction. It is to be borne in mind that in some cases the passage of a bougiemay be attended with a considerable degree of shock, and cases are onrecord in which this has proved fatal without any gross lesion beingfound after death. _Intubation_, or the passage of a cannula through a stricture, isreferred to later. _Œsophagoscopy. _--The _œsophagoscope_--a form of speculum whichenables the œsophagus to be illuminated by an electric lamp--isemployed for the detection and removal of foreign bodies, for theexamination of ulcers, diverticula, and strictures of the tube, andwith its aid it is possible to remove a portion of a growth formicroscopic examination. The mouth, pharynx, and entrance to theœsophagus having been cleansed and cocainised, the patient is placedin the recumbent or sitting posture, and the tube introduced. Forprolonged examinations a general anæsthetic is preferred. The mouth of the œsophagus is closed by the sphincter-like action ofthe lower fibres of the inferior constrictor muscle, and the cervicalpart of the tube appears as a transverse slit, due to the backwardpressure of the trachea. The thoracic portion is more open and maycontain air, so that it is possible to see down to the lower end, theclosed cardiac orifice appearing as an oblique cleft surrounded by arosette-like cushion of mucous membrane. The pulsation of the aortacan be seen just above the prominence formed by the left bronchus. _Radiography. _--Opaque foreign bodies can be detected by the screen orin a radiogram; and the position of a stricture by making the patientswallow capsules containing bismuth and examining with the screen. Todetermine the position and size of a diverticulum, a radiogram istaken after the patient has swallowed some food, such as porridgemixed with bismuth. #Wounds# of the œsophagus inflicted from without, for example stabs, cut-throat or gun-shot injuries, are rare, and are almost invariablyaccompanied by lesions of other important structures in the neck, which may rapidly prove fatal. It is more common to meet with woundsinflicted from within, for example by the swallowing of rough andirregularly shaped foreign bodies, or by unskilful attempts to removesuch bodies or to pass bougies along the œsophagus. The severity ofthe lesion varies from a scratch of the mucous membrane to aperforation of the tube. The less severe injuries are attended withpain on swallowing and a sensation as if something had lodged in theœsophagus. In more severe cases there is bleeding, followed by attacksof coughing and expectoration of blood-stained mucus. When theœsophagus is perforated, diffuse cellulitis of the neck or of theposterior mediastinum may ensue. In the treatment of these injuriesthe chief point is to give the œsophagus rest by feeding the patiententirely by the rectum or through an opening made in thestomach--gastrostomy. #Rupture# of the œsophagus has occurred during violent vomiting, andduring lavage. The tear is longitudinal and is usually near thecardiac orifice. It is probably due to increased pressure within thegullet. The accident has usually been met with in alcoholics, and hasproved fatal by setting up left-sided empyema or cellulitis. #Swallowing of Corrosive Substances. #--The œsophagus is damaged by theswallowing of strong chemicals, such as sulphuric acid, nitric acid, carbolic acid, or caustic potash. These substances produce their worsteffects at the two ends of the œsophagus, but in some cases the wholelength of the tube suffers. The mucous membrane alone may bedestroyed, or the muscular and even the fibrous coats may also beimplicated. The damaged tissue undergoes necrosis, and when thesloughs separate, raw surfaces are left, and are very slow to heal. If not rapidly fatal from shock and œdema of the glottis, theseinjuries are usually attended with intense pain, severe thirst, andvomiting, the vomit containing shreds of mucous membrane and blood. Complications, such as cellulitis, perforation of the œsophagus, orperi-œsophageal abscess, may follow. Later, cicatricial contractiontakes place at the injured portions, producing the most intractableform of fibrous stricture. The _treatment_ consists in administering solutions of carbonate ofpotash, of soda, or of magnesia when an acid has been swallowed, orvinegar diluted with water in the case of an alkali. When carbolicacid has been swallowed, a large quantity of olive oil should beadministered. The stomach should be washed out with water, the tubebeing passed with the greatest gentleness to avoid perforating thesoftened œsophageal wall. Subsequently the patient should be fed bythe rectum, but, in the majority of cases, gastrostomy is called forto enable the patient to take nourishment and put the gullet at rest. As soon as the œsophagus has healed, say in three or four weeks, bougies should be passed every three or four days to preventcicatricial contraction. As the calibre of the tube is restored, theinstruments may be passed less frequently, but for some years--it maybe for the rest of the patient's life--a full-sized bougie should bepassed at least once a month. #Impaction of Foreign Bodies in the Pharynx and Œsophagus. #--It is aninteresting fact that foreign bodies, even as large as a dinner fork, when intentionally swallowed, can pass through the pharynx andœsophagus and enter the stomach without apparent difficulty. When thebody is accidentally swallowed impaction is more liable to take place, probably on account of the spasm induced by fright and byinco-ordinated attempts to eject it. For obvious reasons the accidentis most liable to occur in children, in epileptics, and in those whoare under the influence of alcohol. It happens also during anæsthesiafor the extraction of teeth or if the patient vomits solid substances. The clinical aspects vary according as the object is impacted in thepharynx or in the œsophagus. _In the Pharynx. _--If a large bolus of unmasticated food becomesimpacted in the pharynx, it blocks the openings of both the œsophagusand the larynx, and the patient may, without manifesting the usualsigns of suffocation, suddenly fall back dead, and if he happens to bealone at the time of the accident, the cause of death is liable to beoverlooked unless the pharynx is examined at the post-mortemexamination. Most surgical museums contain specimens illustrating theimpaction of a bolus of meat in the pharynx; this fatal accident hasoccurred especially in men in a condition of alcoholic intoxication. An object of irregular shape, for example a large denture, also, ismost likely to lodge in the pharynx, obstructing the openings of boththe œsophagus and the larynx, and causing suffocation. The faceimmediately becomes blue and engorged, the patient is speechless, andviolent efforts are made to eject the object by retching and coughing. It may be seen from the mouth and touched with the finger. In the case of small sharp bodies, such as fish, game, and muttonbones, there is not the same urgency, and a methodical search for theforeign body is carried out. Even after the foreign body has been gotrid 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, inwhich case the swallowing of a few drops of cocain solution will causethe sensation to disappear. _Treatment. _--In the presence of impending suffocation, the mouth mustbe forced open by an extemporised gag, the finger passed into the backof the throat, and the body hooked out. If this is impossible, and ifsuitable forceps are not at hand, it may be necessary at once toperform laryngotomy, followed by artificial respiration, because, although the patient may appear lifeless, the heart continues to beatafter breathing has ceased. The foreign body should then be removedwith forceps. Sub-hyoid pharyngotomy, which consists in opening thepharynx by a mesial vertical incision carried through the hyo-thyreoidmembrane, may be called for, as in the case of a denture, the hooks ofwhich have penetrated the wall of the pharynx. _In the Œsophagus. _--Smaller bodies, such as coins, bones, or pins, usually enter the œsophagus, and the great majority become impactedabove the level of the manubrium sterni. Those that pass farther downare liable to stick where the tube is narrowed at the crossing of thebronchus, or at the opening through the diaphragm. In children, coinspredominate and are nearly always arrested at the level of the upperend of the sternum; in adults, dentures are the commonest foreignbodies, and may be impacted anywhere. At the moment of impaction there is pain, which assumes the characterof cramp due to spasm of the muscular coat, and which is increased onattempting to swallow, and violent retching and coughing are set up;in many cases, as when bodies are impacted in the pharynx, respiratorydistress is again the predominant feature. If the passage iscompletely obstructed, food and saliva--sometimes blood-stained--areregurgitated with retching soon after being swallowed. When theobstruction is incomplete, fluids may pass into the stomach whilesolids are regurgitated. If the mucous membrane is injured, there is severe stabbing pain andchoking attacks, both due to spasm, sometimes even after the body haspassed on, and the pain is not always referred to the seat of theinjury. The _diagnosis_ is made by the history, and by the use of thefluorescent screen, or X-ray photographs (Figs. 283, 284). Theœsophagoscope is also of great value, both for diagnostic purposes andas an aid in the removal of the impacted body. Bougies are to beemployed with great care, as there is a danger of pushing the foreignbody farther down, or of wedging it more firmly in the œsophagus, andthe information obtained is often misleading. [Illustration: FIG. 283. --Radiogram of Safety-pin impacted in theGullet and perforating the Larynx. (Professor Annandale's case. Radiogram by Dr. Dawson Turner. )] [Illustration: FIG. 284. --Denture impacted in Œsophagus. (Professor F. M. Caird's case. )] It should be borne in mind that drunkards may suffer from a form ofspasm of the œsophagus, which simulates the impaction of a foreignbody; hospital records also show that the patient may only have dreamtthat he has swallowed a foreign body, usually a denture. Thesepossibilities should be always excluded before further procedures areundertaken. _Treatment. _--There being no urgency, a careful examination is carriedout, not only to confirm the impaction of a foreign body, but its siteand its relation to the wall of the gullet. In skilled hands, thesafest and most certain means of removing impacted foreign bodies iswith the aid of the œsophagoscope. If this apparatus is not available, other measures must be adopted varying with the nature of the body, its site, and the manner of its impaction. A bolus of food, for example, or a small smooth object that is likelyto pass safely along the alimentary canal, if it cannot be extractedwith forceps, may be pushed on into the stomach by the aid of abulbous-headed or sponge probang. This must be done gently, especiallyif the body has been impacted for any time, as the inflammatorysoftening of the œsophageal wall may predispose to rupture. Small, sharp, or irregular objects, such as fish bones, tacks, orpins, may be dislodged by the "umbrella probang"--an instrument which, after being passed beyond the foreign body, is expanded into the formof a circular brush which, on withdrawal, carries the foreign body outamong its bristles. Coins usually lodge edgewise in the œsophagus, and are best removed bymeans of an instrument known as a "coin-catcher", which is passedbeyond 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 hookmakes an excellent substitute for a coin-catcher. In difficult cases the removal of solid objects is facilitated bycarrying out the manipulations in the dark room with the aid of theX-rays and the fluorescent screen. Irregular bodies with projecting edges or hooks, such as tooth-plates, tend to catch in the mucous membrane, and attempts to withdraw them byforceps or other instruments are liable to cause laceration of thewall. When situated in the cervical part of the œsophagus, theseshould be removed by the operation of _œsophagostomy_ (_OperativeSurgery_, p. 195). If the foreign body is lodged near the lower end of the gullet, it maybe necessary to perform _gastrostomy_ (_Operative Surgery_, p. 291), making an opening in the anterior wall of the stomach large enough toadmit suitable forceps, or, if necessary, the whole hand, in orderthat the body may be extracted by this route; experience shows that animpacted body is more easily extracted from below, that is, from thestomach, than from above. When the surgeon fails to remove the body by either of these routes, _gastrostomy_ must be performed both to feed the patient and to placethe gullet at rest. Smooth bodies may lie latent for long periods, butthose with points or hooks damage the mucous membrane, causeulceration and perforation with the risk of erosion of vessels andsecondary hæmorrhage or of cellulitis of the neck or mediastinum andempyema. Other complications include septic broncho-pneumonia from damage tothe air-passage, and suppurative thyreoiditis. #Infective conditions# due to pyogenic infection (_œsophagitis_ and_peri-œsophagitis_) are rare. A _chronic form of œsophagitis_ is occasionally met with in alcoholicsubjects, giving rise to symptoms that simulate those of impactedforeign body, or of stricture. In _tuberculous_ lesions the symptoms are pain, dysphagia, andregurgitation of food mixed with blood, and the condition is liable tobe mistaken for gastric ulcer or for cancer of the œsophagus. _Syphilitic affections_ of the œsophagus are rare. #Varix# at the lower end of the œsophagus may give rise tohæmatemesis, and be mistaken for gastric ulcer. Bleeding from thedilated veins may follow the use of bougies or of the œsophagoscope. CONDITIONS CAUSING DIFFICULTY IN SWALLOWING Difficulty in swallowing may arise from a wide variety of causes whichit is convenient to consider together. #Impaction of Foreign Bodies# has already been discussed, andattention has been drawn to the importance of the history given by thepatient and to the various sources of fallacy or deception--inchildren it may be artful reticence or misrepresentation, in adults, the possibility of nightmare and of dreams. #Compression of the Gullet from without. #--Any one of the numerousstructures in relation to the gullet may, when enlarged as a result ofdisease, give rise to narrowing of its lumen, for example alymph-sarcoma at the root of the lung, or any enlargement of thethyreoid or of the mediastinal lymph glands. The possibility ofaneurysm must always be kept in mind because of the risk attending thepassage of instruments for diagnostic purposes. #Spasm of the Muscular Coat. #--As in other tubular structurescontaining circular muscular fibres, sudden contraction or spasm mayoccur in the œsophagus and cause narrowing of the lumen, attended withdifficulty in swallowing. This spasmodic dysphagia includes suchwidely varying conditions as the "globus hystericus" of neurasthenicwomen, the spasm of chronic alcoholics, and the affection known as_cardiospasm_ or "hiatal œsophagismus. " In contrast with other affections causing difficulty in swallowing, spasmodic dysphagia usually has a sudden and unexplained onset, theprogress of symptoms is irregular and erratic, while the remission ofsymptoms common to all affections of the œsophagus, and the influenceof mental impressions, such as excitement, hurry in the presence ofstrangers, are exaggerated. In testing the calibre of the gullet it is found that on one occasiona full-sized bougie may pass easily and be completely arrested atanother. Apart from the treatment of the neurosis underlying the dysphagia, reliance is placed upon dilatation of the portion of gullet affected. #Cardiospasm# is the name given to "a recurrent interference withdeglutition by spasmodic contraction of the lower end of theœsophagus. " As there is no muscular or nervous mechanism at thecardiac end of the œsophagus forming a true sphincter, the term"œsophagospasm" would be more accurate (D. M. Greig). According to H. S. Plummer, who has had an experience of 130 cases, there are three stages in the development of this condition. In theinitial stage, the first attack occurs suddenly and unexpectedly; achoking sensation is felt at some point in the gullet, usually at itslower end. Attacks of choking with difficulty in swallowing occurchiefly at meals, but they have also been known to occur apart fromthe taking of food. In this stage the peristalsis of the gullet issufficient to force the food through the cardia. In the second stage, the peristalsis of the gullet above being nolonger able to overcome the contraction, there is regurgitation offood, which at first is returned to the mouth immediately after beingswallowed, but, as the gullet becomes dilated, is retained for longerperiods. In the third stage, the gullet becomes more and more dilated, and thefood collects in it and is regurgitated at irregular intervals. Thepatient complains of a sensation of weight and discomfort in the lowerpart of the chest, and sometimes of regurgitation of food into thenasal passages during sleep. Cardiospasm should be suspected as the cause of difficulty inswallowing if a rubber tube cannot be passed into the stomach while asolid one can. When it is impossible to pass a solid instrument in theordinary way it can always be passed on a silk thread as a guide. Thepatient is directed to swallow 6 yards of silk thread, half in theafternoon and the remainder on the following morning. The firstportion forms a snarl in the gullet or stomach which passes out intothe intestine during the night; the proximal end is fixed to the cheekby a strip of plaster. The olive heads of the bougies are drilled forthreading from the tip to one side of the base. The _treatment_ consists in dilating the contracted segments by abougie. The results are immediate and are most striking, the patientsbeing almost invariably able to take any kind of food at the followingmeal, and the gain in weight and strength is rapid. In a smallproportion of cases, dilatation fails to give relief, and recourse hasbeen had to anastomosing the lower end of the dilated and pouchedœsophagus with the stomach. #Paralysis of the Gullet. #--As the passage of the food along thegullet is entirely dependent upon muscular peristalsis, when themuscular coat is paralysed, as it may be after diphtheria, forexample, the patient is unable to swallow and the food materials areregurgitated, with consequent loss of flesh and strength. Thedifficulty may be tided over for a time by feeding through a rubbertube, but it is to be remembered that, in children, struggling inresisting the passage of the tube may seriously strain a heart that isalready threatened by the toxins of diphtheria. #Diverticula or Pouches of the Gullet. #--A diverticulum consists inthe protrusion of the mucous and submucous coats through a defect orweak part in the muscular tunic; it is therefore of the nature of ahernia and not a localised dilatation of the tube as a whole. Anatomically, there is such a weak spot in the posterior wall oppositethe cricoid cartilage, known as the _pharyngeal dimple_, between thecircular and oblique fibres of the crico-pharyngeus muscle. As thepouch increases in size by pressure from within, it usually extendsdownwards and to the left. This pouch is described as a _pressure orpulsion diverticulum_ because the hernial protrusion is ascribed toincreased pressure within the pharynx, not only the normal increasecaused by the act of swallowing, but an abnormal pressure from the toorapid swallowing or bolting of imperfectly masticated food materials. [Illustration: FIG. 285. --Radiogram, after swallowing an opaque meal, in a man suffering from malignant stricture of lower end of Gullet. ] The _clinical features_ are not so characteristic of difficulty inswallowing as might be expected. The patient, usually a man over fortyyears of age, complains of dryness in the throat and of a sensation asof a foreign body; later there is regurgitation of saliva and of foodwith occasional choking. In about one-third of the cases, there is afullness, or a palpable tumour in the neck, about three times moreoften on the left than on the right side, which may increase in sizeafter a meal, and pressure on which may cause a gurgling sound and, itmay be, regurgitation of food. It is suggestive of a pouch, if the patient regurgitates foodmaterials which can be identified as having been swallowed severaldays before, currants perhaps being those most easily recognised andremembered. Diverticula are also met with at a lower level, springing from thegullet at or below the upper opening of the thorax; the distension ofthe pouch with food materials presses upon the gullet with moreserious effect, even to the extent of complete obstruction andconsequent rapid emaciation. In men over fifty, the resemblance tocarcinoma may be very close. In this, as in all cases of difficulty in swallowing, chief stressshould be laid on the X-ray appearances after the administration of anopaque meal; a pouch shows as a uniform, spherical shadow of from oneto two inches in circumference. _Treatment_ is influenced by the manner in which the patient may havelearned to overcome the difficulty of getting food into hisstomach--Lord Jeffrey, who was the possessor of the pharyngeal pouchshown in Fig. 286, was in the habit of emptying it, after a meal, bymeans of a long silver spoon. Some patients learn to feed themselvesthrough a soft rubber tube. [Illustration: FIG. 286. --Diverticulum of the Œsophagus at itsjunction with the Pharynx. (Anatomical Museum, University of Edinburgh. )] If an _operation_ is decided upon, and for this it is essential thatthe pouch should be accessible from the neck, the general condition isimproved by feeding through a stomach tube and by rectal andsubcutaneous salines. The operation consists in exposing and isolatingthe pouch by a dissection on the left side of the neck, and eitherexcising it as if it were a tumour or cyst, or if the risk ofinfection of the deeper planes of cellular tissue is regarded withapprehension, the pouch may be _infolded_ into the lumen of thegullet, or the excision be carried out in two _stages_. At the firststage, the pouch is isolated and rotated on its pedicle, in whichcondition it is fixed by sutures; after an interval of from ten tofourteen days it is excised. Should the diverticulum be inaccessible from the neck, and thedifficulty of swallowing be attended with progressive emaciation, _gastrostomy_ may be required to avert death by starvation. _Traction diverticula_ are due to the contraction of scar tissueoutside the gullet, as for example that resulting from tuberculousglands in the posterior mediastinum; they are rarely attended withsymptoms, and are rather of pathological than surgical interest. #Innocent Stricture or Cicatricial Stenosis of the Gullet. #--Theinnocent or fibrous stricture follows upon the swallowing of corrosivesubstances, usually by inadvertence, sometimes with suicidal intent. Having recovered from the initial effects of the corrosive agent, thepatient suffers from gradually increasing difficulty in swallowing, first with solids and later with fluids. There is the usual variationor intermittence of symptoms that attend upon all conditions causingdifficulty of swallowing, the exacerbations being due to superaddedspasm of the muscular coat and congestion of all the coats. As thegullet dilates above the stricture, there is an increasingaccumulation of what has been swallowed, and this the patientregurgitates at intervals; this is usually described as "vomiting, "but the material ejected shows no signs of gastric digestion. There ispain referred to the epigastrium or between the shoulder-blades, thepatient suffers from hunger and thirst, and may present an extremedegree of emaciation. The _diagnosis_ is suggested by the history, and is confirmed by theœsophagoscope or by the X-rays after an opaque meal. The use ofbougies has taken a secondary place since the introduction of thesemethods of examination, but, when other means are not available, thepassage of bougies having a whalebone shaft and a series of metalheads shaped like an olive, may give useful information regarding thesite, number, and size of the strictures that require to be dealtwith. _Treatment. _--If the patient is in a critical state from starvation, gastrostomy must be performed to enable him to be fed; otherwise he isprepared for treatment of the stricture by rest in bed, sedatives, andsuitable liquid or some solid foods to improve his general conditionand eliminate the muscular spasm and congestion already referred to. If the passage of bougies with the object of dilating the stricture isdifficult or impossible, it may be made easier or possible by gettinga silk thread through the stricture. The patient swallows severalyards of a reliable silk thread a day or two before the proposeddilatation is carried out; the thread is expected to pass through thestricture of the stomach, and to enter for some distance into thesmall intestine; the metal head of the bougie, which is canalised inits long axis, is "threaded" on the silk, and the latter acting as aguide, the bougie is passed safely and confidently through thestricture. Larger olive-shaped heads are passed at intervals until thenormal calibre of the gullet is exceeded, after which it is usuallyeasy to pass an ordinary full-sized instrument at intervals of a monthor so. In the event of failure, recourse must be had to gastrostomy, andthrough the stomach it may be possible to dilate the stricture by the"retrograde" route. In aggravated cases, the gastrostomy opening mustbe retained in order to prevent death from starvation. #Malignant Stricture--Carcinoma of the Gullet. #--This is met with intwo forms which present widely different pathological and clinicalfeatures. Cancer of the _cervical_ portion affects the gullet at its junctionwith the pharynx, and for some unexplained reason is much more commonin women, and at the comparatively early age of between thirty andfifty. Cancer of the _thoracic_ portion affects the extreme lower endof the gullet, and is met with almost exclusively in men over fifty. #Cancer of the Cervical Portion. #--Difficulty of swallowing may arisesuddenly; more often it is slow and progressive over a period ofmonths and, in some cases, even of years. Pain on swallowing is not aconstant or prominent feature; it may be referred to the site of thelesion or to one or both ears. In a considerable number of cases, thecomplaints of the patient are referred to the larynx; coughing, withabundant mucous expectoration disturbing the night's rest, hoarseness, or even loss of voice, which symptoms are due either to directinvasion of the larynx or to implication of one or other recurrentnerve; for the same cause, difficulty of breathing may supervene, sometimes of such a nature as to render tracheotomy imperative. Agurgling noise on swallowing, and regurgitation of food areoccasionally observed. Palpation of the neck, and particularly of the larynx and trachea, should be carried out in all cases presenting the symptoms described;and as bearing on the question of operation, enlargement of thecervical lymph glands and of the thyreoid should be looked for; cancerof the thyreoid is sometimes secondary to disease at thepharyngo-œsophageal junction. Direct and indirect laryngoscopic examination is then made; if thelaryngeal mirror fails to reveal anything abnormal, suspensionlaryngoscopy, which gives a more extensive view of that part of thepharynx lying behind the larynx, may be employed, or the œsophagoscopemay be preferred. A portion of the growth may be removed formicroscopical examination. The use of the œsophageal bougie as a diagnostic agent must bedeprecated; it gives no satisfactory explanation of the cause of theobstruction, and its employment when malignant ulceration is present, is not free from serious risk to the patient (Logan Turner). _Treatment. _--The surgeon is dependent on the help of thelaryngologist not only for the diagnosis of the disease at theearliest stage possible, but also for information as to its extent, especially with regard to involvement of the larynx. _Œsophagectomy_, or resection of the cancerous segment of the gullet, in suitable cases, even if it does not yield a permanent cure, notonly prolongs life but relieves the patient of her most distressingsymptoms. 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 thegullet is more satisfactory and the laryngeal symptoms are moreefficiently relieved, than by either of the purely palliativeoperations. In the majority of cases, however, only the palliativemeasures of _œsophagostomy_ or _gastrostomy_ can be adopted. Œsophagostomy presents the advantage, that by exposing the cervicalportion of the gullet, the operator is enabled to investigate theextent of the disease and to revise his opinion on the feasability ofits removal if necessary. In advanced cases, when the disease hasspread widely in the neck and involved, it may be, the thyreoid andthe larynx, it may only be possible to relieve the urgent distress ofthe patient by gastrostomy. _Tracheotomy_ may also become necessarybecause of the spread of the cancer to the interior of the larynx. #Cancer of the Lower End of the Gullet. #--The remarkable preference ofthis location of œsophageal cancer for the male sex has already beenreferred to; it affects the same type of male patients as are subjectto squamous epithelioma in other parts of the body. So far as we haveobserved, its association with chronic irritation of the mucousmembrane in which it takes origin, or with any pre-cancerouscondition, has not been demonstrated. The _clinical features_ resemble those of cicatricial stricture; thedifficulty of swallowing is usually of gradual onset, it concernssolids in the first instance, then semi-solids like porridge or breadand milk, and finally fluids. As in other forms of œsophagealobstruction, the difficulty of swallowing varies quite remarkably fromtime to time, presumably from variations in the degree of congestionof the mucous membrane and of spasm of the muscular coat, but alsofrom mere nervousness, the patient having greater difficulty when in ahurry, as in a railway refreshment room, or embarrassed by thepresence of strangers. As the lumen of the gullet becomes narrower, the food materialsaccumulate above the obstruction, and the consequent dilatation of thegullet above the stricture accounts for the large amount that may beregurgitated and for the patient describing it as vomiting. Along withfood materials there is abundant saliva, and, if the cancer hasulcerated, of pus and blood. Contrary to what might be expected, thereis little or no complaint of hunger, in spite of the progressivestarvation and emaciation which inevitably supervene. Death takes place within a year or so of the onset of symptoms, usually from starvation, but the fatal issue may be precipitated byulceration and perforation of the gullet into a large blood vessel orinto the left pleural sac; in the latter event, there follows a basal_empyema_ which may contain gas and food materials. _Diagnosis. _--In the majority of cases the history is socharacteristic that there is little doubt regarding the diagnosis; themost reliable corroboration, with least risk and distress to thepatient, 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 thesite of stricture (Fig. 285). A filiform, tortuous shadow of thebismuth may be continued downwards and show up the lumen of thestricture. The use of the œsophagoscope and of bougies is to bedeprecated as not free from risk. _Treatment. _--The lower end of the gullet is one of the mostinaccessible portions of the body, and although it has been removed byoperation the prospects of success are so small that it is not atpresent regarded as justifiable. Among _palliative measures_, may be mentioned _intubation_ of thestricture with a view to increasing the amount of food that can beswallowed; a funnel-shaped tube like that of Symonds or of Hill isintroduced into the lumen of the stricture by means of a bougie orwith the help of the œsophagoscope. The tube is anchored to a denture, or by means of a silk thread to the cheek by sticking-plaster. Ourexperience of intubation is that it merely serves to tide the patientover a critical period of starvation, so that he may regain somestrength for any other procedure that may be indicated. The value of making a fistula in the stomach--_gastrostomy_--in orderto feed the patient, is a question about which widely differentopinions are held both by patients and by surgeons. Many patientsallege that they would prefer to die rather than prolong a precariousexistence by being fed through a tube; some surgeons look upon theoperation with disfavour because they doubt whether it even prolongslife, and it is often followed by a pneumonia which rapidly provesfatal. Variation in the results of gastrostomy observed by differentsurgeons is partly due to differences in the stage of the disease atwhich the operation is performed, and probably to a greater extent tothe confusion between cases of slowly growing squamous epithelioma ofthe lower end of the gullet and cases of glandular carcinoma of thecardiac end of the stomach, these being grouped together under theclinical heading of "malignant stricture of the lower end of thegullet. " In our experience cases of epithelioma of the gullet (in thestrict sense of the term) benefit greatly if subjected to gastrostomyas soon as the condition is recognised. In a case operated upon byThomas Annandale the patient survived the operation for three yearsand some months. _Radiation. _--The introduction of a tube of radium into the strictureand its retention there, the silk thread attached to the tube beingsecured to the cheek by a strip of plaster, is described by Hill andFinzi as the most valuable palliative measure that has so far beenemployed in cancer of the gullet; the capacity of swallowing may beregained to a considerable extent. The employment of radium isrendered easier and more efficient if it is preceded by gastrostomy. _The Roux-operation. _--This consists in making a new gullet to replacethat which is obstructed; the abdomen is opened and a loop of jejunumis isolated; its lower end is anastomosed--end to side--to thestomach; the intestine is brought upwards through a tunnel made for itbetween the skin and the sternum, and the upper end is brought out andfixed to the skin, in the supra-sternal notch. It has scarcely passedbeyond the experimental stage. CHAPTER XXIX THE LARYNX, TRACHEA, AND BRONCHI[7] Examination of the larynx--CARDINAL SYMPTOMS OF LARYNGEAL AFFECTIONS: (1) Interference with the voice: _Hoarseness_; _Aphonia_--(2) Dysphagia--(3) Interference with respiration: _Diphtheritic laryngitis_; _Acute œdema of the larynx_; _Intubation of the larynx_; _Tracheotomy_; _Bilateral abductor paralysis_; _Syphilitic affections_; _Tuberculosis_--Tumours: _Papilloma_; _Epithelioma_; _Sarcoma_--Foreign bodies in the air-passages: _In the pharynx_, _larynx_, _trachea_, _bronchi_. [7] Revised by Dr. Logan Turner. #Examination of the Larynx. #--For this purpose the examiner requires alaryngeal reflector with forehead attachment, one or two sizes oflaryngeal mirror, a tongue cloth, and the means of obtaining goodillumination. The source of light should be by preference placedopposite to and on the same horizontal plane as the patient's leftear. The forehead reflector is placed over the observer's right eye sothat he may look through the central aperture, while at the same timehe throws a good circle of light into the patient's mouth. The patientshould be seated with the head thrown slightly back; the tongue isprotruded and covered with the cloth, and held lightly but firmlybetween the finger and thumb of the left hand. A full-sized mirror, warmed so as to prevent the condensation of the breath upon it, isinserted with the reflecting surface turned downwards, and pressedgently against the soft palate so as to push that structure upwards. The handle of the instrument is carried towards the left angle of themouth, and by slightly altering the plane of the reflecting surface ofthe mirror the different parts of the larynx are in turn brought intoview. The movements of the vocal cords should be observed during bothrespiration and phonation, and for the latter purpose the patientshould be directed to phonate the vowel sound "eh. " In the upper part of the mirror the epiglottis usually comes firstinto view: it is of a pinkish yellow colour, and presents a thin, sharply defined free margin. In front of the epiglottis are the medianand lateral glosso-epiglottic folds passing forwards to the base ofthe tongue, and enclosing the two valleculæ. Extending backwards anddownwards from the lateral margins of the epiglottis are the twoary-epiglottic folds which reach the arytenoid cartilages posteriorly. Between the two layers of mucous membrane of which the ary-epiglotticfolds are composed are the cartilages of Wrisberg and Santorini. Inthe interval between the two arytenoid cartilages is theinter-arytenoid fold of mucous membrane, which forms the upper marginof the posterior wall of the larynx. The upper aperture of the larynxis bounded by the epiglottis in front, the ary-epiglottic foldslaterally, and the inter-arytenoid fold behind. In the interior of thelarynx the vocal folds (true vocal cords) form the most prominentfeatures, being conspicuous as two flat white bands, which form theboundary of the rima glottidis or glottic chink. Above each true cord, and parallel with it, the ventricular fold or false cord is evident asa pink fold of mucous membrane. Between the ventricular fold and thevocal fold on each side is a linear interval, which indicates theentrance to the ventricle of the larynx. _Direct Laryngoscopy. _--The larynx may also be examined by the directmethod by means of Jackson's or Killian's spatulæ. After cocainisationof the base of the tongue, the soft palate, and the posterior surfaceof the epiglottis, the patient is seated upon a low stool and his headsupported by an assistant. The light is obtained from a small lamp inthe handle of the instrument or reflected from a forehead mirror. Thespatula is warmed and introduced under the guidance of the eye, itsend being passed over the epiglottis, and pressure exerted so as todraw the latter structure forward. In children a general anæsthetic isrequired, and the examination is made with the head hanging over theend of the table. Killian's "suspension laryngoscopy" affords the bestmethod of examining the larynx in young children. _Tracheoscopy and Bronchoscopy. _--Direct examination of the tracheaand larger bronchi may be carried out in a similar way, by passingthrough the mouth and larynx metal tubes, after the method devised byKillian. This procedure is described as direct upper tracheoscopy andbronchoscopy. The examination may also be made through a tracheotomywound--direct lower tracheoscopy. These procedures have proved ofgreat service in the recognition of foreign bodies in the lowerair-passages, and in their extraction; in the diagnosis of stenosis ofthe trachea, and of aneurysm pressing on the trachea. CARDINAL SYMPTOMS OF LARYNGEAL AFFECTIONS The cardinal symptoms of laryngeal affections are interference withthe voice and with respiration, and pain on swallowing. Laryngealcough of a croupy or barking character may be present, and is usuallyassociated with a lesion of the posterior wall or inter-arytenoidfold. Hæmoptysis is seldom of laryngeal origin, and unless thebleeding spot is visible in the mirror, the source of the bleeding ismuch more likely to be in the bronchi or lungs. #Interference with the Voice. #--_Hoarseness_ results from someaffection of the vocal cords: it may be simple laryngitis, somespecific cause such as tuberculosis or syphilis, or some conditionwhich prevents the proper approximation of the cords, as in tumoursand certain forms of paralysis. Huskiness of voice occurring in amiddle-aged person, lasting for a considerable period, and unattendedby any other local or constitutional symptom, should always arousesuspicion of malignant disease, and calls for an examination of thelarynx. Should this reveal a congested condition of one vocal cord, associated with some infiltration, and should the mobility of the cordbe impaired, suspicion of the malignant character of the affection isstill further increased. The hoarseness in these cases is sometimesgreater than the local appearances would seem to account for. _Aphonia_, or loss of voice, sudden in origin, and sometimestransient, occurs more often in women, and is usually functional orhysterical in nature. Although the patient is unable to speak, she isquite able to cough. In these cases there is a bilateral paralysis ofthe adductor muscles, so that the cords do not approximate onattempted phonation; or the internal tensors may be paretic, leavingan elliptical space between the cords on attempted phonation. If thearytenoideus muscle alone is paralysed, a triangular interval is leftbetween the cords posteriorly. There is no inflammation or otherevidence of local disease. The _treatment_ of functional aphonia should be general and local;tonics such as strychnin, iron, and arsenic should be administered;the intra-laryngeal application of electricity usually effects asudden cure. In obstinate cases the use of the shower-bath and colddouching, the administration of chloroform, and even hypnotism may betried. An examination of the lungs should be made in all cases of adductorparalysis, as this functional condition may be met with in earlypulmonary tuberculosis. #Dysphagia. #--Pain on swallowing, due to causes originating in thelarynx, is usually associated with ulceration of the mucous membranecovering the epiglottis, ary-epiglottic folds, or arytenoidcartilages, that is, in connection with those parts with which thefood is brought into direct contact. The most frequent causes of such ulceration are tuberculosis, syphilis, and malignant disease. The differential diagnosis is oftendifficult from local inspection alone. The Wasserman test, theprevious history, the state of the lungs and sputum, and the resultsof anti-syphilitic treatment may clear it up. The _treatment_ of dysphagia, apart from that of the diseaseassociated with it, resolves itself into the use of local sedativeapplications, such as a weak cocain or eucain spray before meals, insufflations of acetate of morphin and boracic acid, and the use of amenthol spray. One of the best anæsthetic applications is orthoformpowder, introduced by means of the ordinary laryngeal insufflator. Itsaction is more prolonged than that of any of the others, oftenlasting for from twenty-four to forty-eight hours. Injection of the superior laryngeal nerve with a 60 per cent. Solutionof alcohol has been found satisfactory where other means have failed. #Interference with Respiration. #--It is only necessary here to referto such causes of interference with respiration as may call forsurgical treatment. The chief forms of _laryngitis_ to be considered in connection withthe production of dyspnœa, are membranous or diphtheritic laryngitisand acute inflammatory œdema. #Diphtheria of the larynx# is described on p. 110, Volume I. #Acute Œdema of the Larynx. #--Œdema of the larynx may be inflammatoryor non-inflammatory in origin. The former is the more common, and mayarise in connection with disease of the larynx, such as tuberculosisor syphilis, or it may be secondary to acute infective conditions atthe base of the tongue, or in the fauces or pharynx; more rarely itresults from infective conditions of the cellular tissue or glands ofthe neck. The non-inflammatory form may be a local dropsy in renal orcardiac disease, may be induced by pressure on the large cervicalveins, and in some cases it appears to follow the administration ofpotassium iodide in the treatment of laryngeal affections. The œdema consists of an exudation into the loose submucous areolartissue, which may be of a simple serous character or maybecome sero-purulent. The situations mainly involved are theglosso-epiglottic fossæ between the base of the tongue and theepiglottis, the ary-epiglottic folds (Fig. 287), and the false cords. If the infective process commences in front of the epiglottis thisstructure becomes swollen and rigid, and often livid incolour--points which are readily discerned on examination with themirror, or even without its aid in some cases. The patient complainsof great pain on swallowing, and has the sensation of a foreign bodyin the throat. Should the œdema spread to the ary-epiglottic folds, either from the interior of the larynx or from the fauces and pharynx, dyspnœa becomes a prominent and grave symptom. The patient may rapidlybecome cyanosed, the inspirations assume a noisy, stridulouscharacter, and great distress and imminent suffocation supervene. Iflaryngoscopic examination is possible, the ary-epiglottic folds may befound greatly swollen and the upper aperture of the larynx partlyoccluded. Digital examination may reveal the swollen condition of theparts. The urine should be examined for albumin and tube casts. [Illustration: FIG. 287. --Larynx from case of sudden death, due toœdema of ary-epiglottic folds, _a_, _a_. (From drawing lent by Dr. Logan Turner. )] _Treatment. _--In the milder forms, the sucking of ice, the inhalationof medicated steam, or spraying with a solution of adrenalin, and theapplication of poultices to the neck, may suffice to relieve thecondition. Scarification of the epiglottis and ary-epiglottic foldswith a knife, followed by free bleeding, may give complete relief. Diaphoretic and purgative treatment should not be neglected. Ifsuffocation is imminent, tracheotomy or intubation is called for. In performing #tracheotomy#, a roller pillow is placed beneath theneck to put the parts on the stretch, and an incision is carried fromthe lower margin of the cricoid cartilage downwards for about 2inches. The sterno-hyoids and sterno-thyreoids are separated; thecross branch between the anterior jugular veins, and any other veinsmet with, secured with forceps before being divided; and the tracheaexposed by dividing transversely the layer of deep fascia which passesfrom the cricoid to the isthmus of the thyreoid. If the isthmus cannotbe pulled downwards sufficiently, it may be divided in the middleline. All active bleeding having been arrested, the larynx is steadiedby inserting a sharp hook into the lower edge of the cricoidcartilage, and the trachea is opened by thrusting a short, broad-bladed knife through the exposed rings. The back of the knifeshould be directed downwards, and the opening in the trachea enlargedupwards sufficiently to admit the tracheotomy tube. In children it issometimes found necessary to divide the cricoid for this purpose(_laryngo-tracheotomy_). The slit in the trachea is then opened upwith a tracheal dilator, and the outer tube inserted and fixed inposition with tapes. The inner tube is not fixed, so that it may becoughed out if it becomes blocked, and that it may be frequentlyremoved and cleaned by the nurse. The tube should be discarded assoon as the patient is able to breathe by the natural channel. _Intubation of the Larynx. _--This procedure is employed as asubstitute for tracheotomy, especially in children suffering frommembranous and œdematous forms of laryngitis. As experience isrequired to carry out the manipulations successfully, and as its useis attended with certain risks which necessitate that the surgeonshould be constantly within call, the operation is more adapted tohospital than to private practice. O'Dwyer's apparatus is that mostgenerally employed. The operation consists in introducing through theglottis, by means of a specially constructed guide, a small metal orvulcanite tube furnished with a shoulder which rests against the falsevocal cords. The part of the tube which passes beyond the true vocalcords is bulged to prevent it being coughed out. In an emergency a gum-elastic catheter with a terminal aperture may bepassed, as recommended by Macewen and Annandale. #Bilateral Abductor Paralysis. #--Both recurrent nerves may beinterfered with by such conditions as enlargement of the thyreoid, tumour of the œsophagus, or intra-thoracic tumour, or by injury in thecourse of operations for goitre. A gradually increasing inspiratorydyspnœa is developed, which at first is only noticed on exertion, whenthe desire for air is increased; later it becomes permanent, and evenduring sleep the stridor may be marked. Suffocation may becomeimminent. When the larynx is examined with the mirror, the vocal cordsare seen to lie near each other, and on inspiration theirapproximation is still greater. The _treatment_ is directed to removing the cause of pressure on thenerves. In the majority of cases tracheotomy is called for and thetube must be worn permanently. #Syphilitic Affections of the Larynx. #--_Secondary syphilitic_manifestations in the form of congestion of the mucous membrane, mucous patches, or condylomata, are occasionally met with, and giverise to a huskiness of the voice. These conditions usually disappearrapidly under anti-syphilitic treatment. In _tertiary syphilis_, whether inherited or acquired, the most commonlesion is a diffuse gummatous infiltration, which tends to go on toulceration and to lead to widespread destruction of tissue. It usuallyattacks 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 baseis covered with a dirty white secretion, and the surrounding mucosapresents an angry red appearance. When the perichondrium becomesinvaded, necrosis of cartilage is liable to occur. Hoarseness, dyspnœa, and, when the epiglottis is involved, dysphagia, are the most prominent symptoms. Cicatricial contraction leading to stenosis may ensue, and causepersistent dyspnœa. The usual _treatment_ for tertiary syphilis is employed, but onaccount of the tendency of potassium iodide to increase the œdema ofthe larynx, this drug must at first be used with caution. Intubationor tracheotomy may be called for on account of sudden urgent dyspnœaor of increasing stenosis. The stenosis is afterwards treated bygradual dilatation with bougies, which, if a tracheotomy has beenperformed, may conveniently be passed from below upwards. An annularstricture causing occlusion may be excised, and the ends of thetrachea sutured. #Tuberculosis. #--The larynx is seldom the primary seat of tubercle. Inthe majority of cases the patient suffers from pulmonary phthisis, andthe laryngeal mucous membrane is infected from the sputum. The diseasemay take the form of isolated nodules in the vicinity of the arytenoidcartilages, of superficial ulceration of the vocal cords and adjacentparts, or of a diffuse tuberculous infiltration of all the structuresbounding the upper aperture of the larynx. The mucous membrane becomesœdematous and semi-translucent. The nodules coalesce and break down, leading to the formation of multiple superficial ulcers. The partsadjacent to the ulcers are pale in colour. Perichondritis may occurand be followed by necrosis of cartilage and the formation ofabscesses in the submucous tissue of the larynx or in the cellulartissue of the neck. The voice becomes hoarse or may be lost, there is persistent andintractable cough, and in some cases dyspnœa supervenes. When theepiglottis is involved there is pain and difficulty in swallowing. In the presence of advanced pulmonary phthisis the treatment ischiefly palliative, but if the disease in the lungs is amenable totreatment, and the laryngeal lesion limited, the electric cautery maybe used. Tracheotomy may be called for on account of urgent dyspnœa. #Tumours. #--The commonest form of simple tumour met with in the larynxis the _papilloma_. It may occur at any age, and is comparativelycommon in children. It most frequently springs from the vocal cordsand adjacent parts, forming a soft, pedunculated, cauliflower-likemass of a pink or red colour, which may form a fringe hanging fromthe edge of the cord (Fig. 288), or may spread until it nearly fillsthe larynx. In children, the growths are frequently multiple and showa marked tendency to recur after removal. They sometimes disappearspontaneously about puberty. [Illustration: FIG. 288. --Papilloma of Larynx. (From drawing lent by Dr. Logan Turner. )] The most prominent symptoms are hoarseness, aphonia, and dyspnœa, which in children may be paroxysmal. The _treatment_ consists in removing the growth by means of laryngealforceps or the snare, under cocain and adrenalin anæsthesia. For theremoval of multiple papillomata, the removal of the growths throughKillian's tubes or by suspension laryngoscopy has now taken the placeof the external operation in children. In a certain number of cases ithas been found that the tumour disappears after the larynx has beenput at rest by the operation of tracheotomy. #Cancer. #--_Epithelioma_ of the larynx is almost always primary, andusually occurs in males between the ages of forty and seventy. It isimportant to distinguish between those cases in which the growth firstappears in the interior of the larynx--on the vocal cords, theventricular bands, or in the sub-glottic cavity (_intrinsiccancer_)--and those in which it attacks the epiglottis, theary-epiglottic folds, or the posterior surface of the cricoidcartilage (_extrinsic cancer_). _Clinical Features. _--In the great majority of cases of _intrinsic_cancer the first and for many months the only symptom is huskiness ofthe voice, which may go on to complete aphonia before any othersymptoms manifest themselves. When the larynx is examined in an earlystage, the presence of a small warty growth on the posterior part ofone vocal cord, or a papillary fringe extended along the free edge ofthe cord, should raise the suspicion of malignancy, especially if theaffected cord is congested and moves less freely than its fellow. Early diagnosis is essential in intrinsic cancer, and the absence ofenlargement of lymph glands, or of fœtor and cachexia, must in no wayinfluence the surgeon against making a diagnosis of malignancy. Theimpaired mobility of the affected cord is an important point indetermining the malignant nature of the growth. Intrinsic cancer may spread over the upper boundaries of the larynxand become _extrinsic_, or the disease may be extrinsic from theoutset. In cases of _extrinsic_ cancer the early symptoms are much moremarked, pain and difficulty in swallowing, and the secretion offrothy, blood-stained mucus being among the earliest manifestations. The cervical glands are infected early, sometimes even before thereare any symptoms of laryngeal disease. Difficulty of breathing is alsoan early symptom on account of the growth obstructing the entrance ofair. Tracheotomy may therefore be called for. In other respects thecourse and terminations are similar to those of intrinsic cancer. When the growth spreads into the tissues of the neck the patient'ssufferings are greatly increased. The œsophagus may be invaded withresulting dysphagia; the nerve-trunks may be pressed upon, causingintense neuralgic pains; the lymph glands become infected and breakdown, and the growth fungates through the skin. The general healthdeteriorates and death results, usually from septic pneumonia set upby the passage of food particles into the air-passages, fromabsorption of toxins, or from hæmorrhage. The duration of this form ofthe disease varies from one to three years. The _treatment_ consists in removing the growth. In early and limitedforms of intrinsic cancer laryngo-fissure (thyreotomy) gives goodresults; in more advanced cases the entire larynx must beremoved--_complete laryngectomy_--and at the same time, or after aninterval, the associated lymph glands are removed from the anteriortriangle of the neck on both sides. In cases in which excision is impracticable, the sufferings of thepatient may be alleviated by performing low tracheotomy, and byfeeding with the stomach tube or by nutrient enemata. In some casesthe difficulty of feeding the patient may make it necessary to performgastrostomy. #Sarcoma# of the larynx gives rise to the same symptoms as cancer, andcan seldom be diagnosed from it before operation. #Foreign Bodies in the Air-Passages. #--Foreign bodies impacted _in thepharynx_ usually consist of unmasticated pieces of meat or largetooth-plates, and they occlude both the food and the air-passages, frequently causing sudden death. They are considered with affectionsof the pharynx. The bodies most frequently impacted _in the larynx_ are smalltooth-plates in the case of adults, and buttons, beads, sweets, coins, and portions of toys in children. These are drawn from the mouth intothe air-passage during a sudden inspiratory effort, for example whilelaughing or sneezing. If the glottis is completely blocked, rapidlyfatal asphyxia ensues. If the obstruction is incomplete, the patientexperiences severe pain, difficulty of breathing, and a terrifyingsensation of being choked. The irritation of the foreign body causesspasmodic coughing and retching, and may induce spasm of the glottis, with threatening suffocation. Small round bodies may lodge in the upper aperture or in one of theventricles, and give rise to hoarseness and repeated attacks ofdyspnœa and spasmodic cough. Wherever the body is situated, thesymptoms may suddenly become urgent from its displacement into theglottis, or from the onset of œdema. The position of the body mayoften be ascertained by the use of the X-rays. _Treatment. _--If the symptoms are urgent, laryngotomy, which consistsin opening the larynx below the glottis by dividing the crico-thyreoidmembrane, or tracheotomy must be performed at once, and an attemptmade to remove the foreign body thereafter. In less severe cases inadults, the throat should be sprayed with cocain, and the larynxexamined with the mirror; in children, the direct method must beemployed. In both instances an attempt should be made to extract thebody by the direct method. As these manipulations are liable to inducesudden spasm of the glottis, the means of performing tracheotomy mustbe at hand. If it is found impossible to remove the body through themouth, laryngotomy or tracheotomy should be performed, and the bodyextracted through the wound, or pushed up into the pharynx and removedby this route. In the case of small bodies, a strand of gauze pushedup from the tracheotomy wound, through the larynx and out of themouth, catches the foreign body and carries it out (Walker Downie). The foreign bodies that are most likely to become impacted _in thetrachea_ are tooth-plates with projecting hooks, and small coins. Theposition of the foreign body may be ascertained by the use ofKillian's tracheoscope, or by means of the X-rays. If the body remainsmovable in the trachea, it is apt to be displaced when the patientmoves or coughs, and it may be driven up and become impacted in theglottis, setting up violent attacks of coughing and spasmodic dyspnœa. Tracheotomy should be performed at once, and the edges of the trachealwound held widely open with retractors, the patient being inverted, orcoughing induced by tickling the mucous membrane with a feather. Theforeign body is usually expelled, but it may be inhaled into one ofthe bronchi. One of Killian's tracheal tubes may be introducedthrough the tracheotomy wound and the body extracted by means ofsuitable forceps. _Foreign Bodies in the Bronchi. _--Rounded objects, which pass throughthe larynx, usually drop into one or other of the bronchi, usually theright, which is the more vertical and slightly the larger. The bodymay act as a ball-valve, permitting the escape of air with expiration, but preventing its entrance on inspiration, with the result that theportion of lung supplied by the bronchus becomes collapsed. Thephysical signs of collapse of a portion or of the whole lung may berecognised on examination of the chest. In some cases the body isdislodged and driven up into the larynx, causing severe dyspnœicattacks and spasms of coughing. The irritation caused by the foreignbody in the bronchus may set up bronchitis or pneumonia, and abscessof the lung may supervene. This has frequently followed the entranceof an extracted tooth into the air-passage, and it may be aconsiderable time before pulmonary symptoms arise. Sometimes the toothis ultimately coughed up and the symptoms disappear. In some cases thephysical signs closely simulate those of pulmonary phthisis. The _treatment_ consists in removing the body by the aid of Killian'sor Jackson's tube passed through the mouth. If this is not successful, low tracheotomy is performed and the tube is passed through thetracheotomy opening. INDEX Abducens nerve, 400 Abductor paralysis, 404, 639 splint, 221 Abscess. _See_ Individual Organs and Regions Accessory nasal sinuses. _See_ Individual Sinuses nerve, 404 Acetabulum, fracture of, 125 tuberculous disease of, 210 wandering, 210, 227 Achillo-bursitis, 294 Acoustic nerve, 579 Acromion process, fracture of, 69 Actinomycosis. _See_ Individual Organs and Regions Adenoids, 578 Alveolar abscess, 507 process, fracture of, 519 tumours of, 513 Ambulant splint for ankle, 189 treatment of hip disease, 222 Amputation in compound fracture, 26 Anatomy. _See_ Surgical Anatomy Angina Ludovici, 548, 597 Ankle, deformities of, 273 diseases of, 238, 240 dislocations of, 194 fractures in region of, 186, 187 injuries in region of, 185 surgical anatomy of, 185 tuberculous disease of, 238 Ankylosis of joints. _See_ Individual Joints Anosmia, 399, 578 Anterior poliomyelitis, 242 Aphasia, 335 Aphonia, 636 Arm, upper, injuries of, 44 Arthritis. _See also_ Individual Joints Arthritis, septic, 34 Arthrodesis, 246 Astragalus. _See_ Talus Athetosis, 247 Atlo-axoid disease, 440 joint, fracture-dislocation of, 430 Auditory nerve, 403 Aural polypi, 558 vertigo, 555 Auricular appendages, 560 Avulsion of scalp, 322 Balkan frame splint, 150 Basedow's disease, 614 Bell's paralysis, 401 Bennett's fracture, 116 Bezold's mastoiditis, 566 Bier's constricting bandage, 12, 26 Black eye, 370, 484 Blepharospasm, 403 Bones, atrophy of, 2 contusion of, 1 fracture of, 1 gun-shot injuries of, 27 injuries of, 1 repair of, 8 wounds of, 1 Bow-knee, 271 -leg, 271 Box splint, 182 Brachial plexus, lesions of, 597 Brachio-thoracic triangle, 470 Bradford frame, 438 Brain, abscess of, 360, 374, 376, 378, 382 localisation of, 380 adhesions, 358 cerebral irritation, 342, 346 compression of, 347 differential diagnosis of, 350 concussion of, 341, 344 contusion of, 342 cyst of, hæmorrhagic, 344 decompression operations on, 396 diseases of, 373 pyogenic, 373 foreign bodies in, 350 functions of, 331 hæmorrhage into, 352 hernia of, 397 injuries of, 341 mechanism of, 343 repair of, 344 irritation of, 342, 346 laceration of, 342 lesions of, 341 localisation of centres in, 336 membranes of, 328 diseases of, 372 motor area of, 330 sclerosis of, 358 sensory mechanism of, 332 softening of, 342 surgical anatomy of, 328 syphilitic gumma, 395 traumatic œdema of, 343, 352 tuberculosis of, 395 tumours of, 393 localisation of, 394 wounds of, 357 Branchial carcinoma, 601 cysts, 598 fistulæ, 585 Broken back, 427 Bronchi, foreign bodies in, 644 Bronchocele. _See_ Goitre, 605 Bronchoscopy, 635 Bryant's triangle, 129 Bunion, 296 Cachexia strumipriva, 610 Calcaneus, fracture of, 193 separation of, tuberosity of, 193 spurs on, 294 Callipers, ice-tong, 165 Callus, absorption of, 10 excess of, 9 tumours of, 10 varieties of, 8 Cancrum oris, 497 Capitate bone, dislocation of, 114 Carcinoma. _See_ Cancer Cardiospasm, 624 Carotid artery, internal, injuries of, 356 gland, tumours of, 603 Carpal bones, dislocation of, 113 fracture of, 110 Carpo-metacarpal dislocations, 115 Cauda equina, injuries of, 419 Caudal appendage, 458, 459 Cavernous sinus, phlebitis of, 386 Cellulitis. _See_ Individual Regions Cephal-hydrocele, 321 traumatic, 390 Cephaloceles, 387 Cerebello-pontine angle, tumours of, 394 Cerebellum, abscess of, 381 tumours of, 394 Cerebral abscess, 360 apoplexy, 351 centres, 334 embolism, 351 hyperpyrexia, 348 irritation, 342, 346 localisation, 336 œdema, 352 palsies of childhood, 247 shock, 341, 344 softening, 358 tumours, 393 vomiting, 377 Cerebro-spinal fluid, 329, 339 meningitis, 378 Cerebrum. _See_ Brain Cerumen in ear, 561 Cervical auricles, 583 caries, 440 fascia, 583 ribs, 585 sympathetic, 405, 615 Charcot's disease of hip, 228 Chauffeur's fracture, 106 Cheilotomy, 228 Chiene's test, 129 Cilio-spinal reflex, 405 Cirsoid aneurysm of scalp, 326 Clavicle, absence of, 303 dislocations of, 49 fracture of, 45 Cleft palate, 475, 477 Club-foot, 273 Club-hand, 311, 312 Coccydynia, 127, 450 Coccyx, fracture of, 127 Cock-up splint, 77 Coin-catcher, 622 Colles' fracture, 102 reversed, 106 unreduced, 106 Compound dislocation, 40 Compression of brain, 347 Compression fracture of spine, 426 Concussion of brain, 344 of spinal cord, 413 Congenital deformities, 241. _See_ Individual Regions dislocation, 43. _See_ Individual Joints Conus medullaris, injuries of, 419 Coracoid process, fracture of, 69 separation of epiphysis of, 70 Coronoid process, fracture of, 87 Coxa valga, 256, 261 vara, 136, 256, 257 Cranial nerves, affections of, 398. _See_ Individual Nerves Cranium. _See_ Skull Crepitus in fracture, 15, 30 Cricoid cartilage, fracture of, 593 Crossed-leg deformity, 224, 257 Cruciate ligaments, rupture of, 171 Cubitus valgus, 84, 308 varus, 84, 310 Cut-throat, 593 Deafness, varieties of, 553 Decompression of brain, 396 Deep sensibility, 332 Deformities of extremities, 241. _See_ Individual Regions Dental caries, 507 ulcer of tongue, 529 Dentigerous cysts, 517 Diplacusis, 554 Dislocation. _See also_ Individual Joints and Bones compound, 40 congenital, 43 by elongation, 96 with fracture, 40 habitual, 43, 65 old-standing, 40, 65 pathological, 43 recurrent, 43 traumatic, 36 varieties of, 37 Displacement of semilunar menisci, 168 Dorsal abscess, 444 Drop-finger, 318 wrist, 76, 311 Dugas' symptom in dislocation of shoulder, 54, 55 Dupuytren's contraction, 314 fracture, 187, 188, 196 splint, 190 Dysphagia, 623, 636 Ear, 553. _See also_ Tympanic membrane Ear, aspergillus in, 562 boils, 562 cardinal symptoms of disease of, 554 deafness, 553, 554 deformities of, 560 discharge from, 555 earache, 554 eczema of, 562 foreign bodies in, 563 furunculosis of, 562 hearing tests, 555 inspection of, 556 middle, acute infection of, 564 chronic suppuration in, 565 inflation of, 558 noises in, 554 otorrhœa, 555 outstanding, 560 pain in, 554 physiology of, 553 polypi, 558 rupture of membrane of, 563 syringing of, 561 surgical anatomy of, 553 tumours of, 560 vertigo, 555 wax in, 561 Earache, 554 Ectropion, 483 Elbow, ankylosis of, 208 arthritis deformans of, 208 diseases of, 205 dislocations, congenital, 308 paralytic, 308 traumatic, 88, 92 examination of, 80 injuries in region of, 79 neuro-arthropathies of, 208 pyogenic diseases of, 208 sprain of, 96 surgical anatomy of, 79 tennis player's, 97 tuberculous disease of, 206 Empyema of knee, 232 Encephalitis, 376, 377 Encephalocele, 388, 389 Epicritic sensibility, 332 Epilepsy, 397 Jacksonian, 359 traumatic, 358 Epiphyses, separation of. _See_ Individual Bones Epistaxis, 575 Epulis, 513 Ethmoidal cells, suppuration in, 577, 578 Eustachian catheter, 558 Extension by Hodgen's splint, 151, 159 by ice-tong callipers, 150, 158 by perineal band, 152 by Steinmann's apparatus, 150 vertical, 154 by weight and pulley, 220 Extra-dural abscess, 374 Eyeball, injuries of, 486 Eyelids, wounds of, 484 Face, cicatricial contraction of, 483 congenital malformations of, 474, 481 development of, 474 diseases of, 483 epithelioma of, 484 frog-, 581 injuries of, 482 rodent cancer of, 484 tumours of, 484 Facial cleft, 481 nerve, 400 paralysis, 400 spasm, 403 Facio-hypoglossal anastomosis, 403 False joint, 12 Fat embolism in fractures, 19 Femur, fracture of, in children, 135, 154 of condyles of, 162 of greater trochanter of, 139 of head of, 129 just below lesser trochanter of, 139 of lower end of, 157 of neck of, 130 of shaft of, 148 of upper end of, 129 incurvation of neck of, 257 separation of epiphyses of, 129, 139, 161 Fibula, absence of, 272 dislocation of, total, 167 fracture of, 165, 178, 183 Fingers, congenital contraction of, 313 deficiencies, 317 deformities of, 313 dislocation of, 121 drop-, 121, 318 Dupuytren's contraction of, 314 fractures of, 115 hypertrophy of, 317 injuries of, 115 mallet, 121, 318 supernumerary, 316 trigger, 318 webbed, 317 Flat-foot, 285 adolescent, 287 degrees of, 291 exercises for, 291 paralytic, 292 spasmodic, 292 static, 287 traumatic, 293 varieties of, 287, 294 Foerster's operation, 247 Foot, club-, 273 deformities of, 273 flat-, 285 hollow claw-, 284 injuries of, 185 movements of, 185 splay-, 285 surgical anatomy of, 185 Foot and mouth disease, 530 Footballer's knee, 172 Forearm, deformities of, 310 fracture of both bones of, 97 injuries of, 79 intra-uterine amputation of, 311 Fracture, 1. _See also_ Individual Bones amputation in, 26 badly united, 10 Bennett's, 116 during birth, 3 chauffeur's, 106 clinical varieties of, 4 Colles', 102 comminuted, 6 complications of, 18 compound, 5, 24 crepitus in, 15 deformity in, 15 delayed union, 11 depressed, 5, 7 with dislocation, 40 displacement of fragments in, 7 Dupuytren's, 196 extension in, 26 fat embolism in, 19 fever in, 18 fibrous union of, 12 fissured, 5 greenstick, 5, 98 gun-shot, 27 indentation, 5 intra-uterine, 3 Jones', 194 longitudinal, 6 mal-union of, 10, 99, 183 massage in, 21 mechanism of, 14 multiple, 6 non-union, 9, 12 oblique, 6 old-standing, 87 open, 5 operation in, 24 pain in, 17 passive hyperæmia in, 12 pathological, 1 prognosis in, 19, 25 radiography in, 16 reduction of, 20 repair of, 8 retention of, 21 setting of, 20 shock in, 18 simple, 4, 8, 14, 19, 24 Smith's, 106 spiral, 6 splints in, 22 sprain-, 35 subcutaneous, 4 sub-periosteal, 6 transverse, 6 traumatic, 3 treatment of, 20, 25 un-united, 12, 78, 100, 101, 183 varieties of, 4 violence, forms of, causing, 3 X-rays in, 16 Frog-face, 581 Frontal sinus, suppuration in, 577 Gampsodactyly, 302 Genu recurvatum, 263 valgum, 264, 265 varum, 264, 271 Gingivitis, 508 Girdle-pain, 419 Glands, lymph. _See_ Lymph Glands Globus hystericus, 624 Glomus carotica, tumours of, 603 Glossitis, 530, 533 Glosso-pharyngeal nerve, 403 Goitre, 605 adenomatous, 610 colloid, 607 cystic, 607 exophthalmic, 614 fibrous, 607 intra-thoracic, 607, 609, 613 malignant, 612 non-toxic, 605 parenchymatous, 605 retro-sternal, 607, 609, 613 sudden dyspnœa in, 608-610 thyreoidectomy for, 610 toxic, 614 vascular, 607 Gooch's splinting, 22 Graefe's symptom, 614 Graves' disease, 614 Gravitation paraplegia, 414 Greenstick fracture, 5 Gumboil, 507 Gums, affections of, 508 Gun-shot injuries. _See_ Individual Structures Habitual dislocation, 43 Hæmarthrosis, 33 Hæmatoma auris, 560 of periosteum, 1 Hæmatomyelia, 414 Hæmatorrachis, 414 Hallux dolorosus, 298 flexus, 298 rigidus, 298 valgus, 296 varus, 298 Hammer nose, 570 toe, 300 _Hanche à ressort_, 254 Hand, club-, 311, 312 deformities of, 310 injuries of, 102 surgical anatomy of, 102 Hare-lip, 475 Head injuries, 340 after-effects of, 358 Hearing, impairment of, 554 tests of, 555 Heel, painful affections of, 294 Hemianopia, 335 Hemi-glossitis, 530 Hernia cerebri, 397 Hiatal œsophagismus, 624 Hip, ankylosis of, 256 arthritis deformans of, 226 Charcot's disease of, 228 contractures of, 256 contusion of, 147 disease, 209 dislocations, congenital, 248 old-standing, 147 varieties of, 126, 142 examination of, 128, 211 hysterical, 229 injuries in region of, 127 loose bodies in, 229 neuro-arthropathies of, 228 osteo-chondritis deformans juvenilis, 228 paralytic deformities of, 255 Perthes' disease of, 228 pyogenic diseases of, 224 snapping, 254 sprain of, 147 surgical anatomy of, 128 Thomas' splint for, 222 tuberculous disease of, 210 abscess formation in, 217 bilateral, 224 deformities following, 223 diagnosis of, 218 dislocation in, 218 stages of, 211 treatment of, 220 Histrionic spasm, 403 Hoarseness, 635 Hodgen's splint, 151 Hollow claw-foot, 284 Homonymous hemianopia, 335 Hospital throat, 500 Humerus, fracture, of anatomical neck, 74 of condyles, 80 with dislocation of shoulder, 63 of head, 70 of lower end, 84 of shaft, 75 of surgical neck, 70 of tuberosities, 74 un-united, 78 separation of lower epiphysis of, 82, 84 of upper epiphysis of, 73 Hunch-back, 440, 444 Hydrencephalocele, 388, 389 Hydrocele of neck, 599 Hydrocephalus, 391 acute, 386, 391 chronic, 391 Hygroma of neck, 599 sacral, 459 Hyoid bone, fracture of, 593 Hyperæsthesia acustica, 554 Hyperpituitarism, 396 Hyper-thyreoidism, 609, 614 Hypoglossal nerve, 404 Hypophysis cerebri, tumours of, 396 Hypopituitarism, 396 Hysterical aphonia, 636 spine, 448 wry-neck, 592 Ice-tong callipers, 150 Iliac abscess, 445, 446 Ilium, fracture of, 126 Infantile paralysis, 242 Injuries. _See_ Individual Regions Internal derangements of knee-joint, 168 Inter-phalangeal dislocation, 200 Intra-cranial hæmorrhage, 352 in newly born, 356 syphilis, 387, 395 tuberculosis, 386 venous sinuses, injuries of, 356 Intra-uterine amputation, 311 Intubation of larynx, 639 of œsophagus, 632 Ischæmic contracture of muscles, 85, 98, 310 Ischium, fracture of, 127 Jacksonian epilepsy, 359, 394 Jaw, lower. _See_ Mandible upper. _See_ Maxilla _See also_ Temporo-mandibular Joint Joints. _See also_ Individual Joints Charcot's disease of, 228, 238 contusions of, 33 dislocations of, 36 false, 12 gun-shot injuries of, 34 injuries of, 32 sources of strength of, 32 sprains of, 35 wounds of, 34 Jones' fracture of fifth metatarsal, 194 Kernig's sign, 386 Klapp's four-footed exercises for scoliosis, 472 Knee, ankylosis of, 264 arthritis deformans of, 237 bow-, 271 Charcot's disease of, 238 cold abscess of, 234 contracture of, 264 deformities of, 236, 264 diseases of, 229 pyogenic, 237 tuberculous, 231 dislocations of, 165 congenital, 262 empyema of, 232 footballer's, 172 genu-recurvatum, 263 valgum, 265 varum, 271 hydrops of, 172 hysterical diseases of, 238 injuries in region of, 155 injuries of semilunar menisci, 167 internal derangement of, 168 knock-, 265 loose bodies in, 238 rugby, 165 rupture of cruciate ligaments of, 171 sprains of, 171 surgical anatomy of, 155 tuberculous disease of, 231 clinical types of, 231 deformities following, 236 extra-articular abscess in, 234 white swelling of, 233 Knock-knee, 265 Kocher's method of reducing dislocation of shoulder, 58 Kyphosis, 461, 462 Laryngitis, 637 Laryngoscopy, 635 Larynx, cancer of, 641 cardinal symptoms of affections of, 635 diphtheria of, 637 examination of, 634 foreign bodies in, 642 fracture of, 593 inflammation of, 637 intubation of, 639 œdema of, 637 paralysis of, 639 surgical anatomy of, 634 syphilis of, 639 tuberculosis of, 640 tumours of, 640 wounds of, 594 Laryngo-tracheotomy, 638 Lateral curvature of spine, 463 sinus. _See_ Transverse Sinus ventricles, bursting of abscess into, 381 hæmorrhage into, 342 Leg, bow-, 271 fracture of bones of, 178 congenital deficiencies of, 272 injuries of, 155 rickety deformities of, 271 Lepto-meningitis, 376 Leucokeratosis, 530 Leucoplakia, 530 Ligaments, cruciate, rupture of, 171 Lingual dermoids, 537 Lip, chancre of, 491 chronic induration of, 491 cracks of, 491 cysts of, 493 double-lip, 491 epithelioma of, 493 fistulæ of, 482 hare-lip, 475 herpes of, 490 lymphangioma of, 492 macrocheilia, 492 mucous cysts of, 493 strumous, 491 syphilis of, 491 tuberculosis of, 491 tumours of, 492 ulcers of, 491 Lipoma nasi, 570 Liston's long splint, 152 Little's disease, 247, 357 Longitudinal sinus, phlebitis of, 385 Lordosis, 461 Ludwig's angina, 548, 597 Lumbar abscess, 445 puncture, 338 Lunate bone, dislocation of, 114 fracture of, 110 Luxation. _See_ Dislocation Lymphangiomatous macroglossia, 540 Macrocheilia, 492 Macroglossia, 540 Macrostoma, 481 Madelung's deformity of wrist, 313 Malar bone. _See_ Zygomatic Bone Malformations. _See_ Individual Regions Mallet finger, 318 Mandible, actinomycosis of, 512 cleft of, 481 dentigerous cyst of, 517 dislocation of, 523 old-standing, 524 fixation of, 526 tumours of, 517 Manus valga, 109, 313 vara, 313 Massage in fractures, 21 Mastoid, suppuration in, 566 Maxilla, affections of, 510 fracture of, 519 tumours of, 514 Maxillary sinus, suppuration in, 577 Meninges, surgical anatomy of, 328 Meningitis, 360, 374 basal, 377 cerebro-spinal, 378 serous, 377 spinal, acute, 453 chronic, 452 tuberculous, 433 syphilitic, 387 tuberculous, 386 Meningocele, 388 spinal, 454 Meningo-encephalitis, 376 Meningo-myelocele, 454 Mercurial gingivitis, 508 glossitis, 530 Metacarpals, fracture of, 115, 116 Metatarsals, diseases of, 240 fracture of, 194 Metatarsalgia, 295 Micrencephaly, 393 Microstoma, 481 Middeldorpf's splint, 72 Middle-ear disease, cerebral abscess due to, 378 Middle meningeal hæmorrhage, 352 Mid-tarsal dislocation, 199 Miller's method of reducing dislocation of shoulder, 60 Mobile semilunar meniscus, 168 Morbus coxæ, 210 Morton's disease, 295 Motor areas, 330 tracts, 331 Mouth, affections of, 496 floor of, 499 roof of, 498 Mumps, 546 Musculo-spiral nerve. _See_ Radial Nerve Myelitis, compression, 453 hæmorrhagic, 453 spinal, 453 syphilitic, 453 tuberculous, 433 Myelocele, 455 Myxœdema, post-operative, 610 Nasal affections. _See_ Nose bones, fracture of, 567 ducts, injuries of, 567 Naso-pharynx, affections of, 567 tumours of, 580 Navicular bone, dislocation of, 115 fracture of, 110, 194 Neck, actinomycosis of, 598 boils of, 598 branchial carcinoma, 160 bursal swellings in, 599 carbuncles of, 598 cellulitis of, 597 cervical auricles, 583 fascia, 583 ribs, 585 cicatricial contraction of, 592 contusion of, 592 cystic lymphangioma of, 599 cysts of, 598 blood, 599 branchial, 598 bursal, 599 dermoid, 598 fistulæ of, 584, 585 hydrocele of, 599 hygroma of, 599 injuries of, 592 malformations of, 583 paraffin epithelioma of, 602 potato-like tumour of, 603 stiff, 587 surgical anatomy of, 582 thyreo-glossal cysts in, 538 tumours of, 598, 599 wounds of, 593 wry-, 587 Nélaton's line, 129 Nerve anastomosis, 246 Nerve roots, injuries of, 420 Neuralgia, trigeminal, 400 Neuro-arthropathies. _See_ Individual Joints Neurone lesions, 334 Node, traumatic, 1 Nose, adenoids, 578 anomalies of smell, 578 artificial, 570 asthma, reflex, 578 bleeding from, 575 carcinoma of, 573 cardinal symptoms of nasal affections, 571 concretions in, 575 deformities of, 568 discharge from, 574 displacement of cartilages of, 567 emphysema of, 568 erectile swelling of, 572 examination of, 570 foreign bodies in, 574, 576 fracture of, 567 hammer, 570 lipoma nasi, 570 obstruction of, 572 ozæna, 575 polypi of, 573 potato, 570 reflex symptoms, 578 rhinitis, 575 rhinoliths, 575 rhinophyma, 570 saddle, 567, 568 sarcoma of, 580 septum of, deviations, 573 hæmatoma, 573 ridges, 573 spines, 573 sunken-bridge, 568 suppuration in accessory sinuses, 576 swelling of turbinated bones, 572 traumatic saddle, 567 Nystagmus, labyrinthine, 555 Oculo-motor nerve, 399 Odontoid process, fracture of, 430 Odontoma, 517 Œdema glottidis, 637 Œsophagismus, hiatal, 624 Œsophagitis, 623 Œsophagoscopy, 617 Œsophagospasm, 624 Œsophagus, carcinoma of, 629, 631 cicatricial contraction of, 628 compression of, 624 dilatation of, 625 diverticula of, 625 examination of, 616 foreign bodies in, 619, 621, 623 inflammation of, 623 intubation of, 632 paralysis of, 625 rupture of, 618 spasm of, 624 stricture of, cicatricial, 628 malignant, 629 spasmodic, 624 surgical anatomy of, 616 swallowing of corrosive substances, 618 syphilis of, 623 tuberculosis of, 623 tumours of, 629 varix of, 623 wounds of, 618 X-ray examination of, 617 Old-standing dislocations, 40. _See also_ Individual Joints Olecranon, fracture of, 85 separation of epiphysis of, 87 Olfactory nerve, 399 Ophthalmia, sympathetic, 487 Ophthalmoplegia externa, 400 Optic nerve, 399 Orbit, aneurysms of, 490 cellulitis of, 487 contusions of, 484 emphysema of, 486 eyeball, injuries of, 486 foreign bodies in, 485 fractures of, 485 injuries of, 484 tumours of, 487 wounds of, 485 Os magnum. _See_ Capitate Bone Osteo-chondritis deformans juvenilis, 228 Os trigonum tarsi, 193 Otitis media, 564 Otorrhœa, 555 Ozæna, 575 Pachymeningitis, 374, 433 Palate, affections of, 498 cleft, 477 Palmar fascia, Dupuytren's contraction of, 314 Panophthalmitis, 487 Paracusis of Willis, 554 Paralysis, abductor, 404, 639 Bell's, 401 conjugate, 335 crossed, 334 facial, 400 infantile, 242 spastic, 247 of sterno-mastoid, 404 of tongue, 542 of trapezius, 404 Paraplegia dolorosa, 448 gravitation, 414 spastic, 451 Para-thyreoid glands, 604 Parosmia, 578 Parotid, carcinoma of, 552 duct, affections of, 544 fistula, 544 inflammation of, 545 injuries of, 543 mixed tumours of, 549 recurrent enlargement of, 547 sarcoma of, 552 surgical anatomy of, 543 tuberculosis of, 549 tumours of, 549 Parotitis, 545, 547 Patella, absence of, 262 dislocation of, 177 congenital, 262 floating, 171, 229 fracture of, 173 injuries of, 173 Patheticus nerve, 400 Pathological dislocation, 43 fracture, 1 Pelvis, fractures of, 122 injuries of, 122 Periodontitis, 507 Peri-œsophagitis, 623 Periosteum, hæmatoma of, 1 Peri-tonsillitis, 501 Perthes' disease, 228 Pes arcuatus, 273, 284 calcaneo-valgus, 273, 282, 284 calcaneo-varus, 273, 282, 284 calcaneus, 273, 282 cavus, 273, 282, 283, 284 equinus, 273, 280 excavatus, 284 planus, 285, 287 transverso-planus, 294 valgus, 273, 285, 287 varus, 280 Phalanges of fingers, injuries of, 119, 121 of toes, injuries of, 194, 200 Pharyngeal dimple, 626 Pharyngitis, varieties of, 500 Pharynx, affections of, 500, 619 foreign bodies in, 619, 642 tumours of, 504 Phlebitis. _See_ Individual Vessels Phosphorus necrosis of jaw, 510 Pigeon-toe, 298 Pituitary body, tumours of, 396 Plaster-of-Paris splints, 23 Pneumatocele capitis, 326 Pneumogastric nerve, 403 Poliomyelitis, anterior, 242 Politzer's inflation of middle ear, 558 Polydactylism, 303, 316 Polypi. _See_ Individual Organs Poroplastic felt, 23 Post-anal dimple, 459 Posterior nerve roots, resection of, 247 Post-nasal obstruction, 578 Pott's disease of spine, 431 fracture, 186 with inversion, 191 puffy tumour, 375, 406 Premaxillary bone, 474 Protopathic sensibility, 332 Pseudarthrosis, 12 Psoas abscess, 445 Pubes, fracture of, 123 Pulpitis, 507 Pyorrhœa alveolaris, 509 Quinsy, 501 Radial nerve, implicated in fracture of humerus, 76 Radio-carpal joint, dislocation of, 112 Radio-ulnar joint, inferior, dislocation of, 112 superior, synostosis of, 310 Radius, absence of, 310 avulsion of tubercle of, 88 dislocation of, 94 fracture of lower end, 102 of shaft, 100 of tubercle, 88 of upper end, 88 separation of epiphyses, 88, 109, 110 subluxation of, 96 Railway spine, 422 Ranula, 549 Recurrent dislocation, 43 Reduction of dislocations. _See_ Individual Joints Retro-pharyngeal abscess, 441, 442, 505 Rhinitis, 575 Rhinoliths, 575 Rhinophyma, 570 Rhinoscopy, 570, 571 Rib hump, 466 Ribs, cervical, 585 Round shoulders, 462 Rugby knee, 165 Sacral hygroma, 459 Sacro-coccygeal fistulæ, 459 sinuses, 459 tumours, 459 Sacro-iliac joint, tuberculosis of, 446 Sacrum, fracture of, 127 Saddle nose, 567, 568 Salivary calculi, 545 fistulæ, 544 glands. _See_ Parotid, Submaxillary, Sublingual Mikulicz's disease of, 547 recurrent enlargement of, 547 surgical anatomy of, 543 tuberculosis of, 548 tumours of, 549 Scalp, abscess of, 323 air-containing swellings of, 326 aneurysms of, 326 avulsion of, 322 cellulitis of, 322, 406 cirsoid aneurysm of, 326 contusion of, 320 cysts of, 323 dangerous area of, 321 diseases of, 323 emphysema of, 326 erysipelas of, 323 hæmatoma of, 320, 366 infective conditions of, 323 injuries of, 320 lupus of, 323 pneumatocele of, 326 surgical anatomy of, 319 tumours of, 324 wounds of, 321 complications of, 322 Scaphoid. _See_ Navicular Scapula, congenital elevation of, 303 displacements of, 303, 306 fracture of, 67 separation of epiphyses of, 69, 70 winged, 306 Schlatter's disease, 165 Scissors-leg deformity, 224, 257 Scoliosis, of adolescents, 465 congenital, 465 exercises for, 472 habitual, 465 paralytic, 464 postural, 465 rickety, 464 static, 463 Sculler's sprain, 97 Semilunar menisci of knee, injuries of, 167 Sensation, varieties of, 332 Separation of bony processes, 6 of epiphyses. _See_ Individual Bones Shock, cerebral, 341, 344 Shoulder, ankylosis of, 204 arthritis deformans of, 203 contusion of, 66 diseases of, 201 deformities of, paralytic, 308 dislocation of, with fracture of humerus, 63 dislocation of, 52 congenital, 306 old-standing, 65 paralytic, 308 recurrent or habitual, 65 varieties, 53 examination of, 44 injuries of, 44 loose bodies in, 204 neuro-arthropathies of, 203 pyogenic diseases of, 203 sprain of, 66 Sprengel's, 303 surgical anatomy of, 44 tuberculosis of, 201 Sigmoid sinus, phlebitis of, 384 Sinus phlebitis, 383 thrombosis, 360 Skull, contusion of, 361 diseases of, 406 fracture of, 361 base, 367 anterior fossa, 369 middle fossa, 370 posterior fossa, 371 comminuted, 364 compound infected, 382 by _contre-coup_, 362 depressed, 364 fissured, 363 gutter, 364 indentation, 364 pond, 364 punctured, 364 vault, 361 injuries of, 360 necrosis of, 406, 407 osteomyelitis of, 406 periostitis of, 406 surgical anatomy of, 328 syphilis of, 407 tuberculosis of, 407 tumours of, 407 Smell, anomalies of, 399, 578 Smith's fracture of radius, 106 Smoker's patch on tongue, 532 Snapping hip, 254 Sore throat, varieties of, 500 Spastic paralysis, 247 paraplegia, 451 Speech centres, 335 Sphenoidal cells, suppuration in, 578 Spina bifida, 453 occulta, 457 Spinal accessory nerve, 404 Spinal cord, concussion of, 413 diseases of, 431 functions of, 331, 412 hæmorrhage into, 413 injuries of, 413 at different levels, 416 localisation of, lesions in, 410, 412 membranes of, 412 partial lesions of, 420 in Pott's disease, 433 reflex centres in, 412 segments of, 412 surgical anatomy of, 411 total transverse lesions of, 415 tuberculosis of, 433 tumours of, 450 hæmorrhage, 413 Spine, railway, 422 Splay-foot, 285 Splints, 22 abduction; for hip, 221 frame, for arm, 72 ambulant, for ankle, 189 Balkan frame, 150 box, 182 Bradford frame, 438 "cock-up, " 77 for Colles' fracture, 106 Dupuytren's, 190 Hodgen's, 151 Liston's long, 152 Middeldorpf's, 72 Syme's stirrup, 190 Taylor's, for hip, 222 Thomas', arm, 72 double, 439 hip, 222 knee, 149, 159, 235 wheel-barrow, 439 Spondylitis, traumatic, 427 Sprains of joints, 35 fracture, 35, 171 sculler's, 97 Sprengel's shoulder, 303 Status lymphaticus, 602 Steinmann's apparatus, 150 Stenson's duct, 543 Sterno-mastoid, hæmatoma of, 588 Stomatitis, varieties of, 496 Subclavicular dislocation of shoulder, 62 Sub-conjunctival ecchymosis, 369 Sub-coracoid dislocation of shoulder, 54 Subdural abscess, 376 Sub-glenoid dislocation of shoulder, 62 Subgluteal abscess, 446 Sublingual gland, inflammation of, 548 ranula of, 549 surgical anatomy of, 543 tumours of, 552 Submaxillary gland, calculi of, 545 inflammation of, 548 peri-adenitis of, 548 recurrent enlargement of, 547 surgical anatomy of, 543 tuberculosis of, 549 tumours of, 552 Subspinous dislocation of shoulder, 62 Sub-taloid dislocation, 198 Superior sagittal sinus, phlebitis of, 385 Supernumerary fingers, 316 toes, 303 Surgical anatomy, of ankle, 185 of brain, 328 of ear, 553 of elbow, 79 of forearm, 79 of foot, 185 of hip, 128 of knee, 155 of meninges, 328 of neck, 582 of œsophagus, 616 of parotid gland, 543 of salivary glands, 543 of scalp, 319, 328 of shoulder, 44 of sublingual gland, 543 of submaxillary gland, 543 of thymus gland, 582 of thyreoid gland, 604 of tongue, 528 of tympanic membrane, 557 of vertebral column, 411 of wrist, 102 Swallowing, difficulty in, 623, 636 pain in, 623, 636 Syme's stirrup splint, 190 Symonds' tube, 632 Symphysis pubis, separation of, 122 Syndactylism, 303, 317 Synovitis, septic, 34 Syphilis. _See_ Individual Organs Syringo-myelocele, 455 Tail-like appendage, 458, 459 Talipes equino-varus. _See also_ Pes acquired, 279 congenital, 274 Talus, dislocation of, 196 fracture of, 192 Tarso-metatarsal dislocation, 200 Tarsus, diseases of, 240 dislocations of, 196 fractures of, 192 tuberculosis of, 240 Taste, anomalies of, 578 Taylor's splint for hip, 222 Temporal abscess, 380 Temporo-mandibular joint, arthritis of, 525 arthritis deformans of, 525 dislocation of, 523 fixation of, 525 internal derangements of, 524 suppuration in, 525 tuberculosis of, 525 Tendons, lengthening of, 248 transplantation of, 245 Tennis elbow, 97 Tetany, 610 Thomas' flexion test for hip disease, 215 splints, 72, 149, 159, 222, 235, 439 Thoracic duct, 597 Throat, hospital, 500 Thrush, 496 Thumb, dislocation of, 119 fracture of, 116 stave of, 116 Thymic asthma, 603 Thymus death, 603 gland, affections of, 602 surgical anatomy of, 582 stenosis, 602 Thyreo-glossal cysts, 538, 583, 599 fistulæ, 538, 583 tumours, 538 Thyreoid cartilage, fracture of, 593 gland. _See also_ Goitre accessory, 604 adenoma of, 610 carcinoma of, 281 goitre, 605. _See also_ Goitre inflammation of, 605 malignant, 612 physiological hyperæmia of, 604 sarcoma of, 281 surgical anatomy of, 604 syphilis of, 605 tuberculosis of, 605 Thyreoidectomy, 610 Thyreoidism, acute, 610 Thyreoiditis, 605 Thyreotoxicosis, 614 Tibia, absence of, 272 fracture of, 183 upper end of, 162 head of, 162 separation of lower epiphysis of, 192 upper epiphysis of, 165 tuberosity, avulsion of, 165 and fibula, fracture of, 178 Tibio-fibular articulation, inferior, dislocation of, 196 superior, dislocation of, 167 Tinnitus aurium, 554 Toes, clawing of, 280 deformities of, 296 dislocation of, 200 fracture of phalanges of, 194 hammer-, 300 hypertrophy of, 302 pigeon-, 298 supernumerary, 303 webbing of, 303 Tongue, absence of, 540 atrophy of, 540 bifid, 540 cancer of, 534 inoperable, 537 cysts, 537 dental ulcer of, 529 foot and mouth disease, 530 foreign bodies in, 529 glossitis, 530 gumma of, 533 hemi-glossitis, 530 inflammatory affections of, 530 leucokeratosis, 530 leucoplakia, 530 macroglossia, 540 malformations of, 540 mucous patches on, 533 nervous affections of, 540 neuralgia of, 540 paralysis of, 542 sarcoma of, 536 sclerosing glossitis, 533 smoker's parch, 532 spasm of, 542 surgical anatomy of, 528 syphilis of, 533 -tie, 540 tuberculosis of, 532 tumours of, 534, 537 ulcers of, 532, 536 wounds of, 529 Tonsil, calculi of, 503 hypertrophy of, 502 infective conditions of, 500 inflammation of, 500 Luschka's, 579 naso-pharyngeal, 579 quinsy, 501 syphilis of, 503 tuberculosis of, 503 tumours of, 504 Tonsillitis, varieties of, 500 Tooth, wisdom, impaction of, 508 Torn semilunar meniscus, 170 Torticollis, 587. _See_ Wry-neck Trachea, foreign bodies in, 643 fracture of, 593 scabbard, 608 thymus stenosis of, 602 wounds of, 595 Tracheoscopy, 635 Tracheotomy, 638 Transplantation of tendons, 245 Transverse sinus, phlebitis of, 384 tarsal dislocation, 199 Trapezius, paralysis of, 404 Traumatic apoplexy, 355 cephal-hydrocele, 321, 390 epilepsy, 358 insanity, 360 neurasthenia, 345, 358 node, 1 œdema of brain, 352 spondylitis, 427 Trendelenburg's test, 252 Trigeminal nerve, 400 neuralgia, 400 Trigger finger, 318 Trochlear nerve, 400 Tuberculosis. _See_ Individual Organs Tumours. _See_ Individual Organs Tympanic antrum, suppuration in, 566 membrane, lesions of, 557 perforation of, 557 rupture of, 557, 563 surgical anatomy of, 557 Typhoid spine, 448 Ulna, deficiency of, 311 dislocation of, 94 fracture of upper end, 85 lower end, 110 shaft, 100 separation of epiphysis of, 87, 110 Uvula, bifid, 477 elongation of, 499 Vagus nerve, 403 Valsalva's method of inflating ear, 558 Venous sinuses, intra-cranial injuries of, 356 Ventricles, lateral, bursting of abscess into, 381 hæmorrhage into, 342 Vertebral column, actinomycosis of, 448 arthritis deformans of, 449 blastomycosis of, 448 compression fracture of, 426 congenital deformities of, 458 deviations of, 461 diseases of, 431 dislocations of, 424, 427, 428 fracture-dislocation of, 427 fractures of, 425, 426, 427 hydatid cysts of, 448 hysterical affections of, 448 injuries of, 423 kyphosis, 461, 462 lateral curvature of, 463 lordosis, 461 malignant disease of, 447 osteomyelitis of, 431, 448 Pott's disease of, 431 scoliosis, 463 sprains of, 423 surgical anatomy of, 411 syphilis of, 447 tuberculous disease of, 431 tumours of, 447 twists of, 423 typhoid, 448 wounds of, 430 Vertigo, 555 Visual centres, 335 Volkmann's ischæmic contracture, 85, 98, 310 supra-malleolar deformity, 273 Wandering acetabulum, 210, 227 Wax in ear, 561 Webbed fingers, 317 toes, 303 Wens, 324 White swelling of knee, 233 Winged scapula, 306 Wisdom tooth, impaction of, 508 Wounds. _See_ Individual Regions and Organs Wrist, diseases of, 208 dislocation of, 111, 112 congenital, 313 drop-, 311 injuries of, 102 Madelung's deformity of, 313 sprain of, 115 surgical anatomy of, 102 tuberculous disease of, 208, 209 Wry-neck, 587 acute, 587 hysterical, 592 permanent, 588 rheumatic, 587 spasmodic, 591 transient, 587 Xerostomia, 547 X-rays in fracture, 16 Zygomatic bone, fracture of, 519