Produced by Jonathan Ingram, Chris Logan and the Online
Distributed Proofreading Team at http://www.pgdp.net









+--------------------------------------------------------------------+
|                                                                    |
| Transcriber's note: The inverted 'Y' symbol used in this book has  |
| been transcribed as [inverted Y].                                  |
|                                                                    |
+--------------------------------------------------------------------+




                     OXFORD MEDICAL PUBLICATIONS



                          MANUAL OF SURGERY



                                  BY

                 ALEXIS THOMSON, F.R.C.S.Ed. AND Eng.
           _PROFESSOR OF SURGERY, UNIVERSITY OF EDINBURGH_
                  SURGEON EDINBURGH ROYAL INFIRMARY

                                 AND

                     ALEXANDER MILES, F.R.C.S.Ed.
                  SURGEON EDINBURGH ROYAL INFIRMARY


                            VOLUME SECOND
                       EXTREMITIES--HEAD--NECK


                 _SIXTH EDITION REVISED AND ENLARGED_
                       _WITH 288 ILLUSTRATIONS_



                                LONDON
                 HENRY FROWDE and HODDER & STOUGHTON
                        THE _LANCET_ BUILDING
                 1 & 2 BEDFORD STREET, STRAND, W.C.2






    First Edition                                             1904
    Second Edition                                            1907
    Third Edition                                             1909
    Fourth Edition                                            1912
      "       "    Second Impression                          1913
    Fifth Edition                                             1915
      "       "    Second Impression                          1919
    Sixth Edition                                             1921



                     PRINTED IN GREAT BRITAIN BY
                  MORRISON AND GIBB LTD., EDINBURGH




CONTENTS


                                                                  PAGE
    CHAPTER I
    INJURIES OF BONES                                                1

    CHAPTER II
    INJURIES OF JOINTS                                              32

    CHAPTER III
    INJURIES IN THE REGION OF THE SHOULDER AND UPPER ARM            44

    CHAPTER IV
    INJURIES IN THE REGION OF THE ELBOW AND FOREARM                 79

    CHAPTER V
    INJURIES IN THE REGION OF THE WRIST AND HAND                   102

    CHAPTER VI
    INJURIES IN THE REGION OF THE PELVIS, HIP-JOINT, AND THIGH     122

    CHAPTER VII
    INJURIES IN THE REGION OF THE KNEE AND LEG                     155

    CHAPTER VIII
    INJURIES IN REGION OF ANKLE AND FOOT                           185

    CHAPTER IX
    DISEASES OF INDIVIDUAL JOINTS                                  201

    CHAPTER X
    DEFORMITIES OF THE EXTREMITIES                                 241

    CHAPTER XI
    THE SCALP                                                      319

    CHAPTER XII
    THE CRANIUM AND ITS CONTENTS                                   328

    CHAPTER XIII
    INJURIES OF THE SKULL                                          361

    CHAPTER XIV
    DISEASES OF THE BRAIN AND MEMBRANES                            373

    CHAPTER XV
    DISEASES OF THE CRANIAL BONES                                  406

    CHAPTER XVI
    THE VERTEBRAL COLUMN AND SPINAL CORD                           411

    CHAPTER XVII
    DISEASES OF THE VERTEBRAL COLUMN AND SPINAL CORD               431

    CHAPTER XVIII
    DEVIATIONS OF THE VERTEBRAL COLUMN                             461

    CHAPTER XIX
    THE FACE, ORBIT, AND LIPS                                      474

    CHAPTER XX
    THE MOUTH, FAUCES, AND PHARYNX                                 496

    CHAPTER XXI
    THE JAWS, INCLUDING THE TEETH AND GUMS                         507

    CHAPTER XXII
    THE TONGUE                                                     528

    CHAPTER XXIII
    THE SALIVARY GLANDS                                            543

    CHAPTER XXIV
    THE EAR                                                        553

    CHAPTER XXV
    THE NOSE AND NASO-PHARYNX                                      567

    CHAPTER XXVI
    THE NECK                                                       582

    CHAPTER XXVII
    THE THYREOID GLAND                                             604

    CHAPTER XXVIII
    THE 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 similar
injury of the overlying soft parts. The mildest degree consists in a
bruising of the periosteum, which is raised from the bone by an
effusion of blood, constituting a _hæmatoma of the periosteum_. This
may be absorbed, or it may give place to a persistent thickening of
the bone--_traumatic node_.

#Open Wounds of Bone# of the incised and contused varieties are
usually produced by sabres, axes, butcher's knives, scythes, or
circular saws. Punctured wounds are caused by bayonets, arrows, or
other pointed instruments. They are all equivalent to compound,
incomplete fractures.


FRACTURES

A fracture may be defined as a sudden solution in the continuity of a
bone.


PATHOLOGICAL FRACTURES

A pathological fracture has as its primary cause some diseased state
of the bone, which permits of its giving way on the application of a
force which would be insufficient to break a healthy bone. It cannot
be too strongly emphasised that when a bone is found to have been
broken by a slight degree of violence, the presence of some
pathological condition should be suspected, and a careful examination
made with the X-rays and by other means, before arriving at a
conclusion as to the cause of the fracture. Many cases are on record
in which such an accident has first drawn attention to the presence of
a new-growth, or other serious lesion in the bone. The following
conditions, which are more fully described with diseases of bone, may
be mentioned as the causes of pathological fractures.

_Atrophy_ of bone may proceed to such an extent in old people, or in
those who for long periods have been bed-ridden, that slight violence
suffices to determine a fracture. This most frequently occurs in the
neck of the femur in old women, the mere catching of the foot in the
bedclothes while the patient is turning in bed being sometimes
sufficient to cause the bone to give way. Atrophy from the pressure of
an aneurysm or of a simple tumour may erode the whole thickness of a
bone, or may thin it out to such an extent that slight force is
sufficient to break it. In general paralysis, and in the advanced
stages of locomotor ataxia and other chronic diseases of the nervous
system, an atrophy of all the bones sometimes takes place, and may
proceed so far that multiple fractures are induced by comparatively
slight causes. They occur most frequently in the ribs or long bones of
the limbs, are not attended with pain, and usually unite
satisfactorily, although with an excessive amount of callus.
Attendants and nurses, especially in asylums, must be warned against
using force in handling such patients, as otherwise they may be
unfairly blamed for causing these fractures.

Among diseases which affect the skeleton as a whole and render the
bones abnormally fragile, the most important are rickets,
osteomalacia, and fibrous osteomyelitis. In these conditions multiple
pathological fractures may occur, and they are prone to heal with
considerable deformity. In osteomalacia, the bones are profoundly
altered, but they are more liable to bend than to break; in rickets
the liability is towards greenstick fractures.

Of the diseases affecting individual bones and predisposing them to
fracture may be mentioned suppurative osteomyelitis, hydatid cysts,
tuberculosis, syphilitic gummata, and various forms of new-growth,
particularly sarcoma and secondary cancer. It is not unusual for the
sudden breaking of the bone to be the first intimation of the presence
of a new-growth. In adolescents, fibrous osteomyelitis affecting a
single bone, and in adults, secondary cancer, are the commonest local
causes of pathological fracture.

_Intra-uterine fractures_ and fractures occurring _during birth_ are
usually associated with some form of violence, but in the majority of
cases the fœtus is the subject of constitutional disease which renders
the bones unduly fragile.


TRAUMATIC FRACTURES

Traumatic fractures are usually the result of a severe force acting
from without, although sometimes they are produced by muscular
contraction.

When the bone gives way at the point of impact of the force, the
violence is said to be _direct_, and a "fracture by compression"
results, the line of fracture being as a rule transverse. The soft
parts overlying the fracture are more or less damaged according to the
weight and shape of the impinging body. Fracture of both bones of the
leg from the passage of a wheel over the limb, fracture of the shaft
of the ulna in warding off a stroke aimed at the head, and fracture of
a rib from a kick, are illustrative examples of fractures by direct
violence.

When the force is transmitted to the seat of fracture from a distance,
the violence is said to be _indirect_, and the bone is broken by
"torsion" or by "bending." In such cases the bone gives way at its
weakest point, and the line of fracture tends to be oblique. Thus both
bones of the leg are frequently broken by a person jumping from a
height and landing on the feet, the tibia breaking in its lower third,
and the fibula at a higher level. Fracture of the clavicle in its
middle third, or of the radius at its lower end, from a fall on the
outstretched hand, are common accidents produced by indirect violence.
The ribs also may be broken by indirect violence, as when the chest is
crushed antero-posteriorly and the bones give way near their angles.
In fractures by indirect violence the soft parts do not suffer by the
violence causing the fracture, but they may be injured by displacement
of the fragments.

In fractures by _muscular action_ the bone is broken by "traction" or
"tearing." The sudden and violent contraction of a muscle may tear off
an epiphysis, such as the head of the fibula, the anterior superior
iliac spine, or the coronoid process of the ulna; or a bony process
may be separated, as, for example, the tuberosity of the calcaneus,
the coracoid process of the scapula, or the larger tubercle (great
tuberosity) of the humerus. Long bones also may be broken by muscular
action. The clavicle has snapped across during the act of swinging a
stick, the humerus in throwing a stone, and the femur when a kick has
missed its object. Fractures of ribs have occurred during fits of
coughing and in the violent efforts of parturition.

Before concluding that a given fracture is the result of muscular
action, it is necessary to exclude the presence of any of the diseased
conditions that lead to pathological fracture.

Although the force acting upon the bone is the primary factor in the
production of fractures, there are certain subsidiary factors to be
considered. Thus the age of the patient is of importance. During
infancy and early childhood, fractures are less common than at any
other period of life, and are usually transverse, incomplete, and of
the nature of bends. During adult life, especially between the ages of
thirty and forty, the frequency of fractures reaches its maximum. In
aged persons, although the bones become more brittle by the marrow
spaces in their interior becoming larger and filled with fat,
fractures are less frequent, doubtless because the old are less
exposed to such violence as is likely to produce fracture.

Males, from the nature of their occupations and recreations, sustain
fractures more frequently than do females; in old age, however,
fractures are more common in women than in men, partly because their
bones are more liable to be the seat of fatty atrophy from senility
and disease, and partly because of their clothing--a long skirt--they
are more exposed to unexpected or sudden falls.

[Illustration: FIG. 1.--Multiple Fracture of both Bones of Leg.]

#Clinical Varieties of Fractures.#--The most important subdivision of
fractures is that into simple and compound.

In a _simple_ or subcutaneous fracture there is no communication,
directly or indirectly, between the broken ends of the bone and the
surface of the skin. In a _compound_ or open fracture, on the other
hand, such a communication exists, and, by furnishing a means of
entrance for bacteria, may add materially to the gravity of the
injury.

A simple fracture may be complicated by the existence of a wound of
the soft parts, which, however, does not communicate with the broken
bone.

Fractures, whether simple or compound, fall into other clinical
groups, according to (1) the degree of damage done to the bone, (2)
the direction of the break, and (3) the relative position of the
fragments.

(1) _According to the Degree of Damage done to the Bone._--A fracture
may be incomplete, for example in _greenstick fractures_, which occur
only in young persons--usually below the age of twelve--while the
bones are still soft and flexible. They result from forcible bending
of the bone, the osseous tissue on the convexity of the curve giving
way, while that on the concavity is compressed. The clavicle and the
bones of the forearm are those most frequently the seat of greenstick
fracture (Fig. 41). _Fissures_ occur on the flat bones of the skull,
the pelvic bones, and the scapula; or in association with other
fractures in long bones, when they often run into joint surfaces.
_Depressions_ or indentations are most common in the bones of the
skull.

The bone at the seat of fracture may be broken into several pieces,
constituting a _comminuted_ fracture. This usually results from severe
degrees of direct violence, such as are sustained in railway or
machinery accidents, and in gun-shot injuries (Fig. 2).

[Illustration: FIG. 2.--Radiogram of Comminuted Fracture of both Bones
of Forearm.]

_Sub-periosteal_ fractures are those in which, although the bone is
completely broken across, the periosteum remains intact. These are
common in children, and as the thick periosteum prevents displacement,
the existence of a fracture may be overlooked, even in such a large
bone as the femur.

A bone may be broken at several places, constituting a _multiple_
fracture (Fig. 1).

_Separation of bony processes_, such as the coracoid process, the
epicondyle of the humerus, or the tuberosity of the calcaneus, may
result from muscular action or from direct violence. _Separation of
epiphyses_ will be considered later.

(2) _According to the Direction of the Break._--_Transverse_ fractures
are those in which the bone gives way more or less exactly at right
angles to its long axis. These usually result from direct violence or
from end-to-end pressure. _Longitudinal_ fractures extending the
greater part of the length of a long bone are exceedingly rare.
_Oblique_ fractures are common, and result usually from indirect
violence, bending, or torsion (Fig. 3). _Spiral_ fractures result from
forcible torsion of a long bone, and are met with most frequently in
the tibia, femur, and humerus.

[Illustration: FIG. 3.--Showing (1) Oblique fracture of Tibia; (2)
Oblique fracture with partial separation of Epiphysis of upper end of
Fibula; (3) Incomplete fracture of Fibula in upper third. Result of
railway accident. Boy æt. 16.]

(3) _According to the Relative Position of the Fragments._--The bone
may be completely broken across, yet its ends remain in apposition,
in which case there is said to be _no displacement_. There may be an
_angular_ displacement--for example, in greenstick fracture. In
transverse fractures of the patella or of the olecranon there is often
_distraction_ or pulling apart of the fragments (Fig. 35). The broken
ends, especially in oblique fractures, may _override_ one another, and
so give rise to shortening of the limb (Fig. 2). Where one fragment is
acted upon by powerful muscles, a _rotatory_ displacement may take
place, as in fracture of the radius above the insertion of the
pronator teres, or of the femur just below the small trochanter. The
fragments may be _depressed_, as in the flat bones of the skull or the
nasal bones. At the cancellated ends of the long bones, particularly
the upper end of the femur and humerus, and the lower end of the
radius, it is not uncommon for one fragment to be _impacted_ or wedged
into the substance of the other (Fig. 28).

_Causes of Displacement._--The factors which influence displacement
are chiefly mechanical in their action. Thus the direction and nature
of the fracture play an important part. Transverse fractures with
roughly serrated ends are less liable to displacement than those which
are oblique with smooth surfaces. The direction of the causative force
also is a dominant factor in determining the direction in which one or
both of the fragments will be displaced. Gravity, acting chiefly upon
the distal fragment, also plays a part in determining the
displacement--for example, in fractures of the thigh or of the leg,
where the lower segment of the limb rolls outwards, and in fractures
of the shaft of the clavicle, where the weight of the arm carries the
shoulder downwards, forwards, and medially. After the break has taken
place and the force has ceased to act, displacement may be produced by
rough handling on the part of those who render first aid, the careless
or improper application of splints or bandages, or by the weight of
the bedclothes.

In certain situations the contraction of unopposed, or of unequally
opposed, groups of muscles plays a part in determining displacement.
For example, in fracture immediately below the lesser trochanter of
the femur, the ilio-psoas tends to tilt the upper fragment forward and
laterally; in supra-condylar fracture of the femur, the muscles of the
calf pull the lower fragment back towards the popliteal space; and in
fracture of the humerus above the deltoid insertion, the muscles
inserted into the inter-tubercular (bicipital) groove adduct the upper
fragment.


REPAIR OF INJURIES OF BONE

In a _simple fracture_ the vessels of the periosteum and the marrow
being torn at the same time as the bone is broken, blood is poured
out, and clots around and between the fragments. This clot is soon
permeated by newly formed blood vessels, and by leucocytes and
fibroblasts, the latter being derived from proliferation of the cells
of the marrow and periosteum. The granulation tissue thus formed
resembles in every particular that described in the repair of other
tissues, except that the fibroblasts, being the offspring of cells
which normally form bone, assume the functions of _osteoblasts_, and
proceed to the formation of bone. The new bone may be formed either by
a direct conversion of the fibrous tissue into osseous tissue, the
osteoblasts arranging themselves concentrically in the recesses of the
capillary loops, and secreting a homogeneous matrix in which lime
salts are speedily deposited; or there may be an intermediate stage of
cartilage formation, especially in young subjects, and in cases where
the fragments are incompletely immobilised. The newly formed bone is
at first arranged in little masses or in the form of rods which unite
with each other to form a network of spongy bone, the meshes of which
contain marrow.

The reparative material, consisting of granulation tissue in the
process of conversion into bone, is called _callus_, on account of its
hard and unyielding character. In a fracture of a long bone, that
which surrounds the fragments is called the _external_ or _ensheathing
callus_, and may be likened to the mass of solder which surrounds the
junction of pipes in plumber-work; that which occupies the position of
the medullary canal is called the _internal_ or _medullary callus_;
and that which intervenes between the fragments and maintains the
continuity of the cortical compact tissue of the shaft is called the
_intermediate callus_. This intermediate callus is the only permanent
portion of the reparative material, the external and internal callus
being only temporary, and being largely re-absorbed through the agency
of giant cells.

Detached fragments or splinters of bone are usually included in the
callus and ultimately become incorporated in the new bone that bridges
the gap.

In time all surplus bone is removed, the medullary canal is re-formed,
the young spongy bone of the intermediate callus becomes more and more
compact, and thus the original architectural arrangement of the bone
may be faithfully reproduced. If, however, apposition is not perfect,
some of the new bone is permanently required and some of the old bone
is absorbed in order to meet the altered physiological strain upon the
bone resulting from the alteration in its architectural form. In
overriding displacement, even the dense cortical bone intervening
between the medullary canal of the two fragments is ultimately
absorbed and the continuity of the medullary canal is reproduced.

The amount of callus produced in the repair of a given fracture is
greater when movement is permitted between the broken ends. It is also
influenced by the character of the bone involved, being less in bones
entirely ossified in membrane, such as the flat bones of the skull,
than in those primarily ossified in cartilage.

If the fragments are widely separated from one another, or if some
tissue, such as muscle, intervenes between them, callus may not be
able to bring about a bony union between the fragments, and
_non-union_ results.

Bones divided in the course of an operation, for example in osteotomy
for knock-knee, or wedge-shaped resection for bow-leg, are repaired by
the same process as fractures.

#Excess of Callus.#--In comminuted fractures, and in fractures in
which there is much displacement, the amount of callus is in excess,
but this is necessary to ensure stability. In fractures in the
vicinity of large joints, such as the hip or elbow, the formation of
callus is sometimes excessive, and the projecting masses of new bone
restrict the movements of the joint. When exuberant callus forms
between the bones in fractures of the forearm, pronation and
supination may be interfered with (Fig. 4). Certain nerve-trunks, such
as the radial (musculo-spiral) in the middle of the arm, or the ulnar
at the elbow-joint, may become included in or pressed upon by callus.

[Illustration: FIG. 4.--Excess of Callus after compound fracture of
Bones of Forearm.]

#Absorption of Callus.#--It sometimes happens that when an acute
infective disease, especially one of the exanthemata, supervenes while
a fracture is undergoing repair, the callus which has formed becomes
softened and is absorbed. This may occur weeks or even months after
the bone has united, with the result that the fragments again become
movable, and it may be a considerable time before union finally takes
place.

#Tumours of Callus.#--Tumours, such as chondroma and sarcoma, and
cysts which are probably of the same nature as those met with in
osteomyelitis fibrosa, are liable to occur in callus, or at the seat
of old fractures, but the evidence so far is inconclusive as to the
causative relationship of the injury to the new-growth. They are
treated on the same lines as tumours occurring independently of
fracture.

#Badly United Fracture--Mal-Union.#--Union with marked displacement of
the fragments is most common in fractures that have not been properly
treated--as, for example, those occurring in sailors at sea; and in
cases in which the comminution was so great that accurate apposition
was rendered impossible. It may also result from imperfect reduction,
or because the apparatus employed permitted of secondary displacement.
Restlessness on the part of the patient from intractability, delirium
tremens, or mania, is the cause of mal-union in some cases; sometimes
it has resulted because the patient was expected to die from some
other lesion and the fracture was left untreated.

Whether or not any attempt should be made to improve matters depends
largely on the degree of deformity and the amount of interference with
function.

When interference is called for, if the callus is not yet firmly
consolidated, it may be possible, under an anæsthetic, to bend the
bone into position or to re-break it, either with the hands or by
means of a strong mechanical contrivance known as an osteoclast. In
the majority of cases, however, an open operation yields results which
are more certain and satisfactory. When the deformity is comparatively
slight, the bone is divided with an osteotome and straightened; when
there is marked bending or angling, a wedge is taken from the
convexity, as in the operation for bow-leg. To maintain the fragments
in apposition it may be necessary to employ pegs, plates, bone-grafts,
or other mechanical means. Splints and extension are then applied, and
the condition is treated on the same lines as a compound fracture.

[Illustration: FIG. 5.--Multiple Fractures of both Bones of Forearm
showing mal-union.]

#Delayed Union.#--At the time when union should be firm and solid, it
may be found that the fragments are only united by a soft
cartilaginous callus, which for a prolonged period may undergo no
further change, so that the limb remains incapable of bearing weight
or otherwise performing its functions. The normal period required for
union may be extended from various causes. The most important of these
is general debility, but the presence of rickets or tuberculosis, or
an intercurrent acute infectious disease, may delay the reparative
process. The influence of syphilis, except in its gummatous form, in
interfering with union is doubtful. The influence of old age as a
factor in delaying union has been overestimated; in the great majority
of cases, fractures in old people unite as rapidly and as firmly as
those occurring at other periods of life.

_Treatment._--The general condition of the patient should be improved,
by dieting and tonics. One of the most reliable methods of hastening
union in these cases is by inducing passive hyperæmia of the limb
after the method advocated by Bier, and this plan should always be
tried in the first instance. An elastic bandage is applied above the
seat of fracture, sufficiently tightly to congest the limb beyond,
and, to concentrate the congestion in the vicinity of the fracture, an
ordinary bandage should be applied from the distal extremity to within
a few inches of the break. The hyperæmia should be maintained for
several hours (six to twelve) daily. An apparatus should be adjusted
to enable the patient to get into the open air, and in fractures of
the lower extremity the patient should move about with crutches in the
intervals, putting weight on the fractured bone. This method of
treatment should be persevered with for three or four weeks, and the
limb should be massaged daily while the constricting bandage is off.

Among the other methods which have been recommended are the injection
between the fragments of oil of turpentine (Mikulicz), a quantity of
the patient's own blood (Schmieden), or alcohol and iodine; the
forcible rubbing of the ends together, under an anæsthetic if
necessary; and the administration of thyreoid extract. If these
methods fail, the case should be treated as one of un-united fracture.
As a rule, satisfactory union is ultimately obtained, although much
patience is required.

#Non-Union.#--Sometimes the fragments become united by a dense band of
fibrous tissue, and the reparative process goes no further--_fibrous
union_. This is frequently the case in fractures of the patella, the
olecranon, and the narrow part of the neck of the femur.

_False Joint--Pseudarthrosis._--In rare cases the ends of the
fragments become rounded and are covered with a layer of cartilage.
Around their ends a capsule of fibrous tissues forms, on the inner
aspect of which a layer of endothelium develops and secretes a
synovia-like fluid. This is met with chiefly in the humerus and in the
clavicle.

_Failure of Union--"Un-united Fracture."_--As the time taken for union
varies widely in different bones, and ossification may ultimately
ensue after being delayed for several months, a fracture cannot be
said to have failed to unite until the average period has been long
overpassed and still there is no evidence of fusion of the fragments.
Under these conditions failure of union is a rare complication of
fractures. In adults it is most frequently met with in the humerus,
the radius and ulna (Fig. 6), and the femur; in children in the bones
of the leg and in the forearm.

[Illustration: FIG. 6.--Radiogram of Un-united Fracture of Shaft of
Ulna of fifteen years' duration.]

In a radiogram the bones in the vicinity of the fracture, particularly
the distal fragment, cast a comparatively faint shadow, and there may
even be a clear space between the fragments. When the parts are
exposed by operation, the bone is found to be soft and spongy and the
ends of the fragments are rarefied and atrophied; sometimes they are
pointed, and occasionally absorption has taken place to such an extent
that a gap exists between the fragments. The bone is easily penetrated
by a bradawl, and if an attempt is made to apply plates, the screws
fail to bite. These changes are most marked in the distal fragment.

The want of union is evidently due to defective activity of the
bone-forming cells in the vicinity of the fracture. This may result
from constitutional dyscrasia, or may be associated with a defective
blood supply, as when the nutrient artery is injured. Interference
with the trophic nerve supply may play a part, as cases are recorded
by Bognaud in which union of fractures of the leg failed to take place
after injuries of the spinal medulla causing paraplegia. The condition
has been attributed to local causes, such as the interposition of
muscle or other soft tissue between the fragments, or to the presence
of a separated fragment of bone or of a sequestrum following
suppuration. In our experience such factors are seldom present.

If the treatment recommended for delayed union fails, recourse must be
had to operation, the most satisfactory procedure being to insert a
bone graft in the form of an intra-medullary splint. In certain cases
met with in the bones of the leg in children, the degree of atrophy of
the bones is such that it has been found necessary to amputate after
repeated attempts to obtain union by operative measures have failed.

In the tibia we have found that with the double electric saw a rod of
bone can be rapidly and accurately cut, extending well above as well
as below the site of fracture but unequally in the two directions; the
rod is then reinserted into the trough from which it was taken _with
the ends reversed_, so that a strong bridge of bone is provided at the
seat of non-union.


CLINICAL FEATURES OF SIMPLE FRACTURES

In the first place, the _history of the accident_ should be
investigated, attention being paid to the nature of the
violence--whether a blow, a twist, a wrench, or a crush, and whether
the violence was directly or indirectly applied. The degree of the
violence may often be judged approximately from the instrument
inflicting it--whether, for example, a fist, a stick, a cart wheel, or
a piece of heavy machinery. The position of the limb at the time of
the injury; whether the muscles were braced to meet the blow or were
lax and taken unawares; and the patient's sensations at the moment,
such as his feeling something snap or tear, may all furnish
information useful for purposes of diagnosis.

_Signs of Fracture._--The most characteristic signs of fracture are
unnatural mobility, deformity, and crepitus.

_Unnatural mobility_--that is, movement between two segments of a limb
at a place where movement does not normally occur--may be evident when
the patient makes attempts to use his limb, or may only be elicited
when the fragments are seized and moved in opposite directions.
_Deformity_, or the part being "out of drawing" in comparison with the
normal side, varies with the site and direction of the break, and
depends upon the degree of displacement of the fragments. _Crepitus_
is the name applied to the peculiar grating or clicking which may be
heard or felt when the fractured surfaces are brought into contact
with one another.

The presence of these three signs in association is sufficient to
prove the existence of a fracture, but the absence of one or more of
them does not negative this diagnosis. There are certain fallacies to
be guarded against. For example, a fracture may exist and yet
unnatural mobility may not be present, because the bones are impacted
into one another, or because the fracture is an incomplete one. Again,
the extreme tension of the swollen tissues overlying the fracture may
prevent the recognition of movement between the fragments. Deformity
also may be absent--as, for instance, when there is no displacement of
the fragments, or when only one of two parallel bones is broken, as in
the leg or forearm. Similarly, crepitus may be absent when impaction
exists, when the fragments completely override one another, or are
separated by an interval, or when soft tissues, such as torn
periosteum or muscle, are interposed between them. A sensation
simulating crepitus may be felt on palpating a part into which blood
has been extravasated, or which is the seat of subcutaneous emphysema.
The creaking which accompanies movements in certain forms of
teno-synovitis and chronic joint disease, and the rubbing of the
dislocated end of a bone against the tissues amongst which it lies,
may also be mistaken for the crepitus of fracture.

It is not advisable to be too diligent in eliciting these signs,
because of the pain caused by the manipulations, and also because
vigorous handling may do harm by undoing impaction, causing damage to
soft parts or producing displacement which does not already exist, or
by converting a simple into a compound fracture.

It is often necessary for purposes of diagnosis to administer a
general anæsthetic, particularly in injuries of deeply placed bones
and in the vicinity of joints. Before doing so, the appliances
necessary for the treatment of the injury should be made ready, in
order that the fracture may be reduced and set before the patient
regains consciousness.

_Radiography in the Diagnosis of Fractures._--While radiography is of
inestimable value in the diagnosis of many fractures and other
injuries, particularly in the vicinity of joints, the student is
warned against relying too implicitly on the evidence it seems to
afford.

A radiogram is not a photograph of the object exposed to the X-rays
but merely a picture of its shadow, or rather of a series of shadows
of the different structures, which vary in opacity. As the rays
emanate from a single point in the vacuum tube, and as they are not,
like the sun's rays, approximately parallel, the shadows they cast are
necessarily distorted. Hence, in interpreting a radiogram, it is
necessary to know the relative positions of the point from which the
rays proceed, the object exposed, and the plate on which the shadow is
registered. The least distortion takes place when the object is in
contact with the plate, and the shadow of that part of the object
which lies perpendicularly under the light is less distorted than that
of the parts lying outside the perpendicular. The light and the plate
remaining constant, the amount of distortion varies directly with the
distance between the object and the plate.

To ensure accuracy in the diagnosis of fracture by the X-rays, it is
necessary to take two views of the limb--one in the sagittal and the
other in the coronal plane. By the use of the fluorescent screen, the
best positions from which to obtain a clear impression of the fracture
may be determined before the radiograms are taken. Stereoscopic
radiograms may be of special value in demonstrating the details of a
fracture that is otherwise doubtful.

Imperfect technique and faulty interpretation of the pictures obtained
lead to certain fallacies. In young subjects, for example, epiphysial
lines may be mistaken for fractures, or the ossifying centres of
epiphyses for separated fragments of bone. The os trigonum tarsi has
been mistaken for a fracture of the talus. In the vicinity of joints
the bones may be crossed by pale bands, due to the rays traversing the
cavity of the joint. In this way fracture of the olecranon or of the
clavicle may be simulated. The neck of the femur may appear to be
fractured if a foreshortened view is taken.

It is possible, on the other hand, to overlook a fracture--for
example, if there is no displacement, or if the line of fracture is
crossed by the shadow of an adjacent bone. In deeply placed bones such
as those about the hip, or in bones related to dense, solid
viscera--for example, ribs, sternum, or dorsal vertebræ--it is
sometimes difficult to obtain conclusive evidence of fracture in a
radiogram.

It is to be borne in mind also, and especially from the medico-legal
point of view, that, as early callus does not cast a deep shadow in a
radiogram, the appearance of fracture may persist after union has
taken place. The earliest shadow of callus appears in from fourteen to
twenty-one days, and can hardly be relied upon till the fourth or
sixth week. The disturbed perspective produced by divergence of the
rays may cause the fragments of a fracture to appear displaced,
although in reality they are in good position. If the limb and the
plate are not parallel, the bones may appear to be distorted, and
errors in diagnosis may in this way arise. In this relation it should
be mentioned that perfect apposition of the fragments and anatomically
accurate restoration of the outline of the bones are not always
essential to a good functional result.

       *       *       *       *       *

As most of the remaining signs are common to all the lesions from
which fractures have to be distinguished, their diagnostic value must
be carefully weighed.

_Interference with Function._--As a rule, a broken bone is incapable
of performing its normal function as a lever or weight-bearer; but
when a fracture is incomplete, when the fragments are impacted, or
when only one of two parallel bones is broken, this does not
necessarily follow. It is no uncommon experience to find a patient
walk into hospital with an impacted fracture of the neck of the femur
or a fracture of the fibula; or to be able to pronate and supinate the
forearm with a greenstick fracture of the radius or a fracture of the
ulna.

_Pain._--Three forms of pain may be present in fractures: pain
independent of movement or pressure; pain induced by movement of the
limb; and pain elicited on pressure or "tenderness." In injuries by
direct violence, pain independent of movement and pressure is never
diagnostic of fracture, as it may be due to bruising of soft tissues.
In injuries resulting from indirect violence, however, pain localised
to a spot at some distance from the point of impact is strongly
suggestive of fracture--as, for example, when a patient complains of
pain over the clavicle after a fall on the hand, or over the upper end
of the fibula after a twist of the ankle. Pain elicited by attempts to
move the damaged part, or by applying pressure over the seat of
injury, is more significant of fracture. Pain elicited at a particular
point on pressing the bone at a distance, "pain on distal
pressure,"--for example, pain at the lower end of the fibula on
pressing near its neck, or at the angle of a rib on pressing near the
sternum,--is a valuable diagnostic sign of fracture. When nerve-trunks
are implicated in the vicinity of a fracture, pain is often referred
along the course of their distribution.

_Localised swelling_ comes on rapidly, and is due to displacement of
the fragments and to hæmorrhage from the torn vessels of the marrow
and periosteum.

_Discoloration_ accompanies the swelling, and is often widespread,
especially in fracture of bones near the surface and when the tension
is great. It is not uncommon to find over the ecchymosed area,
especially over the shin-bone, large blebs containing blood-stained
serum. In fractures of deep-seated bones, discoloration may only show
on the surface after some days, and at a distance from the break.

Alterations in the relative position of _bony landmarks_ are valuable
diagnostic guides. Alteration in the _length_ of the limb, usually in
the direction of shortening, is also an important sign. Before drawing
deductions, care must be taken to place both limbs in the same
position and to determine accurately the fixed points for measurement,
and also to ascertain if the limbs were previously normal.

_Shock_ is seldom a prominent symptom in uncomplicated fractures,
although in old and enfeebled patients it may be serious and even
fatal. During the first two or three days after a fracture there is
almost invariably some degree of traumatic _fever_, indicated by a
rise of temperature to 99° or 100° F.

#Complications.#--_Injuries to large arteries_ are not common in
simple fractures. The popliteal artery, however, is liable to be
compressed or torn across in fractures of the lower end of the femur;
extravasation of blood from the ruptured artery and gangrene of the
limb may result. If large _veins_ are injured, thrombosis may occur,
and be followed by pulmonary embolism.

_Injuries to nerve-trunks_ are comparatively common, especially in
fractures of the arm, where the radial (musculo-spiral) nerve is
liable to suffer.

The nerve may be implicated at the time of the injury, being
compressed, bruised, lacerated, or completely torn across by broken
fragments, or it may be involved later by the pressure of callus. The
symptoms depend upon the degree of damage sustained by the nerve, and
vary from partial and temporary interference with sensation and motion
to complete and permanent abrogation of function.

In rare instances _fat embolism_ is said to occur, and fat globules
are alleged to have been found in the urine. In persons addicted to
excess of alcohol, _delirium tremens_ is a not infrequent
accompaniment of a fracture which confines the patient to bed.

#Prognosis in Simple Fractures.#--_Danger to life_ in simple fractures
depends chiefly on the occurrence of complications. In old people, a
fracture of the neck of the femur usually necessitates long and
continuous lying on the back, and bronchitis, hypostatic pneumonia,
and bed-sores are prone to occur and endanger life. Fractures
complicated with injury to internal organs, and fractures in which
gangrene of the limb threatens, are, of course, of grave import.

The prognosis as regards the _function of the limb_ should always be
guarded, even in simple fractures. Incidental complications are liable
to arise, delaying recovery and preventing a satisfactory result, and
these not only lead to disappointment, but may even form a ground for
actions for malpraxis.

The chief and most frequent cause of permanent disability after
fracture is angular displacement. A comparatively small degree of
angularity may lead to serious loss of function, especially in the
lower limb; the joints above and below the fracture are placed at a
disadvantage, arthritic changes result from the abnormal strain to
which they are subjected, and rarefaction of the bone may also ensue.

Fibrous union is a common result in fractures of the neck of the femur
in old people and in certain other fractures, such as fracture of the
patella, of the olecranon, coronoid and coracoid processes, and
although this does not necessarily involve interference with function,
the patient should always be warned of the possibility.

Impairment of growth and eventual shortening of the limb may result
from involvement of an epiphysial junction.

Stiffness of joints is liable to follow fractures implicating
articular surfaces, or it may result from arthritic changes following
upon the injury.

Osseous ankylosis is not a common sequel of simple fractures, but
locking of joints from the mechanical impediment produced by the
union of imperfectly reduced fragments, or from masses of callus, is
not uncommon, especially in the region of the elbow.

Wasting of the muscles and œdema of the limb often delay the complete
restoration of function. Delayed union, want of union, and the
formation of a false joint have already been referred to.

#Treatment.#--The treatment of a fracture should be commenced as soon
after the accident as possible, before the muscles become contracted
and hold the fragments in abnormal positions, and before the blood and
serum effused into the tissues undergo organisation.

Care must be taken during the transport of the patient that no further
damage is done to the injured limb. To this end the part must be
secured in some form of extemporised splint, the apparatus being so
designed as to control not only the broken fragments, but also the
joints above and below the fracture.

When the ordinary method of removing the clothes involves any risk of
unduly moving the injured part, they should be slit open along the
seams.

The patient should be placed on a firm straw, horse-hair, or spring
mattress, stiffened in the case of fractures of the pelvis or lower
limbs by fracture-boards inserted beneath the mattress. Special
mattresses constructed in four pieces, to facilitate the nursing of
the patient, are sometimes used.

In many cases, particularly in muscular subjects, in restless
alcoholic patients, and in those who do not bear pain well, a general
anæsthetic is a valuable aid to the accurate setting of a fracture, as
well as a means of rendering the diagnosis more certain.

The procedure popularly known as "setting a fracture" consists in
restoring the displaced parts to their normal position as nearly as
possible, and is spoken of technically as the _reduction_ of the
fracture.

_The Reduction of Fractures._--In some cases the displacement may be
overcome by relaxing the muscles acting upon the fragments, and this
may be accomplished by the stroking movements of massage. In most
cases, however, it is necessary, after relaxing the muscles, to employ
_extension_, by making forcible but steady traction on the distal
fragment, while _counter-extension_ is exerted on the proximal one,
either by an assistant pulling upon that portion of the limb, or by
the weight of the patient's body. The fragments having been freed, and
any shortening of the limb corrected in this way, the broken ends are
moulded into position--a process termed _coaptation_.

The reduction of a recent greenstick fracture consists in forcibly
straightening the bend in the bone, and in some cases it is necessary
to render the fracture complete before this can be accomplished.

In selecting a means of retaining the fragments in position after
reduction, the various factors which tend to bring about
re-displacement must be taken into consideration, and appropriate
measures adopted to counteract each of these.

In addition to retaining the broken ends of the bone in apposition,
the after-treatment of a fracture involves the taking of steps to
promote the absorption of effused blood and serum, to maintain the
circulation through the injured parts, and to favour the repair of
damaged muscles and other soft tissues. Means must also be taken to
maintain the functional activity of the muscles of the damaged area,
to prevent the formation of adhesions in joints and tendon sheaths,
and generally to restore the function of the injured part.

_Practical Means of Effecting Retention--By Position._--It is often
found that only in one particular position can the fragments be made
to meet and remain in apposition--for example, the completely supine
position of the forearm in fracture of the radius just above the
insertion of the pronator teres. Again, in certain cases it is only by
relaxing particular groups of muscles that the displacement can be
undone--as, for instance, in fracture of the bones of the leg, or of
the femur immediately above the condyles, where flexion of the knee,
by relaxing the calf muscles, permits of reduction.

_Massage and Movement in the Treatment of
Fractures._--Lucas-Championnière, in 1886, first pointed out that a
certain amount of movement between the ends of a fractured bone
favours their union by promoting the formation of callus, and
advocated the treatment of fractures by massage and movement,
discarding almost entirely the use of splints and other
retentive appliances. We were early convinced by the teaching of
Lucas-Championnière, and have adopted his principles in fractures.

In the majority of cases the massage and movement are commenced at
once, but circumstances may necessitate their being deferred for a few
days. The measures adopted vary according to the seat and nature of
the fracture, but in general terms it may be stated that after the
fracture has been reduced, the ends of the broken bone are retained in
position, and gentle massage is applied by the surgeon or by a trained
masseur. The lubricant may either be a powder composed of equal parts
of talc and boracic acid, or an oily substance such as olive oil or
lanolin. The rubbing should never cause pain, but, on the contrary,
should relieve any pain that exists, as well as the muscular spasm
which is one of the most important causes of pain and of displacement
in recent fractures. The parts on the proximal side of the injured
area are first gently stroked upwards to empty the veins and
lymphatics, and to disperse the effused blood and serum. The process
is then applied to the swollen area, and gradually extended down over
the seat of the fracture and into the parts beyond. In this way the
circulation through the damaged segment of the limb is improved, the
veins are emptied of blood, the removal of effused fluid is
stimulated, and the muscular irritability allayed. The joints of the
limb are gently moved, care being taken that the broken ends of the
bone are not displaced. After the rubbing has been continued for from
fifteen to twenty minutes, the limb is placed in a comfortable
position, and retained there by pillows, sand-bags, or, if found more
convenient, by a light form of splint.

The massage is repeated once each day; the sittings last from ten to
fifteen minutes. The sequence should be, first, massage; second,
passive movement; and third, active movement. At first massage
predominates, and more passive than active movement; gradually massage
is lessened and movements are increased, active movements ultimately
preponderating.

_Splints and other Appliances._--The appropriate splints for
individual fractures and the method of applying them will be described
later; but it may here be said that the general principle is that when
dealing with a part where there is a single bone, as the thigh or
upper arm, the splint should be applied in the form of a _ferrule_ to
surround the break; while in situations where there are two parallel
bones, as in the forearm and leg, the splint should take the form of a
_box_.

_Simple wooden splints_ of plain deal board or yellow pine, sawn to
the appropriate length and width; or _Gooch's splinting_, which
consists of long strips of soft wood, glued to a backing of
wash-leather, are the most useful materials. Gooch's splinting has the
advantage that when applied with the leather side next the limb it
encircles the part as a ferrule; while it remains rigid when the
wooden side is turned towards the skin. Perforated sheet lead or tin,
stiff wire netting, and hoop iron also form useful splints.

When it is desirable that the splint should take the shape of the part
accurately, a plastic material may be employed. Perhaps the most
convenient is _poroplastic felt_, which consists of strong felt
saturated with resin. When heated before a fire or placed in boiling
water, it becomes quite plastic and may be accurately moulded to any
part, and on cooling it again becomes rigid. The splint should be cut
from a carefully fitted paper pattern. Millboard, leather, or
gutta-percha softened in hot water, and moulded to the part, may also
be employed.

In conditions where treatment by massage and movement is
impracticable, and where movable splints are inconvenient, splints of
_plaster of Paris_, _starch_, or _water-glass_ are sometimes used,
especially in the treatment of fractures of the leg. When employed in
the form of an immovable case, they are open to certain
objections--for example, if applied immediately after the accident
they are apt to become too tight if swelling occurs; and if applied
while swelling is still present, they become slack when this subsides,
so that displacement is liable to occur.

When it is desired to enclose the limb in a plaster case, coarse
muslin bandages, 3 yards long, and charged with the finest quality of
thoroughly dried plaster of Paris, are employed. The "acetic plaster
bandages" sold in the shops set most quickly and firmly. Boracic lint
or a loose stocking is applied next the skin, and the bony prominences
are specially padded. The plaster bandage is then placed in cold water
till air-bubbles cease to escape, by which time it is thoroughly
saturated, and, after the excess of water is squeezed out, is applied
in the usual way from below upward. From two to four plies of the
bandage are required. In the course of half an hour the plaster should
be thoroughly set. To facilitate the removal of a plaster case the
limb should be immersed for a short time in tepid water.

A convenient and efficient splint is made by moulding two pieces of
poroplastic felt to the sides of the limb, and fixing them in position
with an elastic webbing bandage; this apparatus can be easily removed
for the daily massage.

_Padding_ is an essential adjunct to all forms of splints. The whole
part enclosed in the splint must be covered with a thick layer of soft
and elastic material, such as wool from which the fat has not been
removed. All hollows should be filled up, and all bony projections
specially protected by rings of wadding so arranged as to take the
pressure off the prominent point and distribute it on the surrounding
parts. Opposing skin surfaces must always be separated by a layer of
wool or boracic lint. A bandage should never be applied to the limb
underneath the splints and pads, as congestion or even gangrene may be
induced thereby.

#Operative Treatment of Simple Fractures.#--Operation in simple
fracture is specially called for (1) in fracture into or near a joint
where a permanently displaced fragment will cause locking of the
joint; (2) when fragments are drawn apart, as in fractures of the
patella or olecranon; (3) when displacement, especially shortening,
cannot be remedied by other means; (4) when complications are present,
such as a torn nerve-trunk or a main artery; (5) when non-union is to
be feared, as in certain cases of fracture of the neck of the femur in
old people. Under such circumstances it is necessary to expose the
fracture by operation, and to place the fragments in accurate
apposition, if necessary, fixing them in position by wires, pegs,
plates, or screws (_Op. Surg._, p. 52). Operative interference is
usually delayed till about five to seven days after the injury, by
which time the effect of other measures will have been estimated,
accurate information obtained by means of the X-rays regarding the
nature of the lesion and the position of the fragments, and the
tissues recovered their normal powers of resistance. Such operations,
however, are not to be undertaken lightly, as they are often
difficult, and if infection takes place the results may be disastrous.
Arbuthnot Lane and Lambotte advocate a more general resort to
operative measures, even in simple and uncomplicated fractures, and it
must be conceded that in many fractures an open operation affords the
only means of securing accurate apposition and alignment of the
fragments.

Both before and after operation, massage and movement are to be
carried out, as in fractures treated by other methods.


COMPOUND FRACTURES

The essential feature of a compound fracture is the existence of an
open wound leading down to the break in the bone. The wound may vary
in size from a mere puncture to an extensive tearing and bruising of
all the soft parts.

A fracture may be rendered compound _from without_, the soft parts
being damaged by the object which breaks the bone--as, for example, a
cart wheel, a piece of machinery, or a bullet. Sloughing of soft parts
resulting from the pressure of improperly applied splints, also, may
convert a simple into a compound fracture. On the other hand, a simple
fracture may be rendered compound _from within_--for example, a sharp
fragment of bone may penetrate the skin; this is the least serious
variety of compound fracture.

As a rule, it is easy to recognise that the fracture is compound, as
the bone can either be seen or felt.

The _prognosis_ depends on the success which attends the efforts to
make and to keep the wound aseptic, as well as on the extent of damage
to the tissues. When asepsis is secured, repair takes place as in
simple fracture, only it usually takes a little longer; sometimes the
reason for the delay is obvious, as when the compound fracture is the
result of a more severe form of violence and where there is
comminution and loss of one or more portions of bone that would have
contributed to the repair. Sometimes the delay cannot be so explained;
Bier suggested that it is due to the escape of blood at the wound,
whereas in simple fractures the blood is retained and assists in
repair.

If sepsis gains the upper hand in a compound fracture there is,
firstly, the risk of infection of the marrow--osteomyelitis--which in
former times was liable to result in pyæmia; in the second place, not
only do loose fragments tend to die and be thrown off as sequestra,
but the ends of the fragments themselves may undergo necrosis;
involving as this does the dense cortical bone of the shaft, the dead
bone is slow in being separated, and until it is separated and thrown
off, no actual repair can take place. The sepsis stimulates the
bone-forming tissues and new bone is formed in considerable amount,
especially on the surface of the shaft in the vicinity of the
fracture; in macerated specimens it presents a porous, crumbling
texture. Sometimes the new bone--which corresponds to the involucrum
of an osteomyelitis--imprisons a sequestrum and prevents its
extrusion, in which case one or more sinuses may persist indefinitely.
Cases are met with where such sinuses have existed for the best part
of a long life and have ultimately become the seat of epithelioma.

It should be noted that all the above changes can be followed in
skiagrams.

_Treatment._--The leading indication is to ensure asepsis. Even in the
case of a small punctured wound caused by a pointed fragment coming
through the skin it is never wise to assume that the wound is not
infected. It is much safer to enlarge such a wound, pare away the
bruised edges, and disinfect the raw surfaces.

In cases of extensive laceration of the soft parts, all soiled,
bruised, or torn portions of tissue should be clipped away with
scissors, blood-clots removed, and the bleeding arrested by
forci-pressure or ligature. If there is any reason to believe that
the wound is infected, any fragments of bone completely separated from
the periosteum should be removed. In comminuted fractures, extension
applied by strips of plaster or by means of ice-tong callipers or
Steinmann's apparatus (p. 150) often facilitates replacement of the
fragments and their retention in position. Plates and screws are not
recommended for comminuted fractures, owing to the mechanical
difficulty of fixing a number of small fragments and the risks of
infection. The wound should be purified with eusol, and the
surrounding parts painted with iodine. On the whole, it is safer not
to attempt to obtain primary union by completely closing such wounds,
but rather to drain or pack them. To increase the local leucocytosis
and so check the spread of infection, a Bier's constricting bandage
may be applied.

In other respects the treatment is carried out on the same lines as in
simple fractures, provision being made for dressing the wound without
disturbance of the fracture. Massage and movement should be commenced
after the wound is healed and the condition has become analogous to a
simple fracture.

#Question of Amputation in Compound Fractures.#--Before deciding to
perform primary amputation of a limb for compound fracture, the
surgeon must satisfy himself (1) that the attainment of asepsis is
impossible; (2) that the soft parts are so widely and so grossly
damaged that their recovery is improbable; (3) that the vascular and
nervous supply of the parts beyond has been rendered insufficient by
destruction of the main blood vessels and nerve-trunks; (4) that the
bones have been so shattered as to be beyond repair; and (5) that the
limb, even if healing takes place, will be less useful than an
artificial one.

In attempting to save the limb of a young subject, it is justifiable
to run risks which would not be permissible in the case of an older
person. To save an upper limb, also, risks may be run which would not
be justifiable in the case of a lower limb, because, while a
serviceable artificial leg can readily be procured, any portion of the
natural hand or arm is infinitely more useful than the best substitute
which the instrument-maker can contrive. The risk involved in
attempting to save a limb should always be explained to the patient or
his guardian, in order that he may share the responsibility in case of
failure.

Whether or not the amputation should be performed at once, depends
upon the general condition of the patient. If the injury is a severe
one, and attended with a profound degree of shock, it is better to
wait for twenty-four or forty-eight hours. Meanwhile the wound is
purified, and the limb wrapped in a sterile dressing. Means are taken
to counteract shock and to maintain the patient's strength, and
evidence of infection or of hæmorrhage is carefully watched for. When
the shock has passed off, the operation is then performed under more
favourable auspices. Clinical experience has proved that by this means
the mortality of primary amputations may be materially diminished,
especially in injuries necessitating removal of an entire limb.

Having decided to amputate, it is important to avoid having bruised,
torn, or separated tissues in the flaps, as these are liable to slough
or to become the seat of infection. In this connection it should be
borne in mind that the damage to soft tissues is always wider in
extent than appears from external examination.

The attempt to save a limb may fail and amputation may be called for
later because of spreading infective processes, osteomyelitis, or
gangrene; to prevent exhaustion from prolonged suppuration and toxin
absorption; or on account of secondary hæmorrhage.

#Gun-shot Injuries of Bone.#--Fractures resulting from the impact of
bullet or fragments of shell are of necessity compound, and are
usually infected from the outset by organisms carried in by the
missile or by portions of clothing or other foreign material. Not
infrequently the missile lodges in the bone.

[Illustration: FIG. 7.--Excessive Callus Formation after infected
Compound Fracture of both Bones of Forearm--result of gun-shot wound.
Fusion of Bones across Interosseous Space.]

The extent of the injury to the bone varies infinitely, from a mere
chip or gutter-shaped wound to complete pulverisation of the portion
struck. The fracture is of the comminuted and fissured variety, the
cracks radiating from the point of impact and extending for a
considerable distance, sometimes even implicating the articular
surface of the bone some inches away. In comminuted fractures of the
shafts of long bones there is often a large wedge-shaped fragment
completely isolated from the rest, and in the presence of infection
this may form a sequestrum. Healing is often delayed by the separation
of sequestra, which takes place slowly, and union is attended with
excessive formation of callus. When a considerable section of the
shaft has been lost, want of union, fibrous union, or the formation of
a false joint may result.

The treatment is carried out on the same lines as in other forms of
compound fracture, except that mention should be made of the
irrigation method of Carrel, found to be the most potent means of
overcoming the associated infection.


SEPARATION OF EPIPHYSES[1]

[1] We do not employ the term "diastasis," which has been used in
different senses by different writers.

In young subjects before the bones are fully developed the epiphyses
may be separated from the diaphyses. The use of the X-rays has added
greatly to our knowledge of these lesions.

It is useful to remember that in the upper extremity the epiphyses in
the regions of the shoulder and wrist, and, in the lower extremity,
those in the region of the knee, are the latest to unite; and that it
is in these situations that growth in length of the bone goes on
longest and most actively (twenty to twenty-one years). Injuries of
these epiphyses, therefore, are most liable to interfere with the
growth of the limb.

An epiphysis is nourished from the articular arteries and through the
vessels of the periosteum.

_Pathological Separation of Epiphyses._--There are certain
pathological conditions, such as rickets, scurvy, congenital syphilis,
tubercle, suppurative conditions, and tumour growths, which render
separation of the epiphyses liable to occur from injuries altogether
insufficient to produce such lesions under normal conditions.

#Traumatic Separations.#[2]--Speaking generally, it may be said that
injuries which in an adult would be liable to produce dislocation, are
in a young person more apt to cause separation of an epiphysis.
Indirect violence, especially when exerted in such a way as to combine
traction with torsion,--for example, when the foot is caught in the
spokes of a carriage wheel,--is the commonest cause of epiphysial
separation. Direct violence is a much less frequent cause. Muscular
action occasionally produces separation of the epiphyses--for example,
the anterior superior iliac spine, the small trochanter of the femur,
or the upper end of the fibula.

[2] We desire here to acknowledge our indebtedness to Mr. John
Poland's work on _Traumatic Separation of the Epiphyses_.

[Illustration: FIG. 8.--Partial Separation of Epiphysis, with Fracture
running into Diaphysis.]

[Illustration: FIG. 9.--Complete Separation of Epiphysis.]

[Illustration: FIG. 10.--Partial Separation with Fracture of
Epiphysis.]

[Illustration: FIG. 11.--Complete Separation with Fracture of
Epiphysis.]

The majority of separations take place between the eleventh and the
eighteenth years, chiefly because during this period the injuries
liable to produce such lesions are most common. They do not occur
after twenty-five, because by that time all the epiphyses have united.
In females this form of injury is rare, and almost invariably occurs
before puberty.

The following are the most common seats of separation in the order of
their frequency: (1) the lower end of the femur; (2) the lower end of
the radius; (3) the upper end of the humerus; (4) the lower end of the
humerus; (5) the lower end of the tibia; and (6) the upper end of the
tibia.

_Morbid Anatomy._--In a true separation the epiphysial cartilage
remains attached to the epiphysis. As a rule the epiphysis is not
completely separated from the diaphysis, the common lesion being a
separation along part of the epiphysial line, with a fracture running
into the diaphysis (Fig. 8). It is not uncommon for more than one
epiphysis to be separated by the same accident--for example, the lower
end of the femur and the upper ends of the tibia and fibula.
Epiphysial separations, like fractures, may be _simple_ or _compound_.
Incomplete separations are liable to be overlooked at the time of the
accident, but there is reason to believe that they may form the
starting-point of disease. Strain of the epiphysial junction--the
_juxta-epiphysial strain_ of Ollier--is a common injury in young
children.

_Clinical Features._--The symptoms simulate those of dislocation
rather than of fracture. Thus, _unnatural mobility_ at an epiphysial
junction may closely resemble movement at the adjacent joint,
especially when the epiphysis is an intra-capsular one. The
relationship of the bony points, however, serves to indicate the
nature of the lesion. The degree of _deformity_ is often slight,
because the transverse direction of the lesion, the breadth of the
separated surfaces, and the firmness of the periosteal attachment
along the epiphysial line often prevent displacement. In many cases a
distinct, rounded, smooth, and regular ridge, caused by the projection
of the diaphysis, can be felt. The peculiar "muffled" nature of the
_crepitus_ is one of the most characteristic signs. The older the
patient, and the further ossification has progressed, the more does
the crepitus resemble that of fracture.

Of the subsidiary signs, _loss of power_ in the limb is one of the
most constant; indeed, in young children it is sometimes the first,
and may be the only, sign that attracts attention. _Pain_ and
_tenderness_ along the epiphysial line are valuable signs,
particularly when the lesion is due to indirect or muscular violence
and there is no bruising of soft parts. Localised _swelling_,
accompanied by _ecchymosis_, is often marked; and the adjacent joint
may be distended with fluid.

As distinguishing this injury from a dislocation, it may be noted that
in epiphysial separation there is no snap felt when the deformity is
reduced, the tendency to re-displacement is greater, and the amount of
relief given by reduction less than in dislocation. The use of the
Röntgen rays at once establishes the diagnosis.

_Prognosis and Results._--In the majority of cases union takes place
satisfactorily by the formation of callus in the spongy tissue of the
diaphysis and on the deep surface of the periosteum. In spite of the
favourable nature of the prognosis in general, however, the friends of
the patient should be warned that a completely satisfactory result
cannot always be relied upon.

Deformity, with stiffness and locking at the adjacent joint,
especially at the elbow, may result from imperfect reduction, or from
exuberant callus. Arrest of growth of the bone in length is a rare
sequel, and when it occurs, it is due, not to premature union of the
epiphysis with the shaft, but to diminished action at the ossifying
junction.

When the growth of one of the bones of the leg or forearm is arrested
after separation of its epiphysis while the other bone continues to
grow, the foot or hand is deviated towards the side of the shorter
one.

Partial separations may be overlooked at the time of the accident and
cause trouble later from bending of the bone, as in one variety of
coxa vara. The epiphysis at the lower end of the femur may be
displaced into the ham and press on the popliteal vessels.

_Treatment._--The general principles which govern the treatment of
fractures apply equally to epiphysial separations, the essential being
the accurate replacement of the epiphysis.

In _compound separations of epiphysis_, the end of the diaphysis may
be pushed through the skin. The entrance of sepsis may prove an
obstacle to any operative measure that would otherwise be indicated.




CHAPTER II

INJURIES OF JOINTS


SURGICAL ANATOMY--INJURIES: _Contusions_; _Wounds_; _Sprains_;
    _Dislocations_--TRAUMATIC DISLOCATIONS: _Causes_: _Varieties_;
    _Clinical features_; _Treatment_--Compound
    dislocations--Old-standing dislocations.

#Surgical Anatomy.#--The function of a joint is to permit of the
movement of one bone upon another. The articular surfaces are covered
with a thin layer of hyaline cartilage, and are retained in apposition
by the tension of ligaments and of the muscles surrounding the joint.
The articular capsule (capsular ligament) is directly continuous with
the periosteum, and is lined by a synovial layer, which at the line of
attachment of the capsule is reflected on to the bone as far as the
articular cartilage. The synovial layer invests intra-articular
ligaments, and is projected into the interior of the joint in the form
of loose folds wherever the articulating surfaces are not in immediate
contact. The surface of the synovial layer is covered with minute
processes or villi, which in diseased conditions may become
hypertrophied. The synovia owes its lubricating property to mucin,
derived from the solution of the endothelial cells on the free surface
of the synovial layer. The opposing surfaces of a joint being always
in accurate contact, the so-called cavity is only a potential one. If
fluid is poured out into the joint, the synovial layer and the capsule
are put upon the stretch, causing discomfort or actual pain, which is
partly relieved by slightly flexing the joint. If the distension
persists, the ligaments become elongated and the joint unstable.

The common origin of bone, cartilage, periosteum, and synovial layer
from one parent tissue of the embryo, accords with the readiness with
which any one of these tissues may be converted into another under
traumatic or pathological influences; and how in ligaments and in
synovial membrane foci of hyaline cartilage may form and, after
increasing in size, undergo ossification.

Joints derive an abundant blood supply through the articular arteries.
The lymphatics, which take origin in the synovial layer, pass to
efferent vessels which run in the intermuscular and other
connective-tissue planes of the limb. The nerve supply is derived
chiefly from the nerves distributed to the muscles acting on the joint
and to the skin over it.

#Sources of Joint Strength.#--The capacity of a joint to resist
dislocation depends upon (1) the shape of its osseous elements; (2)
the strength and arrangement of its ligaments; (3) the support it
receives from muscles or tendons placed in relation to it; and (4) the
relative stability of adjacent structures. While all these factors
contribute to the strength of a given joint, one or other of them
usually predominates, so that certain joints are osseously strong,
others are ligamentously strong, while a few depend chiefly upon
adjacent muscles for their stability.

The hip and elbows are the best examples of joints deriving their
strength mainly from the architectural arrangement of the constituent
bones. These joints are dislocated only by extreme degrees of
violence, and not infrequently--especially in the elbow--portions of
the bones are fractured before the articular surfaces are separated.

The knee, the wrist, the carpal, the tarsal, and the clavicular joints
depend for their stability almost entirely on the strength of their
ligaments. These joints are rarely dislocated, but as the main
incidence of the violence falls on the ligaments they are frequently
sprained.

The shoulder is the typical example of a joint depending for its
security chiefly upon the muscles and tendons passing over it, and
hence the frequency with which it is dislocated when the muscles are
taken unawares. At the same time the great mobility of the scapula and
clavicle materially increases the stability of the shoulder-joint. The
tendons passing in relation to the knee, ankle, and wrist add to the
stability of these joints.

The proximity of an easily fractured bone also contributes to prevent
dislocation of certain joints--for example, fracture of the clavicle
prevents an impinging force expending itself on the shoulder-joint;
and the frequency of Colles' fracture of the radius, and of Pott's
fracture of the fibula, doubtless accounts to some extent for the
rarity of dislocation of the wrist and ankle-joints respectively. The
immunity from dislocation which the joints of young subjects enjoy is
partly due to the ease with which an adjacent epiphysis is separated.

The mechanical axiom that "what is gained in movement is lost in
stability" applies to joints, those which have the widest range of
movement being the most frequently dislocated.

       *       *       *       *       *

The injuries to which a joint is liable are Contusions, Wounds,
Sprains, and Dislocations.

#Contusions of Joints.#--Contusion is the mildest form of injury to a
joint. Whether the violence is transmitted from a distance, as in
contusion of the hip from a fall on the feet, or acts more directly,
as in a fall on the great trochanter, the bones are violently driven
against one another, and the force expends itself on their articular
surfaces. The articular cartilages and the underlying spongy bone, as
well as the synovial lining, are bruised, and there is an effusion of
blood and serous fluid into the joint and surrounding tissues.

The most prominent _clinical features_ are swelling and discoloration.
The swelling, especially in superficially placed joints, is an early
and marked symptom, and is mainly due to the effusion of blood into
the joint (_hæmarthrosis_). In deeply placed joints, discoloration may
not appear on the surface for some days, especially if the violence
has been indirect. The joint is kept in the flexed position, and is
painful only when moved. In hæmophilic subjects, considerable effusion
of blood into a joint may follow the most trivial injury.

A slight degree of serous effusion into the joint (_hydrarthrosis_)
often persists for some time, and tuberculous affections of joints not
infrequently date from a contusion.

The _treatment_ is the same as for sprains (p. 36).

#Wounds of Joints.#--The importance of accidental wounds of
joints--such, for example, as result from a stab with a penknife or
the spike of a railing--lies in the fact that they are liable to be
followed by infection of the synovial cavity. The infection may
involve only the synovial layer (_septic synovitis_), or may spread to
all the elements of the joint (_septic arthritis_). These conditions
are described with diseases of joints.

Penetration of the joint may sometimes be recognised by the escape of
synovia from the wound, or the synovial layer or articular cartilage
may be exposed. When doubt exists, the wound should be enlarged. The
use of the probe is to be avoided, on account of the risk of carrying
infective material from the track of the wound into the joint.

Penetrating wounds of joints are treated on the same lines as compound
fractures. If the penetrating instrument is to be regarded as
infected,--as, for example, when the spoke of a motor bicycle is
driven through the upper pouch of the knee,--the injury is to be
looked upon as serious and capable of endangering the function of the
joint, loss of the limb, or even life itself. Reliance is chiefly laid
on primary excision of the edges and track of the wound, and other
measures employed in the treatment of gun-shot wounds. While the wound
in the synovialis and capsule is sutured, that in the soft parts is
left open. If drainage is employed, the tube extends down to the
opening in the synovialis, but not into the joint itself. If sepsis
supervenes, the joint is opened and irrigated by Carrel's method. Some
form of splint and a Bier's bandage are valuable adjuncts. The final
recourse is to amputation.

#Gun-shot injuries# of joints vary in severity from a mere puncture of
the synovial layer by a chip of shell to complete shattering of the
articular surfaces. Between these extremes are cases in which the
capsular and synovial layer are extensively lacerated without
involvement of the bones, and others in which the bones are implicated
without serious damage being done to ligaments or synovial layer--for
example, by a bullet passing through and through the cancellated part
of one of the constituent bones, or by a fissure extending into the
articular surface.

In all degrees the great risk is from septic infection, which may be
assumed to be present in all but the last-named variety.

The _treatment_ consists in immediately cleansing the wound by
excising grossly damaged tissue and removing any foreign body that may
have lodged; disinfecting the exposed part of the joint cavity with
eusol, "bipp," or other antiseptic, and closing the wound or
establishing drainage, according to circumstances. The joint is then
immobilised till the wound has healed, after which massage and
movement are commenced. When the bones are shattered or when sepsis
gets the upper hand and disorganises the joint, amputation is called
for.

#Sprains.#--A sprain results from a stretching or twisting form of
violence which causes the joint to move beyond its physiological
limits, or in some direction for which it is not structurally adapted.
The main incidence of the force therefore falls upon the ligaments,
which are suddenly stretched or torn. The synovial layer also is torn,
and the joint becomes filled with blood and synovial fluid.

Muscles and tendons passing over the joint are stretched or torn, and
their sheaths filled with serous effusion. It is not uncommon for
portions of bone to be torn off at the site of attachment of strong
ligamentous bands or tendons, constituting a "sprain fracture"; or for
intra-articular cartilages to be torn and displaced, as in the knee.

_Clinical Features._--The injury is accompanied by intense sickening
pain, and this may persist for a considerable time. At first it is
aggravated by moving the joint, but if the movement is continued it
tends to pass off. The particular ligaments involved may be recognised
by the tenderness which is elicited on making pressure over them, or
by putting them on the stretch. In this way a sprain may often be
diagnosed from a fracture in which the maximum tenderness is over the
injury to the bone.

The effusion of blood and synovia into the joint and into the tissues
around gives rise to swelling and discoloration, and the fluid effused
into tendon sheaths often produces a peculiar creaking sensation,
which may be mistaken for the crepitus of fracture. In sprains, the
bony points about the joint retain their normal relations to one
another, and this usually enables these injuries to be diagnosed from
dislocations. When the swelling is great, it is often necessary to
have recourse to the Röntgen rays to make certain that there is no
fracture or dislocation. The special features and complications of
sprains of the knee are discussed with other injuries of that joint.

_Repair of Sprains._--Blood and synovia are absorbed and torn
structures become reunited, but in this process adhesions may form
inside the joint and in the surrounding tendon sheaths and interfere
with the movement of the joint.

_Prognosis._--Stiffness, lasting for a longer or shorter time, follows
most sprains, but may be largely prevented by proper treatment. In old
and rheumatic persons, changes of the nature of arthritis deformans
are liable to supervene, interfering greatly with movement. While
suppuration is rare, tuberculous disease is alleged to have resulted
from a sprain.

_Treatment._--If seen immediately after the accident, firm pressure
should be applied by means of an elastic bandage over a thick layer of
cotton wool, to prevent bleeding and effusion of synovia. Later the
best treatment is by massage and movement. In the ankle, for example,
massage should be commenced at once, the part being gently stroked
upwards. If the massage is light enough there is no pain, it is
actually soothing. The rubbing is continued for from fifteen to twenty
minutes, and the patient is encouraged to move the toes and ankle; a
moderately firm elastic bandage is then applied. The massage is
repeated once or twice a day, the sittings lasting for about fifteen
minutes. The patient should be encouraged to move the joint from the
first, beginning with the movements that put least strain upon the
damaged ligaments, and gradually increasing the range. In the course
of a few days he is encouraged to walk or cycle, or otherwise to use
the joint without subjecting it to strain, or to a repetition of the
movement that caused the accident. Alternate hot and cold douching, or
hot-air baths, followed by massage, are also useful. Complete rest and
prolonged immobilisation are to be condemned.


TRAUMATIC DISLOCATIONS

A dislocation or luxation is a persistent displacement of the opposing
ends of the bones forming a joint. We are here concerned only with
such dislocations as immediately follow upon injury. Those that are
congenital or that result from disease will be studied later.

_Causes._--The majority of dislocations are the result of _indirect_
violence, the more movable bone acting as a lever, on a fulcrum
furnished by the natural check to movement in the form of ligament,
bone, or muscle. It is in this way that most dislocations of the
shoulder, hip, and elbow are produced.

At the moment the violence is applied, the muscles are relaxed or
otherwise taken at a disadvantage, so that the joint is for the time
being deprived of their support. The joint is moved beyond its
physiological range, and the end of one of the bones being brought to
bear upon the capsule, tears it, and passes through the rent thus
made. The muscles then contract reflexly, and pull the head of the
bone into an unnatural position outside the capsule. The position
assumed will depend upon such factors as the direction of the force,
the structure of the joint, the position of the limb at the time of
the accident, and the relative strength of the different groups of
muscles acting upon the bone which is displaced.

Violence applied _directly_ to the joint is a much less frequent cause
of dislocation. In this way, however, the knee-joint may be
dislocated, one bone being driven past the other--for example, by a
kick from a horse; or the acromio-clavicular joint by a blow on the
shoulder.

_Muscular contraction_ is not often the sole cause of dislocation,
although, as has been mentioned, it plays an important rôle in the
production of the majority of these injuries. The shoulder, mandible,
and patella are, however, not infrequently displaced by muscular
action alone. Acrobats sometimes acquire the power of dislocating
certain joints by voluntary contraction of their muscles.

_Age and Sex._--Dislocations occur most frequently in adult males,
doubtless on account of the nature of their occupations and
recreations. In children the epiphyses are separated, and in old
people the bones are broken by such forms of violence as cause
dislocation in the middle-aged.

Muscular debility and undue laxness of ligaments resulting from
disease or previous dislocation are also predisposing factors.

_Clinical Varieties._--The separation between the bones may be
_complete_ or _partial_. When partial, portions of the articular
surfaces remain in apposition, and the injury is known as a
_sub-luxation_. Like fractures, dislocations may be _simple_ or
_compound_, the latter being specially dangerous on account of the
risk of infection. When seen within a few days of its occurrence, a
dislocation is looked upon as _recent_; but when several weeks or
months have elapsed, it is spoken of as an _old-standing_ dislocation.
The latter will be described later.

Dislocations, like fractures, may be _complicated_ by injuries to
large blood vessels or nerve-trunks, by injuries to internal organs,
or by a wound of the soft tissues which does not communicate with the
joint. Further, a fracture may coexist with a dislocation--a most
important complication.

_Clinical Features._--The most characteristic signs of dislocation are
_preternatural rigidity_, or want of movement where movement should
naturally take place; _mobility in abnormal directions_; and
_deformity_, the part being "out of drawing" as compared with the
uninjured side (Fig. 18). The bony landmarks lose their normal
relationship to one another; and the deformity is characteristic, and
is common to all examples of the same dislocation.

Although any of the subsidiary signs may occur in lesions other than
dislocations, due weight must be given to them in making a diagnosis.
_Loss of function_ is complete as a rule. _Pain_ is much more intense
than in fracture, usually because the displaced bone presses upon
nerve-trunks, and from the same cause there is often numbness and
partial paralysis of the limb beyond. _Swelling_ of the soft parts due
to effused blood is usually less marked in dislocation than in
fracture, but is often sufficiently great to interfere with diagnostic
manipulations. The displaced bone, and sometimes the empty socket, may
be palpable. _Discoloration_ is usually later of appearing than in
fractures. _Alteration in the length_ of the injured limb--usually in
the direction of shortening--is a common feature; while girth
measurements usually show an increase. A peculiar soft _grating_ or
_creaking sensation_ is often felt on attempting to move the joint;
this is due to cartilaginous or ligamentous structures rubbing on one
another, and must not be mistaken for the crepitus of fracture. In the
majority of cases, although not in all, after reduction has been
effected, the bones retain their proper relations without external
support, a point in which a dislocation differs from a fracture. A
careful investigation of the kind of force which produced the injury,
particularly as regards its intensity and direction of action, may aid
in the diagnosis. The diagnosis can always be verified by the use of
the Röntgen rays, and this should be had recourse to whenever
possible, as a fracture may be shown that otherwise would escape
recognition.

_Prognosis._--After having once been dislocated, a joint is seldom as
strong as it was formerly, although for all practical purposes the
limb may be as useful as ever. Some degree of stiffness, of limited
movement, or of muscular weakness, and occasional arthritic changes
and a liability to re-dislocation, are the commonest sequelæ.
Prolonged immobilisation is liable to lead to stiffness by permitting
of the formation of adhesions; while too early movement tends to
produce a laxity of the ligaments which favours re-displacement from
slight causes.

_Treatment._--Reduction should be attempted at the earliest possible
moment. Every hour of delay increases the difficulty. The guiding
principle is to cause the displaced bone to re-enter its socket by
the same route as that by which it left it--that is, through the
existing rent in the capsule. This is done by carrying out certain
manipulations which depend upon the anatomical arrangement of the
parts, and which vary, not only with different joints, but also with
different varieties of dislocation of the same joint. In general terms
it may be said that the main impediments to reduction are: the
contraction of the muscles acting upon the displaced bone; the
entanglement of the bone among tendons or ligamentous bands which fix
it in its abnormal position; and the rent in the capsule being small
or valvular, so that it forms an obstacle to the bone reentering the
socket.

Muscular contraction is best overcome by the administration of a
general anæsthetic, and in all but the simplest cases this should be
given to ensure accurate and painless reduction. Failing this,
however, the muscles may be wearied out by the surgeon making steady
and prolonged traction on the limb, while an assistant makes
counter-extension on the proximal segment of the joint. Advantage may
also be taken of such muscular relaxation as occurs when the patient
is already faint, or when his attention is diverted from the injured
part, to carry out the manipulations necessary to restore the bone to
its normal position.

The appropriate manœuvres for disengaging the head of the bone from
tendons, ligaments, or bony processes with which it may be entangled,
will be suggested by a consideration of the anatomy of the particular
joint involved, and will be described with individual dislocations.

In reducing a dislocation, no amount of physical force will compensate
for a want of anatomical knowledge. All tugging, twisting, or
wrenching movements are to be avoided, as they are liable to cause
damage to blood vessels, nerves, or other soft parts, or even--and
especially in old people--to fracture one of the bones concerned.

After reduction, great benefit is gained by the systematic use of
_massage_ and movement. Before any restraining apparatus is applied
the whole region should be gently stroked in a centrifugal direction
for fifteen or twenty minutes; and this is to be repeated daily, each
sitting lasting for about twenty minutes. From the first day onward,
movement of the joint is carried out in every direction, except that
which tends to bring the head of the bone against the injured part of
the capsule; and the patient is encouraged to move the joint as early
as possible. The appropriate apparatus and the period during which it
should be worn will be considered with the individual dislocations.

_Operation in Simple Dislocations._--In a limited number of cases,
even with the aid of an anæsthetic, reduction by manipulation is found
to be impossible. Resort must then be had to operation, which is a
comparatively safe and satisfactory proceeding, although often
difficult. It may happen in rare instances that the undoing of the
displacement is only possible after the removal of a portion of one or
other of the bones.

#Compound Dislocations.#--Compound dislocations are usually the result
of extreme violence produced by machinery or railway accidents, or by
a fall from a height. In the majority of cases they are complicated by
fracture of one or more of the constituent bones of the joint, as well
as by laceration of muscles, tendons, and blood vessels. In the region
of the ankle, wrist, and joints of the thumb, however, compound
dislocation is sometimes met with uncomplicated by other lesions. The
great risk is infection, which may result in serious impairment of the
usefulness of the joint or even in its complete destruction, results
towards which the concomitant injuries materially contribute. In many
instances where infection has occurred, ankylosis is the best result
that can be hoped for.

_Treatment._--As a rule, the first question that arises is whether
amputation is necessary or not, and the considerations that determine
this point are the same as in compound fractures (p. 26). If an
attempt is to be made to save the limb, the treatment is the same as
in compound fracture (p. 25).

#Dislocation complicated by Fracture.#--In certain dislocations the
separation of small portions of bones or of epiphyses is of common
occurrence--for example, fracture of the tip of the coronoid process
in dislocation of the elbow backwards, and chipping off of a portion
of the edge of the acetabulum in dislocation of the hip.

The most important example of a fracture complicating a dislocation is
fracture of the surgical neck of the humerus coexisting with
dislocation of the shoulder. Here the difficulty of diagnosis is
greatly increased, and the treatment of both injuries requires to be
modified. The dislocation must be reduced--by operation if
necessary--before the fracture is treated, and in many cases it is
advisable to secure the fragments of the broken bone by pegs, or
plates, to admit of movement being commenced early, and so to prevent
stiffness of the joint.

#Old-standing Dislocations.#--When, from want of recognition--and,
curiously enough, a dislocation is much more liable to be overlooked
than would have been thought possible--or from unsuccessful treatment,
a dislocation is left unreduced, changes take place in and around the
joint which render reduction increasingly difficult or impossible. The
rent in the capsule closes upon the neck of the bone, and fibrous
adhesions form between muscles, tendons, and other structures that
have been torn. The articular cartilage of the head, being no longer
in contact with an opposing cartilage, tends in time to be converted
into fibrous tissue, and may become adherent to other fibrous
structures in its vicinity. By pressing on adjacent structures it may
form for itself a new socket of dense fibrous tissue which in time
becomes lined with a secreting membrane. When the displaced head lies
against a bone, the continuous pressure produces a new osseous socket,
from the margins of which osteophytic outgrowths may spring, and as
the surrounding fibrous tissue becomes condensed and forms a strong
capsule, a new joint results. The occurrence of these changes in the
direction of a new ball-and-socket joint is largely dependent on the
behaviour of the patient: a vigorous man, anxious to recover the use
of the limb, will employ it with a degree of determination and
indifference to pain that could not be expected in a sensitive elderly
female. The most perfect example of a new ball-and-socket joint,
following upon an unreduced dislocation at the hip, that has come
under our observation, was in a hunting dog, given one of us by an
Australian pupil, who testified that the animal was as fleet with the
new joint as it had been with the original one. Meanwhile the
cartilage of the original socket is converted into fibrous tissue,
which may come to fill up the cavity. Changes resembling those of
arthritis deformans may occur. The large blood vessels and nerves in
the vicinity may be pressed upon or stretched by the displaced bone,
or may be implicated in fibrous adhesions. In course of time they
become lengthened or shortened in accordance with the altered attitude
of the limb.

[Illustration: FIG. 12.--Os Innominatum showing new socket formed
after old-standing dislocation. The acetabulum is almost obliterated.]

In many cases the new joint is remarkably mobile and useful; but in
others, pain, limited movement, and atrophy of muscles render it
comparatively useless, and surgical intervention is called for.

_Treatment._--It is always a difficult problem to determine the date
after which it is inadvisable to attempt reduction by manipulation in
an old dislocation and no rules can be laid down which will cover all
cases. Rather must each case be decided on its own merits, due
consideration being had to the risks that attend this line of
treatment. The chief of these are: rupture of a large blood vessel or
nerve that has formed adhesions with the displaced bone, or has become
shortened in adaptation to the altered shape or length of the limb;
tearing of muscles or tendons, or even of skin; fracture of the bone,
especially in old people; and separation of epiphyses in the young.

Before carrying out the manipulations appropriate to the particular
dislocation, all adhesions must first be broken down; and during the
proceedings no undue force is to be employed. The first attempt at
reduction may fail, and yet subsequent efforts, at intervals of a few
days, may ultimately prove successful; the vigorous traction and
twisting of the soft parts, matted together as they are by
scar-tissue, causes reactive changes in the vessels and tissues which
render them more liable to yield on subsequent attempts at reduction.
In old people, and where there is an absence of suffering from
pressure on nerves or vessels, it may be wiser to leave the
dislocation unreduced, and strive rather by massage and movement to
obtain a useful variety of false joint. If the conditions are
otherwise, it may be better to improve the function of the limb by an
_open operation_. Tight ligaments and other structures are divided,
and the socket is cleared out. If reduction is still impossible, a
partial excision may be performed and a flap of fascia lata introduced
to prevent ankylosis (arthroplasty). In the case of the hip, the
dislocation may be left alone and the femur divided below the
trochanter, especially if there is pronounced flexion.

#Habitual or recurrent dislocation# is almost exclusively met with in
the shoulder, and will be described with the injuries of that joint.

#Pathological Dislocations.#--Joints may become dislocated in the
course of certain diseases. These pathological dislocations fall into
different groups: (1) those due to gradual stretching of the capsular
and other ligaments weakened by inflammatory and suppurative
processes, such as sometimes follow on typhoid, scarlet fever, or
diphtheria, and in pyæmia; (2) those due to destructive changes in the
ligaments and bones--typically seen in tuberculous arthritis, in
arthritis deformans, in Charcot's disease, and in nerve lesions,
_e.g._ dislocation of the hip in spastic conditions, such as Little's
disease; (3) those associated with deformed attitudes of the limb; (4)
those due to changes in the articular surfaces, _e.g._ the phalanges
in arthritis deformans. These will be considered with the conditions
which give rise to them.

#Congenital Dislocations.#--Congenital dislocations are believed to be
the result of abnormal or arrested development _in utero_, and are to
be distinguished from dislocations occurring during birth, which are
essentially traumatic in origin. They will be described along with the
Deformities of the Extremities.




CHAPTER III

INJURIES IN THE REGION OF THE SHOULDER AND UPPER ARM


Surgical Anatomy--FRACTURES OF CLAVICLE: _Varieties_--DISLOCATION OF
    CLAVICLE: _Varieties_--DISLOCATION OF SHOULDER:
    _Varieties_--Sprains and contusions of shoulder--FRACTURE OF
    SCAPULA: Sites--FRACTURE OF UPPER END OF HUMERUS: _Surgical neck_;
    _Separation of epiphysis_; _Fracture of head, anatomical neck, or
    tuberosities_--FRACTURES OF SHAFT OF HUMERUS.

The injuries met with in the region of the shoulder include fractures
and dislocations of the clavicle, fractures of the scapula,
dislocations and sprains of the shoulder-joint, and fractures of the
upper end of the humerus.

#Surgical Anatomy.#--For the examination of an injury in the region of
the shoulder the patient should be seated on a low stool or chair.
After inspecting the parts from the front, the surgeon stands behind
the patient and systematically examines by palpation the shoulder
girdle and upper end of the humerus. The uninjured side should be
examined along with the other for purposes of comparison.

Immediately lateral to the supra-sternal notch, the sterno-clavicular
articulation may be felt, the large end of the clavicle projecting to
a varying degree beyond the margins of the small and shallow articular
surface on the sternum. Any dislocation of this joint is at once
recognised. The clavicle being subcutaneous throughout its whole
length, any irregularity in its outline can be easily detected. A
small tubercle (deltoid tubercle) which frequently exists near the
acromial end is liable to suggest the presence of a fracture. The
lateral end forms with the acromion the acromio-clavicular joint,
which, however, is not always readily identified. The fingers are now
carried over the acromion, which often exhibits in the situation of
its epiphysial cartilage a prominent ridge, which must not be mistaken
for a fracture. The tip of the acromion is usually employed as a fixed
point in measuring the length of the upper arm.

The outline of the spine of the scapula can be traced back to the
vertebral border; and the body of the bone may be manipulated, and its
movements tested by moving the arm.

The coracoid process can be recognised in the upper and lateral angle
of the triangular depression bounded by the pectoralis major, the
deltoid, and the clavicle.

The head and surgical neck of the humerus may now be felt from the
axilla, if the axillary fascia is relaxed by bringing the arm to the
side. The great tuberosity can be indistinctly felt on the lateral
aspect of the shoulder through the fibres of the deltoid. It lies
vertically above the lateral epicondyle, and may be felt to rotate
with the shaft. The inter-tubercular (bicipital) groove looks forward,
and lies in a line drawn vertically through the biceps muscle.

The subclavian artery, with its vein to the median side and the cords
of the brachial plexus to the lateral side, passes under the middle of
the clavicle, and may be compressed against the first rib immediately
above this bone.


FRACTURE OF THE CLAVICLE

Fracture of the clavicle is one of the commonest injuries met with in
practice. As about one-third of the cases occur in children, the
fracture is often of the greenstick variety. The fractures are seldom
compound or complicated, unless as a result of gun-shot injuries; but
occasionally one of the fragments pierces the skin, or comes to press
upon the subclavian vessels or the cords of the brachial plexus,
arresting the pulsation in the vessels of the limb, and causing severe
pain in the arm.

[Illustration: FIG. 13.--Oblique Fracture of Right Clavicle in Middle
Third, united.]

The most common site of fracture is in the _middle third_ (Fig. 13),
and this usually results from indirect violence, such as a fall on the
outstretched hand, the elbow, or the outer aspect of the shoulder, the
force being transmitted through the glenoid cavity to the scapula, and
thence by the coraco-clavicular ligaments to the clavicle. The
violence is therefore of a twisting character, and the bone gives way
near the junction of the lateral and middle thirds, just where the two
natural curves of the bone meet, and where the supporting muscular and
ligamentous attachments are weakest.

The fracture so produced is usually oblique from above, downwards and
inwards. The sternal fragment may be slightly drawn upwards by the
clavicular fibres of the sterno-mastoid, while the acromial fragment
falls by the weight of the arm, and the fragments usually overlap to
the extent of about half an inch. The shoulder, having lost the
buttressing support of the clavicle, falls in towards the chest wall,
narrowing the axillary space, while the weight of the arm pulls it
downward, and the muscles inserted in the region of the bicipital
groove pull it forward.

Fracture of the middle third may result also from a direct stroke,
such as the recoil of a gun, or from violent muscular contraction, the
fracture as a rule being transverse, and the displacement less marked
than in fracture by indirect violence.

_Clinical Features._--The attitude of the patient is characteristic:
the elbow is flexed and is supported by the opposite hand, while the
head is inclined towards the affected shoulder to relax the muscles of
the neck. Crepitus is elicited on bracing back the shoulders, or on
attempting to raise the arm beyond the horizontal, and these movements
cause pain. Tenderness is elicited on making pressure over the seat of
fracture, and also on distal pressure. The sternal fragment almost
invariably overrides the acromial, and can usually be palpated through
the skin; on measurement, the clavicle is found to be shortened. When
the fracture is incomplete (greenstick) or transverse, the symptoms
are less marked.

[Illustration: FIG. 14.--Fracture of Acromial End of Clavicle. Shows
forward rotation of lateral fragment, and line of fracture united by
bone.]

Fracture of the _lateral_ or _acromial third_ of the clavicle is a
common form of accident at football matches, and usually results from
direct violence, the bone being driven down against the coracoid
process, and broken as one breaks a stick over the knee. The fracture
may take place through the attachment of the conoid and trapezoid
ligaments, in which case the only symptoms are pain and tenderness at
the seat of fracture, with impaired movement of the limb. Displacement
and crepitus are prevented by the splinting action of the ligaments.

When the break is lateral to the attachment of the trapezoid ligament,
the fracture is usually transverse, and is almost always due to a fall
on the back of the shoulder--the angle between the spine and the
acromion process striking the ground. The acromial fragment rotates
forward (Fig. 14), sometimes even to a right angle, causing the tip of
the shoulder to pass forwards, and so to lie slightly nearer the
middle line. The integrity of the coraco-clavicular ligaments prevents
any marked drooping of the shoulder. It is noteworthy that the
displacement is not always evident at first.

Fractures of the _medial_ or _sternal third_ are rare, are usually
oblique, and result either from an indirect force acting in the line
of the clavicle, or, less frequently, from direct violence or muscular
action. As a rule, the deformity is insignificant, except when the
costo-clavicular ligament is torn, in which case the medial end of the
distal fragment is tilted up by the weight of the arm. The shoulder
passes downwards, forwards, and medially. When close to the sternal
end, this fracture may simulate a dislocation of the sterno-clavicular
joint or a _separation of the clavicular epiphysis_. This last is a
rare accident, which may occur between the seventeenth and the
twenty-fifth years, and is usually the result of violent muscular
action. It differs from the other injuries in this region in being
more easily reduced and retained in position, the epiphysis lying
entirely within the limits of the articular capsule of the
sterno-clavicular joint.

_Simultaneous fracture of both clavicles_ usually results from a
severe transverse crush of the upper part of the thorax or from a fall
on the outstretched hands--for example, in hunting. The middle third
of the bone is implicated, and there is marked displacement and
overriding. The patient is rendered helpless, and from the extrinsic
muscles of respiration being thrown out of action and the weight of
the powerless limbs pressing on the chest, there is considerable
difficulty in breathing, and this is often increased by the fracture
being complicated by injuries of the lung or pleura.

The _prognosis_ as to union in all these injuries is good. Firm bony
union usually occurs within twenty-one days. Non-union, false-joint,
or fibrous union is but rarely met with. At the same time it is to be
borne in mind that, in spite of all precautions, some deformity and
shortening may result, without, however, interfering with the
usefulness of the limb.

_Treatment._--The displacement in complete fractures of the clavicle
is readily reduced by supporting the elbow, bracing back the
shoulders, and levering out the tip of the affected shoulder. In a few
cases the interposition of some fibres of the subclavius muscle
between the fragments has prevented perfect reduction.

In the greenstick variety the bone may be bent back into its normal
position, but no great force should be employed, as, in spite of
imperfect reduction, the clavicle usually straightens as it grows, and
although some deformity may persist, the function of the limb is not
interfered with.

_Recumbent Position._--There is little doubt that the most perfect
æsthetic results are obtained by treating the patient in the recumbent
position. In girls, therefore, in whom it is desired that the
shoulders should be perfectly symmetrical, the best results are
obtained from placing the patient on a firm mattress, with a narrow,
firm cushion between the shoulder-blades, so that the weight of the
shoulder may carry the acromial fragment laterally and backwards. A
pad is inserted in the axilla, the elbow raised, and the arm placed by
the side on a pillow and steadied with sand-bags. Massage is applied
daily. As this position must be maintained uninterruptedly for two or
three weeks, it proves too irksome for most patients. When both
clavicles are fractured, however, it is, short of operation, the only
available method of treatment.

In ordinary cases the arm should be placed in that position which
gives the best alignment of the fragments and least deformity. A thin
layer of wool is placed in the axilla to separate the skin surfaces. A
sling, supporting the _elbow_, is now applied, maintaining the arm in
position, and a body bandage fixes the arm to the side. Massage and
movement should be commenced at once.

A simple method, which yields satisfactory results, is that suggested
by Wharton Hood. The fracture having been reduced, three strips of
adhesive plaster, each an inch and a half wide, are applied from a
point immediately above the nipple to a point 2 inches below the angle
of the scapula (Fig. 15). The middle strap covers the seat of
fracture, and is applied first: the others, slightly overlapping it,
extend about half an inch on either side. The elbow is supported in a
sling. This plan has the advantage that it permits of movement of the
shoulder being carried out from the first, but the plaster rather
interferes with massage.

_The Handkerchief Method._--In cases of emergency, one of the best
methods applicable to all fractures of the clavicle is to brace back
the shoulders by means of two padded handkerchiefs, folded _en
cravate_, placed well over the tips of the shoulders and tied, or
interlaced, between the scapulæ. The forearm is then supported by a
third handkerchief applied as a sling, the base of which is placed
under the elbow, the ends passing over the sound shoulder.

_Operative treatment_ may be called for in compound or comminuted
fractures when the fragments have injured, or are likely to injure,
the subclavian vessels or the cords of the brachial plexus, or when it
is otherwise impossible to reduce the fracture or to retain the
fragments in apposition. It is also indicated in some cases of
fracture of both clavicles.

These various methods of treatment are not equally applicable to all
cases. In our experience, in the circumstances indicated, the
following methods have proved the most satisfactory: (1) As a
temporary means of retention in emergency cases,--for example,
accidents occurring on the football field,--the handkerchief method.
(2) In uncomplicated fractures of average severity in any part of the
bone, the method of sling and body bandage. (3) In cases where, for
æsthetic reasons, the chief consideration is the avoidance of
deformity and the maintenance of the symmetry of the shoulders, as in
girls, the treatment by recumbency. (4) When retentive apparatus
fails, or when the fragments are exerting injurious pressure,
operative treatment.

[Illustration: FIG. 15.--Adhesive Plaster applied for Fracture of
Clavicle.]

In quite a number of cases, there is an excessive amount of pain,
preventing sleep; where this is due to cramp-like contractions of the
muscles and movements of the fragments, it is relieved by more
accurate fixation, as by strips of plaster; otherwise a hypodermic
injection of heroin or morphin is indicated.


DISLOCATION OF THE CLAVICLE

Dislocation of the #acromial end#--sometimes, and perhaps more
correctly, spoken of as dislocation of the scapula--is more frequent
than that at the sternal end, and it usually results from a blow from
behind, or from a fall on the tip of the shoulder, driving down the
scapula, so that the clavicle projects _upwards_ and overrides the
acromion process.

_Downward_ displacement of the acromial end of the clavicle is much
rarer, and may follow a fall on the elbow or a blow over the clavicle.
The end of the bone lies under the acromion process, in contact with
the capsule of the shoulder-joint, and the acromion stands out
prominently.

The _clinical features_ are so well marked that the diagnosis is
unmistakable. The head inclines towards the affected side, and the tip
of the shoulder tends to pass slightly downward, forward, and
medially. The displaced end of the bone can be seen and felt as a
prominence under the skin, or the empty socket can be palpated, while
the muscles attached to the displaced clavicle stand out in relief.
The movements at the shoulder are restricted, particularly in the
direction of abduction above the level of the shoulder. These injuries
are sometimes associated with fracture of the ribs, a complication
which adds materially to the difficulties of treatment.

_Treatment._--Reduction is easily effected by bracing back the
shoulders and replacing the bone in its socket by manipulation; but
retention is invariably difficult, and in many cases impossible; even
when the displacement is permanent, however, the usefulness of the arm
is not necessarily impaired.

Treatment is similar to that for fracture of the clavicle by sling and
body bandage. Another plan is to place a pad over the acromial end of
the clavicle, and fix it in this position by a few turns of elastic
bandage carried over the shoulder and under the elbow. The forearm is
placed in a sling with the elbow well supported, and the arm is bound
to the side by a circular bandage. When the bone cannot be kept in
position and the usefulness of the limb is impaired, the joint
surfaces may be rawed and the bones wired, with a view to obtaining
ankylosis.

#The sternal end# may be dislocated forwards, backwards, or upwards.

_Forward_ dislocation is the most common; the end of the clavicle lies
on the front of the sternum, somewhat below the level of the
sterno-clavicular joint, and its articular surface can be distinctly
palpated (Fig. 16). The inter-articular cartilage sometimes remains
attached to one bone, sometimes to the other; the rhomboid ligament is
usually intact.

In the _backward_ dislocation the end of the clavicle lies behind the
manubrium sterni and the muscles attached to it; there is a marked
hollow in the position of the joint, and the facet on the sternum can
be felt. In a comparatively small number of cases the bone exerts
pressure upon the trachea and œsophagus, producing difficulty in
breathing and swallowing. It has also been known to press upon the
subclavian artery and on other important structures at the root of the
neck.

[Illustration: FIG. 16.--Forward Dislocation of Sternal End of Right
Clavicle. From a fall on a polished floor, in a man æt. 40.]

In rare cases the rhomboid ligament is torn, and the end of the
clavicle passes _upwards_, and rests in the episternal notch behind
the sterno-mastoid muscle.

The bone may be retained in position by keeping the shoulders braced
back by a figure-of-eight bandage, or by padded handkerchiefs, and
making pressure over the displaced end of the bone with a pad. The
forearm is supported by a sling, and the arm fixed to the side.
Massage is employed from the first, and the patient is allowed to move
the arm by the end of a week. Imperfect reduction interferes so little
with the functions of the limb that operative measures are seldom
required except for æsthetic reasons.

Dislocation of #both ends# of the clavicle has occasionally occurred
from a severe crush. The ultimate result has been satisfactory, as one
or other end has always healed in normal position, and the function of
the arm has thus been maintained.


DISLOCATION OF THE SHOULDER

The shoulder is more frequently dislocated than all the other joints
in the body taken together. This is explained by its exposed position,
the wide range of movement of which it is capable, the length of the
lever afforded by the humerus, and the anatomical construction of the
joint--the large, round humeral head imperfectly fitting the small and
shallow glenoid cavity, and the ligaments being comparatively lax and
thin. The capsule of the joint is materially strengthened in its upper
and back parts by the tendons of the supra- and infra-spinatus and
teres minor muscles; while it is weakest below and in front, between
the subscapularis and teres major tendons. It is here that it most
frequently gives way and allows of the escape of the head of the bone.
The determining factor is probably that when the arm is abducted the
neck of the humerus comes in contact with the tip of the acromion, and
further abduction forces the head against the lower, weak portion of
the capsule, which gives way.

The violence is usually transmitted from the hand or elbow, less
frequently from the lateral aspect of the shoulder, the limb being
usually abducted and the muscles relaxed and taken unawares. The head
of the humerus, thus brought to bear on the weakest part of the
capsule, ruptures it and passes out through the rent. Dislocation is
readily produced in an unconscious person--as, for example, in
conducting artificial respiration in a patient suffering from opium
poisoning, the arms being hyper-abducted to exert traction on the
chest.

_Varieties._--Several varieties of dislocation are recognised,
according to the position in which the head of the humerus finally
rests (Fig. 17). The simplest of these is the _sub-glenoid_ variety,
in which the head rests on the long tendon of the triceps, where it
arises from the axillary border of the scapula just below the glenoid
cavity. In almost all dislocations of the shoulder the head of the
bone is at least momentarily in this position, but the sharp edge of
the scapula and the rounded head are ill adapted to one another, and
the position is not long maintained. The subsequent course taken by
the humerus depends upon the nature and direction of the force, the
position of the limb at the moment of injury, and the relative
strength and capacity for effective action of the different groups of
muscles acting upon the bone.

[Illustration: FIG. 17.--Diagram of most common varieties of
Dislocation of the Shoulder.]

In the great majority of cases it passes forward and medially, and
comes to lie against the anterior surface of the neck of the
scapula, under cover of the tendons of origin of the biceps and
coraco-brachialis muscles, constituting the _sub-coracoid
dislocation_. Much less frequently it passes under cover of the
pectoralis minor and against the edge of the clavicle--the
_sub-clavicular_ variety. In rare cases the head passes backward and
lies against the spine on the dorsum of the scapula, beneath the
infra-spinatus muscle--the _sub-spinous_ variety. Other varieties are
so rare that they do not call for mention.

_Clinical Features common to all Varieties._--Dislocation of the
shoulder is commonest in adult males; in advanced life the proportion
of female sufferers increases. It is usually attended with great pain,
and there is often numbness of the limb due to pressure of the head of
the bone upon the large nerve-trunks. There is sometimes considerable
shock. The patient inclines his head towards the injured side, and,
while standing, the forearm is supported by the hand of the opposite
side. The acromion process stands out prominently, the roundness of
the shoulder giving place to a flattening or depression immediately
below it, so that a straight-edge applied to the lateral aspect of the
limb touches both the acromion and the lateral epicondyle. The
vertical circumference of the shoulder is markedly increased; this
test is easily made with a piece of tape or bandage and is compared
with a similar measurement on the normal side--we lay great stress on
this simple measure, as it is a most reliable aid in diagnosis. The
head of the bone can usually be felt in its new position, and the axis
of the humerus is correspondingly altered, the elbow being carried
from the side--forward or backward according to the position of the
head. The empty glenoid may sometimes be palpated from the axilla. In
most cases, although not in all, the patient is unable at one and the
same time to bring his elbow to the side and to place his hand upon
the opposite shoulder (Dugas' symptom). Measurements of the length of
the limb from acromion to lateral epicondyle are rarely of any
diagnostic value.

The #sub-coracoid dislocation# (Fig. 18) is that most frequently met
with. It usually results from hyper-abduction of the arm while the
scapula is fixed, as in a fall on the medial side of the elbow when
the arm is abducted from the side. The surgical neck of the humerus is
then brought to bear upon the under aspect of the acromion, which
forms a fulcrum, and the head of the bone is pressed against the
medial and lower part of the capsule. In some cases muscular action
produces this dislocation; it may also result from force applied
directly to the upper end of the humerus.

[Illustration: FIG. 18.--Sub-coracoid Dislocation of Right Shoulder.]

The head leaves the capsule through the rent made in its lower part,
and, either from a continuation of the force or from contraction of
the muscles inserted into the inter-tubercular (bicipital) groove,
particularly the great pectoral, passes medially under cover of the
biceps and coraco-brachialis till it comes to rest against the
anterior surface of the neck of the scapula, just below the coracoid
process. The anatomical neck of the humerus presses against the
anterior edge of the glenoid, and there is frequently an _indentation
fracture of the head of the humerus_ where the two bones come into
contact (F. M. Caird). The subscapularis is bruised or torn, the
muscles inserted into the great tuberosity are greatly stretched, or
the tuberosity itself may be avulsed, allowing the long tendon of the
biceps to slip laterally, where it may form an impediment to
reduction. The axillary (circumflex) nerve is often bruised or torn,
and the head of the humerus is liable to press injuriously on the
nerves and vessels in the axilla.

The _clinical features_ common to all dislocations are prominent,
although Dugas' symptom is not constant.

[Illustration: FIG. 19.--Sub-coracoid Dislocation of Humerus.

(Sir H. J. Stiles' case. Radiogram by Dr. Edmund Price.)]

_Treatment._--The guiding principle in the reduction of these
dislocations is to make the head of the bone retrace the course it
took in leaving the socket. The main obstacles to reduction being
muscular contraction and the entanglement of the head with tendons,
ligaments, or bony points, appropriate means must be taken to
counteract each of these factors.

A general anæsthetic is an invaluable aid to reduction, and should be
given unless there is some reason for withholding it. It is specially
indicated in strong muscular subjects, and in nervous patients who do
not bear pain well, and particularly when the dislocation has existed
for a day or two. In quite recent cases, however, the surgeon may
succeed in replacing the bone by taking advantage of a temporary
faintness, or by engaging the patient's attention with other matters
while he carries out the appropriate manipulations.

When an anæsthetic is employed, the patient should be laid on a
mattress on the floor, or on a narrow, firm table; otherwise he should
be seated on a chair.

_Kocher's method_ is suitable for the great majority of cases of
sub-coracoid dislocation. (1) The elbow is firmly pressed against the
side, and the forearm flexed to a right angle. The surgeon grasps the
wrist and elbow and firmly _rotates the humerus away from the middle
line_ (Fig. 20) till distinct resistance is felt and the deltoid
becomes more prominent. In this way the rent in the lower part of the
capsule is made to gape, and the head of the humerus rolls away from
the middle line till it lies opposite the opening, rotation taking
place about the fixed point formed by the contact of the anatomical
neck of the humerus with the anterior lip of the glenoid cavity (D.
Waterston). (2) _The elbow is next carried forward, upward, and
towards the middle line_ (Fig. 21); the humerus acting as the long arm
of a lever on the fulcrum furnished by the muscles inserted in the
region of the surgical neck, the head, which forms the short arm of
the lever, is carried backward, downward, and laterally, and is thus
directed towards the socket. (3) The humerus is now _rotated towards
the middle line_ by carrying the hand across the chest towards the
opposite shoulder (Fig. 22). The anatomical neck of the humerus is
thus disengaged from the edge of the glenoid, and the head is pulled
into the socket by the tension of the surrounding muscles.

[Illustration: FIG. 20.--Kocher's Method of reducing Sub-coracoid
Dislocation--First Movement; Rotation of Arm away from Middle Line.]

[Illustration: FIG. 21.--Kocher's Method--Second Movement; Elbow
carried forward, upward, and towards the Middle Line.]

[Illustration: FIG. 22.--Kocher's Method--Third Movement; Rotation of
Arm towards Middle Line.]

A method of reduction has been formulated by A. G. Miller, which we
have found to be quite as successful as Kocher's method. The limb is
grasped above the wrist and elbow, the forearm flexed to a right
angle, and the upper arm abducted to the horizontal (Fig. 23). While
an assistant makes counter-extension and fixes the scapula, the
surgeon gradually draws the arm away from the body till the head of
the humerus is felt to pass laterally. The humerus is then rotated
medially by dropping the hand (Fig. 24), and the bone gradually glides
into the socket.

[Illustration: FIG. 23.--Miller's Method of reducing Sub-coracoid
Dislocation--First Movement.]

[Illustration: FIG. 24.--Miller's Method of reducing Sub-coracoid
Dislocation--Second Movement.]

In a certain number of cases reduction can be effected by
_hyper-abduction_ of the shoulder with traction. The patient is laid
upon a firm mattress, and the surgeon, seated behind him while an
assistant fixes the acromion, slowly and steadily extends the arm
until it is raised well above the head. In some cases the head of the
humerus spontaneously slips into its socket; in others it may be
manipulated into position by pressure from the axilla. This method is
restricted to recent cases, as in those of long standing the axillary
vessels are liable to be stretched or torn.

The method of reduction by traction on the arm with the heel in the
axilla is only to be used when other measures have failed, as it
depends for its success on sheer force.

_After-Treatment._--After reduction, the part is gently massaged for
ten or fifteen minutes, a layer of wool is placed in the axilla, the
forearm is supported by a sling, and the arm fixed to the side by a
circular bandage. Massage is carried out from the first, and movement
of the shoulder in every direction except that of abduction may be
commenced on the first or second day. The circular bandage may be
dispensed with at the end of a week, and abduction movements
commenced, and by the end of a month the patient should be advised to
use the arm freely.

The #sub-clavicular dislocation# (Fig. 17) is to be looked upon as an
exaggerated degree of the sub-coracoid rather than as a separate
variety. It is produced by the same mechanism, but the violence is
greater, and the damage to the soft parts more severe. The head passes
farther upwards and towards the middle line under cover of the
pectoralis minor, resting under the clavicle against the serratus
anterior and chest wall. The symptoms are usually so marked that they
leave no doubt as to the diagnosis. The outline of the head of the
humerus in its abnormal position is visible through the skin, and the
shortening of the limb is more marked than in the sub-coracoid
variety. The treatment is the same as for sub-coracoid dislocation.

#Sub-glenoid dislocation# (Fig. 17) is less frequently met with than
the sub-coracoid variety, and almost always results from forcible
abduction of the arm. The head of the humerus passes out through a
small rent in the lower and medial portion of the capsule, and rests
against the anterior edge of the triangular surface immediately below
the glenoid cavity, supported behind by the long head of the triceps,
and in front by the subscapularis muscle. It is readily felt in the
axilla. All the tendons in relation to the upper end of the humerus
are stretched or torn, and the great tuberosity is not infrequently
avulsed. There is sometimes bruising of the axillary nerve.

The projection of the acromion, the flattening of the deltoid, the
increased depth of the axillary fold, and the abduction of the elbow
are well marked; the arm is slightly lengthened, rotated out, and
carried forward. It is reduced by the hyper-abduction method (p. 60).

#Sub-spinous Dislocation.#--Backward dislocation is usually termed
sub-spinous, although in a considerable proportion of cases the head
of the humerus does not pass beyond the root of the acromion process
(_sub-acromial_) (Fig. 17). This dislocation is usually produced by a
fall on the elbow, the arm being at the moment adducted and rotated
medially, so that the head of the humerus is pressed backwards and
laterally against the capsule, which ruptures posteriorly. All the
muscles attached to the upper end of the humerus are liable to be
torn, and the tuberosities are frequently avulsed. The long tendon of
the biceps may slip from its position between the tuberosities, and
prevent reduction or favour re-dislocation, necessitating an open
operation.

In the milder cases the _clinical features_ are not always well
marked, and on account of the swelling this dislocation is apt to be
overlooked. In addition to the ordinary symptoms, the shoulder is
broadened, there is a marked hollow in front in which the coracoid
projects, and the arm is held close to the side with the elbow
directed forward. The head of the bone may be seen and felt in its
abnormal position below the spine of the scapula.

Reduction can usually be effected by making traction on the arm with
medial rotation, and pressing the head forward into position, while
counter-pressure is made upon the acromion.

_Prognosis._--The ultimate prognosis in dislocations of the shoulder
should always be guarded. The axillary nerve may be stretched or torn,
and this may lead to atrophy of the deltoid; or other branches of the
brachial plexus may be injured and the muscles they supply permanently
weakened. In a certain number of cases traumatic neuritis has resulted
in serious disability of the limb. The movements of the shoulder-joint
may be restricted by cicatricial contraction of the torn portion of
the capsule and of the damaged muscles. A marked tendency to recurrent
dislocation may follow if abduction movements are permitted before
repair of the capsule has had time to occur.

#Dislocation of the Shoulder complicated with Fracture of the Upper
End of the Humerus.#--In these injuries the dislocation is almost
always of the sub-coracoid variety, and the most common fractures by
which it is complicated are those of the surgical neck, the anatomical
neck, or the greater tuberosity. The most common cause is a fall
directly on the shoulder, and it seems probable that the head of the
bone is first dislocated, and, the force continuing to act, the upper
end of the humerus is then broken; or the two lesions may be produced
synchronously.

When seen soon after the accident, the existence of the fracture of
the humerus is liable to be overlooked, the condition being mistaken
for dislocation alone, or for a fracture through the neck of the
scapula. On careful examination under an anæsthetic, however, it is
observed that not only is the head of the humerus absent from the
glenoid cavity, but that it does not move with the rest of the bone,
abnormal mobility and crepitus are recognised at the seat of fracture,
and the upper arm is shortened. The extravasation in the axilla is
usually greater than that accompanying a simple dislocation, and the
pain and shock are more severe. A fracture through the neck of the
scapula alone is readily recognised by the ease with which the
deformity is reduced, and the way in which it at once recurs when the
support is withdrawn. In many cases it is only by the aid of a
radiogram that an accurate diagnosis can be made (Fig. 25).

[Illustration: FIG. 25.--Dislocation of Shoulder with Fracture of Neck
of Humerus.

(Sir Robert Jones' case. Radiogram by Dr. D. Morgan.)]

_Treatment._--Unless the dislocation is reduced at once, the movements
of the arm are certain to be seriously restricted, and painful
pressure effects from excess of callus are liable to ensue. An attempt
should first be made, under anæsthesia, to replace the head in its
socket, by making extension on the arm in the hyper-abducted
(vertical) position, and manipulating the upper fragment from the
axilla.

On no account should the lower fragment be employed as a lever in
attempting reduction. When reduction by manipulation fails, recourse
should be had to an open operation. The upper fragment should be
exposed by an incision over its lateral aspect, and made to return to
the socket by using Arbuthnot Lane's levers or M'Burney's hook, or a
long steel pin may be inserted into the fragment to give the necessary
leverage.

Reduction having been accomplished, the fracture is adjusted in the
usual way, advantage being taken of the open wound, if necessary, to
fix the fragments together by plates. The best position in which to
fix the limb is that of abduction at a right angle. Massage and
movement should be commenced early to prevent stiffness of the joint.

When it is found impossible to reduce the dislocation, it is usually
advisable to remove the upper fragment.

The method of allowing the fracture to unite without reducing the
dislocation, and then attempting reduction, usually results in
re-breaking the bone, or else in failure to replace the head in the
socket, and has nothing to recommend it.

#Old-standing Dislocation of the Shoulder.#--It is impossible to lay
down definite rules as to the date after which it is inadvisable to
attempt reduction by manipulation of an old-standing dislocation of
the shoulder. Experience of a hundred cases in Bruns' clinic led
Finckh to conclude that, provided there are no complications,
reduction can generally be effected within four weeks of the accident;
that within nine weeks the prospect of success is fairly good; but
that beyond that time reduction is exceptional.

The patient is anæsthetised, and all adhesions broken down by free yet
gentle movement of the limb. The appropriate manipulations for the
particular dislocation are then carried out, care being taken that no
undue force is employed, as the humerus is liable to be broken. If
these are not successful, they should be repeated at intervals of two
or three days, as it is frequently found that reduction is
successfully effected on a second or third attempt.

Should manipulative measures fail, it may be advisable to have
recourse to operation if the age of the patient and his general health
warrant it, and if the condition of the limb is interfering with his
occupation or involves serious disability. If operation is deemed
advisable, a few days should be allowed to elapse to permit of the
parts recovering from the effects of the manipulations. The joint is
freely exposed, the capsule divided, the head of the bone freed and
returned to the glenoid cavity. It is sometimes so difficult to
replace the head of the bone that it is necessary to resect it and aim
at the formation of a new joint, an operation which usually yields
satisfactory results.

#Habitual or Recurrent Dislocation.#--Cases are occasionally met with
in which the shoulder-joint shows a marked tendency to be dislocated
from causes altogether insufficient to produce displacement under
ordinary circumstances. This condition is usually met with in young
women, and, in some cases at least, appears to be due to too early and
too free movement of the joint after an ordinary dislocation, so that
the capsule is stretched and remains lax. In some cases it would
appear that the liability to dislocation is due to some structural
defect in the joint, and under these conditions both sides are
sometimes affected, and the accident is not attended with the usual
pain and disability either at the time or after reduction. The
facility and frequency with which dislocation recurs render the limb
comparatively useless, and may seriously incapacitate the patient. We
have had cases under observation in which dislocation resulted from
the hyper-abduction of the arm in swimming, from throwing the arms
above the head in dancing and in gymnastic exercises, and even in
"doing" the hair.

The _treatment_ consists in preventing the patient making the
particular movements which tend to produce the dislocation. These are
chiefly movements of hyper-abduction and overhead movements; we have
found an apparatus consisting of a belt applied around the thorax, and
fixed to another around the upper arm by a band which passes above the
axillary fold of the dress, useful in restraining these movements. If
these measures fail, it may be advisable to have recourse to
operation; this may consist in tightening up the capsule, the results
of which are said to be uncertain, or in detaching a portion of the
deltoid or subscapularis muscle and stitching it beneath the joint to
cover and strengthen the weakened portion of the capsule. It is
suggestive that in performing this operation no rent in the capsule is
discovered.

The condition is also met with in epileptics; and it is generally
found that the head of the bone is deficient, as a result either of
fracture or disease; that the muscles which naturally support the
joint are atrophied or torn; and that the capsule is unduly lax.

#Sprain# of the shoulder-joint is comparatively rare, because of the
wide range of movement of which it is capable. The region of the
shoulder becomes swollen and tender to pressure, the point of maximum
tenderness being over the front of the joint, just below the acromion
process; pain is elicited also when the ligaments or tendons are put
upon the stretch.

#Contusion# of the region of the shoulder, on the other hand, is
exceedingly common. In most cases it is merely the deltoid muscle and
the subcutaneous tissue over it that are bruised, but sometimes a
hæmatoma forms either in the muscle or in the sub-deltoid bursa. There
is pain on moving the limb, and the patient may be unable to abduct
the arm at the shoulder-joint. Under treatment by massage and
movement, the symptoms usually pass off completely in two or three
weeks. The affections of the _bursa_ are described elsewhere.

In other cases, the cords of the brachial plexus above the clavicle
are stretched, or the axillary nerve is bruised, and these injuries
are liable to be followed by prolonged pain, loss of abduction, and
stiffness in the arm. The deltoid frequently undergoes considerable
atrophy, and there is severe neuralgic pain in the axillary nerve,
especially marked in the region of the insertion of the deltoid.

In addition to maintaining the limb in the abducted position, it is
necessary to keep up the nutrition of the muscles by massage and
electricity.


FRACTURE OF THE SCAPULA

Fractures of the scapula may implicate the body, the surgical neck,
the acromion, or the coracoid process. They are rarely compound.

#Fracture of the Body.#--Considering its exposed position, the body of
the scapula is comparatively seldom fractured, doubtless because of
its mobility, and the support it receives from the elastic ribs and
soft muscular cushions on which it lies. Apart from gun-shot injuries,
it is most frequently broken by a severe blow or crush. The scapula
presents two natural arches--one longitudinal, the other
transverse--and when the bone is crushed or struck, the force produces
fracture by undoing its curves (E. H. Bennett). A main fissure usually
runs transversely across the infra-spinous fossa, and secondary cracks
radiate from it (Fig. 26). In other cases the line of the primary
fracture is longitudinal, passing through the spine and involving both
fossæ.

[Illustration: FIG. 26.--Transverse Fracture of Scapula, with fissures
radiating into spinous process and dorsum.]

The _clinical features_ are obscured by swelling of the overlying soft
parts. Crepitus may sometimes be elicited by placing one hand firmly
over the bone, and with the other moving the arm and shoulder. When
the spine is implicated, the fragments may be grasped and made to move
one upon another. The displacement, which usually consists in
overlapping of the fragments--although sometimes they are drawn
apart--is partly due to the action of the serratus anterior and teres
major muscles, and partly depends on the direction of the force.
Movement is restricted and painful. Osseous union usually takes place
rapidly, and although displacement often persists, the function of the
limb is unimpaired.

_Treatment._--As these fractures are usually complicated by other
injuries, especially of the thorax, and are accompanied by severe
shock, it is necessary to confine the patient to bed. It is usually
sufficient to fix the arm and shoulder to the chest wall by a firm
binder, in the position which admits of the most complete apposition
of fragments. This retentive apparatus is employed for about three
weeks, after which the patient is allowed to use his arm. The bandages
are removed daily to admit of massage.

#Fracture of the surgical neck of the scapula#, although a rare
accident, is of importance, as it is liable to be mistaken for
dislocation of the shoulder. The line of fracture runs through the
scapular notch, downwards and laterally to the lower margin of the
glenoid, so that the glenoid and the coracoid process are separated
from the rest of the bone.

The coraco-acromial and coraco-clavicular ligaments are usually torn,
and the detached fragment, along with the head of the humerus, sinks
into the axilla, causing a flattening of the shoulder, and leaving a
depression below the projecting acromion. These signs may be obscured
by the general swelling of the shoulder. The arm may be lengthened
about an inch. By supporting the arm the deformity is at once reduced,
but recurs as soon as the support is withdrawn. Crepitus is usually
detected on carrying out this manipulation; and the coracoid process
is found to move with the arm and not with the scapula. By these
tests, and by the X-rays, this injury is distinguished from a
dislocation.

A partial fracture carrying away the lower part of the _glenoid
cavity_ simulates a sub-glenoid dislocation. This is, however, a rare
injury.

The _treatment_ consists in bracing back the shoulders and supporting
the elbow, and this is most satisfactorily done by a body bandage and
sling for the elbow, as for fracture of the middle third of the
clavicle. Passive movements and massage are employed from the first.

#Fracture of the acromion process# may result from a blow or fall on
the shoulder. It is often overlooked on account of the swelling
resulting from bruising of the soft parts, and the absence of marked
displacement. On palpation, crepitus and an irregularity at the seat
of fracture may sometimes be detected. The shoulder is slightly
flattened, and abduction of the arm is difficult. In rare cases the
fracture passes into the acromio-clavicular joint, and is associated
with dislocation of the clavicle.

In connection with this fracture, reference must be made to a
condition frequently met with, in which the epiphysial portion
of the acromion is found to be separate from the body of the
process--_separate acromion_. This is by some (Symington, Hamilton)
looked upon as a want of union of the epiphysis, but the weight of
evidence seems to prove that it is rather of the nature of an
un-united fracture at this level, even when, as sometimes happens, it
is bilateral (Struthers, Arbuthnot Lane).

Between the fourteenth and twenty-second years a true _separation of
the epiphysis_ may be met with, but it is seldom possible to make a
positive diagnosis of this injury. As is the case in all fractures of
the acromion, bony union seldom takes place.

The _treatment_ is the same as for fracture of the lateral end of the
clavicle.

#Fracture of the coracoid process# is rare. It may result from direct
violence, such as the recoil of a gun, but it is more often an
accompaniment of dislocation of the shoulder or of the lateral end of
the clavicle upward. As the coraco-clavicular ligaments usually remain
intact, there is no displacement; but when these are torn the coracoid
is dragged downwards and laterally by the combined action of the
pectoralis minor, biceps, and coraco-brachialis muscles. Crepitus may
be elicited on moving the fragment. _Separation of the epiphysial
portion_ of the coracoid may occur up to the seventeenth year.

The _treatment_ consists in placing the arm across the front of the
chest, to relax the muscles causing the displacement, and retaining it
in that position by a sling and roller bandage.


FRACTURE OF THE UPPER END OF THE HUMERUS

It is most convenient to study fractures of the upper end of the
humerus in the following order: (1) fracture of the surgical neck; (2)
separation of the epiphysis; (3) fracture of head, anatomical neck, or
tuberosities.

[Illustration: FIG. 27.--Fracture of Surgical Neck of Humerus, united
with Angular Displacement.]

#Fracture of the Surgical Neck.#--The surgical neck of the humerus
extends from the level of the epiphysial junction to the insertion of
the pectoralis major and teres major muscles, and it is within these
limits that most fractures of the upper end of bone occur. This
fracture is most common in adults, and usually follows direct violence
applied to the shoulder, but may result from a fall on the hand or
elbow, or from violent muscular action, as, for example, in throwing a
stone. It is usually transverse, and there is often little or no
displacement, the fragments being retained in position by the long
tendon of the biceps and the long head of the triceps. When the
fracture is oblique, the fragments are often comminuted, and sometimes
impacted. The displacement of the upper fragment seems to depend upon
the attitude of the limb at the moment of fracture. When the upper arm
is approximated to the side, the upper fragment retains its vertical
position, but is slightly rotated laterally by the muscles inserted
into the greater tuberosity, while the lower fragment is drawn upwards
and medially towards the coracoid process by the muscles inserted into
the inter-tubercular groove and the longitudinal muscles of the upper
arm, and can be felt in the axilla. The elbow points laterally and
backwards, and the upper arm is shortened. The shoulder retains its
rotundity, but there is a slight hollow some distance below the
acromion. On grasping the elbow and moving the shaft, it is found that
the head and tuberosities do not move with it, and unnatural mobility
and crepitus at the seat of fracture may be detected. When the upper
arm is abducted at the moment of fracture, the upper fragment is
retained in that position by the lateral rotator and abductor muscles
inserted into it, while the lower fragment passes upwards and
medially.

[Illustration: FIG. 28.--Impacted Fracture of Neck of Humerus, in man
æt. 75.

(Sir H. J. Stiles' case. Radiogram by Dr. Edmund Price.)]

Although there is sometimes overlapping and broadening after union,
beyond some limitation of the range of abduction the usefulness of the
limb is seldom impaired.

_Treatment._--Massage, by allaying spasm of the muscles, soon
overcomes the moderate amount of displacement which is usually met
with. Further, the skin surfaces of the axilla having been separated
by a thin layer of cotton wool, a sling is applied to support the
wrist, and the arm is bound to the side by a body bandage.

In comminuted fractures and those with marked displacement, a general
anæsthetic may be required to ensure accurate reduction; and to
maintain the fragments in apposition, and to avoid any limitation of
abduction after union, the limb may be fixed in the position of
abduction at a right angle by means of a Thomas' arm splint with
swivel ring, and extension applied, if necessary, to maintain this
attitude. After a week or ten days the patient is allowed up, wearing
an abduction frame (Fig. 29), or a splint, such as Middeldorpf's,
which consists of a double inclined plane, the base of which is fixed
to the patient's side, while the injured arm rests on the other two
sides of the triangle. Massage and movement are employed daily.

[Illustration: FIG. 29.--Ambulatory Abduction Splint for Fracture of
Humerus.]

Should these measures fail, the fracture may be exposed by an incision
carried along the anterior border of the deltoid, and the ends
mechanically fixed, after which the limb is put up in the abducted
position for three or four weeks. Massage is commenced on the second
or third day. Union is usually complete in about four weeks.

#Separation of Epiphysis.#--The upper epiphysis of the humerus
includes the head, both tuberosities, and the upper fourth of the
inter-tubercular groove. On its under aspect is a cup-like depression
into which the central pyramidal-shaped portion of the diaphysis fits.
This epiphysis unites about the twenty-first year.

[Illustration: FIG. 30.--Radiogram of Separation of Upper Epiphysis of
Humerus.]

Traumatic separation is met with chiefly between the fifth and
fifteenth years, and is most common in boys. It usually results from
forcible traction of the arm upwards and away from the side, as in
lifting a child by the upper arm, or from direct violence, but may be
caused by a fall on the lateral side of the elbow.

The epiphysis, especially in young children, may be separated without
being displaced, or the displacement may be incomplete.

When the epiphysis is completely separated from the shaft, the
clinical features closely resemble those of fracture of the surgical
neck, and the diagnosis is made by a consideration of the age of the
patient, and the muffled character of the crepitus, when it can be
elicited. The upper end of the diaphysis forms a projecting ridge
which may be felt below and in front of the acromion. The diagnosis
can usually be established by the use of the X-rays (Fig. 30).
Dislocation is rare at the age when separation of the epiphysis
occurs.

Reduction is often difficult on account of the periosteum and other
soft tissues getting between the fragments, and on account of the
small size of the upper fragment. Union almost invariably results, but
the growth of the limb may be interfered with and its shape altered,
especially when the injury occurs at an early age and its nature is
overlooked.

_Treatment._--This injury is treated on the same general lines as
fracture of the surgical neck. General anæsthesia is almost always
necessary to secure satisfactory reduction, and retention is most
easily secured if the patient is confined to bed with the upper arm
fixed in the fully abducted position. Operative treatment is called
for in exceptional cases.

#Fractures of the Head, Anatomical Neck, and Tuberosities of
Humerus.#--These fractures are met with as accompaniments of
dislocation of the shoulder, and as results of gun-shot injuries,
blows, or falls.

In sub-coracoid dislocation the _head_ of the humerus may be indented
by coming in contact with the anterior edge of the glenoid cavity (F.
M. Caird).

The _anatomical neck_ may be fractured in an old person by a direct
blow on the shoulder. In a few cases the fracture is entirely
intra-capsular, the head of the bone remaining loose in the cavity of
the joint. As a rule, however, the fracture passes laterally and
implicates the tuberosities. In some cases there is impaction, and in
others comminution of the fragments. The use of the X-rays has shown
that in many cases in which prolonged stiffness has followed a severe
blow of the shoulder, there has been a fracture of the anatomical
neck.

The _tuberosities_ may be implicated in other fractures in this region
and in dislocation of the shoulder; and either of them may be
separated by muscular contraction or by direct violence.

_Clinically_ all these injuries are difficult to diagnose with
accuracy, and, without the use of the X-rays, it is impossible in many
cases to go further than to say that a fracture exists above the level
of the surgical neck. Fracture of the anatomical neck is attended with
little deformity beyond slight flattening of the shoulder and
sometimes slight shortening of the upper arm.

When the _great tuberosity_ is torn off, considerable antero-posterior
broadening of the shoulder may be recognised by grasping the region of
the tuberosities between the fingers and thumb. Crepitus can be
elicited on rotating the humerus. At the same time it will be
recognised that the tuberosity does not move with the shaft. Firm
union, with considerable formation of callus and some broadening of
the shoulder, usually results, but the usefulness of the joint is not
necessarily impaired. There may, however, be prolonged stiffness and
impaired movement from adhesion; or pain and crackling in the joint
may result from arthritic changes like those of arthritis deformans.

_Treatment._--These fractures are treated on the same lines as
fracture of the surgical neck of the humerus.

The combination of fracture of the upper end of the humerus with
dislocation of the shoulder has already been referred to.


FRACTURE OF THE SHAFT OF THE HUMERUS

Fractures occurring in the shaft of the humerus between the surgical
neck and the base of the condyles may, for convenience of description,
be divided into those above, and those below, the level of the deltoid
insertion--the majority being in the latter situation.

Direct violence is the most common cause of these fractures, but they
may occur from a fall on the elbow or hand; and a considerable number
of cases are on record where the bone has been broken by muscular
action--as in throwing a cricket-ball. Twisting forms of violence may
produce spiral fractures.

The fracture is usually transverse in children and in cases in which
it is due to muscular action. In adults, when due to external
violence, it is usually oblique, the fragments overriding one another
and causing shortening of the limb. The displacement depends largely
on the direction of the force and the line of fracture, but to a
certain extent also on the action of muscles attached to the
fragments. Thus, in fractures above the insertion of the deltoid the
upper fragment is usually dragged towards the middle line by the
muscles inserted into the inter-tubercular groove, while the lower is
tilted laterally by the deltoid. When the break is below the deltoid
insertion the displacement of the fragments is reversed. The signs of
fracture--undue mobility, deformity, shortening, and crepitus--are at
once evident, and the patient himself usually recognises that the bone
is broken.

The nerve-trunks in the arm--the median, ulnar, and radial
(musculo-spiral)--are apt to be damaged in these injuries; in
fractures of the lower part of the shaft the radial nerve is specially
liable to be implicated. This may occur at the time of the injury, the
nerve being contused by the force causing the fracture, or pressed
upon by one or other of the fragments, or its fibres may be partly or
completely torn across. When there is evidence of nerve injury, the
practitioner should draw the attention of the patient to it then and
there, and so guard himself against actions for malpraxis should
paralysis of the muscles ensue. Later, the nerve may become involved
in callus, or be damaged by the pressure of ill-fitting splints.
Weakness or paralysis of the extensors of the wrist and hand results,
giving rise to the characteristic "wrist-drop." The actions of the
muscles should always be tested before applying splints, and each time
the apparatus is removed or readjusted, to assure that no undue
pressure is being exerted on the nerves.

Union takes place in from four to six weeks in adults, and in from
three to four weeks in children. Delayed union, or want of union and
the formation of a false joint, is more common in fractures of the
middle of the shaft of the humerus than in any other long bone--a
point to be borne in mind in treatment. Arrest of growth in the bone
from injury to the nutrient artery is also said to have occurred.

_Treatment._--To restore the alignment of the bone, extension is made
on the lower fragment and the ends are manipulated into position. This
may necessitate the use of a general anæsthetic, and care must be
taken that no soft tissue intervenes between the fragments, as is
evidenced radiographically by the persistence of a clear space between
the ends even when they appear to be in apposition.

In _transverse_ fractures the position may be maintained by a simple
ferrule of poroplastic or Gooch-splinting. The elbow is flexed at a
right angle, and the forearm supported in a sling midway between
pronation and supination. For a few days the limb may be bound to the
chest by a broad roller bandage.

[Illustration: FIG. 31.--"Cock-up" Splint, for maintaining
Dorsiflexion at Wrist.]

The splints are removed daily to admit of massage and movement being
carried out, and while the splints are off, the patient is allowed to
exercise the fingers and wrist. If at the end of four or five weeks,
osseous union has not occurred, the reparative process may be hastened
by inducing venous congestion by Bier's method.

In _oblique and spiral_ fractures it is often necessary to control the
shoulder and elbow-joints to prevent re-displacement. This can be done
by means of a plaster of Paris case enclosing the upper part of the
thorax, together with the upper arm, abducted, and the elbow, at right
angles.

[Illustration: FIG. 32.--Gooch Splints for Fracture of Shaft of
Humerus; and Rectangular Splint to secure Elbow.]

It is sometimes necessary to apply continuous extension to the lower
fragment to prevent overriding. For this purpose a Thomas' arm splint
is employed, the extension tapes being attached to its lower end, but
care must be taken that the traction is not sufficient to separate
the fragments and leave a gap between them. The elbow should not be
retained in the extended position for more than three weeks.

In rare cases it is necessary to have recourse to operative treatment.

When there is evidence that the radial nerve has been injured, and no
sign of improvement appears within three or four days of the accident,
operative interference is indicated. An incision is made on the
lateral side of the arm, and the nerve exposed and freed from
pressure, or stitched, as may be necessary; the opportunity should
also be taken of dealing with the fracture. The limb is put up in a
"cock-up" splint, with the hand in the attitude of marked dorsiflexion
(Fig. 31).

Satisfactory results have been obtained without the use of splints, by
relying upon massage to overcome the spasm of muscles, and allowing
the weight of the arm to act as an extending force (J. W. Dowden and
A. Pirie Watson).

In cases of _un-united fracture_, a vertical or semilunar incision is
made over the lateral aspect of the bone, and the muscles separated
from one another till the fracture is exposed, care being taken to
avoid injuring the radial nerve. The fibrous tissue is removed from
the ends of the bone, and the rawed surfaces fixed in apposition; the
wound is then closed, and appropriate retentive apparatus applied. As
soon as the wound has healed, massage and movement are employed.




CHAPTER IV

INJURIES IN THE REGION OF THE ELBOW AND FOREARM


Surgical Anatomy--Examination of injured elbow--FRACTURE OF LOWER END
    OF HUMERUS: _Supra-condylar_; _Inter-condylar_; _Separation of
    epiphysis_; _Fracture of either condyle alone_; _Fracture of
    either epicondyle alone_--FRACTURE OF UPPER END OF ULNA:
    _Olecranon_; _Coronoid_--FRACTURE OF UPPER END OF RADIUS: _Head_;
    _Neck_; _Separation of epiphysis_--DISLOCATION OF ELBOW: _Both
    bones_; _Ulna alone_; _Radius alone_--FRACTURE OF FOREARM: _Both
    bones_; _Radius alone_; _Ulna alone_.

The injuries met with in the region of the elbow-joint include the
various fractures of the lower end of the humerus, and upper ends of
the bones of the forearm, including the olecranon; and dislocations
and sprains of the elbow-joint. The differential diagnosis is often
exceedingly difficult on account of the swelling and tension which
rapidly supervene on most of these injuries, the pain caused by
manipulating the parts, and the difficulty of determining whether
movement is taking place _at_ the joint or _near_ it.

#Surgical Anatomy.#--The medial epicondyle of the humerus is more
readily felt through the skin than the lateral. The two epicondyles
are practically on the same level, and a line joining them behind
passes just above the tip of the olecranon when the arm is fully
extended. On flexing the joint, the tip of the olecranon gradually
passes to the distal side of this line, and when the joint is fully
flexed the tip of the olecranon is found to have passed through half a
circle. The head of the radius can be felt to rotate in the dimple on
the back of the elbow just below the lateral epicondyle. The coronoid
process may be detected on making deep pressure in the hollow in front
of the joint. As the line of the radio-humeral joint is horizontal,
while that of the ulno-humeral joint slopes obliquely downwards, the
arm forms with the fully extended and supinated forearm an obtuse
angle, opening laterally--the "carrying angle." This angle is usually
more marked in women, in harmony with the greater width of the female
pelvis. The ulnar nerve lies in the hollow between the olecranon and
the medial condyle, and the median nerve passes over the front of the
joint, with the brachial artery and biceps tendon to its lateral side.
The radial nerve divides into its superficial and deep (posterior
interosseous) branches at the level of the lateral condyle.

In _examining an injured elbow_, the thumb and middle finger are
placed respectively on the two epicondyles, while the index locates
the olecranon and traces its movements on flexion and extension of the
joint. The movements of the head of the radius are best detected by
pressing the thumb of one hand into the depression below the lateral
epicondyle, while movements of pronation and supination are carried
out by the other hand. The uninjured limb should always be examined
for purposes of comparison.

In injuries about the elbow much aid in diagnosis is usually obtained
by the use of the X-rays; but in young children it is sometimes
impossible, even with excellent pictures, to make an accurate
diagnosis by means of radiograms alone. In cases of suspected
fracture, a radiogram should be taken with the back of the limb
resting on the plate, the forearm being extended and supinated. If a
dislocation is suspected and a lateral view is desired, the arm should
be placed on its medial side. In obscure cases it is useful to take
radiograms of the healthy limb in the same position.


FRACTURES OF THE LOWER END OF THE HUMERUS

The following fractures occur at the lower end of the humerus: (1)
supra-condylar fracture; (2) inter-condylar fracture; (3) separation
of epiphyses; (4) fracture of either condyle alone; and (5) fracture
of either epicondyle alone.

All these injuries are common in children, and result from a direct
fall or blow upon the elbow, or from a fall on the outstretched hand,
especially when at the same time the joints are forcibly moved beyond
their physiological limits, more particularly in the direction of
pronation or abduction. While it is generally easy to diagnose the
existence of a fracture, it is often exceedingly difficult to
determine its exact nature. Although the ulnar and median nerves are
liable to be injured in almost any of these fractures, they suffer
much less frequently than might be expected.

Ankylosis, or, more frequently, locking of the joint, is a common
sequel to many of these injuries. This is explained by the difficulty
of effecting complete reduction, and by the wide separation of
periosteum which often occurs, favouring the production of an
excessive amount of new bone, particularly in young subjects.

The #supra-condylar# fracture usually results from a fall on the
outstretched hand with the forearm partly flexed, from a direct blow,
or from a twisting form of violence. The line of fracture is generally
transverse, or but slightly oblique from behind downwards and
forwards, so that the lower fragment is forced backward together with
the bones of the forearm, simulating backward dislocation of the
elbow; the lower end of the upper fragment lies in front (Fig. 33).

[Illustration: FIG. 33.--Radiogram of Supra-condylar Fracture of
Humerus, in a child æt. 7.]

_Clinical Features._--The elbow is flexed at an angle of 120° or 130°,
and the forearm, held semi-pronated, is supported by the other hand.
Around the seat of fracture great swelling rapidly ensues. The
olecranon projects behind, but the mutual relations of the bony points
of the elbow are unaltered. The lower end of the upper fragment may be
felt in front above the level of the joint, as a rough and sharp
projection, and this sometimes pierces the soft parts and renders the
fracture compound. Movement at the joint is possible, but unnatural
mobility may be detected above the level of the joint. Crepitus and
localised tenderness may be elicited. The displacement is readily
reduced by manipulation, but usually returns when the support is
withdrawn. The arm is shortened to the extent of about half an inch.

In rare cases the obliquity of the fracture is downward and backward,
and the lower fragment is displaced forward.

The #inter-condylar# fracture is a combination of the supra-condylar
with a vertical split running through the articular surface, and so
implicating the joint. The condyles are thus separated from one
another, as well as from the shaft, by a T- or Y-shaped cleft. As such
fractures usually result from severe forms of direct violence, they
are often comminuted and compound. In addition to the signs of
supra-condylar fracture, the joint is filled with blood. The condyles
may be felt to move upon one another, and coarse crepitus, which has
been likened to the feeling of a bag of beans, may be elicited if the
fragments are comminuted.

[Illustration: FIG. 34.--Radiogram of T-shaped Fracture of Lower End
of Humerus.]

#Separation of the lower epiphysis# of the humerus is met with in
children of three or four years of age, but it may occur up to the
thirteenth or fourteenth year. The more common lesion, however, is a
combination of separated epiphysis with fracture, and this lesion is
produced by the same forms of violence as cause supra-condylar
fracture. If the periosteum is not torn, there is little or no
displacement, but as a rule the clinical features closely resemble
those of transverse fracture above the condyles, or of dislocation of
the elbow. In separation of the epiphysis there is a peculiar
deformity of the posterior aspect of the joint, consisting of two
projections--one the olecranon, and the other the prominent capitellum
with a scale of cartilage which it carries with it from the lateral
condyle (R. W. Smith and E. H. Bennett). The end of the diaphysis may
be palpated through the skin in front. Muffled crepitus can usually be
elicited, and there is pain on pressing the segments against one
another. Sometimes the separation is _compound_, the diaphysis
protruding through the skin.

Union takes place more rapidly than in fracture, but, owing to the
excessive formation of callus from the torn periosteum in front of the
joint, full flexion is often interfered with. If the displaced
epiphysis is imperfectly reduced, serious interference with the
movements of the elbow is liable to ensue, and may call for operative
treatment.

#Fracture of either Condyle alone.#--The lateral condyle or trochlea
is more frequently separated from the rest of the bone than is the
medial or capitellum. In either, the size of the fragment varies, but
the line of fracture is partly extra-capsular and partly
intra-capsular, so that the joint is always involved. Pain, crepitus,
and the other signs of fracture are present. As the ligaments of the
joint are not as a rule torn, there is little or no immediate
displacement of the fragment. Secondary displacement is liable to
occur, however, during the process of union, producing alterations in
the "carrying angle" of the limb--_cubitus varus_ or _cubitus valgus_.

#Fracture of Epicondyles.#--Fracture of the _lateral epicondyle_ alone
is so rare that it need only be mentioned.

The _medial epicondyle_ may be chipped off by a fall on the edge of a
table or kerbstone, or it may be forcibly avulsed by traction through
the ulnar collateral (internal lateral) ligament, as an accompaniment
of dislocation. It is usually displaced downwards and forwards by the
flexor muscles attached to it, and may thus come to exert pressure on
the ulnar nerve. The fragment may be grasped and made to move on the
shaft, producing crepitus. Fibrous union is the usual result.

Up to the age of seventeen or eighteen the epiphysis of the epicondyle
may be separated.

#Treatment of Fractures in Region of Elbow.#--The administration of a
general anæsthetic is a valuable aid to accurate reduction and
fixation of fractures in this region. Much discussion has taken place
as to the best position in which to treat these fractures. In our
experience the best approximation of the fragments, as shown by the
X-rays, is obtained when the limb is fixed in the position of full
flexion with supination. American surgeons favour the position of
flexion at a right angle. In the region of the elbow there is a risk
of promoting too much callus formation by early and vigorous massage,
with the result that the movements of the joint are restricted by
locking of the bony projections. This is probably due to bone cells
being forced into the surrounding tissues, where they multiply and
form new bone on an exaggerated scale.

The _supra-condylar fracture_ is reduced by first extending the elbow
to free the lower fragment from the triceps, and then, while making
traction through the forearm, manipulating the fragments into
position, and finally flexing the elbow to an acute angle and
supinating the forearm. In this way the triceps is put upon the
stretch and forms a natural posterior splint. A layer of wadding is
placed in the bend of the elbow to separate the apposed skin surfaces,
the arm placed in a sling so arranged as to support the elbow, and
fixed to the side by a body bandage. This position is maintained for
three weeks, with daily massage and movement. The last movement to be
attempted is that of complete extension. Operative treatment is rarely
called for.

_Separation of the epiphysis_ and _fracture of the medial epicondyle_
are treated on the same lines as supra-condylar fracture.

_T- or Y-shaped fractures_ and _fractures of the condyles_, inasmuch
as they implicate the articular surfaces, present greater difficulties
in treatment, but they are treated on the same lines as the
supra-condylar. In young subjects whose occupation entails free
movement of the elbow-joint, it is sometimes advisable to expose the
fracture by operation and secure the fragments in position. The
details of the operation vary in different cases, and depend upon the
line of obliquity of the fracture, and the disposition of the
individual fragments, points which may usually be determined by the
use of the X-rays. In performing the operation, care must be taken to
disturb the periosteum as little as possible, otherwise there may
follow excessive formation of new bone.

Operative interference is sometimes necessary for ankylosis or locking
of the joint after the fracture is united, or to relieve the ulnar
nerve when it is involved in callus. _Volkmann's ischæmic contracture_
is liable to occur after fractures in the region of the elbow from
impairment of the blood supply as a result of tight bandaging.


FRACTURE OF THE UPPER END OF THE ULNA

#Fracture of the olecranon# is a comparatively common injury in
adults. It usually follows a fall on the flexed elbow, and results
from the direct impact, supplemented by the traction of the triceps
muscle. In a few cases it has been produced by muscular action alone.
The line of fracture may pass through the tip of the process, or
through its middle, less frequently through the base. It may be
transverse, oblique, T- or V-shaped, but is rarely comminuted or
compound.

_Clinical Features._--As the fracture almost invariably implicates the
articular surface, there is considerable swelling from effusion of
blood into the joint. The power of extending the forearm is impaired,
and other symptoms of fracture are present. The amount of displacement
depends upon the level of the fracture, and the extent to which the
aponeurotic expansion of the triceps is torn. As the fracture is
usually near the tip, the displacement is comparatively slight, the
prolongation of the fibres of insertion of the triceps on to the sides
and posterior part of the process holding the small fragment in
position; and the fracture may easily escape recognition. When the
line of fracture is nearer the base, however, the contraction of the
triceps tends to separate the fragments widely (Fig. 35), and a
distinct gap, which is increased on flexing the elbow, may often be
felt between them, and if the elbow is passively extended, the
fragments may be brought into apposition, and crepitus elicited.

[Illustration: FIG. 35.--Radiogram of Fracture of Olecranon Process,
showing marked degree of displacement.

(Sir Robert Jones' case. Radiogram by Dr. D. Morgan.)]

When there is little displacement, bony union may result, but in many
cases the fragments are united only by fibrous tissue. The upper
fragment sometimes forms attachments to the shaft of the humerus, and
this leads to stretching of the fibrous band between the fragments and
to marked wasting of the triceps.

Separation of the olecranon _epiphysis_ is one of the rarest forms of
epiphysial detachment (Poland). When the epiphysis is displaced
upwards and unites in this position, it may interfere with complete
extension of the elbow.

_Treatment._--It would appear that too much stress has hitherto been
laid on the necessity of bringing the fragments into perfect
apposition, and too little attention paid to the importance of
maintaining the functions of the triceps and the movements of the
elbow-joint.

Massage and movements are carried out from the first, and the forearm
is supported in a sling. Full flexion is the last movement to be
attempted. In carrying out the movements, the tip of the olecranon is
pressed down with the thumb, so that it is obliged to follow the
movements of the ulna, and is prevented from adhering to the humerus.

It was formerly the practice to have the arm almost, but not quite,
fully extended, and a Gooch splint, extending from the lower border of
the axilla to the finger-tips, and cut to the shape of the extended
limb, applied anteriorly and fixed in position by a bandage, the
region of the elbow being covered by a convergent spica.

_Operative Treatment._--Operative treatment may be had recourse to,
particularly in cases in which there is wide separation of the
fragments. The fracture is exposed, the joint cavity opened up and
cleared of clots, and silver-wire sutures passed through the fragments
without encroaching upon the articular cartilage. The limb is fixed
with the elbow-joint in the position of almost complete extension.
Movement may be commenced at the end of a week, the angle at which the
joint is fixed being changed morning and evening. During the day the
flexed position should be maintained and the arm carried in a sling;
during the night the limb is fixed to a pillow in the extended
position. The patient is allowed to use the joint cautiously within a
fortnight.

_Old-standing Fracture._--When union fails to take place, the interval
between the fragments tends to increase by the contraction of the
triceps gradually stretching the intermediate fibrous tissue, so that
a wide gap comes to separate the fragments. It is quite common that
the function of the arm is all that can be desired in spite of a gap
between the fragments, but, if this is not the case, the fragments may
be united by operation.

#Fracture of the coronoid process# is rare except as a complication of
backward dislocation of the elbow. It may be produced by direct
violence, as well as by muscular action. As the fracture is usually
within a quarter of an inch of the tip, the fibres of insertion of the
brachialis prevent displacement. The ordinary evidence of fracture is
often absent, and the diagnosis is seldom completed without the aid of
the X-rays. The treatment consists in flexing the elbow and supporting
the forearm in a sling. In some cases associated with dislocation,
however, the small fragment has been so far displaced as to become
attached to the back of the humerus (Annandale).


FRACTURE OF THE UPPER END OF THE RADIUS

Intra-capsular fracture of the #head of the radius# may result from
direct violence, from a fall on the pronated hand, or from forcible
pronation or abduction--that is, deviation of the forearm to the
radial side. It may accompany dislocation of the elbow or fracture of
adjacent bones. The head may be completely separated, or may be split
into two or more fragments. Up to the seventeenth year, the
_epiphysis_, which is entirely intra-articular, may be separated.

The _clinical features_ are localised pain, crepitus, interference
with pronation and supination, while the elbow can be almost fully
extended and flexed, and in some cases the fragment may be felt
through the skin, although it usually continues to move with the shaft
in pronation and supination.

Union generally takes place satisfactorily, but in some cases the
fragments form new attachments resulting in impaired movement at the
elbow, and necessitating operative interference.

Fracture of the #neck of the radius# between the capsule and the
tubercle is rare.

#Avulsion of the tubercle# may occur from forcible contraction of the
biceps, or, in children, from traction made on the forearm (A. L.
Hall).

These injuries are treated with the elbow in the flexed position, and
massage and movement are carried out as already described.


DISLOCATION OF THE ELBOW

Dislocations of the elbow-joint may involve one or both bones of the
forearm, and may be complete or incomplete.

#Dislocation of both bones backward# is the most common of all
dislocations of the elbow, and is the only dislocation that is
frequently met with in children. It usually results from a fall on the
outstretched hand, causing hyper-extension of the joint with
abduction--that is, deviation towards the radial side; but it may
follow a direct blow on the back of the humerus, a fall on the elbow,
or a twist of the forearm.

[Illustration: FIG. 36.--Backward Dislocation of Elbow, in a boy æt.
10, caused by a fall off a wall, landing on the elbow.]

_Morbid Anatomy._--All the ligaments of the elbow, except the annular
(orbicular), are torn or stretched. The radius and ulna pass backward,
the coronoid process coming to rest opposite the olecranon fossa
behind the humerus, and the head of the radius behind the lateral
condyle. The condyles of the humerus bear their normal relations to
one another. The olecranon and the triceps tendon form a marked
prominence on the back of the elbow, the tip of the olecranon lying
above and behind the condyles. The lower end of the humerus lies in
the flexure of the joint with the biceps tendon tightly stretched over
it. The coronoid process is often broken, or the tendon of the
brachialis torn. The median and ulnar nerves may be stretched or torn.
Not infrequently the bones of the forearm are displaced towards the
medial side as well as backward.

Occasionally, as a sequel to the dislocation, processes of bone
develop in relation to the insertion of the brachialis and interfere
with the movements of the joint. These outgrowths are due to
displacement of bone-forming elements, either at the time of the
original injury or as a result of forcible efforts at reduction.
According to D. M. Greig, they do not develop in the tendon of the
brachialis, but under it, and are not of the nature of myositis
ossificans. In from four to six weeks after reduction of the
dislocation, the movements begin to be restricted, and a hard mass can
be felt in the cubital fossa, which with the X-rays is seen to be a
bony outgrowth springing from the quadrilateral space on the front of
the elbow below the coronoid process (Fig. 37). This gradually
increases in size and leads to fixation of the joint. In most cases
the effects reach their maximum in about six months, and then
reabsorption of the mass begins.

[Illustration: FIG. 37.--Bony Outgrowth in relation to insertion of
Brachialis Muscle, following Backward Dislocation of Elbow.

(Sir Robert Jones' case. Radiogram by Dr. D. Morgan.)]

If the disability shows no sign of abatement within a year, or if the
bony outgrowth is producing pressure effects on the median nerve, it
should be removed by operation.

It is important not to mistake this condition for the effects of a
fracture which has complicated the dislocation and been overlooked at
the time of the accident.

[Illustration: FIG. 38.--Radiogram of Incomplete Backward Dislocation
of Elbow.]

_Clinical features._--The elbow is held fixed at an angle of about
120°, pronated or midway between pronation and supination. Any attempt
at movement causes great pain, and is followed by an elastic rebound
to the abnormal position. The antero-posterior diameter of the joint
is increased, and the forearm, as measured from the lateral epicondyle
to the tip of the styloid process of the radius, is shortened to the
extent of about an inch. If examined before swelling ensues, the
outlines of the articular surfaces may be recognised in their abnormal
positions, but swelling usually comes on rapidly, and, by obscuring
the bony landmarks, renders the diagnosis difficult.

This injury has to be diagnosed from supra-condylar fracture with
backward displacement of the lower fragment and from separation of the
lower humeral epiphysis. A general anæsthetic is often necessary to
enable an accurate diagnosis to be made. When the deformity is once
reduced, there is no tendency to its reproduction unless the
coronoid process is also fractured. In a considerable number of
cases--according to E. H. Bennett, in the majority--this dislocation
is _incomplete_, the coronoid process resting at the level of the
trochlea, and the backward projection of the olecranon being scarcely
appreciable. The head of the radius, however, is unduly prominent. In
such cases the lesion is liable to be overlooked, and therefore to go
untreated, leading to permanent stiffness at the elbow.

#Dislocation forward# is much less common than the backward variety.
It is produced by severe force acting from behind on the flexed elbow,
the ulna being driven forward, tearing the ligaments of the joint and
the muscles attached to the condyles. The olecranon is frequently
fractured at the same time (Fig. 39). When it remains intact, it may
rest below the condyles (incomplete or first stage of dislocation), or
may pass in front of them, especially if the triceps is ruptured
(complete or second stage). The forearm is lengthened, the elbow
slightly flexed, the posterior aspect of the joint flattened, and the
condyles, in their abnormal relationship, can be palpated from behind.

#Medial and Lateral Dislocations.#--Dislocation towards the ulnar side
is always incomplete, some portion of the articular surface of the
bones of the forearm remaining in contact with the condyles.

The dislocation to the radial side is also incomplete as a rule,
although cases have been recorded in which complete separation had
taken place.

These forms of dislocation are rare, that towards the ulnar side being
more frequently observed. Each form is often combined with other
injuries in the vicinity.

The most common cause of these dislocations is a fall on the
outstretched hand, the forearm at the moment being strongly pronated.
Forced abduction favours the displacement to the ulnar side; adduction
to the radial side. The limb is held flexed and pronated, and the
facility with which the bony points can be palpated renders the
diagnosis easy.

In a few cases _diverging dislocations_ have been met with, the radius
and ulna being separated from one another, the annular (orbicular)
ligament being torn and no longer holding them together.

#Treatment of Dislocations of Elbow.#--The chief obstacle to reduction
is the spasmodic contraction of the muscles passing over the joint,
and, in the backward variety, the hitching of the coronoid process
against the edge of the olecranon fossa. In recent cases, to effect
reduction the patient is seated on a chair, while the surgeon grasps
the humerus and wrist, and places his knee in the bend of the elbow.
The limb is first fully extended, or even hyper-extended, to relax the
triceps and free the coronoid process. Traction is then made in
opposite directions upon the forearm and arm, the surgeon's knee
meanwhile making pressure, in a backward direction, upon the lower end
of the humerus. The joint is next slowly flexed, and the bones slip
into position, often with a distinct snap. If the patient be
anæsthetised, these manipulations must be adapted to the recumbent
position.

When some days have elapsed before reduction is attempted, forcible
manipulations are to be deprecated as they greatly increase the risk
of ossification occurring in relation to the brachialis (D. M. Greig);
and recourse should be had to open operation, and the tearing or
bruising of the soft parts should be reduced to a minimum.

After reduction, the limb is flexed to rather less than a right angle
and supported by a sling. Massage and movement are commenced at once.

Fracture of the coronoid process predisposes to recurrence of the
dislocation; when this complication exists, therefore, the limb should
be fixed at an acute angle, and movements of full extension postponed
for a fortnight. Massage and limited movements, however, may be
carried out from the first.

If there is a fracture of the olecranon, the treatment must be
modified accordingly (p. 87).

[Illustration: FIG. 39.--Forward Dislocation of Elbow, with Fracture
of Olecranon.

(Sir Robert Jones' case. Radiogram by Dr. D. Morgan.)]

Comminuted and compound injuries usually call for operative treatment,
the fractured bones being wired after reduction of the dislocation, or
the loose fragments removed.

The _forward dislocation_ is reduced by fully flexing the elbow, and
then pushing the bones of the forearm backward, while the humerus is
pulled forward.

_Old-standing Dislocations._--No attempt should be made to reduce by
manipulation a dislocation of the elbow which has remained displaced
for five or six weeks, especially when it has been complicated by a
fracture. The joint surfaces become welded together by adhesions, and
separated fragments often form attachments which lock the joint.
Attempts to break these down are attended with considerable risk of
re-fracturing the bone or of tearing the soft parts. In such cases it
is best to expose the joint, and if reduction is not easily effected a
sufficient amount of the lower end of the humerus should be removed to
provide a movable joint.

#Dislocation of the ulna alone# is a rare injury, and is usually
associated with fracture of one or other of its processes or of the
inner condyle.

#Dislocation of the radius alone#, on the other hand, is comparatively
common, especially as a concomitant of fracture of the upper third of
the shaft of the ulna (Fig. 40).

The injury may result from a blow on the back of the upper end of the
radius, a fall on the outstretched hand, or, in children, from
forcible traction on the forearm while in the pronated position. The
displaced head usually passes _forward_, and rests on the anterior
edge of the capitellum, thus preventing complete flexion and
supination of the limb.

The limb is held partly flexed and pronated. The displaced head of the
radius can be felt to rotate with the shaft in its abnormal position,
and the articular facet on the head of the radius may also be felt;
there is a depression posteriorly below the lateral epicondyle where
the head should be. The radial side of the forearm is slightly
shortened. The superficial and deep (posterior interosseous) branches
of the radial nerve are liable to be pressed upon or torn by the
displaced head of the radius, especially if the ulna is fractured,
leading to disturbances in the area of their distribution.

[Illustration: FIG. 40.--Radiogram of Forward Dislocation of Head of
Radius, with Fracture of Shaft of Ulna.]

In a few cases the displacement of the head has been _backwards_ or
_laterally_.

_Treatment._--To effect reduction, the forearm should be alternately
flexed and extended, while traction is made upon it from the wrist,
and the head of the radius is pressed backward with the thumb in the
fold of the elbow. When reduction is prevented by the interposition
of a portion of the torn ligaments between the bones, it is sometimes
necessary to open the joint to ensure accurate adjustment. The joint
is fixed in acute flexion to relax the biceps, to allow of union of
the torn ligaments, and to prevent recurrence.

In old-standing cases, to obtain a useful joint, or to remove pressure
from the branches of the radial nerve, resection of the head of the
radius may be necessary.

#Sub-luxation of the head of the radius#, or "dislocation by
elongation," is a comparatively common injury in children between the
ages of two and six. It almost invariably results from the child being
lifted or dragged by the hand or forearm. The traction and torsion
thus put upon the radius causes the front part of its head to pass out
of the annular ligament, the edge of which slips between the bones.

The person holding the child may feel a click at the moment of
displacement. The child complains of pain in the region of the elbow:
the arm at once becomes useless, and is held flexed, midway between
pronation and supination. All movements are painful, but especially
movements in the direction of supination. The deformity is slight, but
the head of the radius may be unduly prominent in front. From the way
in which the injury is produced the wrist also is often swollen, and
in some cases the patient is brought to the surgeon on account of the
condition of the wrist, and attention is not directed to the elbow.

_Treatment._--Reduction frequently takes place spontaneously or during
examination, the function of the arm being at once completely
restored. In other cases it is necessary, under anæsthesia, to
manipulate the head of the bone into position. This is usually easily
done by flexing the elbow, making slight traction on the forearm, and
alternately pronating and supinating it. After reduction, a few days'
massage is all that is necessary, the joint in the intervals being
kept at rest in a sling.

#Sprain# of the elbow is comparatively common as a result of a fall on
the hand or a twist of the forearm. The point of maximum tenderness is
usually over the radio-humeral joint, the radial collateral and
annular ligaments being those most frequently damaged. Effusion takes
place into the synovial cavity, and a soft, puffy swelling fills up
the natural hollows about the joint. The bony points about the elbow
retain their normal relationship to one another--a feature which aids
in determining the diagnosis between a sprain and a dislocation or
fracture. In children it is often difficult to distinguish between a
sprain and the partial separation of an epiphysis. Sprains of the
elbow are treated on the same lines as similar lesions elsewhere--by
massage and movement.

The condition known as _tennis elbow_ is characterised by severe pain
over the attachment of one or other of the muscles about the elbow,
particularly the insertion of the pronator teres during the act of
pronation, and is due to stretching or tearing of the fibres of that
muscle, and of the adjacent intermuscular septa. A similar
injury--_sculler's sprain_--occurs in rowing-men from feathering the
oar. The treatment consists in massage and movement, care being taken
to avoid the movement which produced the sprain.


FRACTURE OF THE FOREARM

The _shafts_ of the bones of the forearm may be broken separately, but
it is much more common to find both broken together.

#Fracture of both bones# may result from a direct blow, from a fall on
the hand, or from their being bent over a fixed object. The line of
fracture is usually transverse, both bones giving way about the same
level. The common situation is near the middle of the shafts. In
children, greenstick fracture of both bones is a frequent result of a
fall on the hand--this indeed being one of the commonest examples of
greenstick fracture met with (Fig. 41).

[Illustration: FIG. 41.--Greenstick Fracture of both Bones of the
Forearm, in a boy.]

The _displacement_ varies widely, depending partly upon the force
causing the fracture, partly on the level at which the bones break,
and on the muscles which act on the respective fragments. It is common
to find an angular displacement of both bones to the radial or to the
ulnar side. In other cases the four broken ends impinge upon the
interosseous space, and may become united to one another, preventing
the movements of pronation and supination. There may be shortening
from overriding of fragments.

When the radius is broken above the insertion of the pronator teres,
its upper fragment may be supinated by the biceps and supinator
muscles, while the lower fragment remains in the usual semi-prone
position. If union takes place in this position, the power of complete
supination is permanently lost.

The usual _symptoms_ of fracture are present, and there is seldom any
difficulty in diagnosis.

The _prognosis_ must be guarded, especially with regard to the
preservation of pronation and supination. These movements are
interfered with if union takes place in a bad position with angular or
rotatory deformity of one or both bones, or if callus is formed in
excess and causes locking of the bones. In some cases the callus fuses
the two bones across the interosseous space, and pronation and
supination are rendered impossible.

Persistent angular deformity of the forearm is also liable to ensue,
either from failure to correct the displacement primarily, or from
subsequent bending due to ill-applied splints or slings. Want of
union, or the formation of a false joint in one or both bones, is
sometimes met with, particularly in children, and, like the
corresponding fracture of the leg, is liable to prove intractable.

A considerable number of cases of gangrene of the hand after simple
fracture of the forearm are on record. This is sometimes attributable
to damage inflicted upon the blood vessels by the fractured bones, or
to the force that caused the fracture, but is oftener due to a roller
bandage applied underneath the splints strangulating the limb, to
injudiciously applied pads, or to too tight bandaging over the
splints. Volkmann's ischæmic contracture occasionally develops after
fractures of the forearm.

In uncomplicated cases, union takes place in from three to four
weeks.

_Treatment._--To ensure accurate reduction and coaptation, a general
anæsthetic is usually necessary. In the greenstick variety the bones
must be straightened, the fracture being rendered complete, if
necessary, for this purpose.

To retain the bones in position, anterior and posterior splints are
then applied. These are made to overlap the forearm by about half an
inch on each side, to avoid compressing the forearm from side to side,
and so making the fractured ends encroach upon the interosseous space.
The dorsal splint is usually made to extend from the olecranon to the
knuckles, and the palmar one from the bend of the elbow to the flexure
in the middle of the palm, a piece being cut out to avoid pressure on
the ball of the thumb (Fig. 42). The splints are applied with the
elbow flexed to a right angle, and, except when the radius is broken
above the level of the insertion of the pronator teres, with the
forearm midway between pronation and supination. The limb is placed in
a sling, so adjusted that it supports equally the hand and elbow in
order to avoid angular deformity. The use of special interosseous pads
is to be avoided.

[Illustration: FIG. 42.--Gooch Splints for Fracture of both Bones of
Forearm. (These are applied with the wooden side towards the skin.)]

When the fracture of the radius is above the insertion of the pronator
teres, the forearm should be placed in the position of complete
supination, with the elbow flexed to an acute angle, and retained in
this position by a moulded posterior splint, and the arm fixed to the
side by a body bandage. Great care is necessary in the adjustment of
the apparatus to prevent pronation.

Massage and movement should be carried out from the first. It is
usually necessary to continue wearing the splints for about three
weeks.

In cases of _mal-union_, especially when the bones are ankylosed to
one another across the interosseous space, operation may be necessary,
but it is neither easy in its performance nor always satisfactory in
its results. The seat of fracture should be exposed by one or more
incisions so placed as to enable the muscles to be separated and to
give access to the callus. When the limb is straight, it is only
necessary to gouge away the exuberant callus that interferes with
rotatory movements; but when there is an angular deformity the bones
must, in addition, be divided and re-set, and, if necessary,
mechanically fixed in good position. In comparatively recent cases it
is sometimes possible, without operation, to re-fracture the bones and
to set them anew.

_Un-united fracture_ of both bones of the forearm is not uncommon and
is treated on the usual lines; the gap between the fragments of the
radius is bridged by a portion of the fibula, that should be long
enough to overlap by at least an inch at either end; it is rarely
necessary to bridge the gap in the ulna, unless it alone is the seat
of non-union.

#Fracture of the shaft of the radius alone# may be due to a direct
blow; to indirect violence, such as a fall on the hand; or to forcible
pronation against resistance, as in wringing clothes. It is rare in
comparison with fracture of both bones. When broken above the
insertion of the pronator teres, the upper fragment is flexed and
supinated by the biceps and supinator, while the lower fragment
remains semi-prone, and is drawn towards the ulna by the pronator
quadratus.

When the fracture is below the pronator teres, the displacement
depends upon the direction of the force and the obliquity of the
fracture. In fractures of the lower third of the shaft, the hand may
be flexed toward the radial side, and the styloid lies at a higher
level, as in a Colles' fracture. From the frequency with which this
fracture occurs while cranking a motor-car, it is conveniently
described as _Chauffeur's fracture_; we have observed in doctors, who
have sustained this fracture in their own persons, that they were
under the impression that they had sustained a trivial sprain of the
wrist.

In addition to the ordinary signs of fracture, there is partial or
complete loss of pronation and supination. The head of the radius as a
rule does not move with the lower part of the shaft, but may do so if
the fracture is incomplete or impacted.

#Fracture of the shaft of the ulna alone# is also comparatively rare.
It is almost always due to a direct blow sustained while protecting
the head from a stroke, or to a fall on the ulnar edge of the forearm,
as in going up a stair.

The upper third is most frequently broken, and this injury is often
associated with dislocation of the head of the radius (Fig. 40), or
some other injury implicating the elbow-joint. On account of the
superficial position of the bone, this fracture is frequently
compound.

The displacement depends on the direction of the force, the fragments
being usually driven towards the interosseous space. There is seldom
marked deformity unless the head of the radius is dislocated at the
same time. The diagnosis is, as a rule, easy.

The _treatment_ is the same as for fracture of both bones, but the
splints may be discarded at the end of a fortnight.

For some unexplained reason, a fracture of the upper third of the
shaft of the ulna frequently fails to unite.




CHAPTER V

INJURIES IN THE REGION OF THE WRIST AND HAND


Surgical Anatomy--FRACTURE OF LOWER END OF RADIUS: _Colles' fracture_;
    _Chauffeur's fracture_; _Smith's fracture_; _Longitudinal
    fracture_; _Separation of epiphysis_--FRACTURE OF LOWER END OF
    ULNA: _Shaft_; _Styloid process_; _Separation of
    epiphysis_--FRACTURE OF CARPAL BONES--DISLOCATION: _Inferior
    radio-ulnar joint_; _Radio-carpal joint_; _Carpal bones_;
    _Carpo-metacarpal joint_--SPRAINS--INJURIES OF FINGERS:
    _Fractures_; _Dislocations_; _Mallet finger_.


INJURIES IN THE REGION OF THE WRIST

These include fractures of the lower ends of the bones of the forearm
and separation of their epiphyses; sprains and dislocations of the
inferior radio-ulnar, and of the radio-carpal articulations; and
fractures and dislocations of the carpus.

#Surgical Anatomy.#--The most important landmarks in the region of the
wrist are the styloid processes of the radius and ulna. The tip of the
radial styloid is palpable in the "anatomical snuff-box" between the
tendons of the long and short extensors of the thumb, and it lies
about half an inch lower than the ulnar styloid. The ulnar styloid is
best recognised on making deep pressure a little below and in front of
the head of the ulna, which forms the rounded subcutaneous prominence
seen on the back of the wrist when the hand is pronated.

The tubercle of the navicular (scaphoid) and the greater multangular
(trapezium) can be felt between the radial styloid and the ball of the
thumb, a little below the radial styloid; and the pisiform and hook of
the hamatum (unciform) are palpable, slightly below and in front of
the ulnar styloid.

In examining an injured wrist, the different bony points should be
located, and their relative positions to one another and to the
adjacent joints noted; and the shape, position, and relations of any
unnatural projection or depression observed, using the wrist on the
other side as the normal standard for comparison. The power and range
of movement--active and passive--at the various joints should also be
tested.


FRACTURE OF THE LOWER END OF THE RADIUS

#Colles' Fracture.#--This injury, which was described by Colles of
Dublin in 1814, is one of the commonest fractures in the body, and is
especially frequent in women beyond middle age. It is almost
invariably the result of a fall on the palm of the hand, in the
three-quarters pronated position, the force being received on the ball
of the thumb, and transmitted through the carpus to the lower end of
the radius which is broken off, the lower fragment being driven
backwards.

The fracture takes place through the cancellated extremity of the
bone, within a half to three-quarters of an inch of its articular
surface (Fig. 45). It is usually transverse, but may be slightly
oblique from above downwards and from the radial to the ulnar side. In
a considerable proportion of cases it is impacted, and not
infrequently the lower fragment is comminuted, the fracture extending
into the radio-carpal joint.

[Illustration: FIG. 43.--Colles' Fracture showing radial deviation of
hand.]

[Illustration: FIG. 44.--Colles' Fracture showing undue prominence of
ulnar styloid.]

When impaction takes place, it is usually reciprocal, the dorsal edge
of the proximal fragment piercing the distal fragment, and the palmar
edge of the distal fragment piercing the proximal. The periosteum is
usually torn and stripped from the palmar aspect of the fragments,
while it remains intact on the dorsum.

In the majority of cases the styloid process of the ulna is torn off
by traction exerted through the medial ulno-carpal (internal lateral)
ligament, and in a considerable proportion there is also a fracture of
one of the carpal bones.

The resulting _displacement_ is of a threefold character: (1) the
distal fragment is displaced backwards; (2) its carpal surface is
rotated backwards on a transverse diameter of the forearm; while (3)
the whole fragment is rotated so that the radial styloid comes to lie
at a higher level than normal.

[Illustration: FIG. 45.--Radiogram showing the line of fracture and
upward displacement of the radial styloid in Colles' Fracture.]

_Clinical Features._--In a typical case there is a prominence on the
dorsum of the wrist, caused by the displaced distal fragment, with a
depression just above it (Fig. 43); and the wrist is broadened from
side to side. The natural hollow on the palmar aspect of the radius is
filled up by the projection of the proximal fragment. The carpus is
carried to the radial side by the upward rotation of the distal
fragment, and the radial styloid is as high, or even higher, than that
of the ulna. The lower end of the ulna is rendered unduly prominent by
the flexion of the hand to the radial side. The fingers are partly
flexed and slightly deviated towards the ulnar side; and the patient
supports the injured wrist in the palm of the opposite hand, and
avoids movement of the part. Occasionally the median nerve is bruised
or torn, causing motor and sensory disturbances in its area of
distribution.

The general outline of the wrist and hand has been compared not
inaptly to that of "an inverted spoon." Pronation and stipulation are
lost, the joint is swollen, and there is tenderness on pressure,
especially over the line of fracture. Tenderness over the position of
the ulnar styloid may indicate fracture of that process, although it
is sometimes present without fracture. No attempt should be made to
elicit crepitus in a suspected case of Colles' fracture as the
manipulations are painful, and are liable to increase the
displacement.

_Treatment._--It cannot be too strongly insisted upon that success in
the treatment of Colles' fracture with displacement and impaction
depends chiefly upon complete and accurate reduction, and to enable
this to be effected a general anæsthetic is almost essential. The
surgeon grasps the patient's hand, as if shaking hands with him, and,
resting the palmar surface of the wrist on his bent knee, makes
traction through the hand, and counter-extension through the forearm,
with lateral movements, if necessary, to undo impaction. When the
fragments are freed from one another, the wrist is flexed, and the
hand carried to the ulnar side, while the lower fragment is moulded
into position by the thumb of the surgeon's disengaged hand. When
reduction is complete, the deformity disappears, and the two styloid
processes regain their normal positions relative to one another.

As there is no tendency to re-displacement and no risk of non-union,
no retentive apparatus is required, but, if it adds to the patient's
sense of security, a bandage or a poroplastic wristlet may be applied.
In severe cases, however, anterior and posterior splints, similar to
those used for fracture of both bones of the forearm, or a dorsal
splint padded so as to flex the wrist to an angle of 45°, but somewhat
narrower, may be employed. The hand and forearm are in any case
supported in a sling.

To avoid the stiffness that is liable to follow, massage and movement
of the wrist and fingers should be carried out from the first, the
range of movement being gradually increased until the function of the
joints is perfectly restored. If splints are used, they should be
discarded in a week, and the patient is then encouraged to use the
wrist freely.

The various special splints recommended for the treatment of Colles'
fracture, such as Carr's, Gordon's, the "pistol splint," and many
others, are all designed to correct the deformity as well as to
control the fragments. It has already been pointed out that if
reduction is complete there is no deformity to correct, and if it is
not complete the deformity cannot be corrected by any form of splint.

_Unreduced Colles' Fracture._--When union has been allowed to take
place without the displacement having been reduced, an unsightly
deformity results. In young subjects whose occupation is likely to be
interfered with, and in women for æsthetic reasons, the fracture is
reproduced and the displacement of the lower fragment corrected. This
is conveniently done by means of Jones' wrench, which grasps the
distal fragment and affords sufficient leverage to break the bone.

#Chauffeur's Fracture.#--A fracture of the lower end of the radius
frequently occurs from the recoil of the crank, "by back firing," in
starting the engine of a motor-car. The injury may be produced either
by direct violence, the handle as it recoils striking the forearm, or
by indirect violence, from forcible hyper-extension of the hand while
grasping the handle. The fracture may pass transversely through the
lower end of the radius, as in Colles' fracture, but is more often met
with two or three inches above the wrist (Fig. 46). It is treated on
the same lines as Colles' fracture.

[Illustration: FIG. 46.--Radiogram of Chauffeur's Fracture.]

A fracture of the lower end of the radius _with forward displacement
of the carpal fragment_, was first described by R. W. Smith of Dublin
(_Colles' fracture reversed_, or #Smith's fracture#) (Fig. 47). It is
nearly always due to forcible flexion, as from a fall on the back of
the hand. Like Colles' fracture, it may be transverse or slightly
oblique, impacted, or comminuted. The deformity is characterised by an
elevation on the dorsum running obliquely upwards from the ulnar to
the radial side of the wrist, and caused by the head of the ulna,
which remains in position, and the distal end of the proximal
fragment. Below this, over the position of the distal radial fragment,
is a gradual slope downwards on to the dorsum of the hand. Anteriorly
there is a prominence in the flexure of the wrist, and the distal
fragment may be felt under the flexor tendons. The hand deviates to
the radial side, and thereby still further increases the prominence
caused by the lower end of the ulna. The radial styloid is displaced
forward, upward, and to the radial side, and the ulnar styloid may be
torn off.

[Illustration: FIG. 47.--Radiogram of Smith's Fracture.

(Sir George T. Beatson's case.)]

When the deformity is not well marked, this injury may be mistaken for
forward dislocation of the wrist, for fracture of both bones low down,
or for sprain of the joint.

The _treatment_ is carried out on the same lines as in Colles'
fracture.

_Longitudinal fractures_ of the lower end of the radius opening into
the joint usually result from the hand being crushed by a heavy weight
or in machinery. They are often compound and comminuted.

#Separation of the lower epiphysis# of the radius, which is on the
same level as that of the ulna and lies above the level of the
synovial membrane of the wrist-joint, is comparatively common between
the ages of seven and eighteen, especially in boys, and is caused by
the same forms of violence as produce Colles' fracture.

Although clinically the appearances in these two injuries bear a
general resemblance to one another, separation of the epiphysis may
usually be identified by the directly transverse line of the dorsal
and palmar projections, the folding of the skin observed in the palmar
depression, the absence of abduction of the hand and the ease with
which muffled crepitus can be elicited (E. H. Bennett). The deformity
is readily reduced, and the fragments are easily retained in position.

This injury is often complicated with fracture of the shaft or styloid
process of the ulna, or with dislocation of the radio-ulnar joint, and
it is not infrequently compound, the lower end of the shaft being
driven through the skin on the palmar aspect immediately above the
wrist. Impairment of growth in the radius seldom occurs; when it does,
it results in a valgus condition of the hand (Fig. 48), calling for
resection of the lower end of the ulna.

[Illustration: FIG. 48.--Manus Valga following separation of lower
radial epiphysis in childhood.

(Mr. H. Wade's case.)]

The _treatment_ is the same as for Colles' fracture.

#Fracture of the Lower End of the Ulna.#--The lower end of the _shaft_
of the ulna is seldom fractured alone. The _styloid process_, as has
already been pointed out, is frequently broken in association with
Colles' and other fractures of the lower end of the radius.

Separation of the _lower epiphysis_ of the ulna sometimes occurs, and
in rare cases results in arrest of the growth of the bone, leading to
a varus condition of the hand and bending of the radius. Sometimes the
separated epiphysis fails to unite, and although this gives rise to no
disability, it is liable to lead to errors in the interpretation of
skiagrams.

The _treatment_ is similar to that for the corresponding injuries of
the radius.

Simultaneous separation of the _epiphysis of both radius and ulna_
sometimes occurs, and, as a result of severe violence, may be
compound, the lower ends of the diaphyses projecting through the skin
on the palmar aspect above the wrist.

#Fracture of Carpal Bones.#--The use of the Röntgen rays has shown
that fracture of individual carpal bones is commoner than was
previously supposed, and that many cases formerly looked upon as
severe sprains are examples of this injury.

The _navicular_ (scaphoid) and _lunate_ (semilunar) are those most
commonly fractured, usually by indirect violence, by forced
dorsiflexion from a fall on the extended hand. The clinical features
are: localised swelling on the radial side of the wrist, increase in
the antero-posterior diameter of the carpus, marked tenderness in the
anatomical snuff-box when the hand is moved laterally, especially in
the direction of adduction, and, rarely, crepitus. The median nerve is
sometimes over-stretched or partly torn. In many cases, however, the
symptoms are so obscure that an accurate diagnosis can only be made by
the use of the X-rays (Fig. 49). Codman recommends taking pictures of
the navicular by placing the two wrists of the patient in adduction,
and of the lunate, in abduction.

[Illustration: FIG. 49.--Radiogram showing Fracture of Navicular
(Scaphoid) Bone.]

The _treatment_ of simple fractures consists in massage and movement.
Codman and Chase recommend excision of the proximal half of the
fractured bone, through a dorsal incision to the lateral side of the
extensor digitorum communis. When the fracture is compound, the loose
fragments should be removed.


DISLOCATIONS IN THE REGION OF THE WRIST

Dislocation may occur at the inferior radio-ulnar, the radio-carpal,
mid-carpal, inter-carpal, or carpo-metacarpal joints, but the strong
ligaments of these articulations, the comparatively free movement at
the various joints, and the relative weakness of the lower end of the
radius whereby it is so frequently fractured, render dislocation a
rare form of injury.

Dislocation of the #inferior radio-ulnar# articulation may complicate
fracture of the lower end of the radius, or accompany sub-luxation of
the head of the radius. The head of the ulna usually passes backward.

In children, the commonest cause is lifting the child by the hand, and
the displacement is only partial. In adults, it may result from
forcible efforts at pronation or supination, as in wringing clothes,
or from direct violence, the separation being frequently complete, and
sometimes compound.

The head of the ulna is unduly prominent, and there is a depression on
the opposite aspect of the joint. The hand is generally pronated, the
rotatory movements at the wrist are restricted and painful, while
flexion and extension are comparatively free.

Reduction is effected by making pressure on the displaced bone and
manipulating the joint, especially in the direction of supination. If
the ligaments fail to unite, the head of the ulna tends to slip out of
place in pronation and supination--_recurrent dislocation_.

Dislocation at the #radio-carpal# articulation, usually spoken of as
_dislocation of the wrist_, is attended by tearing of the ligaments
and displacement of tendons, and is frequently compound. The carpus
may be displaced backward or forward, and the articular edge of the
radius towards which it passes may be chipped off.

_Backward_ dislocation is commonest, the injury resulting from a
severe form of violence, such as a fall from a height on the palm
while the hand is dorsiflexed and abducted. The clinical appearances
closely simulate those of Colles' fracture, or of separation of the
lower radial epiphysis, but the unnatural projections, both in front
and behind, are lower down, and end more abruptly (Fig. 50). The hand
is more flexed, and the palm is shortened. The styloid processes
retain their normal relations to one another, and the carpal bones lie
on a plane posterior to the styloids, the articular surfaces may be
recognised on palpation. The forearm is not shortened.

_Forward_ dislocation of the carpus may result from any form of forced
flexion, such as a fall on the back of the hand, or from direct
violence. The displaced carpus forms a marked projection on the palmar
aspect of the wrist, and there is a corresponding depression on the
dorsum. The attitude of the hand and fingers is usually one of
flexion.

In both varieties reduction is readily effected by making traction on
the hand and pushing the carpus into position. A moulded poroplastic
splint, which keeps the hand slightly dorsiflexed, adds to the comfort
of the patient, but this should be removed daily to admit of movement
and massage being employed.

[Illustration: FIG. 50.--Dorsal Dislocation of Wrist at Radio-carpal
Articulation, in a man, æt. 24, from a fall.]

#Dislocation of Carpal Bones.#--The two rows of carpal bones may be
separated from one another, or any one of the individual bones may be
displaced. These injuries are rare, and result from severe forms of
violence, usually from a fall on the extended hand. Pain, deformity,
and loss of function are the ordinary symptoms. The treatment consists
in making direct pressure over the displaced bone, while traction is
made on the hand, which is alternately flexed and extended.

Of these injuries that most frequently observed is displacement of the
_head of the capitate bone_ (_os magnum_) from the navicular
(scaphoid) and lunate (semilunar) bones. Frequently these bones are
fractured, and fragments accompany the displaced os magnum. In full
palmar flexion of the wrist the displaced head of the os magnum forms
a prominence on the dorsum opposite the base of the third metacarpal,
which temporarily disappears when the hand is dorsiflexed. There is an
increase in the antero-posterior diameter of the wrist, situated on a
lower level than that which accompanies fracture of the lower end of
the radius; flexion and extension of the wrist are limited; and in
some cases there are symptoms referable to pressure on the median
nerve. By keeping the hand in the dorsiflexed position for a week or
ten days, the bone may become fixed in its place and the function of
the wrist be restored, but it is often necessary to excise the bone.

The _lunate_ may be displaced forward by forcible dorsiflexion of the
hand, and forms a projection beneath the flexor tendons; there is
usually loss of sensibility in the distribution of the ulnar nerve in
the hand. The most satisfactory treatment is removal of the bone.

In a few cases the _navicular_ has been displaced (Fig. 51), and has
had to be subsequently replaced by operation. Separation of any of the
other bones is rare.

[Illustration: FIG. 51.--Radiogram showing Forward Dislocation of
Navicular (Scaphoid) Bone.]

#Carpo-metacarpal Dislocations.#--Any or all of the metacarpal bones
may be separated from the carpus by forced movements of flexion or
extension. The commonest displacement is backward. The thumb seems to
suffer oftener than the other digits. These injuries, however, are so
rare, and the deformity is so characteristic, that a detailed
description is unnecessary.

#Sprain of the wrist# is a common injury, and results from a fall on
the hand, a twist of the wrist, or from the back-firing of a
motor-crank dorsiflexing the hand. The marked swelling which rapidly
ensues may render it difficult to distinguish a sprain from the other
injuries that are liable to result from similar causes--Colles'
fracture, separation of the lower radial epiphysis, dislocation of the
wrist, and fractures and dislocations of the carpal bones.

In a sprain the normal relations of the styloid processes and other
bony points about the wrist are unaltered, and there is no radial
deviation of the hand, as in Colles' fracture. The most marked
swelling is over the line of the articulation on the anterior and
posterior aspects of the joint. There is usually some effusion into
the sheaths of the tendons passing over the joint, and in some cases
on moving the fingers a peculiar creaking, which may simulate
crepitus, can be elicited. There is marked tenderness on making
pressure over the line of the joint, as well as over one or other of
the collateral ligaments, depending upon which ligament has been
over-stretched or torn. Movements that tend to put the damaged
ligaments on the stretch also cause pain. It has to be borne in mind,
however, that in many cases of Colles' fracture there is extreme
tenderness on pressing over the ulnar styloid and medial ulno-carpal
ligament, as these structures are frequently injured as well as the
radius, but the point of maximum pain and tenderness is over the seat
of fracture of the radius. In all doubtful cases the X-rays should be
employed to establish the diagnosis.

The _treatment_ consists in the immediate employment of massage and
movement, supplemented by alternate hot and cold douches, on the same
lines as in sprains of other joints.


INJURIES OF THE FINGERS

#Fracture.#--_Fractures of the metacarpals of the fingers_ are
comparatively common. When they result from direct violence, such as
a crush between two heavy objects, they are often multiple and
compound. Indirect violence, acting in the long axis of the bone and
increasing its natural curve, such as a blow on the knuckle in
striking with the closed fist, usually produces an oblique fracture
about the middle of the shaft, the proximal end of the distal fragment
projecting towards the dorsum. Apart from this there is little
deformity, as the adjacent metacarpals act as natural splints and tend
to retain the fragments in position. A sudden sharp pain may be
elicited at the seat of fracture on making pressure in the long axis
of the finger; and unnatural mobility and crepitus may usually be
detected. These fractures are readily recognised by the X-rays. Firm
union usually results in three weeks.

The shaft of the _metacarpal of the thumb_ is frequently broken by a
blow with the closed fist. The fracture is usually transverse, and
situated near the proximal end of the shaft; frequently it is
comminuted, and in some instances there is a longitudinal split.

_Treatment._--When the fracture is transverse, and especially when it
implicates the middle or ring fingers, the most convenient method is
to make the patient grasp a firm pad, such as a roller bandage covered
with a layer of wool, and to fix the closed fist by a figure-of-eight
bandage. In this way the adjoining metacarpals are utilised as side
splints. Active and passive movements must be carried out from the
first, and the bandage may be dispensed with at the end of a week or
ten days.

In oblique fractures with a tendency to overriding of the fragments,
especially in the case of the index and little fingers, it is
sometimes necessary to apply extension to the distal segment of the
digit, by means of adhesive plaster, to which elastic tubing is
attached and fixed to the end of a bow splint, reaching well beyond
the finger-tips (Fig. 52). This should be worn for a week or ten days.

[Illustration: FIG. 52.--Extension apparatus for Oblique Fracture of
Metacarpals.]

#Bennett's Fracture of the Base of the First Metacarpal
Bone.#--Bennett of Dublin described an injury of the thumb which,
although comparatively common, is often mistaken for a sub-luxation
backward of the carpo-metacarpal joint, or a simple "stave of the
thumb." It consists in an "oblique fracture through the base of the
bone, detaching the greater part of the articular facet with that
piece of the bone supporting it which projects into the palm" (Fig.
53). We have frequently observed the fracture extend for a
considerable distance along the palmar aspect of the shaft.

[Illustration: FIG. 53.--Radiogram of Bennett's Fracture of Base of
Metacarpal of Right Thumb.]

It usually results from severe force applied directly to the point of
the thumb, driving the metacarpal against the greater multangular bone
(trapezium), and chipping off the palmar part of the articular
surface, but it may result from a blow with the closed fist. The rest
of the metacarpal slips backward, forming a prominence on the dorsal
aspect of the joint. The pain and swelling in the region of the
fracture often prevent crepitus being elicited, and as the deformity
is not at once evident, the nature of the injury is liable to be
overlooked. The fracture is recognised by the use of the X-rays.
Unless properly treated this injury may result in prolonged impairment
of function, full abduction and fine movements requiring close
apposition of the thumb being specially interfered with.

The _treatment_ consists in reducing the fracture by extension in the
attitude of full abduction and applying an accurately fitting pad over
the extremity of the displaced bone, maintained in position by a light
angular splint. This splint is first fixed to the extended and
abducted thumb, and while extension is made by pushing it downwards
the upper end is fixed to the wrist (Fig. 54 A). The apparatus is worn
for three weeks, being carefully readjusted from time to time to
maintain the extension and abduction. A moulded poroplastic splint
added on the same principle may be employed, and is more comfortable
(Fig. 54 B). Excellent results are obtained after reduction of the
displacement, by massage and movement from the first, and the support
merely of a figure-of-eight bandage (Pirie Watson).

[Illustration: FIG. 54.--A. Splint applied as used by Bennett. B.
Poroplastic Moulded Splint for Bennett's Fracture.]

#Fractures of phalanges# usually result from direct violence, and on
account of the superficial position of the bones, are often compound,
and attended with much bruising of soft parts. Force applied to the
distal end of the finger may also fracture a phalanx. The proximal
phalanges are broken oftener than the others. The deformity is usually
angular, with the apex towards the palm, and if union takes place in
this position, the power of grasping is interfered with. Unnatural
mobility and crepitus can usually be recognised, but, on account of
the swelling and tenderness, the fracture is apt to be overlooked.
Firm union takes place in two or three weeks. In oblique and
comminuted fractures, union may take place with overlapping, producing
a deformity which may prevent the wearing of a glove or of rings. In
compound fractures, non-union sometimes occurs, and causes persistent
disability. In doubtful cases radioscopy renders valuable aid, as the
parts are readily seen with the screen.

_Treatment._--Early movement and massage are all-important. The
contiguous fingers may be utilised as side splints, and a long palmar
splint projecting beyond the fingers is applied. In oblique and
comminuted fractures it may be necessary to anæsthetise the patient to
effect reduction. When it is particularly desirable to avoid
deformity, an open operation may be advisable.

#Dislocation.#--_Dislocation of the Metacarpo-phalangeal Joint of the
Thumb._--The commonest dislocation at this joint is a _backward_
displacement of the proximal phalanx, which may be complete or
incomplete. Its special clinical importance lies in the fact that much
difficulty is often experienced in effecting reduction.

This dislocation is usually produced by extreme dorsiflexion of the
thumb, whereby the volar accessory (palmar) and the collateral
ligaments are torn from their metacarpal attachments, the phalanx
carrying with it the volar accessory ligament and sesamoid bones. The
head of the metacarpal passes forward between the two heads of the
short flexor of the thumb, and the tendon of the long flexor slips to
the ulnar side. The phalanx passes on to the dorsum of the metacarpal,
where it is held erect by the tension of the abductor and adductor
muscles.

The attitude of the thumb is characteristic. The metacarpal is
adducted, its head forming a marked prominence on the front of the
thenar eminence, and the phalanges are displaced backwards, the
proximal being dorsiflexed and the distal flexed towards the palm.

Many explanations of the difficulty so often experienced in reducing
this variety of dislocation have been offered, but the consensus of
opinion seems to be that it is due to the interposition of the volar
accessory ligament and the sesamoid bones between the phalanx and the
metacarpal, and that this is most frequently the result of ill-advised
efforts at reduction. In some cases the tension of the long flexor
tendon may be a factor in preventing reduction, but the
"button-holing" by the short flexor is probably of no importance.

Reduction is to be effected by flexing and abducting the metacarpal
while the phalanx is hyper-extended and pushed down towards the joint
and levered over the head of the metacarpal.

When this manipulation fails, the volar accessory ligament should be
divided longitudinally through a puncture made with a tenotomy knife
on the dorsal aspect of the joint, so as to separate the sesamoid
bones and permit the passage of the head between them. An open
operation is seldom necessary.

Dislocation _forward_ is rare. It results from forced flexion of the
thumb with abduction, tearing the posterior and medial collateral
ligaments. The deformity is characteristic: the rounded head of the
metacarpal projecting behind the level of the joint, while the base of
the phalanx forms a prominence among the muscles of the thenar
eminence.

Reduction is easily effected by making traction on the phalanges and
carrying out movements of flexion and extension. The deformity,
however, is liable to be reproduced unless a retentive apparatus is
securely applied.

Dislocation of the thumb to one or other side is rare.

Dislocations of the _metacarpo-phalangeal joint of the fingers_ may be
backward or forward. They are less common than those of the thumb, but
present the same general characters. In the backward variety the same
difficulty in reduction occurs as is met with in the corresponding
dislocation of the thumb, and is to be dealt with on the same lines.

_Inter-phalangeal Dislocation._--The second and the ungual phalanges
may be displaced backwards, forwards, or to the side. The clinical
features are characteristic, and the diagnosis, as well as reduction,
is easy. These dislocations are frequently the result of machinery
accidents, and being compound and difficult to render aseptic, often
necessitate amputation.

_Persistent flexion of the terminal phalanx_ of the thumb or fingers
(_drop_ or _mallet finger_) may result from violence applied to the
end of the digit when in the extended position--as, for example, in
attempting to catch a cricket-ball. The terminal phalanx is flexed
towards the palm, and the patient is unable to extend it voluntarily.
A palmar splint is applied securing extension of the distal joint for
three or four weeks. If the deformity has been allowed to occur it can
only be corrected by an open operation, suturing or tightening the
extensor tendon at its insertion into the base of the terminal
phalanx.




CHAPTER VI

INJURIES IN THE REGION OF THE PELVIS, HIP-JOINT, AND THIGH


FRACTURES OF PELVIS: _Varieties_--INJURIES IN REGION OF HIP: Surgical
    anatomy; _Fracture of head of femur_; _Fracture of neck of femur_;
    _Fracture below lesser trochanter_--DISLOCATION OF HIP:
    _Varieties_--Sprains--Contusions--FRACTURE OF SHAFT OF FEMUR.


FRACTURE OF THE PELVIS

For descriptive as well as for practical purposes, it is useful to
divide fractures of the pelvis into those that involve the integrity
of the pelvic girdle as a whole, and those confined to individual
bones.

In all, the prognosis depends upon the severity of the visceral
lesions which so frequently complicate these injuries, rather than
upon the fractures themselves.

#Fractures implicating the pelvic girdle as a whole# usually result
from severe crushing forms of violence, such as the fall of a mass of
coal or a pile of timber, or the passage of a heavy wheel over the
pelvis. The force may act in the transverse axis of the pelvis, or in
its antero-posterior axis. The pelvic viscera may be lacerated by the
tearing asunder of the bones, or perforated by sharp fragments, or
they may be ruptured by the same violence as that causing the
fracture.

As a rule, more than one part of the pelvis is broken, the situation
of the lesions varying in different cases.

_Separation of the pubic symphysis_ may result from violence inflicted
on the fork, as in coming down forcibly on the pommel of a saddle;
from forcible abduction of the thighs; or it may happen during
child-birth. In some cases the two pubic bones at once come into
apposition again, and there is no permanent displacement, the only
evidence of the injury being localised pain in the region of the
symphysis elicited on making pressure over any part of the pelvis. In
other cases the pubic bones overlap one another, and the membranous
portion of the urethra, or the bladder wall, is liable to be torn. The
displaced bones may be palpated through the skin, or by vaginal or
rectal examination.

The _pubic portion_ of the pelvic ring is the most common seat of
fracture. The bone gives way at its weakest points--namely, through
the superior (horizontal) ramus of the pubes just in front of the
ilio-pectineal eminence, and at the lower part of the inferior
(descending) ramus (Fig. 55). The intervening fragment of bone is
isolated, and may be displaced. These fractures are frequently
bilateral, and are often associated with separation of the sacro-iliac
joint, with longitudinal fracture of the sacrum (Fig. 55), or with
other fractures of the pelvic-bones.

[Illustration: FIG. 55.--Multiple Fracture of Pelvis through
Horizontal and Descending Rami of both Pubes, and Longitudinal
Fracture of left side of Sacrum.]

Injuries of the membranous urethra and bladder are frequent
complications, less commonly the rectum, the vagina, or the iliac
blood vessels are damaged.

Localised tenderness at the seat of fracture, pain referred to that
point on pressing together or separating the iliac crests, and
mobility of the fragments with crepitus, are usually present. The
fragments may sometimes be felt on rectal or vaginal examination. In
all cases shock is a prominent feature.

_The lateral and posterior aspects_ of the pelvic ring may be
implicated either in association with pubic fractures or
independently. Thus a fracture of the iliac bone may run into the
greater sciatic notch; or a vertical fracture of the sacrum or
separation of the sacro-iliac joint may break the continuity of the
pelvic brim. In rare cases these injuries are accompanied by damage to
the intestine, the rectum, the sacral nerves, or the iliac blood
vessels.

[Illustration: FIG. 56.--Fracture of left Iliac Bone; and of both
Pubic Arches.]

_Treatment._--It is of importance that the patient be moved and
handled with care lest fragments become displaced and injure the
viscera. He should be put to bed on a firm mattress, which may be
made in three pieces, for convenience in using the bed-pan and for the
prevention of bed-sores.

Before the treatment of the fracture is commenced, the surgeon must
satisfy himself, by the use of the catheter and by other means, that
the urethra and bladder are intact. Should these or any other of the
pelvic viscera be damaged, such injuries must first receive attention.

The treatment of the fracture itself consists in adjusting the
fragments, as far as possible by manipulation, applying a firm binder
or many-tailed bandage round the pelvis, and fixing the knees together
by a bandage (Fig. 57).

[Illustration: FIG. 57.--Many-tailed Bandage and Binder for Fracture
of Pelvic Girdle.]

When there is displacement of fragments extension should be applied to
both legs, with the limbs abducted and steadied by sand-bags.

Compound fractures, being commonly associated with extravasation of
urine, are liable to infective complications. Loose fragments should
be removed, as they are prone to undergo necrosis.

The patient is confined to bed for six or eight weeks, and it may be
several weeks more before he is able to resume active employment.

The #acetabulum# may be fractured by force transmitted through the
femur, usually from a fall on the great trochanter, less frequently
from a fall on the feet or other form of violence. It may merely be
fissured, or the head of the femur may be forcibly driven through its
floor into the pelvic cavity, either by fracturing the bone or, in
young subjects, by bursting asunder the cartilaginous junction of the
constituent bones. When the femoral head penetrates into the
pelvis--the _central dislocation of the hip_ of German writers--the
condition simulates a fracture of the neck of the femur, but the
trochanteric region is more depressed and the trochanter lies nearer
the middle line. The limb is shortened, and movements of the joint are
painful and restricted, especially medial rotation. In some cases
there is pain along the course of the obturator nerve.

On rectal or vaginal examination there is localised tenderness over
the pelvic aspect of the acetabulum, and in some cases a convex
projection, or even crepitating fragments can be detected. The
diagnosis is completed by an X-ray picture.

When the head of the femur penetrates the acetabulum, reduction should
be attempted by traction and manipulation. The pelvis is held rigid,
and the thigh is flexed and forcibly adducted, while the medial side
of the thigh rests against a firm sand-bag; the femoral head is thus
lifted out of the pelvis. In a recent injury the amount of force
required is relatively slight. The head is kept in its corrected
position by extension.

Fracture of the _upper and back part of the rim_ of the acetabulum may
accompany or simulate dorsal dislocation of the hip. Crepitus may be
present in addition to the symptoms of dislocation, and after
reduction the displacement is easily reproduced. The treatment is by
extension with the limb adducted.

#Fracture of Individual Bones of the Pelvis.#--_Ilium._--The expanded
portion of the iliac bone is often broken by direct violence, the
detached fragments varying greatly in size and position (Fig. 56).

The whole or part of the _crest_ may be separated by similar forms of
violence.

When the fracture implicates the _ala_ of the bone, it usually starts
at the triangular prominence near the middle of the crest, and runs
backwards or forwards, passing for a variable distance into the iliac
fossa. The displaced fragment can sometimes be palpated and made to
move when the muscles attached to it are relaxed. This is done by
flexing the thighs and bending the body forward and towards the
affected side. Pain and crepitus may be elicited on making this
examination.

These fractures are treated by applying a roller bandage or broad
strips of adhesive plaster over the seat of fracture, and by placing
the patient in such a position as will relax the muscles attached to
the displaced fragment--in the case of the iliac spine by flexing the
thigh upon the pelvis; in the case of the crest or ala by raising the
shoulders. Union takes place in three or four weeks.

In young persons, the _anterior superior spine_ has been torn off and
displaced downwards by powerful contraction of the sartorius muscle;
and the _anterior inferior spine_ by strong traction on the
ilio-femoral or [inverted Y]-shaped ligament. These injuries are best
treated by fixing the displaced fragment in position by a peg or
silver wire sutures and relaxing the muscles acting on it.

Fracture of the _ischium_ alone is rare. It results from a fall on the
buttocks, the entire bone or only the tuberosity being broken. There
is little or no displacement, and the diagnosis is made by external
manipulation and by examination through the rectum or vagina.

A longitudinal fracture of the _sacrum_ may implicate the posterior
part of the pelvic ring, as has already been mentioned. In rare cases
the lower half of the bone is broken _transversely_ from a fall or
blow, and the lower fragment is bent forward so that it projects into
the pelvis and may press upon or tear the rectum, or the sacral nerves
may be damaged, and partial paralysis of the lower limbs, bladder, or
rectum result. These fractures are frequently comminuted and compound,
and the soft parts may be so severely bruised and lacerated that
sloughing follows. On rectal examination the lower segment of the bone
can be felt, and on manipulating it pain and crepitus may be elicited.

Fracture of the _coccyx_ may be due to a direct blow, or may occur
during parturition. As a result of this injury the patient may have
severe pain on sitting or walking, and during defecation. The loose
fragment can be palpated on rectal examination. There is considerable
difficulty in keeping the fragment in position, and if it projects
towards the rectum it should be removed. If the lower fragment unites
at an angle so as to cause pressure on the rectum, it gives rise to
the symptoms of _coccydynia_, which may call for excision.


INJURIES IN THE REGION OF THE HIP

These include the various fractures of the upper end of the femur;
dislocation and sprain of the hip-joint; and contusion of the hip.

#Surgical Anatomy.#--The strength of the hip-joint depends primarily
on its osseous elements--the rounded head of the femur filling the
deep socket of the acetabulum, to the bottom of which it is attached
through the medium of the ligamentum teres. The edge of the acetabulum
is specially strong above and behind, while at its lower margin there
is a gap, bridged over by the labrum glenoidale (cotyloid ligament).

In relation to fractures of the upper end of the femur, it is to be
borne in mind that as the antero-posterior diameter of the neck is
less than that of the shaft, and as a considerable portion of the
great trochanter lies behind the junction of the neck with the shaft,
the greater part of any strain put upon the upper end of the femur is
borne by the neck of the bone and not by the trochanter. The head and
neck of the femur are nourished chiefly by the thick, vascular
periosteum, and through certain strong fibrous bands reflected from
the attachment of the capsule--the retinacular or cervical ligaments
of Stanley. The integrity of these ligaments plays an important part
in determining union in fractures of the neck of the femur, both by
keeping the fragments in position and by maintaining the blood-supply
to the short fragment. Whether it be true or not that an alteration in
the angle of the femoral neck takes place with advancing years, it is
generally recognised that this change is of no importance in relation
to fractures in this region.

The articular capsule of the hip is of exceptional strength. It is
attached above to the entire circumference of the acetabulum, and
below to the neck of the femur in such a way that while the whole of
the anterior and inferior aspects of the neck lies within its
attachment, only the inner half of the posterior and superior aspects
is intra-capsular. The capsule is augmented by several accessory
bands, the most important of which is the _ilio-femoral or [inverted
Y]-shaped ligament_ of Bigelow, which passes from the anterior
inferior iliac spine to the anterior inter-trochanteric line, its
fasciculi being specially thick towards the upper and lower ends of
this ridge. The medial limb of this ligament limits extension of the
thigh, while the lateral limits eversion and adduction. The weakest
part of the capsular ligament lies opposite the lower and back part of
the joint.

The hip-joint is surrounded by muscles which contribute to its
strength, the most important from the surgical point of view being the
obturator internus, which plays an important part in certain
dislocations, and the ilio-psoas, which influences the attitude of the
limb in various lesions in this region.

Except in thin subjects, the constituent elements of the hip-joint
cannot be palpated through the skin. A line drawn vertically downwards
from the middle of Poupart's ligament passes over the centre of the
joint, which in adults lies on the same level as the tip of the great
trochanter. In children it is somewhat higher.

For purposes of clinical diagnosis it is necessary to locate certain
bony prominences, the most important being--(1) The _anterior superior
iliac spine_, which is most readily recognised by running the fingers
along Poupart's ligament towards it. (2) The _ischial tuberosity_,
which in the extended position of the limb is overlapped by the lower
margin of the gluteus maximus muscle, and is therefore not easily
located with precision. By flexing the limb and making pressure from
below upwards in the gluteal fold, the smooth, rounded prominence can
usually be detected. (3) The quadrilateral _great trochanter_ is
readily recognised on the lateral aspect of the hip. Its highest point
or _tip_ can best be felt by pressing over the gluteal muscles from
above downwards.

_Clinical Tests._--If a line is drawn from the anterior superior iliac
spine to the most prominent part of the ischial tuberosity, it just
touches the tip of the great trochanter. This is known as _Nélaton's
line_ (Fig. 58).

[Illustration: FIG. 58.--Nélaton's Line.]

_Bryant's test_ (Fig. 59) is applied with the patient lying on his
back, and consists in dropping a perpendicular AB from the anterior
superior iliac spine, and drawing a line CD from the tip of the great
trochanter to intersect the perpendicular at right angles. This is
done on both sides of the body, and the length of the lines CD
compared. Shortening on one side indicates an upward displacement of
the trochanter, lengthening a downward displacement. The third side AC
of the triangle indicates the distance between the anterior spine and
the tip of the trochanter.

[Illustration: FIG. 59.--Bryant's Line.]

_Chiene's test_, which is simpler than either of these, consists in
applying a strip of lead or tape across the front of the body at the
level of the anterior superior iliac spines, and another touching the
tips of the two trochanters. Any want of parallelism in these lines
indicates a change in the position of one or other trochanter.


FRACTURE OF THE UPPER END OF THE FEMUR

The fractures of the upper end of the femur that are liable to be
confused with one another and with dislocations of the hip, include
fractures of the head, the neck, the trochanters, and separation of
the upper epiphyses, and fracture of the shaft just below the
trochanters.

Fracture of the #head of the femur# is rare, and is usually a
complication of backward dislocation of the hip. It takes the form of
a split of the articular surface caused by impact against the edge of
the acetabulum, and is analogous to the indentation fracture of the
head of the humerus, which may accompany dislocation of the shoulder.

The #epiphysis of the head#, which lies entirely within the capsule
of the joint (Fig. 60), is occasionally separated, and the symptoms
closely simulate those of fracture of the narrow part of the neck. If
the condition is overlooked or imperfectly treated, it may in course
of time be followed by coxa vara.

[Illustration: FIG. 60.--Section through Hip-Joint to show epiphyses
at upper end of femur, and their relation to the joint.

    _a_, Epiphysis of head.
    _b_, Epiphysis of great trochanter.
    _c_, Epiphysis of small trochanter.
    _d_, Capsular ligaments.

(After Poland.)]


FRACTURE OF THE NECK

It has long been customary to divide fractures of the neck of the
femur into two groups--"intra-" and "extra-capsular"; but as in a
considerable proportion of cases the line of fracture falls partly
within and partly without the capsule, this classification is wanting
in accuracy. It is more correct to divide these fractures into (1)
those occurring _through the narrow part of the neck_, which are
nearly always purely intra-capsular; and (2) those occurring _through
the base of the neck_ in which the line of fracture lies inside the
capsule in front, but outside of it behind.

It is of considerable importance to distinguish between fractures in
these two positions. The first group occurs almost exclusively in old
persons as a result of slight forms of indirect violence, and it is
liable, on account of the feeble vascular supply to the upper
fragment, to be followed by absorption of the neck, which delays or
may even entirely prevent union (Fig. 61). The second group usually
occurs in robust adults, and results from severe forms of violence
applied to the trochanter. In this group firm osseous union usually
takes place.

[Illustration: FIG. 61.--Fracture through Narrow Part of Neck of Femur
on section. The Neck of the bone has undergone absorption.]

#Fracture of the Narrow Part of the Neck# or #Intra-capsular
Fracture#.--This fracture is most frequently met with in elderly
persons, especially women, and is usually produced by comparatively
slight forms of indirect violence--such, for example, as result from
the foot catching on the edge of a carpet, a stumble in walking, or
missing a step in going downstairs.

The line of fracture, which is usually transverse but may be oblique
or irregular, lies for the most part within the capsule, and the
posterior part of the neck is more comminuted than the anterior. The
distal fragment, which includes the base of the neck, the
trochanters, and the shaft, is usually displaced upward and rotated
laterally. If the periosteum and the retinacular ligaments remain
intact, displacement is prevented and union favoured.

Impaction is less common than in fracture through the base of the
neck; it usually results from the patient falling on the trochanter,
the distal fragment being driven as a wedge into the proximal (Fig.
62).

[Illustration: FIG. 62.--Impacted Fracture through Narrow Part of Neck
of Femur.]

_Clinical Features._--In non-impacted cases the limb is at once
rendered useless, and the patient is unable to rise. There is pain and
tenderness in the region of the hip on making the slightest movement;
and a specially tender spot may be localised, indicating the seat of
fracture.

On placing the pelvis as square as possible, and comparing the
measurements of the limbs from the anterior superior spine to the
medial malleolus, shortening of the injured limb to the extent of from
1 to 3 inches may be found. On applying Nélaton's, Bryant's, or
Chiene's test, the tip of the great trochanter will be found elevated.
It is also farther back and less prominent than normal.

The whole limb is usually everted to a greater or less degree, and is
slightly abducted. In some cases, when the impaction is of the
anterior portion of the neck, the limb is inverted. On comparing the
ilio-tibial band of the fascia lata on the two sides, it is found to
be relaxed on the side of the injury.

The violence being as a rule indirect, there is at first little or no
discoloration in the vicinity of the hip, but this may appear a few
days later.

Crepitus is not a constant sign, and should not be sought for, as the
necessary manipulations are liable to disengage the fragments and to
increase the deformity. For the same reason rotatory movements are to
be avoided.

In all cases in which the diagnosis is uncertain, the patient should
be put to bed, and treated as for a fracture. In the course of a few
days it is nearly always possible to make an accurate diagnosis.

In examining an old person who has sustained an injury in the region
of the hip, it should be borne in mind that the limb may be shortened
and everted as a result of arthritis deformans, and that the symptoms
of that disease may simulate those of fracture. In arthritis
deformans, however, the ilio-tibial band of the fascia lata is not
relaxed as it is in fracture.

[Illustration: FIG. 63. Fracture of Neck of Right Femur, showing
shortening, abduction, and eversion of limb.]

In some cases, and particularly in those in which the periosteum of
the neck and the retinacular ligaments remain intact, the shortening
does not become apparent till a few days after the accident. As the
other symptoms are correspondingly obscure, the condition is apt to be
mistaken for a bruise. In all doubtful cases the part should be
examined from day to day, and, if possible, the X-rays should be used.

In _impacted_ cases the signs of fracture are often obscure, and the
patient may even be able to walk after the accident. The skin over the
trochanter is generally discoloured from bruising. Eversion is usually
present, but there may be little shortening. Crepitus is absent. In
old people it is never advisable to undo impaction, as the
interlocking of the bones favours the occurrence of osseous union.

_Prognosis._--A fracture of the neck of the femur in an old person is
always attended with danger to life, a considerable proportion of the
patients dying within a few weeks or months of the accident from
causes associated with it. In some cases the mental and physical shock
so far diminishes the vitality of the patient that death ensues within
a few days. It is possible that fat embolism may account for death in
some of the more rapidly fatal cases. In others, the continued dorsal
position induces hypostatic congestion of the lungs, or, owing to the
difficulties of nursing, bed-sores may form and death result from
absorption of toxins. Frequently the prolonged confinement to bed, the
continuous pain, and the natural impairment of appetite wear out the
strength. In many cases the patient becomes peevish, irritable, or
mentally weak.

Osseous union is the exception in intra-capsular fracture, especially
when the periosteum and the retinacular ligaments have been completely
torn, but in sub-periosteal and in impacted fractures it sometimes
occurs. As a rule, however, the neck of the femur becomes absorbed and
disappears, the head of the bone comes to lie in contact with the base
of the trochanter, and a false joint forms (Fig. 64). Chronic changes
of the nature of arthritis deformans may occur in and around such
false joints.

[Illustration: FIG. 64.--Fracture of Narrow Part of Neck of Femur. The
neck has become absorbed, the head has not united, and a false joint
has formed.]

When osseous union fails to take place, although the patient may
eventually be able to get about, he can do so only with the aid of a
stick or crutch, and as there is marked shortening, he walks with a
decided limp. There is considerable antero-posterior thickening of
the neck of the femur, and the femoral vessels may be pushed forward
in Scarpa's triangle.

_Treatment._--In treating a fracture through the narrow part of the
neck, it is necessary to consider the age and general condition of the
patient; whether the fracture is impacted or not; and the site of the
fracture--whether in the narrow part of the neck or at its base. "The
first indication is to save life, the second to get union, and the
third to correct or diminish displacements" (Stimson).

In old and debilitated patients, bony or even firm fibrous union
seldom takes place, and it is generally advisable to get them out of
bed as speedily as possible. For the first few days the patient may be
kept on his back, the limb massaged daily, and in the interval
steadied by sand-bags; but on the first sign of respiratory or cardiac
trouble he should be propped up in bed, and as soon as possible lifted
into a chair. In all such cases care should be taken to avoid undoing
impaction.

When the general condition of the patient permits of it, an attempt
should be made to secure bony union.

_Extension_ is applied by one or other of the methods described for
fracture of the shaft (p. 149), so modified as to maintain the limb
_in the abducted position_, which ensures the most accurate apposition
of the fragments (Royal Whitman). This position may be maintained by a
hinged long-splint, an adaptation of Thomas' hip splint. The fragments
may be fixed to one another by a long steel peg introduced through the
skin over the great trochanter, and passed so as to transfix them; or
they may be exposed by operation and sutured together. Albe uses a
bone peg.

#Fracture of the Neck of the Femur in Children.#--The use of the
X-rays has shown that this fracture is comparatively common in
children, as a result of a fall or a forcible twist of the leg. The
fracture is most frequently of the greenstick variety; when complete,
it is usually impacted. There is shortening to the extent of a half or
three-quarters of an inch, a slight degree of eversion, the movements
of the hip are restricted, and there is some pain. The patient is
often able to move about after the accident, but walks with a limp.
Unless the use of the X-rays reveals the fracture, the condition is
liable to be overlooked.

When the lesion is diagnosed, the deformity should be completely
corrected, any impaction that exists being undone; and the limb is put
up in a wide abduction splint (p. 221) or in a plaster-of-Paris case
in the position of extreme abduction.

If the condition is not recognised and treated, it is liable to be
followed by the development of coxa vara (Royal Whitman) (Fig. 65).

[Illustration: FIG. 65.--Coxa Vara following Fracture of Neck of Femur
in a child.]

#Fracture through the Base of the Neck.#--This fracture is usually
produced by a fall on the great trochanter, although it is
occasionally due to a fall on the feet or knees.

[Illustration: FIG. 66.--Non-impacted Fracture through Base of Neck.]

Although often spoken of as "extra-capsular," the line of fracture is
generally partly within and partly without the capsule. The fracture
usually lies close to the junction of the neck with the shaft, and in
the great majority of cases is accompanied by breaking of one or both
trochanters. This is due to the neck being driven as a wedge into the
trochanters, splitting them up. When the fragments remain interlocked,
the fracture is of the _impacted_ variety (Fig. 67).

[Illustration: FIG. 67.--Fracture through Base of Neck of Femur with
Impaction into the Trochanters.]

_Clinical Features._--Although this fracture is commonly met with in
strong adults, it may occur in the aged.

The lateral aspect of the hip shows marks of bruising, and there is
severe pain and a considerable degree of shock. The limb lies
helpless; there is generally marked eversion, with shortening, which,
in _non-impacted_ cases, may amount to 1-1/2 or 2 inches, and is
evident immediately after the accident; it is due to the distal
fragment being drawn up by the muscles inserted into the great
trochanter and upper end of the shaft. In a limited number of cases
the distal fragment lies in front of the proximal, and there is
inversion of the limb.

[Illustration: FIG. 68.--Non-impacted Fracture through Base of Neck.
Union has occurred with diminution of angle of neck--Coxa Vara.]

On applying the various tests, the great trochanter is found to be
displaced upwards, there is some antero-posterior broadening of the
trochanteric region, and the ilio-tibial band is relaxed. On pressing
the fingers into the lateral part of Scarpa's triangle, a mass
consisting of the bony fragments may be felt, and is tender on
pressure. Unnatural mobility with crepitus may be elicited.

In the _impacted variety_, the shortening seldom exceeds one inch; the
eversion is less marked; there is some power of voluntary movement;
and crepitus is absent. The broadening of the trochanteric region is
greater, and the great trochanter is approximated to the acetabulum.

_Prognosis._--The risks to life in the aged are similar to those of
intra-capsular fracture. In youths and healthy adults the chief danger
is that the limb may be shortened and its function thereby impaired.

As the periosteum and retinacular ligaments which transmit the blood
vessels to the proximal fragments are intact, bony union is the rule.
There is always, however, considerable thickening in the region of the
trochanter due to displaced fragments and callus, and in a certain
number of cases, even with the greatest care in treatment, there is a
varying degree of shortening and eversion of the limb. In cases in
which the distal fragment lies in front of the proximal there is
permanent inversion.

_Treatment._--As this fracture usually occurs in robust patients,
there is no danger from prolonged confinement to bed; and as union
without deformity can be attained in no other way, this is always
advisable. When the shortening and eversion are excessive, they should
be completely corrected under anæsthesia before the retentive
apparatus is applied, any impaction that exists being undone. When the
deformity resulting from impaction is slight, however, it is best to
leave it, as it facilitates speedy and firm union.

Extension is obtained by the same appliances as are used in fracture
of the shaft, and the limb should be kept in the abducted position.

Fracture of the #greater trochanter# occurring apart from fracture of
the neck usually results from direct violence, but may be due to
muscular action. The trochanter is displaced by the gluteal muscles,
causing broadening of the lateral aspect of the hip. In young persons
the _epiphysis_ of the great trochanter may be separated, but this is
rare. The treatment consists in retaining the fragments in position by
keeping the limb abducted between sand-bags, or by pegs driven in
through the skin.

#Fracture immediately below the lesser trochanter# may be produced by
direct or by indirect violence, and the displacement depends largely
on whether the line of fracture is transverse or oblique. The proximal
fragment is kept tilted forward, rotated laterally, and abducted by
the ilio-psoas muscle and the lateral rotators inserted in the region
of the great trochanter. The lower fragment passes upward, and is
rotated laterally by the weight of the limb; the displacement is
aggravated by the contraction of the flexor and adductor muscles. The
tilting of the proximal fragment may be increased by the displaced
distal fragment pushing it forward.

On account of the difficulty of controlling the short proximal
fragment, union is liable to take place with considerable shortening
and deformity (Fig. 69).

[Illustration: FIG. 69.--Fracture of the Femur just below the Small
Trochanter united, showing flexion and lateral rotation of upper
fragment.]

_Treatment._--When it is found, under an anæsthetic, that the
displacement can be completely reduced, and does not tend to recur,
this fracture is treated on the same lines as fracture of the shaft of
the bone.

In cases in which the proximal fragment cannot be brought into line
with the distal one, however, it is necessary to flex, evert, and
abduct the thigh in order to get the fragments into apposition and
into line. A Hodgen's splint (Fig. 77) is applied with the highest
sling under the upper end of the lower fragment and with sufficient
extension to correct overriding. The upper end is then strongly lifted
by a counter-weight of about 15 lbs. This secures apposition of the
fragments with slight forward angulation at the seat of fracture. By
the end of a month sufficient callus has formed to prevent
re-displacement, and if the counter-weight is gradually diminished the
two fragments sag back together into a normal alignment (J. N. J.
Hartley). A double-inclined plane (Fig. 70), with extension applied in
the axis of the thigh, gives satisfactory results.

[Illustration: FIG. 70.--Adjustable Double-inclined Plane.]


DISLOCATION OF THE HIP

It is unnecessary for our present purpose to attempt a comprehensive
classification of the numerous varieties of dislocation that have been
met with at the hip-joint. It will suffice if we divide them into
those in which the head of the femur passes backward, and comes to
rest on the dorsum ilii, or in the vicinity of the great sciatic
notch; and those in which it passes forward and comes to rest in the
obturator foramen, or on the pubes (Fig. 71).

[Illustration: FIG. 71.--Diagram of the most common Dislocations of
the Hip.]

The backward are much more common than the forward dislocations, in
contrast to what obtains at the shoulder, where the forward varieties
predominate.

On account of the great strength of the hip-joint, dislocation is by
no means a common injury. It occurs most frequently in strong adults
after the epiphyses have ossified, and before the bones have commenced
to become brittle; and it is much more common in men than in women. It
is invariably the result of severe violence, the limb at the moment
being in such a position that the ligaments are on the stretch and the
muscles taken at a disadvantage. The head of the femur usually leaves
the joint at the lower and back part, where the socket is most shallow
and the ligaments weakest. The ligamentum teres is almost always torn
from its femoral attachment, and one or more of the muscles inserted
in the region of the trochanters may be ruptured. The [inverted
Y]-shaped ligament, on the other hand, is seldom torn, and so long as
it remains intact the dislocation belongs to one or other of the types
above named. All atypical dislocations, such as the supra-cotyloid,
infra-cotyloid, ilio-pectineal, are due to rupture of some part of the
[inverted Y]-ligament, and are so rare as not to call for individual
description. The central dislocation of German authors, in which the
head is driven through the floor of the acetabulum, is described on
page 126.

Like other dislocations, those of the hip may be complicated by
laceration of muscles, blood vessels, or nerves, or by fracture of one
or other of the bones in the vicinity.

#Dislocation on to the Dorsum Ilii.#--This, the commonest form of
dislocation of the hip, is usually the result of the patient falling
from a height, or receiving a heavy weight on the back while stooping
forward with the thigh flexed, slightly adducted, and rotated
medially. It is also said to have occurred from muscular action. The
shaft of the femur acts as the long limb of a lever of which the neck
is the short limb, the femoral attachment of the [inverted Y]-ligament
forming the fulcrum. The head, thus brought to bear upon the lower and
back part of the capsule, tears it and leaves the socket, passing
upwards and coming to rest on the dorsum of the ilium, above and
anterior to the tendon of the obturator internus (Fig. 73). The
articular surface is directed backward, while the trochanter looks
forward.

[Illustration: FIG. 72.--Dislocation of Right Femur on to Dorsum
Ilii.]

_Clinical Features._--The affected limb is flexed, adducted, and
inverted, so that the knee crosses the lower third of the opposite
thigh, and the ball of the great toe lies on the dorsum of the sound
foot. There is shortening to the extent of from 1-1/2 to 2 inches, the
trochanter being displaced above Nélaton's line, and lying nearer to
the anterior superior iliac spine than on the normal side. The patient
is unable to move the limb or to bear weight upon it; abduction and
lateral rotation are specially painful; and traction fails to restore
the limb to its proper length. On making these attempts a
characteristic elastic resistance is felt.

The head of the femur in its new position may sometimes be felt
through the fibres of the gluteus maximus, but swelling of the soft
parts often obscures this sign. The normal depression behind the
great trochanter is lost, the gluteal fold is raised, and there is
often a degree of lordosis which compensates for the flexion. The
fingers can be pressed more deeply into Scarpa's triangle on the
dislocated than on the normal side--a point in which this injury
differs from fracture of the base of the neck of the femur.

In a certain number of cases the lateral limb of the [inverted
Y]-ligament is ruptured and the limb is everted--_dorsal dislocation
with eversion_.

[Illustration: FIG. 73.--Dislocation on to Dorsum Ilii. Note relation
of neck of femur to tendons of obturator internus and gemelli
(diagrammatic).]

#Dislocation into the Vicinity of the Great Sciatic Notch#, or
"_dislocation below the tendon_."--This variety of backward
dislocation is less common than that on to the dorsum, although
produced in the same way. The head of the femur passes beneath the
obturator internus, and this tendon, catching on its neck, checks its
upward movement (Fig. 74).

The _clinical features_ are the same as those of the dorsal variety,
but, on the whole, are less marked.

_Differential Diagnosis._--Backward dislocation of the hip is usually
easily recognised. When dislocation below the tendon occurs in a stout
person, however, it is liable to be overlooked on account of the
difficulty of feeling the displaced bone, and of the comparatively
slight amount of deformity present. The nature of the accident, the
absence of broadening of the trochanter, and the adduction and
inversion of the limb are usually sufficient to prevent a dislocation
being mistaken for an impacted extra-capsular fracture.

#Dislocation into the Obturator Foramen# (Fig. 71).--This dislocation
is produced by great force applied from behind while the thigh is
flexed and abducted, as when a weight falls on the back of a man
stooping forward with the legs wide apart. It may also result from
violent abduction by wide separation of the thighs.

The capsule gives way at its medial and lower part, and the head of
the femur comes to rest on the surface of the external obturator
muscle, its articular surface looking forward, while the trochanter
looks backward.

_Clinical Features._--In the standing position the thigh is slightly
flexed and abducted, with the foot pointing directly forward or a
little outward. The body is bent forward to relax the ilio-psoas
muscle and the [inverted Y]-ligament, the foot is advanced and the
heel drawn up. It is not uncommon for the patient to be able to walk
after the accident, and only to seek advice some time later on account
of inability to adduct and extend the limb. There is apparent
lengthening of the limb due to tilting of the pelvis downward on the
affected side. The hip is flattened, the trochanter less prominent
than usual, and the head of the bone may sometimes be felt in its
abnormal position.

[Illustration: FIG. 74.--Dislocation into the vicinity of the
Ischiatic Notch. Note relation of neck of femur to tendons of
obturator and gemelli, "Dislocation below the tendon" (diagrammatic).]

#Dislocation on to the pubes# is a further degree of the obturator
form (Fig. 71). It is usually produced by forcible hyper-extension and
lateral rotation of the hip, such as occurs when the body is bent back
while the thigh remains fixed.

The capsule is torn farther forward than in the other varieties, and
the head rests on the horizontal ramus of the pubes against the
ilio-pectineal line.

_Clinical Features._--There is marked eversion, flexion, and
abduction, but the shortening is inconsiderable. The ilio-psoas and
[inverted Y]-ligament are tense. The head of the femur may be felt in
the groin, with the femoral vessels over, or to one or other side of
it. There is sometimes pain and numbness in the distribution of the
femoral (anterior crural) nerve. The prominence of the great
trochanter is lost.

#Treatment of Dislocation of the Hip.#--For the reduction of a
dislocation of the hip complete anæsthesia is necessary, and the
patient should be placed on a firm mattress on the floor to give the
surgeon the best possible purchase upon the limb. The surgeon grasps
the ankle with one hand, while the other is placed behind the head of
the tibia, the leg being held at right angles to the thigh. An
assistant meantime steadies the pelvis by making firm pressure over
the iliac crests.

As the chief obstacle to reduction is the tension of the ilio-femoral
ligament, the first indication is to relax this structure by flexing
the hip _to its fullest extent_.

In the _backward_ varieties (dorsal and sciatic) the [inverted
Y]-ligament is relaxed by flexing the thigh upon the pelvis in the
position of adduction. The thigh is then fully abducted, to cause the
head of the bone to retrace its steps forwards towards the rent in the
capsule; and at the same time rotated laterally to relax the rotator
muscles. This combined movement tends also to open up the rent in the
capsule. Finally, the limb is quickly extended to cause the head to
enter the socket. This object is often aided by making vertical
traction or lifting movements on the abducted and laterally rotated
limb before extending.

For the reduction of the _forward_ varieties (obturator and pubic),
the thigh is first fully flexed on the pelvis, but in the abducted
position. The limb is then strongly rotated medially and abducted, and
finally extended. Lifting movements may be found useful in these cases
also.

All methods of reduction by forcible traction on the extended limb are
to be avoided, as they fail to meet the primary indication of relaxing
the [inverted Y]-ligament.

After reduction, the limb is steadied by sand-bags; massage is carried
out from the first, and movement after a few days. The range of
movement is gradually increased, and the patient is allowed to use the
limb with caution in from two to three weeks.

When the rim of the acetabulum has been fractured, the patient must be
confined to bed with extension for six to eight weeks, to avoid the
risk of re-dislocation.

Changes of the nature of chronic arthritis are liable to occur in and
around the joint in old and rheumatic subjects; and atrophy or
paralysis of muscles may follow, if their nerves are implicated.

#Old-standing Dislocation.#--It is impossible to lay down any
time-limit for attempting reduction in old-standing dislocations of
the hip. Manipulation may succeed in cases of some months' standing,
and may fail when the bone has been out only a few weeks. In certain
cases, even after reduction has been effected, there is a marked
tendency to re-displacement. In any case, the attempt does good by
breaking down adhesions, provided no undue force is employed such as
may damage the sciatic nerve or vessels, or fracture the neck of the
femur, and success may attend on a second or even a third attempt at
intervals of from three to five days. If manipulation fails, and if
the deformity is great and the usefulness of the limb seriously
impaired, an attempt may be made to effect reduction by operation; the
operation, however, is one of considerable difficulty, and in the
event of failure the head of the bone should be excised. If the head
has formed a new socket for itself and there is a fairly useful joint,
the condition should be left alone.

_Congenital dislocation of the hip_ is described with Deformities of
the Extremities.

#Sprain# of the hip is comparatively rare. It results from milder
degrees of the same forms of violence as produce dislocation. The
ligaments are stretched or partly torn, and there is effusion of fluid
into the joint. Pressure over the joint elicits tenderness; and the
limb assumes the position of slight flexion, abduction, and lateral
rotation, but there is no alteration in length. Such injuries, unless
carefully treated by massage and movement from the outset, are apt to
be followed by the formation of adhesions, resulting in stiffness of
the joint.

#Contusion# in this region, on the other hand, is not uncommon. It is
produced by a fall on the trochanter, and gives rise to symptoms which
simulate to some extent those of fracture of the neck. The limb lies
in the position of slight flexion, but the bony points retain their
normal relationship to one another, and there is no shortening. The
swelling and tenderness often prevent a thorough examination being
made, and when any doubt remains as to the diagnosis, the patient
should be kept in bed till the doubt is cleared up by the use of the
X-rays. If the bone has been broken, this will reveal itself in the
course of a few days by the occurrence of shortening and other
evidence of fracture.

In elderly patients, contusion of the hip may be followed by changes
in the joint of the nature of arthritis deformans; and it has been
stated, although proof is wanting, that absorption of the neck of the
femur sometimes occurs. These injuries are treated by rest in bed,
massage, and the other measures already described as applicable to
sprains and contusions.


FRACTURE OF THE SHAFT OF THE FEMUR

This group includes all fractures between that immediately below the
lesser trochanter and the supra-condylar fracture.

_In adults_, when due to direct violence, the fracture is usually
transverse, and may be attended with comparatively little
displacement. Indirect violence, on the other hand, usually produces
an oblique fracture, which is frequently comminuted and often
compound. The break is most commonly situated a little above the
middle of the shaft, the obliquity being downward, forward, and
medially, and of such a nature that the fragments tend to override one
another (Fig. 75). The most serious forms are those associated with
gun-shot wounds.

[Illustration: FIG. 75.--Longitudinal section of Femur showing recent
Fracture of Shaft with overriding of Fragments.]

The direction and nature of the displacement depend more upon the
fracturing force, the weight of the lower part of the limb, and the
action of the muscles attached to the respective fragments, than upon
the direction of the obliquity. As a rule, the proximal fragment
passes forward and laterally, and is maintained in this position by
the ilio-psoas and glutei muscles, while the distal fragment is
displaced upward and medially and is rotated outward by the combined
action of the weight of the limb, the longitudinal muscles, and the
adductors.

_Clinical Features._--The limb is at once rendered useless, and there
is great swelling from effusion of blood in the region of the
fracture. This, together with the muscularity of the part, often
renders an accurate diagnosis as to the site and direction of the
fracture exceedingly difficult. The shortening varies from 1/2 inch to
3 or 4 inches--averaging about 1 inch in adults--and eversion is
always marked. Mobility may be detected and crepitus elicited without
disturbing the patient, by placing the hand under the seat of fracture
and gently attempting to raise the limb; or by fixing the proximal
fragment by one hand placed in front of it while the distal part of
the limb is carefully lifted. It will be found that the great
trochanter does not rotate with the lower segment of the femur. These
tests must be employed with great caution lest the deformity be
increased or the fracture rendered compound.

In many fractures of the thigh, and especially in those produced by
indirect violence, the knee is sprained, and there is a considerable
effusion into the joint, and this may lead to stiffness unless massage
is employed from the outset.

_Treatment._--Fracture of the shaft of the femur is one of the most
difficult fractures in the body to treat successfully. In cases of
oblique fracture, the patient should be warned that shortening to the
extent of from 3/4 to 1 inch is liable to result, however carefully
the treatment may be carried out. This does not necessarily imply a
permanent limp, as by tilting the pelvis he may be enabled to walk
quite well; if this is not sufficient to equalise the length of the
limbs, the sole of the boot may be raised. A general anæsthetic is
necessary to ensure accurate reduction, and extension must be applied
to maintain the fragments in apposition and prevent shortening. The
splint which has been found most generally useful is the Thomas' knee
splint, the ring of which rests against the ischial tuberosity. To
admit of flexion at the knee the Thomas' splint should have a hinged
attachment on which the leg is supported. This leaves the knee free
and allows of movement being made to prevent stiffness. The limb is
suspended by broad strips of flannel or linen, fixed to the side bars
of the splint by means of safety pins or strong spring paper clips.

In simple fractures extension may be obtained by means of broad strips
of adhesive plaster applied to each side of the thigh and reaching
well above its middle. The plaster is secured by a bandage, and to its
lower ends are attached broad tapes which are buckled to a stirrup
through which traction is made by means of a cord passing over a
pulley fixed to an upright at the foot of the bed.

The lower end of the splint is suspended, and the counter-extension is
obtained by pressing the ring against the ischial tuberosity. To
prevent the ring overriding the tuberosity and pressing on the soft
tissues of the buttock, it is slung by the rope to a cross-bar above
the bed, _e.g._ the Balkan frame (Fig. 81).

In compound fractures the presence of a wound may prevent adhesive
plaster being used, and it is necessary to take the extension directly
through the bone. A posterior gutter splint is applied to prevent
sagging. After pulling the skin upward, a small incision is made over
the upper expanded border of each condyle, and the points of an
ice-tong calliper are made to grip the bone without penetrating into
the cancellous tissue. A cord attached to the handles of the calliper
passes over a pulley and supports the weight necessary to give the
desired amount of traction (Fig. 81).

An alternative method of exerting traction directly through the bone
is by means of Steinmann's apparatus (Fig. 76). In a moderately
muscular adult, a weight of from 12 to 15 pounds by means of strips of
plaster applied to the skin, or 10 to 25 pounds by direct traction on
the bone, should be applied in the first instance. The correct weight
to employ is that which maintains the length of the limb at its
normal, and is therefore liable to revision from time to time.

[Illustration: FIG. 76.--Radiogram of Steinmann's Apparatus applied
for Direct Extension to the Femur.]

_Hodgen's splint_ is a comfortable and efficient means of treating
these fractures, as it allows the patient a certain amount of
movement, admits of the part being massaged, and facilitates nursing.

It consists of a wire frame (Fig. 77) to one side of which a series of
strips of flannel about 4 inches wide are attached. Extension
strapping is first applied, and then the frame, which extends from the
level of Poupart's ligament to well beyond the sole, is placed over
the front of the limb, and the loose ends of the flannel strips
brought round behind the limb, and fixed to the other side of the
frame, convert it into a sling. The tapes attached to the extension
strapping are now tied to the end of the frame. By suspending the limb
in this splint by means of cords passing obliquely over a pulley
attached to an upright at the foot of the bed, the weight of the limb
is made to act as the extending force.

[Illustration: FIG. 77.--Hodgen's Splint.]

The retentive apparatus should be worn for from six to eight weeks,
after which the patient is allowed up with crutches, which he usually
requires to use for three or four weeks longer, before he can bear his
weight upon the limb. The old dictum of Nélaton, that the treatment of
fracture of the thigh should last for a hundred days, is a safe
working-rule. In fractures of the shaft an ordinary Thomas' knee
splint, or a "walking calliper splint" which is fixed to the heel of
the boot, may be worn when the patient gets up.

Union may be exceedingly slow in fracture of the femur, and may even
be delayed for months. Mal-union sometimes occurs, the fracture
uniting with an angular deformity outward and forward.

Re-fracture is liable to occur if the patient falls or twists the limb
within a few months of the original injury. It has happened not
infrequently just after the retentive apparatus has been removed from
the nurse raising the limb by the foot in order to wash it.

_Liston's long splint_ is only employed as a temporary expedient for
immobilising the fragments during transport; a Thomas' splint, if
available, is better for this purpose.

[Illustration: FIG. 78.--Long Splint with Perineal Band.]

_Operative treatment_ is sometimes called for when simpler measures
fail to reduce the displacement, and in cases of un-united fracture or
of vicious union. The incision, which must be free, is preferably
placed in the line of the lateral intermuscular septum; the
periosteum is interfered with as little as possible. The application
of extension by the calliper method is often of great service, during
the operation, in enabling the operator to get the fragments into
position; sometimes no fixation is required, but, if necessary,
recourse is had to plating or pegging, or an intra-medullary pin. The
extension apparatus is retained for three or four weeks. The
after-treatment is carried out on the same lines as for simple
fracture, but the retentive apparatus must be worn for a considerably
longer period.

[Illustration: FIG. 79.--Fracture of Thigh treated by Vertical
Extension.]

#Fracture of the Femur in Children.#--In children, especially below
the age of ten, this fracture is quite common. It is often of the
greenstick variety, or, if complete, is transverse and sub-periosteal,
and as it is accompanied by few symptoms and but little deformity, is
liable to be overlooked.

When there is displacement, the deformity is similar to that in
adults, and the treatment is carried out on the same lines.

In young children the nursing is greatly facilitated by applying
vertical extension to one or both lower extremities (Fig. 79). If the
fracture is transverse and shows little tendency to displacement, the
local Gooch splints may be dispensed with; in any case, massage should
be employed from the first.

The patient may be allowed out of bed in from three to four weeks,
wearing a retentive apparatus.

The shaft of the femur is sometimes fractured _during delivery_,
particularly in breech cases. The simplest and most efficient means of
controlling the fracture is by extension strapping fixed to the lower
end of a Thomas' knee splint.




CHAPTER VII

INJURIES IN THE REGION OF THE KNEE AND LEG


_Surgical Anatomy_--FRACTURE OF LOWER END OF FEMUR: _Supra-condylar_;
    _T- or Y-shaped_; _Separation of epiphysis_; _Either
    condyle_--FRACTURE OF UPPER END OF TIBIA: _Of head_; _Separation
    of epiphysis_; _Avulsion of tubercle_--DISLOCATIONS OF KNEE:
    _Dislocations of superior tibio-fibular joint_--INTERNAL
    DERANGEMENTS OF KNEE--INJURIES OF PATELLA: _Fractures_;
    _Dislocations_--INJURIES OF LEG: _Fracture of both bones_;
    _Fracture of tibia alone_; _Fracture of fibula alone_.


INJURIES IN THE REGION OF THE KNEE

These include the supra-condylar fracture of the femur, the T- or
Y-shaped fracture opening into the joint, separation of the lower
femoral epiphysis; fracture of the head of the tibia, and separation
of its upper epiphysis; the various sprains and dislocations of the
knee, as well as its internal derangements; and fractures and
dislocations of the patella.

#Surgical Anatomy.#--Of the two epicondyles the medial is the more
prominent and palpable. The adductor tubercle, which is situated on
the upper and back part of the medial epicondyle, gives attachment to
the round tendon of the adductor magnus, and marks the level of the
epiphysial line and of the upper limit of the trochlear surface of the
femur. Between the medial condyle of the femur and the medial condyle
(tuberosity) of the tibia, when the limb is in the flexed position,
the line of the joint can be recognised as a groove or cleft, and this
is made use of in measuring the length of the tibia. The lateral
condyle (tuberosity) of the tibia can also be palpated, and must not
be mistaken for the head of the fibula, which lies farther back and at
a slightly lower level, and can readily be identified by tracing to it
the tendon of the biceps. The tuberosity of the tibia, into which the
quadriceps extensor tendon is inserted, lies on the same level as the
head of the fibula. In the extended position of the limb, the patella
is loose and movable on the front of the trochlear surface of the
femur, while in the flexed position it sinks between the condyles,
resting chiefly on the lateral one and becoming fixed.

The popliteal artery and vein and the tibial (internal popliteal)
nerve lie in close relation to the posterior aspect of the joint; and
the common peroneal (external popliteal) nerve passes behind and to
the medial side of the biceps tendon.

The knee is an example of a joint which depends for its strength
chiefly on its ligaments. Not only are the tibial and fibular
collateral (external and internal lateral) ligaments and the posterior
part of the capsular ligament particularly strong, but the cruciate
ligaments and the menisci (semilunar cartilages) inside the cavity of
the joint further add to its stability. The powerful tendon of the
quadriceps extensor muscle, in which the patella is developed as a
sesamoid bone, protects and strengthens the front of the joint and
functionates as the anterior ligament of the joint. In the attitude of
complete extension in which the joint is locked, no demand is made on
the quadriceps apparatus; with the commencement of flexion, the
stability of the joint, and the weight-bearing capacity of the limb as
a whole, depend largely on the controlling influence of the
quadriceps muscle; this becomes evident on going down an incline and
more markedly on going down stairs. Hence it is, that in recurrent
sprains of the knee, including under this term the various forms of
internal derangement of the joint, the wasting with loss of tone of
the quadriceps is an important factor in aggravating the disability of
the limb and in retarding and preventing recovery. In the treatment of
recurrent sprains of the knee, therefore, special attention must be
directed towards the wasting of the quadriceps by means of massage and
appropriate exercises.

The synovial cavity extends from the level of the head of the tibia to
an inch or more above the trochlear surface of the femur, passing
slightly higher on the medial aspect of the joint than on the lateral
(Fig. 80). The large bursa between the quadriceps muscle and the femur
(_sub-crural bursa_) generally communicates with the cavity of the
joint. The synovial cavity of the superior tibio-fibular articulation
is usually distinct from that of the knee-joint, but may communicate
with it through the popliteal bursa.

[Illustration: FIG. 80.--Section of Knee-joint showing extent of
Synovial Cavity.

    _a_, Pre-patellar bursa.
    _b_, Infra-patellar bursa.
    _c_, Ligamentum mucosum.
    _d_, Ligamentum patellæ.
    _e_, Posterior cruciate ligament.
    _f_, Medial semilunar meniscus.

(After Braune.)]

A large bursa (_pre-patellar_) lies over the lower part of the patella
and upper part of the ligamentum patellæ; and a smaller one separates
the ligamentum patellæ from the tuberosity of the tibia. Several
important bursæ are found in the popliteal space, one of which--the
semi-membranosus bursa--sometimes communicates with the knee-joint.


FRACTURE OF THE LOWER END OF THE FEMUR

Fractures involving the lower end of the femur, especially the
supra-condylar and T-shaped fractures, are to be looked upon as
serious injuries, on account of the difficulties attending their
treatment, and the risk of damage to the popliteal vessels and of
impairment of the usefulness of the knee-joint.

#Supra-condylar# fracture is usually the result of a fall on the feet
or knees, or of direct violence, and is most common in adult males.
The line of fracture is generally irregularly transverse, or it may be
slightly oblique from above downwards and forwards, so that the
proximal fragment passes forward towards the patella, while the distal
is rotated backward on its transverse axis by the gastrocnemius
muscle.

_Clinical features._--Soon after the accident a copious effusion of
blood and synovia takes place into the cavity of the knee-joint,
adding to the swelling caused by the displaced bones, and rendering it
difficult to recognise the precise nature of the lesion. As it is
important to make an accurate diagnosis, the X-rays should be employed
if possible, and a general anæsthetic should be given when necessary.

The proximal end of the distal fragment is usually palpable in the
popliteal space, while the proximal fragment is unduly prominent in
front. By flexing the knee the fragments may be brought into
apposition and crepitus elicited. In oblique fractures, the pointed
lower end of the proximal fragment may transfix the quadriceps
extensor muscle and may be felt under the skin, or it may perforate
the skin and thus render the fracture compound. It should be
disengaged by fully flexing and making traction on the knee. The thigh
is shortened to the extent of from 1/2 to 1 inch.

The popliteal vessels lie so close to the bone that they are liable to
be torn by the displaced distal fragment, giving rise to the usual
signs of ruptured artery. Sometimes, owing to the feeble state of the
circulation from shock, the bleeding does not take place at the time
of the accident, but ensues some hours later. The vessels may merely
be pressed upon by the displaced bone, but the nutrition of the limb
beyond is endangered and gangrene may ensue if early reduction be not
effected.

_Treatment._--The small size of the distal fragment, its depth from
the surface, and the accompanying effusion into and around the joint,
render its control difficult. In the majority of cases the two
fragments can only be brought into apposition when the knee is flexed
on the thigh and the thigh on the pelvis, and it is almost always
necessary to carry out the reduction under anæsthesia.

In the few cases in which the fragments can be accurately approximated
in the extended position of the limb, retention may be effected by
means of a box splint reaching well up the thigh (p. 180).

In the majority, however, flexion is necessary, and a Thomas' knee
splint with flexion attachment bent to an angle of 30° (Fig. 81) and
extension by means of ice-tong callipers secures the best apposition.
If this apparatus is not available the limb must be fixed on a
double-inclined plane, so constructed that the angle of flexion can be
adjusted to meet the requirements of the individual case (Fig. 70).

[Illustration: FIG. 81.--Extension applied by means of ice-tong
callipers for Fracture of Femur.]

Hodgen's splint, bent nearly to a right angle, may also be employed.

A careful watch must be kept on the circulation of the limb during the
first few days, lest it be interfered with by the pressure of the
apparatus.

In a considerable number of cases these means of retaining the
fragments in apposition prove ineffectual, and it is necessary to have
recourse to operative measures for mechanical fixation. Division of
the tendo calcaneus (Achillis) is not to be recommended as a means of
combating the backward tilting of the distal fragment.

In all cases the retentive apparatus must be worn for about four
weeks, after which the limb is flexed over a pillow; but massage and
movement should be employed as soon as possible, as persistent
stiffness of the knee is one of the most troublesome sequelæ of these
injuries.

Compound and complicated fractures are dealt with on the general
principles governing the treatment of such injuries. Amputation may
become necessary should gangrene ensue from injury to the popliteal
vessels, or if infective complications threaten the life of the
patient.

Operative interference may be called for to rectify deformities
resulting from mal-union.

The #T- or Y-shaped fracture# is, as a rule, produced by direct
violence, the force first breaking the bone above the condyles and
then causing the proximal fragment to penetrate the distal and split
it up into two or more pieces. The fracture implicates the articular
surface, and the main fissure is usually through the inter-condylar
notch; the lower end of the bone is sometimes severely comminuted.

The knee is broadened, and pain and crepitus are readily elicited on
moving the condyles upon one another or on pressing them together. On
moving the patella transversely, it may be felt to hitch against the
edge of one or other of the fragments. The shortening may amount to
one or two inches.

The treatment is carried out on the same lines as in supra-condylar
fracture, but as the joint is implicated there is greater risk of
subsequent impairment of its functions.

#Separation of the lower epiphysis# is a comparatively common injury.
It is seldom pure, a portion of the diaphysis usually being broken
off and remaining attached to the epiphysis. It occurs usually in boys
between the ages of thirteen and eighteen, from severe violence such
as results from the limb being caught between the spokes of a
revolving wheel, or from hyper-extension of the knee. It has also been
produced in attempting forcibly to rectify knock-knee and other
deformities in this region, and in making traction on the limb to
correct deformities following recovery from tuberculous disease of the
knee. As a rule, there is little displacement of the loose epiphysis,
but it may pass in any direction, forward being much the most common
(Fig. 82), and when displaced it is difficult to reduce and to
maintain in position. The age of the patient, the mode of injury, the
finding of the smooth broad end of the diaphysis in the popliteal
space or on the front of the thigh, according to the displacement,
usually serve to establish the diagnosis. The X-rays afford reliable
information as to the position of the fragments. Pressure on the
popliteal vessels is a serious aggravation of the injury, and adds
greatly to the difficulties of treatment.

[Illustration: FIG. 82.--Radiogram of Separation of Lower Epiphysis of
Femur, with backward displacement of the diaphysis; pressure on
popliteal vessels caused sloughing of calf.]

[Illustration: FIG. 83.--Separation of Lower Epiphysis of Femur, with
fracture of lower end of diaphysis.]

The treatment is the same as for supra-condylar fracture, but, owing
to the serious disability that follows on incomplete reduction, it may
be necessary to have recourse to operation. After an epiphysial
separation, the growth of the limb is sometimes, although not always,
interfered with.

#Either condyle# may be broken off without the continuity of the shaft
being interrupted, by a direct blow or fall on the knee, or by violent
twisting of the leg. The separated condyle may not be displaced, or it
may be pushed upwards or rotated on its transverse axis.

There is broadening of the knee but no shortening of the thigh, and
the ecchymosis, crepitus, and pain are localised to the affected side
of the joint; the knee can usually be moved towards the injured side
in a way that is characteristic. If allowed to unite with the condyle
displaced, the articular surface is oblique and bow- or knock-knee
results.

If there is difficulty in replacing the broken condyle and maintaining
it in position, it may be fixed by means of a steel nail inserted
through the skin.


FRACTURE OF THE UPPER END OF THE TIBIA

#Fracture of the head of the tibia# is a comparatively rare injury. It
may result from a direct blow, such as the kick of a horse, or from
indirect forms of violence, and the line of fracture may be
transverse or oblique. Occasionally the distal fragment is impacted
into the proximal and comminutes it. In oblique fracture a gliding
displacement is liable to occur and cause bow- or knock-knee.
Transverse fracture of the head of the fibula sometimes accompanies
fracture of the head of the tibia, and there is always considerable
effusion into the knee-joint. One or other of the condyles may be
chipped off by forcible adduction or abduction at the knee.

[Illustration: FIG. 84.--Radiogram of Fracture of Head of Tibia and
Upper Third of Fibula.]

The ordinary clinical features of fracture are well marked, and the
diagnosis is easy. From some unexplained cause this fracture may take
a long time, sometimes several months, to consolidate.

#Separation of the upper epiphysis# of the tibia, which includes the
tongue-like process for the tubercle and the facet for the fibula, is
also rare. It usually occurs between the ages of three and nine. The
displacement of the epiphysis is almost always forward or lateral, and
is accompanied by the usual signs of such lesions. The growth of the
limb is sometimes arrested, and shortening and angular deformity may
result.

_Treatment._--After reduction under an anæsthetic these fractures are
usually satisfactorily treated in a box splint (Fig. 91), carried
sufficiently high to control the knee-joint. When the head of the
tibia is comminuted or split obliquely, weight-extension--direct from
the bone, the ice-tong callipers grasping the malleoli or the
calcaneus--may be used. Massage and movement are employed from the
outset.

Avulsion of the #tuberosity of the tibia# occasionally occurs in
youths, from violent contraction of the quadriceps--as in jumping. The
limb is at once rendered powerless; the osseous nodule can be felt,
and on moving it crepitus is elicited.

This is best treated by pegging the tuberosity in position, and fixing
the extended limb on an inclined plane to relax the quadriceps muscle.

In young, athletic subjects, the tongue-like process of the epiphysis
(Fig. 85), into which the ligamentum patellæ is inserted, may be
partly or completely torn away, giving rise to localised swelling, and
pain which is aggravated by any muscular effort--_Schlatter's disease_
or "rugby knee." It has been frequently observed in cadets as a result
of kneeling at drill. The treatment consists in rest and massage, but
the symptoms are slow to disappear.

[Illustration: FIG. 85.--Radiogram illustrating Schlatter's disease.]

The condition is liable to be mistaken for some chronic inflammatory
condition of the bone, such as tubercle, unless an X-ray examination
is made.

The #upper end of the fibula# is seldom broken alone. The chief
clinical interest of this fracture lies in the fact that it may
implicate the common peroneal nerve, and cause drop-foot.


DISLOCATIONS OF THE KNEE

Dislocation of the knee is a rare injury, and occurs as a result of
extreme degrees of violence, especially of a wrenching or twisting
character.

Rupture of the popliteal vessels, or pressure exerted on them by the
displaced bones, may lead to gangrene of the limb, and necessitate
amputation. The common peroneal nerve is frequently damaged. When the
lesion is compound, also, amputation may become necessary on account
of infective complications.

The varieties of dislocation are named in terms of the direction in
which the tibia passes: forward, backward, medial, and lateral.

#Dislocation forward# is the most common variety, and results from
sudden hyper-extension of the knee, tearing the collateral and
cruciate ligaments. The leg remains fully extended, and lies on a
plane anterior to that of the thigh. The condyles of the femur are
palpable posteriorly, and the skin is tightly stretched over them, or
may even be torn, rendering the dislocation compound. The patella is
projected forward, the quadriceps tendon is lax, and the skin over it
is thrown into transverse folds. The limb is shortened by two or three
inches.

#Dislocation backward# is usually due to a direct blow driving one of
the bones past the other. The leg remains hyper-extended, the head of
the tibia occupies the popliteal space, while the lower end of the
femur projects forward with the patella either in front or to one side
of it.

The #medial and lateral dislocations# are generally incomplete, and
are liable to be mistaken for separation of the lower epiphysis of the
femur. When the tibia passes _medially_, the lateral condyle of the
femur forms a prominence, and there is a depression below it. The head
of the tibia projects on the medial side, and the medial condyle is in
a depression.

When the tibia is displaced _laterally_, the relative position of the
prominences and depressions is reversed.

_Treatment._--In dislocations of the knee no special manipulations are
necessary to restore the displaced bone to its place, and reduction is
not accompanied by a distinct snap.

If, while the patient is fully anæsthetised, traction is made on the
leg and counter-traction on the thigh with the knee in the flexed
position, the bones can usually be replaced by manipulation.

After reduction has been effected, in antero-posterior dislocations,
the limb should be flexed and placed on a pillow, massage and movement
being employed from the first. The patient is usually able to walk
within a month.

In medial and lateral dislocations there is at first considerable
tendency to re-displacement, and it is therefore necessary to secure
the joint in a box splint, specially padded, for about fourteen days,
massage being employed from the first, and movement commenced when the
splint is removed. It is usually about six weeks before the patient
can use the limb with freedom.

In compound dislocations, and in those complicated by injury to the
popliteal vessels, the question of amputation may have to be
considered.

#Dislocation of the Superior Tibio-Fibular Articulation.#--This joint
may be dislocated by twisting forms of violence applied to the foot or
leg, or by forcible contraction of the biceps muscle. The displacement
may be forward or backward, and the head of the fibula can be felt in
its new position with the prominent tendon of the biceps attached to
it. The movements of the knee are quite free, but the patient is
unable to walk on account of pain. Reduction and retention are, as a
rule, easy, and the ultimate result satisfactory. We have frequently
met with this injury accompanying compound fractures of both bones of
the leg resulting from railway and similar accidents.

By applying direct pressure over the displaced bone with the knee
flexed, the dislocation is easily reduced. It is kept in position by a
firm bandage or a light rigid splint.

#Total Dislocation of Fibula.#--Very rarely the fibula is separated
from the tibia at both ends and displaced upwards. Bennett of Dublin
has pointed out that in some persons the upper end of the fibula does
not reach the facet on the tibia--a condition which might be mistaken
for a dislocation.


INJURIES OF THE SEMILUNAR MENISCI

The semilunar menisci are two crescentic plates of white
fibro-cartilage, which lie upon the upper end of the tibia, and serve
to deepen the articular surface for the condyles of the femur. Each
cartilage is firmly attached to the tibia by its anterior and
posterior ends, and, through the medium of the coronary ligaments, is
loosely attached along its peripheral, convex edge to the head of the
tibia, the medial meniscus being connected also to the capsular
ligament of the joint. The tendon of the popliteus muscle intervenes
between the lateral meniscus and the capsule. The central, concave
edges of the menisci are thin and unattached.

The cartilages enjoy a limited range of movement within the joint,
passing backwards during flexion, and forwards again when the limb is
extended; under normal conditions the lateral moves more freely than
the medial. While the limb is partly flexed, a slight degree of
rotation of the leg at the knee is possible, and during this movement
the cartilages glide from side to side, and the tibia rotates below
them.

Any abnormal laxity of the ligaments of the joint may render the
cartilages unduly mobile, so that they are liable to be displaced from
comparatively slight causes, and when so displaced it is not uncommon
for one or other to be torn by being nipped between the femur and the
tibia. It is convenient to consider these "internal derangements of
the knee-joint" separately, according to whether the meniscus is
merely abnormally mobile, or is actually torn.

#Mobile Meniscus--Displacement of Medial Semilunar Cartilage# (Fig.
86).--The _medial_ meniscus exhibits undue mobility much more
frequently than the lateral, and the condition is usually met with in
adult males who engage in athletics, or who follow an employment which
entails working in a kneeling or squatting position for long periods,
with the toes turned outwards--for example, coal-miners. The tibial
collateral ligament, and through it the coronary ligament, are thus
gradually stretched, so that the cartilage becomes less securely
anchored, and is rendered liable to be displaced towards the centre of
the joint during some sudden movement which combines flexion of the
knee with medial rotation of the femur upon the tibia, as, for
example, in rising quickly from a squatting position, or turning
rapidly and pushing off with the foot, in the course of some game such
as football or tennis. It may occur also from tripping on a loose
stone or slipping off the kerbstone.

[Illustration: FIG. 86.--Diagram of Longitudinal Tear of Posterior End
of Right Medial Semilunar Meniscus.]

What actually happens when the meniscus is displaced would appear to
be, that the combined flexion and abduction of the knee opens up the
medial side of the joint by separating the medial condyles of the
femur and tibia, and that the medial meniscus in its movement backward
during flexion slips under the femoral condyle and is caught between
it and the tibia. It may even slip past the condyle and into the
intercondyloid notch, and come to lie against the cruciate ligaments.

The mechanism by which this lesion is produced doubtless explains the
greater frequency with which the _left_ knee is affected, as most
sudden movements are made from right to left, thus throwing the strain
upon the left knee.

_Clinical Features._--When seen immediately after the accident, the
patient usually gives the history that while making a sudden movement
he was seized with an intense sickening pain in the knee, accompanied,
it may be, by a sensation of something giving way with a distinct
crack, and followed by locking of the joint. He may fall to the
ground and be unable to rise. On examination, the knee is found to be
fixed in a slightly flexed position; and while the surgeon may be able
to carry out movements of flexion to a considerable extent without
increasing the pain, any attempt to extend the joint completely is
extremely painful. Tenderness may be elicited on making pressure to
the medial side of the ligamentum patellæ in the groove between the
femur and the tibia, but the meniscus cannot be recognised by
palpation. Considerable effusion rapidly takes place into the synovial
cavity.

The condition is liable to be mistaken for a sprain of the joint,
particularly one implicating the tibial collateral ligament, but
whereas in the lesion of the meniscus the maximum tenderness is in the
interval _between_ the bones, in the sprain of the ligament the
maximum tenderness is over its attachment to the bone, usually the
tuberosity of the tibia.

_Treatment._--To reduce the displacement, the patient is placed on a
couch, and, after the knee is fully flexed, the leg is rotated
laterally and abducted, to separate the medial femoral condyle from
the tibia, and while the rotation and abduction are maintained the leg
is quickly extended. The return of the meniscus to its place is
sometimes attended with a distinct snap, but in other cases reduction
is only recognised to have taken place by the fact that the joint can
be completely extended without causing pain.

Alternate flexion and extension combined with rotatory movements is
sometimes successful. Several attempts are often necessary, and a
general anæsthetic may be called for. After reduction, the limb is
fixed with sand-bags, and massage and movement are employed to get rid
of effusion, care being taken that no rotatory movement at the knee is
permitted. Rest and support are necessary to allow of repair of the
torn ligaments, and when the patient begins to use the limb he must be
careful to avoid movements which throw strain on the damaged
ligaments.

In a considerable proportion of cases no recurrence takes place, and
in the course of a month or two the patient is able to resume an
active life with a perfectly useful joint. In other cases there is a
tendency to recurrence of the displacement.

#Recurrent Displacement.#--In cases of recurrent displacement, each
attack is accompanied by symptoms similar in kind to those above
described, but less severe, and the patient usually learns to carry
out some manipulation by which he is able to return the meniscus into
position. He seeks advice with a view to having something done to
prevent displacement occurring, and to restore the stability of the
joint, which, in many cases, is impaired, preventing him following his
occupation. There persists a variable amount of fluid in the joint,
the ligaments are stretched and slack, and the quadriceps muscle is
markedly wasted.

The symptoms closely resemble those of a "loose body," and it is often
difficult to differentiate between them. In the case of a body free in
the cavity of the joint, the site of the pain varies in different
attacks, and the body can sometimes be palpated. Loose bodies wholly
or partly composed of bone may be identified with the X-rays.

Attempts may be made to retain the meniscus in position by pads,
bandages, or other forms of apparatus, so arranged as to prevent
rotation and side-to-side movement at the knee. In the majority of
cases, however, the best results are obtained by opening the joint and
excising the meniscus in whole or in part, as may be necessary.

The limb is flexed on a splint until the wound has healed, after which
massage should be employed and movement of the joint commenced. At the
end of two or three weeks the patient is allowed up, wearing an
elastic bandage. In most cases the use of the joint is completely
regained in from four to six weeks. As an indication of the perfect
recovery of the functions of the joint after removal of the meniscus,
professional football players are often able to resume their
occupation.

#Displacement of the lateral meniscus# is comparatively rare. It is in
every way comparable to displacement of the medial meniscus, and is
treated on the same lines.

#Torn or Lacerated Meniscus.#--In a large proportion of cases of
displaced meniscus in which the condition assumes the recurrent type,
it is found, on opening the joint, that, in addition to being unduly
mobile, the meniscus is torn or lacerated. The experience of surgeons
varies regarding the nature of the laceration. In our experience the
most common form is a longitudinal split, whereby a portion of the
inner edge of the cartilage is separated from the rest and projects as
a tag towards the centre of the joint (Fig. 86). As a rule, it is the
anterior end that is torn, less frequently the posterior end.
Sometimes the meniscus is split from end to end, the outer crescent
remaining in position, while the inner crescent passes in between the
condyles and lies curled up against the cruciate ligaments.
Occasionally the anterior end is torn from its attachment to the
tibia, less frequently the posterior end. In one case we found the
meniscus separated at both ends and lying between the bones and the
capsule.

The _clinical features_ are similar to those of mobile meniscus with
displacement, and as a rule the exact nature of the lesion is only
discovered after opening the joint.

The _treatment_ consists in excising the loose tag or the whole
meniscus, according to circumstances. The recovery of function is
usually complete. It is not advisable to attempt to stitch the torn
portion in position.

#Rupture of the Cruciate Ligaments.#--A few cases have been recorded
in which, as a result of severe twisting forms of violence, the
cruciate ligaments have been torn from their attachments, leaving the
joint loose and unstable, so that the tibia and the femur could be
moved from side to side on one another. When the disability persists,
the joint may be opened and the ligaments sutured in position (Mayo
Robson).

#Sprains# of the knee are comparatively common as a result of sudden
twisting or wrenching of the joint. In addition to the stretching or
tearing of ligaments, there is usually a considerable effusion of
fluid into the synovial cavity, and examination with the X-rays
occasionally reveals that a portion of bone has been torn away with
the ligament--_sprain-fracture_. The swelling fills up the hollows on
either side of the patella, and extends for some distance in the
synovial pouch underneath the quadriceps. The patella is raised from
the front of the femur by the collection of fluid in the
joint--"floating patella"--and, if firmly pressed upon, it may be made
to rap against the trochlear surface.

A sprain is to be diagnosed from separation of one or other of the
adjacent epiphyses, fracture involving the articular ends of the
bones, and displacement of the semilunar menisci. On account of the
swelling, which obscures the outline of the part, the differential
diagnosis is often difficult, but as the swelling goes down under
massage it becomes easier. Chief reliance is to be placed upon the
bony points retaining their normal relationships, and upon the fact
that the points of maximum tenderness are over the attachments of one
or other of the collateral ligaments. As the tibial collateral
ligament suffers most frequently, the most tender spot is usually over
its attachment to the medial aspect of the head of the tibia--less
frequently over the medial condyle of the femur.

Unless efficiently treated, a sprain of the knee is liable to result
in weakness and instability of the joint from stretching of the
ligaments, and this is often associated with effusion of fluid in the
synovial cavity (_traumatic hydrops_). This is more likely to occur if
the joint is repeatedly subjected to slight degrees of violence, such
as are liable to occur in football or other athletic exercises--hence
the name "footballer's knee" sometimes applied to the condition.

A further cause of disability, following upon sprains of the knee, is
_wasting of the quadriceps muscle_. The stability of the joint,
whenever the position of full extension has been departed from, is
largely dependent upon its capacity of controlling the amount of
flexion, notably in descending a stair or in walking on uneven ground,
hence it is that with a wasted quadriceps there is increasing
liability to a repetition of the sprain. With each repetition of the
sprain, there is an addition to the fluid in the joint, stretching of
ligaments, and further wasting of the quadriceps. A form of vicious
circle is established in which there is at the same time increased
liability to sprain and diminished capacity of recovering from it.
Even after the repair of the damaged ligament or the removal of the
mobile or torn meniscus, wasting of the quadriceps remains a source of
weakness and disability and calls for treatment by massage and
electricity.

_Treatment._--In recent and severe cases the patient must be confined
to bed, and firm pressure applied over the joint by means of cotton
wool and a bandage. This may be removed once or twice a day to admit
of the joint being douched, and at the same time it should be massaged
and moved to promote absorption of the effusion and prevent the
formation of adhesions.

Chronic effusion into the joint is most rapidly got rid of by rest and
blistering. If the patient is unable to lie up, massage should be
systematically employed, and a firm elastic bandage worn. A patient
who has once had a severe sprain of the knee, or who has developed the
condition of "footballer's knee," must give up violent forms of
exercise which expose him to further injuries, otherwise the condition
is liable to be aggravated and to result in permanent impairment of
the stability of the joint.


INJURIES OF THE PATELLA

#Fracture of the patella# is a comparatively common injury in adult
males. Most frequently it is due to _muscular action_ the patella
being snapped across the lower end of the femur by a sudden and
forcible contraction of the quadriceps extensor muscle while the limb
is partly flexed--as, for example, in the attempt to avoid falling
backward. The bone is then broken as one breaks a stick by bending it
across the knee, and the line of fracture, which is transverse or
slightly oblique, crosses the bone a little below its middle.
Fractures produced in this way are almost never compound.

[Illustration: FIG. 87.--Radiogram of Fracture of Patella.]

The degree of displacement of the fragments depends upon the extent to
which the expansion of the quadriceps tendon is lacerated. As a rule,
it is but slightly torn, so that the separation of the fragments does
not exceed an inch. In other cases it is widely torn, and the
contraction of the quadriceps muscle is then able to separate the
fragments by three or four inches, and sometimes causes tilting of the
upper fragment. The blood effused into the joint tends still further
to increase the separation. As the periosteum is usually torn at a
level lower than the fracture, its free margin hangs as a fringe from
the proximal fragment, and by getting between the broken ends may form
a barrier to osseous union (Macewen).

_Clinical Features._--Immediately the bone breaks, the patient falls,
and he is unable to rise again, as the limb is at once rendered
useless, and in attempting to do so we have known him to fracture the
patella of the other limb. The power of extending the limb is lost,
and the patient is unable to lift his foot off the ground. The
knee-joint is filled with blood and synovia, which usually extend into
the bursa under the quadriceps. The two fragments can be detected,
separated by an interval which admits of the finger being placed
between them, and which is increased on flexing the knee. On relaxing
the quadriceps, the fragments may be approximated more or less
completely.

_Prognosis._--In cases with little displacement, if the fragments have
been kept in perfect apposition, osseous union may take place, but in
the great majority of cases the union is fibrous. The shortening of
the quadriceps and the gradual stretching and thinning of the
connecting fibrous band may allow of further separation of the
fragments (Fig. 88), which to a variable extent interferes with the
stability and functions of the limb. The proximal fragment sometimes
becomes attached to the front of the femur, and moves with it, and the
fibrous band between the two fragments gradually becomes stretched.
After bony union has occurred, it is not uncommon for the patella to
be fractured again by a fall within a month or two of the original
accident.

[Illustration: FIG. 88.--Fracture of Patella, showing wide separation
of fragments, which are united by a fibrous band.

(Anatomical Museum of the University of Edinburgh.)]

_Treatment._--It is probably true that the best functional results are
most speedily obtained by operative measures. The laceration of the
aponeurosis of the quadriceps, the tilting of the fragments, and the
interposition of the torn periosteum between them, can in no other way
be rectified with certainty. The operation, however, should only be
undertaken by those who are familiar with wound technique, and who
have the means at their disposal for carrying it out. Operative
treatment is specially indicated in young subjects who lead an active
life, and in labouring men, particularly those who follow dangerous
employments necessitating stability of the knee.

As soon as the wound is healed,--in a week or ten days,--massage and
movement of the limb are commenced, and the patient is encouraged to
move his limb in bed. At the end of another week he may be allowed up
with sticks or crutches.

_Non-operative Treatment._--In the majority of cases occurring in
patients who do not follow a laborious occupation or otherwise lead an
active life, a satisfactory result can be obtained without having
recourse to operation. We have reason to be satisfied with the
following method: the patient is kept in bed for a few days, the
injured region being supported on a pillow and massaged daily, and the
patella moved from side to side as a whole to prevent adhesion to the
femur. About the fourth day he is allowed to get about with crutches.
As osseous union of the fragments is not essential to a good
functional result, and as fibrous union does not necessarily entail
any material interference with the usefulness of the limb, no attempt
need be made to approximate the fragments, but every effort must be
made to maintain the function of the quadriceps muscle and the
mobility of the joint.

If it is desired to bring the fragments into contact and to secure
osseous union, the limb should be placed upon an inclined plane to
relax the quadriceps muscle, and means taken to arrest effusion and to
diminish the swelling by systematic massage and a supporting bandage.
When, in the course of a few days, this has been accomplished, the
attempt is made to approximate the fragments, by fixing a large
horseshoe-shaped piece of adhesive plaster to the front of the thigh,
embracing the proximal fragment. Extension is made upon this by means
of rubber tubing, which is fixed to the foot-piece of the splint. The
bandage which binds the limb to the splint should make upward pressure
on the distal fragment, or this may be done by a special piece of
adhesive plaster with elastic tubing pulling in an upward direction.

The retentive apparatus is kept on for about three weeks, and a rigid,
but easily removable, apparatus is thereafter applied, and the patient
allowed up on crutches, the limb being massaged and exercised daily to
improve the tone of the muscles.

When the fracture is caused by _direct violence_, such as a fall on
the knee or the kick of a horse, it may be transverse, oblique, or
vertical, but in many cases it is stellate, the bone being broken into
several irregular pieces. These comminuted fractures are frequently
compound. In transverse and oblique fractures, the displacement
depends upon the same causes as in fracture by muscular action. In
vertical and stellate fractures, unless the knee has been forcibly
flexed after the bone has been broken, there is little or no
displacement. The treatment is governed by the same considerations as
in fractures by muscular action.

_Old-standing Fracture._--As fibrous union, even with an interval of
several inches between the fragments, is not incompatible with a
useful limb, it is not often necessary to operate for this condition,
but when the usefulness of the limb is seriously impaired, operative
treatment is indicated. The operation is carried out on the same lines
as for recent fracture, the ends of the bones being rawed and
adhesions divided. When the proximal fragment has become attached to
the femur, it should be separated and a layer of fascia interposed; it
is sometimes necessary to lengthen the quadriceps muscle by making a
number of V-shaped incisions through its substance; or a flap may be
turned down from the rectus and stitched to the patella and the
ligamentum patellæ.

When operative treatment is contra-indicated, the patient should be
fitted with a firm apparatus which will limit flexion of the knee and
support the fragments.

#Dislocation of the patella# is rare. It results from exaggerated
muscular movements when the limb is in the fully extended position, or
from a blow on one or other edge of the bone. Laxity of the ligaments
and knock-knee are predisposing factors. It is sometimes associated
with fracture of the edge of the trochlear surface, which renders
retention in position difficult.

The _lateral_ is the most common variety--the _medial_ being rare.
Either may be complete or incomplete. Sometimes the bone is rotated so
that its edge rests on the front of the femur--_vertical_ dislocation;
and in a few cases it has been completely turned round, so that the
articular surface is directed forwards.

_Clinical Features._--The joint is fixed, usually in a position of
slight flexion, and the displaced patella can readily be palpated. The
deformity is a striking one, and at first sight suggests a much more
serious injury. Although easily reduced, the dislocation is liable to
recur.

To effect reduction, the quadriceps must be thoroughly relaxed by
extending the leg upon the thigh and flexing the thigh upon the
pelvis; the patella is then tilted by making firm pressure on that
edge which lies farthest from the middle of the joint, and at the same
time pushing towards the middle line. The limb is placed on a
posterior splint, and firm elastic pressure made on the joint to
prevent or diminish effusion. Massage and movement are carried out
from the first.

As the displacement is liable to recur, the patient should wear a firm
elastic bandage or a strong knee-cap.

_Permanent and recurrent dislocation of the patella_ will be described
later.


FRACTURE OF THE BONES OF THE LEG

The bones of the leg may be broken together or separately.

#Fracture of both Bones.#--The features of this injury depend to a
large extent upon the nature of the violence producing it. In fracture
by _direct_ violence, such as the passage of a wheel over the limb or
a severe blow, the bones give way at the point of impact, and the line
of fracture tends to be transverse, both bones being broken at the
same level (Fig. 89). There is little or no displacement, and such as
there is is angular, and is determined by the direction of the
fracturing force.

[Illustration: FIG. 89.--Radiogram of Transverse Fracture of both
Bones of Leg by direct violence.]

When the violence is _indirect_, as from a fall on the feet, or a
twist of the leg, the tibia usually gives way at the junction of its
lower and middle thirds, and the fibula at a higher level (Fig. 90).
Torsion of the tibia is probably the most important factor in the
production of the fracture, the distal fragment being fixed by the
pressure of the foot upon the ground, while the proximal fragment is
rotated by the impetus of the body. Both fractures are usually
oblique--that in the tibia running from above downward, forward, and
medially, and it is generally found that the obliquity of the fibular
fracture corresponds with that in the tibia.

[Illustration: FIG. 90.--Radiogram of Oblique Fracture of both Bones
of Leg by indirect violence.]

There is usually considerable displacement, the weight of the lower
portion of the limb causing it to fall backwards and to roll away from
the middle line, and the traction of the calf muscles pulling up the
heel and pointing the toes. The proximal fragment forms a projection
on the front of the limb.

On account of the superficial position of the tibia and the pointed
character of the fragments, this fracture is frequently rendered
compound by the bone being forced through the skin. The projecting
piece of bone is usually the distal end of the proximal fragment. This
fracture is often comminuted. It has been observed that when the line
of fracture forms the letter V on the subcutaneous surface of the
tibia, there is invariably a fissure passing down along the back of
the bone into the ankle-joint--a complication which adds to the risk
of subsequent stiffness and impaired usefulness of the limb. Apart
from this, the ankle is usually sprained in fractures by indirect
violence, and we have frequently found the superior tibio-fibular
articulation torn open in severe fractures of both bones of the leg
from indirect violence.

_Clinical Features._--The tibial fracture is readily recognised by
detecting an irregularity on running the fingers along the crest of
the shin, and at this point abnormal mobility, tenderness, and
crepitus can usually be elicited. It is often difficult to detect the
fibular fracture, and it is not always advisable to attempt to do so,
especially if the manipulations cause pain or tend to increase the
displacement. The condition of the fibula is usually to be inferred by
noting the amount of displacement and the extent of mobility of the
tibial fragments. Not infrequently the seat of fracture may be
recognised by locating a point at which pain is elicited on making
pressure over the bone at a distance--pain on distal pressure.

On account of the close connection of the skin to the periosteum on
the subcutaneous aspect of the tibia, the tension caused by
extravasated blood is often extreme; blisters frequently form over the
area of ecchymosis, and when these become infected, sloughing of the
skin may take place and the fracture thus be rendered compound.

The vessels and nerves of the leg are seldom seriously damaged.

_Treatment._--If there is marked displacement, reduction is most
satisfactorily accomplished under anæsthesia. Traction is made upon
the foot and the fragments are manipulated into position, the pointing
of the toes and the outward rotation of the foot being at the same
time corrected. The normal outline of the foot in relation to the leg
is restored when the ball of the great toe, the medial malleolus, and
the medial edge of the patella are in the same vertical plane. As in
other fractures of the lower extremity, the limb should be placed in
the natural position of slight eversion: not with the toes pointing
straight forward.

The retentive apparatus to be applied depends upon the tendency to
re-displacement, the degree of swelling, and the extent of the damage
to the skin.

In the average case, the leg is supported between sand-bags, and
massage and movements are employed from the outset. When there is a
tendency to re-displacement, the limb may be immediately enclosed in a
rigid apparatus, such as lateral poroplastic splints retained in
position by an elastic bandage, or a Cline's splint, which can readily
be removed to admit of massage. When the fracture is in the lower
third of the leg, the ambulatory splint gives excellent results, and
is of special service in hospital practice (Fig. 95).

As an emergency appliance, for example for purposes of transport, the
_box splint_ (Fig. 91) is simple and efficient. We have not found it
effectual in controlling the fragments, particularly in oblique
fractures, and it requires constant supervision and readjustment. It
consists of two pieces of wood extending from above the knee to an
inch or two beyond the sole, and a little broader than the maximum
diameter of the leg. These are rolled into the opposite ends of a
folded sheet, so as to form two sides of a box, of which the sheet
constitutes a third side. It is found advantageous to insert another
board, fitted with a foot-piece, between the folds of the sheet
forming the third side of the box, to add to the rigidity of the
splint, and to aid in controlling the foot. By folding one side of the
sheet somewhat obliquely, the box is made a little wider at the knee
than at the ankle, and so fits the limb more accurately.

[Illustration: FIG. 91.--Box Splint for Fractures of Leg.]

The limb is placed in this box, the sides of which have been carefully
padded. Ring pads are applied to take pressure off the condyles, the
head of the fibula, the malleoli, and the prominence of the heel, and
a large supporting pad is placed behind the tendo calcaneus. A folded
towel is laid over the front of the leg, forming a lid to the box, and
the whole is bound to the limb by three slip-knots. Finally, the foot
is fixed at right angles to the leg and slightly abducted by a
figure-of-eight bandage or a piece of elastic webbing. Sand-bags
placed alongside serve to steady the limb. In fractures of the lower
third of the leg, the box splint may stop short of the knee and the
limb may then be suspended in a Salter's cradle, which allows the
patient to move about more freely in bed.

[Illustration: FIG. 92.--Box Splint (applied).]

To prevent shortening in oblique fractures and in those near the
ankle-joint, where it is often difficult to control the lower
fragment, extension, applied by weight and pulley, or through a
Thomas' knee splint, may be of service. The strapping may be applied
only to the distal fragment, but we prefer to carry it to the upper
third of the leg. If the overriding of the fragments persists,
extension may be taken directly from the bone, the ice-tong callipers
gripping the malleoli or the calcaneus.

When the skin is damaged, as it so frequently is on the medial aspect
of the tibia, means must be taken to prevent infection.

Massage is carried out daily, and, to prevent stiffness, the ankle is
moved from the first. In the course of three weeks, lateral
poroplastic splints retained by an elastic bandage may be substituted,
and the patient allowed up on crutches. In simple fractures without
displacement, union is usually complete in from six to eight weeks,
but when the fracture is oblique, comminuted, or compound, union is
often delayed, and the functions of the limb may not be fully regained
for three or even four months after the accident.

_Operative Treatment._--When overriding cannot otherwise be corrected,
it is advisable to replace the fragments by operation. A curved
incision with its convexity backward is made over the medial side of
the tibia, exposing the fragments, which are then levered into
position and if necessary plated or otherwise fixed according to
circumstances. It is seldom necessary to deal separately with the
fibula. A box splint is applied till the wound has healed, after which
a poroplastic splint is substituted and massage commenced.

We do not share in the dissatisfaction expressed by some surgeons,
notably Arbuthnot Lane, as to the results obtained by non-operative
means in the common fractures of the leg, and do not recommend a
systematic resort to operative treatment.

_Un-united fracture_ of the bones of the leg is sometimes met with. It
is treated on the same lines as in other situations, but may prove
extremely intractable, especially in children, in whom, indeed, it is
sometimes incurable.

_Mal-union_, on account of the disability it entails, may call for
operative treatment in the form of osteotomy of one or both bones.

_Compound fractures_ of the leg are common, and are treated on the
lines already laid down for the treatment of compound fractures in
general (p. 25).

#Fracture of the tibia alone#, when due to direct violence, is usually
transverse, there is little displacement, and as the fibula retains
the fragments in position, union usually takes place rapidly and
without deformity. Oblique and spiral fractures result from indirect
violence.

#Fracture of the fibula alone# may result from direct violence, and,
on account of the support given by the tibia, is usually unattended by
displacement. Bennett of Dublin has pointed out that it is common to
meet with an oblique fracture of the upper third of the fibula as the
result of an outward twist of the ankle while the foot is extended. It
is characterised by pain localised at the seat of the break, on moving
the foot in such a way as to bring the talus to bear against the
fibula. Local pressure also may make the fibula yield and may elicit
crepitus. In some cases this fracture is associated with sprain of the
ankle-joint. It is often overlooked, and from want of proper treatment
may result in prolonged impairment of usefulness.

Fractures of the tibia or fibula alone are treated on the same lines
as fractures of both bones, and splints are rarely necessary. The
ambulant method is useful in these cases (Fig. 95).




CHAPTER VIII

INJURIES IN REGION OF ANKLE AND FOOT


Surgical Anatomy--FRACTURES: _Pott's fracture_; _Converse of Pott's
    fracture_; _Separation of lower epiphysis_; _Fracture of talus_;
    _Fracture of calcaneus_; _Fractures of other tarsal bones_;
    _Fractures of metatarsal bones_; _Fractures of
    phalanges_--DISLOCATIONS: _Of ankle joint_; _Of inferior
    tibio-fibular joint_; _Complete dislocation of talus_; _Sub-taloid
    dislocation_; _Medio-tarsal dislocation_; _Tarso-metatarsal
    dislocation_; _Dislocations of toes_.

The fractures in this region include Pott's fracture, and its
converse; separation of the lower epiphysis of the tibia; fractures of
the talus, calcaneus, and other tarsal bones; and fractures of the
metatarsals and phalanges. Various dislocations also occur, the most
important being those of the ankle joint, of the talus, and the
sub-taloid dislocation.

#Surgical Anatomy.#--For the study of injuries in the region of the
ankle-joint it is of importance to define the terms employed in
describing the movements of the foot. Thus by _flexion_ or
_dorsiflexion_ is meant that movement which approximates the dorsum of
the foot to the front of the leg; while _extension_ or _plantar
flexion_ means the drawing up of the heel so that the toes are
pointed. In _inversion_ the medial edge of the foot is drawn up so
that the sole looks towards the middle line of the body, an attitude
which is analogous to supination of the hand. In _eversion_ the
lateral edge of the foot is drawn up, the sole looking away from the
middle line--analogous to pronation of the hand. _Adduction_ indicates
the rotation of the foot so that the toes are turned towards the
middle line of the body; while in _abduction_ the toes are turned away
from the middle line.

The most prominent bony landmarks in the region of the ankle are the
two _malleoli_, the lateral lying slightly farther back, and about
half an inch lower than the medial. On the medial side of the foot
from behind forward may be felt the _medial process (internal
tuberosity)_ of the calcaneus; the _sustentaculum tali_, which lies
about 1 inch vertically below the tip of the malleolus; the _tubercle
of the navicular_, about 1 inch in front of the malleolus, and at a
slightly lower level; the _first (internal) cuneiform_, and the base,
shaft, and head of the _first metatarsal_.

On the lateral side may be recognised the _lateral process (external
tuberosity)_ of the calcaneus; the _trochlear process (peroneal
tubercle)_ on the same bone; the _cuboid_; and the prominent base of
the _fifth metatarsal_.

The talo-navicular joint lies immediately behind the tuberosity of the
navicular, and a line drawn straight across the foot at this level
passes over the calcaneo-cuboid joint.

The _ankle-joint_, formed by the articulation of the tibia and fibula
with the talus, lies about half an inch above the tip of the medial
malleolus, and is so constructed that when the foot is at a right
angle with the leg it is only possible to flex and extend the joint.
When the toes are pointed, however, slight side-to-side and rotatory
movements are possible. The chief seat of side-to-side movement of the
foot is at the talo-navicular and calcaneo-cuboid articulations--"the
mid-tarsal or Chopart's joint."

The ankle-joint owes its strength chiefly to the malleoli and the
collateral ligaments, and to the inferior tibio-fibular ligaments,
which bind together the lower ends of the bones of the leg. The
numerous tendons passing over the joint on every side also add to its
stability.

The synovial membrane of the ankle-joint passes up between the bones
of the leg to line the inferior tibio-fibular joint; but it is
distinct from that of the intertarsal joints, which communicate with
one another in a complicated manner. The epiphysial cartilage at the
lower end of the fibula lies on the level of the talo-tibial
articulation, while that of the tibia is about half an inch higher
(Fig. 93).

[Illustration: FIG. 93.--Section through Ankle-Joint showing relation
of epiphyses to synovial cavity.

    _a_, Lower epiphysis of tibia.
    _b_, Lower epiphysis of fibula.
    _c_, Talus.
    _d_, Calcaneus.

(After Poland.)]


FRACTURES IN THE REGION OF THE ANKLE

#Pott's Fracture.#--It must be understood that various lesions
occurring in the region of the ankle-joint are included under the
clinical term "Pott's fracture." Although of a similar nature, and
produced by the same forms of violence, these vary considerably in
their anatomy and clinical features. They are all the result of
_combined eversion and abduction_ of the foot--produced, for example,
by slipping off the kerbstone, or by jumping from a height and landing
on the medial side of the foot.

When forcible _eversion_ is the chief movement, the tightening of the
deltoid (internal lateral) ligament usually tears off the medial
malleolus across its base. The talus is then brought to bear on the
lateral malleolus, and the force continuing to act, the lower end of
the fibula is pressed laterally, and breaks close above the
malleolus. The tibio-fibular interosseous ligament may rupture, or the
outer portion of the tibia, to which it is attached, may be avulsed.
This form is sometimes called _Dupuytren's fracture_. When the bones
are widely separated in Dupuytren's fracture the talus may be forced
up between them.

When the movement of _abduction_ predominates, the deltoid ligament is
usually ruptured, or the anterior edge or tip of the medial malleolus
torn off. The tibio-fibular interosseous ligament usually resists, and
an oblique fracture of the fibula 2 or 4 inches above its lower end
results.

_Clinical Features._--In a considerable proportion of cases--in our
experience in the majority--this fracture is not accompanied by any
marked deformity of the foot, and the patient is often able to walk
after the injury with only a slight limp.

In others, however, the deformity is marked and characteristic (Fig.
94). The foot is everted, its inner side resting on the ground. The
medial malleolus is unduly prominent, stretching the skin, which may
give way if the patient attempts to walk. The foot, having lost the
support of the malleoli, is often displaced backward, and the toes are
pointed by the contraction of the calf muscles. There is abnormal
mobility--both from side to side and antero-posteriorly--and crepitus
may be elicited. The points of tenderness are over the deltoid
ligament or medial malleolus, the inferior tibio-fibular joint, and at
the seat of fracture of the fibula. Distal pressure over the shaft of
the fibula, or on the extreme tip of the malleolus, may elicit pain
and crepitus at the seat of fracture. There is usually considerable
ecchymosis and swelling in the hollows below and behind the malleoli;
and the malleoli appear to be nearer the level of the sole. In
Dupuytren's fracture, when the talus passes up between the tibia and
fibula, there is great broadening of the ankle.

[Illustration: FIG. 94.--Radiogram of Pott's Fracture with lateral
displacement of foot.]

There is often considerable difficulty in distinguishing a _sprain_ of
the ankle from a fracture without displacement, as both forms of
injury result from the same kinds of violence, and are rapidly
followed by swelling and discoloration of the overlying soft parts. In
a sprain, the point of maximum tenderness is over the ligaments and
tendon sheaths that have been damaged, while in fracture the site of
the break is the most tender spot. The X-rays are useful in the
diagnosis of doubtful cases.

_Treatment._--In those cases of fracture of the lower end of the
fibula in which there is no marked displacement,--and they constitute
a considerable proportion,--the limb should be massaged and laid on a
pillow between sand-bags, or placed in a box splint for two or three
days, until the swelling subsides. Some form of rigid apparatus, such
as side poroplastic splints fixed in position with an elastic bandage,
which will allow the patient to get about with crutches, is then
applied. This is removed daily to permit of massage and movement being
carried out--a point of great practical importance, because, if this
is neglected, not only does union take place more slowly, but the
stiffness of the ankle and œdema of the leg and foot which ensue,
prolong the period of the patient's incapacity and endanger the
usefulness of the limb.

It is in cases of this kind that the _ambulatory method_ of treatment
yields its best results. When, in the course of two or three days, the
swelling has subsided, a plaster-of-Paris case (Fig. 95) is applied in
such a way that when the patient walks the weight is transmitted from
the condyles of the tibia through the plaster case to the ground, no
weight being borne by the bones at the seat of fracture. The apparatus
is applied as follows: A boracic lint bandage is applied to the limb
as far as the knee, and protecting pads or rings of wool are placed
over the condyles of the tibia, the head of the fibula, and the
malleoli. A pad of wool about 3 inches thick is then placed under the
sole and fixed in position by a plaster-of-Paris bandage, which is
carried up the limb in the usual way. The case is made specially
strong on the sole, around the ankle, up the sides of the leg, and at
the bearing-point at the head of the tibia. After the plaster has
thoroughly set, the patient is allowed to walk about with a stick,
crutches being unnecessary. In the course of three weeks the plaster
case may be removed and the limb massaged. It is usually found that
the movements of the ankle are scarcely interfered with, and the
patient is generally able to resume work within a month of the
accident.

[Illustration: FIG. 95.--Ambulant Splint of plaster of Paris.]

When there is marked eversion of the foot, it may be necessary to
administer a general anæsthetic to reduce the deformity; and to
prevent recurrence of the displacement _Dupuytren's splint_ (Fig. 96)
may be used. This splint, which is of the same shape as Liston's long
splint, but on a small scale, is applied to the medial side of the leg
extending from just below the knee to well beyond the sole of the
foot. A large pad is placed in the hollow above the medial malleolus,
and it must be thick enough to carry the splint so far from the limb
that when the foot is fully inverted it does not touch the splint. The
upper end of the splint having been fixed to the leg at the level of
the condyles of the tibia, a bandage is applied to correct the
eversion of the foot, and at the same time to support the heel, and,
as far as possible, to overcome the pointing of the toes. Care must be
taken to avoid carrying the turns of this bandage over the seat of
fracture. The limb may then be slung in a cradle, or placed on a
pillow resting on its lateral side with the knee flexed. In the course
of a few days, a poroplastic splint may be substituted and massage
commenced.

[Illustration: FIG. 96.--Dupuytren's Splint applied to correct
eversion of foot.]

When backward displacement of the heel is the prominent deformity,
_Syme's horse-shoe_ or _stirrup splint_ (Fig. 97) may be employed. It
is applied to the anterior aspect of the limb, which is carefully
padded to prevent undue pressure on the edge of the shin bone. After
the upper end of the splint has been fixed, the heel is pulled forward
by a few turns of bandage passed over the prongs at the lower end of
the splint. The foot is then inverted and brought up to a right angle
by a few supplementary turns of the bandage. In a few days this
appliance may be replaced by a poroplastic splint.

[Illustration: FIG. 97.--Syme's Horse-shoe Splint applied to correct
backward displacement of foot.]

_Operative Treatment._--If the displacement is not completely
corrected by the measures described, the fibular fracture is exposed
by a free incision and the fragments are levered into position, and if
necessary fixed by lashing with catgut or by other mechanical means.

Mal-union of Pott's fracture may necessitate re-fracture by means of a
Jones' wrench, used in the same manner as for club-foot, or the parts
are exposed by operation; the bone is divided by means of an
osteotome, the foot forcibly inverted, and the limb put up in the same
way as in a recent fracture.

#The Converse of Pott's Fracture--sometimes called "Pott's Fracture
with Inversion."#--This injury is fairly common, and results from
forcible inversion of the foot. The lateral malleolus is broken across
its base, or, in young subjects, along the epiphysial line. The medial
malleolus alone may be carried away, or a portion of the broad part of
the tibia may accompany it.

The foot is inverted, the heel falls back, and the toes are pointed.
In other respects it corresponds to the typical Pott's fracture, and
is treated on the same principles. When Dupuytren's splint is
required, it is, of course, applied to the lateral side of the leg.

#Separation of the lower epiphysis of the tibia# is not common. It
occurs most frequently between the ages of eleven and eighteen, as a
result of forcible eversion or inversion of the foot. It is usually
accompanied by fracture of the diaphysis of the fibula (Fig. 98), and
is not infrequently compound. When the epiphysis is displaced to one
side, the deformity is characteristic. In rare cases the growth of the
tibia is arrested, the continued growth of the fibula causing the foot
to become inverted. The treatment is the same as for Pott's fracture.

[Illustration: FIG. 98.--Radiogram of Fracture of lower end of Fibula,
with separation of lower epiphysis of Tibia.]

#Fracture of the talus# usually occurs as a result of a fall from a
height, the bone being crushed between the tibia and the calcaneus. It
is usually associated with other fractures, and is sometimes
impacted, the foot assuming the position of equino-varus. The
diagnosis is only to be made by exclusion, or by the use of the
Röntgen rays. In interpreting radiograms of injuries in this region,
care must be taken not to mistake the _os trigonum tarsi_ for a
fracture. In uncomplicated cases, the treatment consists in
immobilising the foot and leg in a poroplastic splint and applying
massage. In comminuted and in impacted fractures with persistent
deformity, complete excision of the bone yields good results.

The #calcaneus# is most frequently broken by the patient falling from
a height and landing on the sole of the foot, and the injury may occur
simultaneously in both feet.

The primary fracture is usually longitudinal, passing through the
facets for the talus and cuboid, and from this various secondary
fissures radiate; the cancellated tissue is much crushed, so that the
whole bone is flattened out. In spite of the great comminution, it is
often impossible to elicit crepitus, as the fragments are held
together by the investing soft parts. In other cases the foot may feel
like "a bag of bones." The lesion is often mistaken for a fracture of
the lower end of the fibula, or is not diagnosed at all. The chief
clinical feature is pain on movement of the foot, or on attempting to
walk; the foot appears flat, and the hollows on either side of the
tendo Achillis are filled up. In many cases there is a persistent
tenderness which delays restoration of function for some months, but
the ultimate result is usually satisfactory.

_Treatment._--In simple comminuted fractures the patient should be
anæsthetised, and the foot moulded into position, care being taken to
restore the arch in order to avoid any tendency to flat foot. The foot
is supported on a pillow, and to prevent stiffness, massage and
movements of the ankle and tarsal joints should be commenced without
delay.

Compound fractures confined to the calcaneus may be treated on
conservative lines, but if associated with other injuries of the foot
they may necessitate amputation.

_The tuberosity of the calcaneus_, into which the tendo Achillis is
inserted, is sometimes separated by forcible contraction of the calf
muscles, or from a fall on the ball of the foot. The separated
fragment may be pulled up for a distance of 1 or 2 inches, and the
rough surface from which it has been torn may be recognisable. The
patient may be able to walk immediately after the accident, although
with difficulty; or he may have pain for many months.

A good functional result is usually obtained by relaxing the calf
muscles and fixing the foot in the position of extreme plantar flexion
with the knee flexed, but in some cases it is advisable to peg the
fragments, either through the skin or after exposing them by
operation.

The #other bones of the tarsus# are rarely fractured separately. The
_tuberosity of the navicular_ is sometimes torn away by violent
traction on the ligaments attached to it.

#Fractures of the metatarsals and phalanges# usually result from
direct violence, such as a crush of the foot, in which the soft parts
are severely damaged. The use of the Röntgen rays has shown, however,
that certain painful conditions in the foot following comparatively
slight injuries, such as kicking a stone, are due to a fracture of one
of the metatarsals or phalanges.

When simple, these injuries are often overlooked, on account of the
difficulty of eliciting the signs of fracture from the swelling which
accompanies them. They are best treated in a moulded splint.

Compound fractures are more common, and are to be treated on the same
principles as govern such injuries elsewhere.

_A fracture of the base of the fifth metatarsal_ has been described by
Sir Robert Jones. It is produced by the patient coming down forcibly
on the lateral edge of the foot while the foot is inverted and the
heel raised--as, for example, in dancing. There is a localised
swelling over the base of the fifth metatarsal, and pain when the
patient puts weight on the foot. There is no crepitus or deformity.
The fracture is readily recognised by the Röntgen rays. Massage and
movement are employed from the first.


DISLOCATIONS IN THE REGION OF THE ANKLE

#Dislocation of the Ankle-Joint.#--In describing dislocation of the
talus from the tibio-fibular socket, the varieties are named according
to the direction in which the foot passes--backward, forward,
medially, laterally, or upward.

All of them may be complete, but they are more frequently incomplete,
and are liable to be rendered compound, either from tearing of the
skin at the time of the injury, or by its sloughing later. Although as
a rule there is little difficulty in effecting reduction by
manipulation, these injuries are liable to be followed by stiffness
and impaired usefulness of the joint.

The _backward_ dislocation is the most common, and results from
extreme plantar flexion of the foot, as from a fall backwards while
the foot is fixed, wedging the talus between the tibia and fibula.
The collateral ligaments are torn, and one or both malleoli may be
broken, or the posterior part of the articular edge of the tibia
chipped off (Fig. 99).

[Illustration: FIG. 99.--Radiogram of Backward Dislocation of Ankle.

(Professor Chiene's case.)]

The foot appears shortened, the heel is unduly prominent behind, and
the lower ends of the tibia and fibula project in front, sometimes
coming through the skin. The tendons around the joint are stretched or
torn.

_Forward_ dislocation results from extreme dorsal flexion at the
ankle-joint. The foot appears lengthened, the heel is less prominent
than normal, and the hollows on each side of the tendo Achillis are
obliterated. The talus is felt in front of the tibia, and the malleoli
appear to be displaced backwards and to lie nearer the sole.

_Medial_ or _lateral_ dislocation is only possible after fracture of
one or both malleoli, and may be looked upon as a complication of
these injuries.

In cases in which the interosseous ligament is ruptured, and in severe
cases of Dupuytren's fracture, the talus may be driven _upwards_
between the bones of the leg. There is great broadening in the region
of the ankle, and the malleoli are unduly prominent under the skin,
which is tightly stretched over them. They are also nearer to the sole
than normally. The movements of the ankle-joint are lost.

Dislocation of the _inferior tibio-fibular joint_ is exceedingly rare,
except in association with fractures of the lower ends of the bones of
the leg, particularly Dupuytren's fracture, or with dislocation of the
ankle-joint proper.

_Treatment of Dislocation of Ankle._--The patient having been
anæsthetised, the foot is extended and the knee and hip joints flexed
to relax the calf muscles as completely as possible. Traction is then
made upon the foot, while counter-extension is applied to the leg, and
the bones are manipulated into position. Reduction usually takes place
gradually without the characteristic snap which accompanies reduction
of most dislocations. It is sometimes necessary to divide the tendo
Achillis, particularly in cases of forward dislocation.

When the talus passes upwards between the tibia and fibula, it is
sometimes impossible to effect reduction by manipulation, and the best
results are then obtained by operation.

The after-treatment consists in keeping the leg on a pillow between
sand-bags, and carrying out the usual massage and movement.

In compound dislocations which have become infected, primary
amputation may be indicated, but in young and healthy subjects an
attempt may be made to save the foot.

#Dislocation of the talus# from its articulations with the bones of
the leg above and the calcaneus and navicular below, is a
comparatively common injury, and results from a violent wrench of the
foot. It may be incomplete or complete. When the foot is plantar
flexed at the moment of injury, the displacement is generally
_forward_ with a tendency outward. The talus comes to rest on the
third cuneiform and cuboid bones, the foot being abducted, inverted,
and displaced medially. In a large proportion of cases the
dislocation is compound, more or less of the talus being forced
through the skin (Fig. 100).

[Illustration: FIG. 100.--Compound Dislocation of the Talus.]

When the foot is dorsiflexed at the moment of injury the displacement
is _backward_, but this is rare, as is also _dislocation to one or
other side_, and _dislocation by rotation_, in which the talus is
rotated in its socket. In all these injuries the body of the talus
loses its normal relationship with the malleoli.

An attempt should be made to reduce the dislocation under anæsthesia,
the limb being placed in the same position as for reduction of
dislocation of the ankle. While traction is made upon the foot, an
assistant presses directly on the displaced bone and endeavours to
manipulate it into position. In incomplete dislocations this usually
succeeds, but it not infrequently fails in those which are complete,
and under these circumstances it may be necessary to chisel through
the lateral malleolus to admit of reduction, or to excise the talus.
In most cases of compound dislocation also, this bone should be
removed.

#Sub-taloid Dislocation.#--In this dislocation, which results from the
same kinds of violence as the last, the talus retains its position in
the tibio-fibular socket, and the calcaneus and navicular, with the
rest of the foot, are carried away from it. The body of the talus,
therefore, maintains its normal relationship with the malleoli--a
point of importance in the differential diagnosis between this injury
and dislocation of the talus. The displacement is usually incomplete,
and the foot may either pass backward and medially, or backward and
laterally. When the foot passes _backward and medially_, the head of
the talus projects on the outer part of the dorsum, resting on the
cuboid. The dorsum of the foot is shortened, the heel lengthened, the
toes adducted, and the medial border of the foot raised. The lateral
malleolus is unduly prominent, and reaches nearly to the sole.

[Illustration: FIG. 101.--Radiogram of Fracture-Dislocation of Talus.]

In the _backward and lateral_ variety, the medial malleolus and head
of the talus project unduly towards the medial side of the foot, which
is abducted and everted.

In neither variety is there any mechanical obstacle to movement at the
ankle-joint.

The _treatment_ is carried out on the same lines as for dislocation of
the talus, reduction being effected without difficulty in most cases.
If this fails, as it occasionally does, it may be necessary to excise
the talus.

#Mid-tarsal or transverse tarsal dislocation#--that is, at the
talo-navicular and calcaneo-cuboid articulations--is extremely rare.
The distal segment of the foot is usually displaced towards the sole;
the foot is foreshortened, the malleoli raised from the sole, the
arch of the foot is lost, and the first row of tarsal bones projects
on the dorsum. The treatment consists in reducing the displacement by
manipulation, after which massage and movement are employed.

#Tarso-metatarsal Dislocations.#--One, several, or all of the
metatarsals may be separated from the distal row of tarsal bones--the
usual cause being a fall from a horse, the foot being fixed in the
stirrup. The bases of the metatarsal bones are displaced laterally and
towards the dorsum. The base of the second metatarsal and the first
cuneiform are sometimes fractured. Reduction by manipulation is
generally easy in dorsal dislocations, but may be difficult when the
bones are displaced laterally. This may be due to fragments of bone or
soft parts getting between the bones, and may necessitate operative
interference. In old-standing dislocations, operation is to be advised
only when locomotion is seriously interfered with.

#Dislocation of the Toes.#--The great toe may be dislocated at its
metatarso-phalangeal joint, the base of the proximal phalanx passing
towards the dorsum (Fig. 102). Diagnosis and reduction are alike easy.

[Illustration: FIG. 102.--Radiogram of Dislocation of Toes.

(Sir Montagu Cotterill's case.)]

#Inter-phalangeal# dislocations are rare and are easily reduced.




CHAPTER IX

DISEASES OF INDIVIDUAL JOINTS


THE SHOULDER-JOINT

The shoulder is seldom the seat of disease, and most affections of the
joint are met with in adults. In young subjects, infective processes
result chiefly from extension of disease from the upper epiphysial
junction of the humerus, which is partly included within the limits of
the synovial cavity. The synovial membrane, in addition to lining the
capsular ligament, is prolonged down the inter-tubercular (bicipital)
groove around the long tendon of the biceps, and pus may escape from
the joint by this diverticulum and gravitate down the arm; we have
also observed loose bodies of synovial origin in this diverticulum.
There is frequently a communication between the joint and the
sub-deltoid bursa. There is no attitude characteristic of disease of
the shoulder-joint, but the girdle is usually elevated, the upper arm
held close to the side and rotated medially, while the elbow is
carried a little backwards. In the later stages, the head of the
humerus may be drawn upwards and medially towards the coracoid
process. Fixation of the shoulder-joint is largely compensated for by
movement of the scapula on the thorax, so that when testing for
rigidity the scapula should be fixed with one hand while passive
movements of the arm are carried out with the other. The deltoid is
usually atrophied, allowing the acromion, coracoid, and great
tuberosity of the humerus to stand out prominently beneath the skin.
Swelling is rarely a prominent feature, except when there is a
collection of synovial fluid or of pus in the bursa beneath the
deltoid.

#Tuberculous Disease# is usually met with in young adults, and is more
common in the right shoulder. The prominent features are pain,
rigidity, and wasting of the deltoid and scapular muscles. The pain is
sometimes severe, shooting down the arm and interfering with sleep,
and it may be associated with tenderness on pressure over the upper
end of the humerus. In cases with carious destruction of the
articular surfaces there are starting pains, and the arm is shortened.
If a cold abscess forms in the bursa underneath the deltoid, the pus
may burrow and appear at the anterior or posterior boundary of the
axilla or in the axillary space. Pus formed in the joint tends to
gravitate along the inter-tubercular groove. The axillary glands may
be infected.

The primary lesion is either a caseating focus in one of the
bones--most often in the upper end of the humerus--or it is of the
nature of caries sicca. The greater part of the head may disappear,
and the upper end of the shaft be drawn against the socket. In
exceptional cases, portions of the glenoid or humerus are found
separated as sequestra, or the disease involves parts outside the
joint, such as the acromion or coracoid process. Hydrops with
melon-seed bodies is rare. In young subjects, destruction of the
tissues at the ossifying junction may result in considerable
shortening of the arm.

The _diagnosis_ is to be made from (1) arthritis deformans, in which
the movements are less restricted, and are attended with grating and
cracking; (2) paralysis involving the deltoid and scapular muscles--by
the absence of pain, and the flail-like character of the movements;
(3) disease in the sub-deltoid bursa--by the absence of rigidity and
other evidence of implication of the articular surfaces; and (4)
sarcoma of the upper end of the humerus--by the history of the case,
the use of the X-rays or an exploratory incision. Injuries in the
region of the upper epiphysis resulting in loss of movement, may, in
the absence of a reliable history, be mistaken for tuberculous
disease.

While the _prognosis_ is favourable on the whole, recovery is usually
attended with fibrous ankylosis and incapacity to raise the arm above
the level of the shoulder. The disease often progresses slowly, and
may last for years.

_Treatment._--The limb should be immobilised in the position of
abduction with the forearm and hand directed forwards; the most
efficient apparatus is a plaster spica embracing the thorax and the
upper limb down as far as the wrist. If the articular surfaces are
affected and the disease is likely to lead to ankylosis, the arm
should be abducted to a right angle. The severe pain of caries sicca
may be relieved by blistering or by the application of the cautery. To
inject iodoform, the needle is introduced either immediately outside
the coracoid process, or just below the junction of the acromion
process and spine of the scapula. When the disease does not yield to
conservative measures, or the X-rays show a gross lesion in the bone,
excision of the joint should be performed; a close fibrous ankylosis
usually results, and the arm is quite a useful one provided the
abducted position has been maintained throughout.

#Pyogenic Diseases.#--The shoulder-joint may be infected by extension
of suppurative osteomyelitis from the upper end of the humerus, or
from suppuration in the axilla, or through the blood stream by
ordinary pus organisms, pneumococci, typhoid bacilli, or gonococci.
Extension should be applied to the arm abducted at a right angle. When
it is necessary to open the joint, the incision should be placed
anteriorly in the line of the inter-tubercular groove; if a
counter-opening is required it is made on the posterior aspect by
cutting on the point of a dressing forceps introduced through the
anterior incision.

#Arthritis Deformans.#--The shoulder is seldom affected alone, except
when the arthritis is a sequel to injury, such as a fracture of the
neck of the humerus. The common type of lesion is a dry arthritis with
fibrillation and eburnation of the articular surfaces. The long tendon
of the biceps is usually destroyed, the head of the bone is drawn
upwards, and, after wearing through the capsule, rubs on the under
surface of the acromion, which also becomes eburnated. The clinical
features are pain, stiffness, and cracking on movement, and as these
symptoms may also be caused by loose bodies in the joint, an X-ray
picture should be taken to differentiate between them.

#Neuro-arthropathies# of the shoulder are met with chiefly in
syringomyelia. In some cases there is a large fluctuating and
painless swelling; in others marked and rapid wasting of the deltoid
and scapular muscles with flail-like movements of the joint associated
with disappearance of the upper end of the humerus (Fig. 104).

[Illustration: FIG. 103.--Arthropathy of Shoulder in Syringomyelia.
The upper end of the humerus has disappeared and the movements are
flail-like (cf. Fig. 104).]

[Illustration: FIG. 104.--Radiogram of specimen of Arthropathy of
Shoulder in Syringomyelia. The head of the humerus has disappeared and
masses of new bone have formed in the surrounding muscles (cf. Fig.
103).]

#Loose bodies# are rare in the shoulder; we have met with a case in
which the joint-cavity was distended with loose bodies of synovial
origin, and as most of these had undergone ossification, the X-ray
appearances were highly characteristic. They were removed through an
anterior incision.

#Ankylosis# is not so disabling at the shoulder as at other joints, as
the mobility of the scapula on the chest wall largely compensates for
the fixation of the joint.


THE ELBOW-JOINT

In disease of the elbow, the usual attitude is that of flexion with
pronation of the hand. Swelling of the joint, whether from effusion of
fluid or from thickening of the synovial membrane, is observed chiefly
on the posterior aspect, above and on either side of the olecranon,
because the synovial sac is here nearest the surface. The free
communication between the elbow and the superior radio-ulnar joint
should be borne in mind.

[Illustration: FIG. 105.--Radiogram showing Multiple partially
ossified Cartilaginous Loose Bodies in Shoulder-joint. The lowest one
is in the synovial prolongation along the tendon of the biceps.]

#Tuberculous disease# is the most common and important affection (Fig.
106). It usually occurs in patients under twenty, but may be met with
at any age; in children the age-incidence is earlier than in the other
large joints, a considerable proportion being met with in the first
two years of life (Stiles). When the disease is confined to the
synovial membrane, its onset is insidious, there is little or no pain,
and no interference with any movement except complete extension. The
chief evidence of disease is a white swelling on either side of and
above the olecranon, obscuring the bony landmarks. The further
progress is attended with wasting of the triceps, symptoms of
involvement of the articular surfaces, and with abscess formation.

[Illustration: FIG. 106.--Diffuse Tuberculous Thickening of Synovial
Membrane of Elbow (white swelling) in a boy æt. 12.]

The occurrence of articular caries without swelling of the synovial
membrane is exceptional, and is associated with a good deal of pain
and considerable restriction of movement. Rigidity from muscular
contraction occurs late, and is rarely complete. Tuberculous foci in
the bones are met with chiefly in the lower end of the diaphysis of
the humerus; in children, the epiphyses are so small that the
ossifying junction is intra-articular. Foci are also met with in the
upper end of the ulna. The grosser osseous lesions cause enlargement
of the bone, and are readily demonstrated by skiagraphy. Abscess
formation most commonly occurs beneath the triceps, and the abscess
points at one or other edge of that muscle. A subcutaneous abscess
may form over the upper end of the ulna or over the radio-humeral
joint. Tuberculous hydrops with melon-seed bodies is rare.

[Illustration: FIG. 107.--Contracture of Elbow and Wrist following a
burn in childhood. Treated by resection of both joints, and the
insertion, on the palmar aspect of each, of a flap from the abdominal
wall.]

_Treatment._--Conservative measures are persevered with so long as
there is a prospect of securing a movable joint. The limb is placed in
a light form of splint reaching from the axilla to the wrist, flexed
to rather less than a right angle and with the hand semi-pronated and
dorsiflexed. To inject iodoform or other anti-tuberculous agent, the
needle of the syringe is easily introduced between the lateral condyle
and the head of the radius. A localised focus of disease in one or
other of the bones may be eradicated without opening into the synovial
cavity.

If the articular surfaces are so involved that recovery is likely to
be attended with ankylosis, the disease should be removed by
operation, and cure with a useful and movable joint may then be
reasonably anticipated within two or three months. When the patient's
occupation is such that a strong stiff joint is preferable to a weaker
movable one, bony ankylosis at rather less than a right angle should
be aimed at.

#Arthritis deformans# occurs as a hydrops with hypertrophy of the
synovial fringes and loose bodies, or as a dry arthritis with
eburnation and lipping of the articular margins.

#Neuro-arthropathies# are met with chiefly in syringomyelia, and are
attended with striking alterations in the shape of the bones and with
abnormal mobility.

#Pyogenic diseases# result from staphylococcal osteomyelitis--chiefly
of the humerus or ulna--and from gonorrhœa.

The remaining diseases at the elbow include syphilitic disease in
young children, bleeder's joint, hysterical affections, and loose
bodies, and do not call for special description.

#Ankylosis# of the elbow-joint, if interfering with the livelihood of
the patient, may be got rid of by resecting the articular ends of
the bones, or by inserting between them a flap of fascia and
subcutaneous fat derived from the posterior aspect of the upper
arm--_arthroplasty_.


THE WRIST-JOINT

The close proximity of the flexor sheaths to the carpal articulations
permits of infective processes spreading readily from one to the
other. The arrangement of the synovial membranes also favours the
extension of disease throughout the numerous articulations in the
region of the wrist.

#Tuberculous disease# is met with chiefly in young adults, but may
occur at any age. It usually originates in the synovial membrane, but
foci are frequently present in the carpal bones, and less commonly in
the lower ends of the radius and ulna, or in the bases of the
metacarpals. The clinical features are almost invariably those of
white swelling, which is most marked on the dorsum where it obscures
the bony prominences and the outlines of the extensor tendons. Wasting
of the thenar and hypothenar eminences, and filling up of the hollows
above and below the anterior annular ligament, render the appearance
on the palmar aspect characteristic.

The attitude is one of slight flexion with drooping of the hand and
fingers. The fingers become stiff as a result of adhesions in the
tendon sheaths, and the power of opposing the thumb and fingers may be
lost. Pain is usually absent until the articular surfaces become
carious. Softening of the ligaments may permit of lateral mobility,
and sometimes partial dislocation occurs. Abscess may be followed by
sinuses and infection of the tendon sheaths, especially those in the
palm.

The localisation of disease in individual bones or joints can be
determined by the use of the X-rays.

_Treatment._--Conservative measures may be persevered with over a
longer period than in most other joints. The forearm, wrist, and
metacarpus are immobilised in the attitude of dorsal flexion, while
the fingers and thumb are left free to allow of passive movements. It
may be necessary to give an anæsthetic to obtain the necessary degree
of dorsiflexion. To inject iodoform, the needle is inserted
immediately below the radial or the ulnar styloid process. Sometimes
the carpal bones are so soft that the needle can be made to penetrate
them in different directions. Operative treatment is indicated in
cases which resist conservative measures, or when the general health
calls for speedy removal of the disease.

_Other diseases of the wrist_ are comparatively rare. They include
pyogenic affections, such as those resulting from infective conditions
in the palm of the hand, different types of gonorrhœal, rheumatic, and
gouty affections, and arthritis deformans. An interesting feature,
sometimes met with in arthritis deformans, consists in eburnation of
the articular surfaces of the carpal bones, although the range of
movement is almost nil.


THE HIP-JOINT

Owing to the depth of this joint from the surface, it is not possible
to detect the presence of effusion or of synovial thickening as
readily as in other joints, hence in the recognition of hip disease we
have to rely largely upon indirect evidence, such as a limp in
walking, an alteration in the attitude of the limb, or restriction of
its movements.

The whole of the anterior and fully one-half of the posterior aspect
of the neck of the femur is covered by synovial membrane, so that
lesions not only of the epiphysis and epiphysial junction, but also of
the neck of the bone, are capable of spreading directly to the
synovial membrane and to the cavity of the joint. Conversely, disease
in the synovial membrane may spread to the bone in relation to it.
Infective material may escape from the joint into the surrounding
tissues through any weak point in the capsule, particularly through
the bursa which intervenes between the capsule and the ilio-psoas, and
which in one out of every ten subjects communicates with the joint.


TUBERCULOUS DISEASE

Tuberculous disease of the hip, morbus coxæ, or "hip-joint disease,"
is especially common in the poorer classes. It is a frequent cause of
prolonged invalidism, and of permanent deformity, and is attended with
a considerable mortality. It is essentially a disease of early life,
rarely commencing after puberty, and almost never after maturity.

#Pathological Anatomy.#--Bone lesions bulk more largely in hip disease
than they do in disease of other joints--five cases originating in
bone to one in synovial membrane being the usual estimate. The upper
end of the femur and the acetabulum are affected with about equal
frequency.

In addition to primary tuberculous lesions, secondary changes result
from the inflamed and softened bones pressing against one another
subsequent to the destruction of their articular cartilages. The head
of the femur undergoes absorption from above downwards, becoming
flattened and truncated, or disappearing altogether. In the acetabulum
the absorption takes place in an upward and backward direction,
whereby the socket becomes enlarged and elongated towards the dorsum
ilii. To this progressive enlargement of the socket Volkmann gave the
suggestive name of "wandering acetabulum" (Fig. 108). The
displacement of the femur resulting from these secondary changes is
one of the causes of real shortening of the limb.

[Illustration: FIG. 108.--Advanced Tuberculous Disease of Acetabulum
with caries and perforation into pelvis.

(Anatomical Museum, University of Edinburgh.)]

#Clinical Features.#--It is customary to describe three stages in the
progress of hip disease, but this is arbitrary and only adopted for
convenience of description.

_Initial Stage._--At this stage the disease is confined to a focus in
the bone which has not yet opened into the joint or to the synovial
membrane. The onset is insidious, and if injury is alleged as an
exciting cause, some weeks have usually elapsed between the receipt of
the injury and the onset of symptoms. The child is brought for advice
because he has begun to limp and to complain of pain. There is a
history that he has become pale and has ceased to take food well, that
his sleep has been disturbed, and that the pain and the limp, after
coming and going for a time, have become more pronounced. On walking,
the affected limb is dragged in such a way as to avoid movement at the
hip, and to substitute for it movement at the lumbo-sacral junction.
The child throws the weight of the trunk as little as possible on to
the affected limb, and inclines to rest on the balls of the toes
rather than on the sole. There is usually some wasting of the muscles
of the thigh and flattening of the buttock. Diminution or loss of the
gluteal fold indicates flexion at the hip which might otherwise escape
notice. Pain is complained of in the hip, or is referred to the medial
side of the knee, in the distribution of the obturator nerve.
Sometimes the pain is confined to the knee, and if the examination is
restricted to that joint the disease at the hip may be overlooked. At
this stage the attitude of the limb is not constant; at one time it
may be natural, and at another slightly flexed and abducted.
Tenderness of the joint may be elicited by pressing either in front or
behind the head of the bone, but is of little diagnostic importance.
Pain elicited on driving the head against the acetabulum may
occasionally assist in the recognition of hip disease, but the
diagnostic value of this sign has been overrated and, in our opinion,
this test should be omitted.

Most information is gained by testing the functions of the joint, and
if this is done gently and without jerking, it does not cause pain.
The child should lie on his back, either on his nurse's knee or on a
table; and to reassure him the movements should be first practised on
the sound limb. On slowly flexing the thigh of the affected limb, it
will be found that the range of flexion at the hip is soon exhausted,
and that any further movement in this direction takes place at the
lumbo-sacral junction. The child is next made to lie on his face with
the knees flexed in order that the movements of rotation may be
tested. The thigh is rotated in both directions, and on comparing the
two sides it will be found that rotation is restricted or abolished on
the side affected, any apparent rotation taking place at the
lumbo-sacral junction. These tests reveal the presence of _rigidity_
resulting from the involuntary contraction of muscles, which is the
most reliable sign of hip disease during the initial stage, and they
possess the advantage of being universally applicable, even in the
case of young children.

_Second Stage._--This probably corresponds with commencing disease of
the articular surfaces, and progressive involvement of all the
structures of the joint. The child complains more, and usually
exhibits the attitude of abduction, eversion, and flexion (Fig. 109).

[Illustration: FIG. 109.--Early Tuberculous Disease of Right Hip-joint
in a boy æt. 14, showing flexion, abduction, and apparent lengthening
of the limb.]

At first the attitude is maintained entirely by the action of muscles;
but when it is prolonged, the muscles, fasciæ, and ligaments undergo
shortening, so that it becomes fixed.

On looking at the patient, the abnormal attitude may not be at once
evident, as he usually restores the parallelism of the limbs by
lowering the pelvis on the affected side and adducting the sound limb.
This obliquity or tilting of the pelvis causes _apparent lengthening_
of the diseased limb, and is best demonstrated by drawing one straight
line between the anterior iliac spines, and another to meet it from
the xiphoid cartilage through the umbilicus; if the pelvis is in its
normal position, the two lines intersect at right angles; if it is
tilted, the angles at the point of intersection are unequal. The
flexion may be largely compensated for by increasing the forward curve
of the lumbar spine (lordosis), and by flexing the leg at the knee.
There may also be an attempt to compensate for the eversion of the
limb by rotating the pelvis forwards on the affected side.

[Illustration: FIG. 110.--Disease of Left Hip: position of ease
assumed by patient, showing moderate flexion and lordosis.]

[Illustration: FIG. 111.--Disease of Left Hip: disappearance of
lordosis on further flexion of the hip.]

To demonstrate the lordosis, the patient should be laid on a flat
table; in the resting position the lordosis is moderate, when the hip
is flexed it disappears, when it is extended the lordosis is
exaggerated, and the hand or closed fist may be inserted between the
spine and the table (Fig. 112).

[Illustration: FIG. 112.--Disease of Left Hip: exaggeration of
lordosis produced by extending the limb.]

When the functions of the joint are tested, it will be found that
there is rigidity, and that both active and passive movements take
place at the lumbo-sacral junction instead of at the hip. While
rigidity is usually absolute as regards rotation, it may sometimes be
possible with care and gentleness to obtain some increase of flexion.
For diagnostic purposes most stress should therefore be laid on the
presence or absence of rotation.

If the sound limb is flexed at the hip and knee until the lumbar spine
is in contact with the table, the real flexion of the diseased hip
becomes manifest, and may be roughly measured by observing the angle
between the thigh and the table (Fig. 113). This is known as "Thomas'
flexion test," and is founded upon the inability to extend the
diseased hip without producing lordosis.

[Illustration: FIG. 113.--Thomas' Flexion Test, showing angle of
flexion at diseased (left) hip.]

_Swelling_ is seen on the anterior aspect of the joint; it may fill up
the fold of the groin and push forward the femoral vessels. It is
doughy and elastic, but may at any time liquefy and form a cold
abscess. Swelling about the trochanter and neck of the bone may be
estimated by measuring the antero-posterior diameter with callipers,
and comparing with the sound side. Swelling on the pelvic aspect of
the acetabulum can sometimes be discovered on rectal examination.

_Third Stage._--This probably corresponds with caries of the articular
surfaces, since pain is now a prominent feature, and there are usually
startings at night. The attitude is one of adduction, inversion,
flexion, and apparent or real shortening of the limb (Fig. 114). The
_flexion_ is usually so pronounced that it can no longer be concealed
by lordosis, so that when the patient is recumbent, although the spine
is arched forwards, the limb is still flexed both at the hip and at
the knee; with the spine flat on the table, the flexion of the thigh
may amount to as much as a right angle. The _adduction_ varies greatly
in degree; when it is slight, as is most often the case, the toes of
the affected limb rest on the dorsum of the sound foot. When moderate,
it is compensated for by raising the pelvis on the affected side, with
_apparent shortening_ of the limb, this being the result of an effort
on the part of the patient to restore the normal parallelism of the
limbs, the sound limb being abducted to the same extent as the
affected limb is adducted. It is important to recognise the cause of
this shortening, as it can be corrected by treatment. As a result of
the obliquity of the pelvis, the patient, when erect, exhibits a
lateral curvature of the spine with the dorso-lumbar convexity to the
sound side.

[Illustration: FIG. 114.--Tuberculous Disease of Left Hip: third
stage, showing adduction and shortening.]

When adduction is pronounced, the patient is unable to restore the
normal parallelism of the limbs, and the knee on the affected side may
cross the sound limb. There is a deep groove at the junction of the
perineum and thigh, great prominence of the trochanter, and the pelvis
may be tilted to such an extent that the iliac crest comes into
contact with the lower ribs.

As a result of the pressure of the carious articular surfaces against
one another, the acetabulum is enlarged and the upper end of the femur
is drawn gradually upwards and backwards within the socket.
Examination will then reveal the existence of a variable amount of
_actual shortening_; it will also be found that the trochanter is
displaced above Nélaton's line, while above and behind the trochanter
there is a prominent hard swelling corresponding to the enlarged
acetabulum.

There may, therefore, be a combination of real and apparent shortening
together amounting to several inches (Fig. 115).

[Illustration: FIG. 115.--Advanced Tuberculous Disease of Left
Hip-joint in a girl æt. 14, showing flexion, adduction, shortening,
and iliac abscess.]

In cases of long standing, beginning in childhood, the shortening is
still further added to by deficient growth in length of the femur, and
it may be of all the bones of the limb; even the foot is smaller on
the affected side.

The most reasonable explanation of the attitudes assumed in hip
disease is that given by König. If the patient walks without crutches,
as he is usually able to do at an early stage of the disease, the
attitude of abduction, eversion, and slight flexion enables him to
save the limb to the utmost extent; on the other hand, if he uses a
crutch, as he is obliged to do at a more advanced stage, he no longer
uses the limb for support, and therefore draws it upwards and medially
into the position of adduction, inversion, and greater flexion.
Similarly, if he is confined to bed, he lies on the sound side, and
the affected limb sinks by gravity so as to lie over the normal one in
the position of adduction, inversion, and flexion. König's explanation
accords with the fact that in the exceptional cases which begin with
adduction and inversion we have usually to deal with a severe type of
the disease, associated with grave osseous lesions--precisely those
cases in which the patient is compelled from the outset to lie up or
to adopt the use of crutches. Further, the transition from the
abducted to the adducted position usually follows upon such an
aggravation of the symptoms that the patient is no longer able to walk
without the assistance of a crutch.

During the third stage the other signs and symptoms become more
pronounced; the patient looks ill and thin, he is usually unable to
leave his bed, his sleep is disturbed by startings of the limb, and
the rigidity of the joint and the wasting of the muscles are well
marked. The temperature may rise slightly after examination of the
limb, or after a railway journey.

#Abscess Formation in Hip Disease.#--The formation of abscess is not
related to any stage of the disease; it may occur before there is
deformity, and it may be deferred until the disease is apparently
cured. Its importance lies in the fact that if a mixed infection with
pyogenic organisms occurs, the gravity of the condition is greatly
increased.

An abscess may appear _in the thigh_ in front or behind the joint. The
_anterior abscess_ emerges on one or other side of the psoas muscle;
from the resistance offered by the fascia lata, the pus may gravitate
down the thigh before perforating the fascia. It has occasionally
happened that when such an abscess has been opened and become infected
with pyogenic organisms, the femoral vessels have been eroded, and
serious or even fatal hæmorrhage has resulted. The _posterior abscess_
appears in the buttock and may make its way to the surface through the
gluteus maximus; more often it points at the lower border of this
muscle in the region of the great trochanter, or it may gravitate down
the thigh.

Abscesses which form _within the pelvis_ originate either in
connection with the acetabulum or in relation to the psoas muscle
where it passes in front of the joint. Those that are directly
connected with disease of the acetabulum may remain localised to the
lateral wall of the pelvis, or may spread backwards towards the hollow
of the sacrum. They may open into the bladder or rectum, or may ascend
into the iliac fossa and point above Poupart's ligament (Fig. 115), or
descend towards the ischio-rectal fossa. The abscess which develops in
relation to the psoas muscle may be shaped like an hour-glass, one sac
occupying the iliac fossa, the other filling up Scarpa's triangle, the
two sacs communicating with each other through a narrow neck beneath
Poupart's ligament.

So long as the skin is intact, the abscess is unattended with
symptoms, and may escape notice. If it bursts externally, pyogenic
infection is almost inevitable, and the patient gradually passes into
the condition of hectic fever or chronic toxæmia; he loses ground from
day to day, may become the subject of waxy disease in the viscera, or
may die of exhaustion, tuberculous meningitis, or general
tuberculosis.

#Dislocation# is a rare complication of hip disease, and is most
likely to occur during the stage of adduction with inversion. It has
been known to take place during sleep, apparently from spasmodic
contraction of muscles. In the dorsal dislocation, which is the most
common form, adduction and inversion are exaggerated, the trochanter
projects above and behind Nélaton's line, and the head of the bone may
be felt on the dorsum ilii. It is a striking fact that after
dislocation has occurred there is less complaint of pain or of
startings than before, and passive movements may be carried out which
were previously impossible.

#Diagnosis of Hip Disease.#--The diagnosis is to be made not only from
other affections of the joint, but also from morbid conditions in the
vicinity of the hip, as in any of these the patient may seek advice on
account of pain and a limp in walking. The patient should be stripped,
and if able to walk, his gait should be observed. He is then examined
lying on his back, and attention is directed to the comparative length
of the limbs, to the attitude of the limbs and pelvis, and to the
movements at the hip-joint, especially those of rotation. When there
is any doubt as to the diagnosis, the examination should be repeated
at intervals of a few days. In children, there are three non-febrile
conditions attended with a limp and with shortening of the limb, which
may be mistaken for hip disease,--_congenital dislocation_, _coxa
vara_, and _paralysis following poliomyelitis_--but in all of these
the movements are not nearly so restricted as they are in disease of
the joint.

In tuberculous disease of the _sacro-iliac joint_, while the pelvis
may be tilted, and the limb apparently lengthened, the movements at
the hip are retained. In tuberculous disease of the _great
trochanter_, or of either of the _bursæ_ over it, while there may be
abduction, eversion, impairment of mobility, and swelling in the
region of the trochanter followed by abscess formation, the movements
are less restricted than in disease of the joint.

In _psoas abscess_ associated with spinal disease, or in _disease of
the bursa underneath the psoas_, the limb is flexed and everted, there
may be lordosis, and the patient may limp in walking, but the
movements at the hip are restricted only in the directions of
extension and inversion, while in hip disease they are restricted in
all directions.

_New-growths_ in the vicinity of the hip--especially central sarcoma
of the upper end of the femur--are difficult to differentiate from hip
disease without the help of the X-rays.

Among other conditions which by interfering with the free mobility of
the hip may simulate hip disease, are appendicitis, inflammation of
the glands in the groin, staphylococcal disease of the upper end of
the femur, and sciatica.

The diagnosis _from other diseases of the hip-joint_ is made by
careful consideration of the history, symptoms, and X-ray appearances.

#Prognosis.#--The prognosis in hip disease is more serious than in
tuberculosis of other joints, excepting only those of the spine, and
it is most unfavourable when there are gross lesions of the bones and
infected sinuses.

Whatever the stage of the disease, recovery is a slow process, and
even in early and mild cases it seldom takes place in less than one or
two years, and is liable to be attended with some impairment of
function. During the process of cure, complications are liable to
occur, and after apparent recovery relapses are not uncommon. When
arrested during the initial stage, recovery may be complete; but when
there has been destruction of the articular surfaces, there is apt to
be ankylosis of the joint and shortening of the limb.

In cases which terminate fatally, death usually results from
meningeal, pulmonary, or general tuberculosis, or from pyogenic
complications and waxy degeneration.

#Treatment.#--A large proportion of cases recover under conservative
treatment, and the functional results are so much better than those
following operative interference that unless there are special
indications to the contrary, conservative measures should always be
adopted in the first instance.

_Conservative Treatment._--The first essential is to take the weight
off the limb and secure its fixation in the attitude of almost
complete extension and moderate abduction. When the symptoms are well
marked, the child is kept in bed and the limb is extended with a
weight and pulley.

_Extension by Weight and Pulley_ (Fig. 116).--The weight employed
varies from one to four pounds in children, to ten or more pounds in
adolescents and adults, and must be adjusted to meet the requirements
of each case. If pain returns after having been relieved, it is due to
stretching of the ligaments, and the weight should be diminished or
removed for a time. If there is deformity, the line of traction should
be in the axis of the displaced limb until the deformity is got rid
of. The extension should be continued until pain, tenderness, and
muscular contraction have disappeared, and the limb has been brought
into the desired attitude.

[Illustration: FIG. 116.--Extension by adhesive plaster and Weight and
Pulley.]

In restless children, in addition to the extension, a long splint is
applied on the sound side and a sand-bag on the affected one; or,
better still, a double long splint and cross-bar, the long splint on
the affected side being furnished with a hinge opposite the hip to
permit of varying the degree of abduction (Fig. 117).

[Illustration: FIG. 117.--Stiles' Double Long Splint to admit of
abduction of diseased limb.]

When the deformed attitude does not yield rapidly to extension, it
should be corrected under an anæsthetic, and if the adductor tendons
and fasciæ are so contracted that this is difficult, they should be
forcibly stretched or divided.

The immediate correction of deformed attitudes under anæsthesia has
largely replaced the more gradual method by extension with weight and
pulley; and in hospital practice it is usually followed by the
application of a plaster case. The plaster bandages are applied over a
pair of knitted drawers; the pelvis and both thighs, the diseased one
in the abducted position, are included. The case may be strengthened
by strips of aluminium, and should be renewed every six weeks or two
months.

_Ambulant Treatment._--When the patient is able to use crutches, the
affected limb is prevented from touching the ground by fixing a patten
on the sole of the boot on the sound side. This may suffice, or, in
addition, the hip-joint is kept rigid by a Thomas' (Fig. 118) or a
Taylor's splint. The Thomas' splint must be fitted to the patient
under the supervision of the surgeon, who must make himself familiar
with the construction of the splint, and its alteration by means of
wrenches.

[Illustration: FIG. 118.--Thomas' Hip Splint applied for disease of
Right Hip. Note patten under sound foot. The foot on the affected side
is too near the ground.]

In children who are unable to use crutches, a double Thomas' splint is
employed; the child thereby is converted into a rigid object, capable
of being carried from one room to another and into the open air.
Personally we have obtained satisfaction from the double Thomas'
splint employed for spinal disease, which extends from the occiput to
the soles of the feet.

The fixation of the hip-joint and the taking of the weight off the
limb by one or other of the above methods, should, as a general rule,
be continued for at least a year.

Should an abscess develop, it is treated on the usual lines.

_Operative Interference._--Widely diverse opinions are held on the
question as to whether or not recourse should be had to operative
interference.

Some surgeons are opposed to operative interference, on the grounds
that however advanced the disease may be it will yield to conservative
measures if judiciously and perseveringly carried out. Other surgeons
advocate operative treatment in all cases which do not speedily show
improvement under conservative treatment. An intermediate attitude may
be adopted which recommends operation in cases in which the disease
progresses in spite of conservative treatment, and in which periodic
examination with the X-rays shows that there are progressive lesions
in the upper end of the femur or in the acetabulum.

It is claimed by those who advocate operation under these conditions
that pain and suffering are at once got rid of, sleep is restored,
appetite returns, and there is a marked improvement in the general
health, and that this result is obtained in months instead of years,
and that the cure is more likely to be permanent. It is certainly
unwise to delay operation until sinuses have formed, as such a course
is largely responsible for the bad results which formerly followed
excision of the joint.

_Amputation_ for tuberculous disease of the hip has become one of the
rarest of operations, but is still required in cases which have
continued to progress after excision, and when there is disease of the
pelvis or of the shaft of the femur, with sinuses, albuminuria, and
hectic fever.

#The Correction of Deformity resulting from Antecedent Disease of the
Hip.#--From neglect or from improper treatment, deformity may have
been allowed to persist, while the disease has undergone cure. It is
associated with ankylosis of the joint, or contracture of the soft
parts or both. The contracture of the soft parts involves specially
the tendons, fasciæ, and ligaments on the anterior and medial aspects
of the joint, and is usually present to such a degree that, even if
the joint were rendered mobile, these shortened structures would
prevent correction of the deformity. The usual deformity is a
combination of shortening, flexion, and adduction.

#Bilateral Hip Disease.#--Both hip-joints may become affected with
tuberculous disease, either simultaneously or successively, and
abscesses may form on both sides. The patient is necessarily confined
to bed, and if the disease is recovered from, his capacity for walking
may be seriously impaired, especially if the joints become fixed in an
undesirable attitude. The most striking deformity occurs when both
limbs are adducted so that they cross each other--one variety of the
"scissor-leg" or "crossed-leg" deformity--in which the patient, if
able to walk at all, does so by forward movements from the knees. An
attempt should be made by arthroplasty to secure a movable joint at
least on one side.


OTHER DISEASES OF THE HIP-JOINT

#Pyogenic Diseases# are met with in childhood and youth as a result of
infection with the common pyogenic organisms, gonococci, pneumococci,
or typhoid bacilli. While the organisms usually gain access to the
tissues of the joint through the blood stream, a direct infection is
occasionally observed from suppuration in the femoral lymph glands or
in the bursa under the ilio-psoas.

The _clinical features_ are sometimes remarkably latent and are much
less striking than might be expected, especially when the hip
affection occurs as a complication of an acute illness such as scarlet
fever. It may even be entirely overlooked during the active stage, and
only noticed when the head of the femur is found dislocated, or the
joint ankylosed. In the acute arthritis of infants also, the clinical
features may be comparatively mild, but as a rule they assume a type
in which the suppurative element predominates. The limb usually
becomes flexed and adducted, and a swelling forms in front of the
joint at the upper part of Scarpa's triangle; the upper femoral
epiphysis may be separated and furnish a sequestrum.

The flexion and adduction of the limb favour the occurrence of
dislocation. A child who has recovered with dislocation on to the
dorsum ilii is usually able to walk and run about, but with a limp or
waddle which becomes more pronounced as he grows up. The condition
closely resembles a congenital dislocation, but the history, and the
presence of gross alterations in the upper end of the femur as seen
with the X-rays, should usually suffice to differentiate them.

_Treatment._--In the acute stage the limb is extended by means of the
weight and pulley, and kept at rest with the single or double long
splint, or by sand-bags. If there is suppuration, the joint should be
aspirated or opened by an anterior incision, and Murphy's plan of
filling the joint with formalin-glycerine may be adopted. In children,
it is remarkable how completely the joint may recover.

If there is dislocation, the head of the femur should be reduced by
manipulation with or without preliminary extension; it has been
successful in about one-half of the cases in which it has been
attempted. Preliminary tenotomy of the shortened tendons is required
in some cases. When reduction by manipulation is impossible, the joint
structures should be exposed by operation and the head of the bone
replaced in the acetabulum. When the upper end of the femur has
disappeared, the neck should be implanted in the acetabulum, and the
limb placed in the abducted position.

#Arthritis Deformans.#--This disease is comparatively common at the
hip, either as a mon-articular affection or simultaneously with other
joints.

[Illustration: FIG. 119.--Arthritis Deformans, showing erosion of
cartilage and lipping of articular edge of head of femur.]

_The changes in the joint_ are characteristic of the dry form of the
disease, and affect chiefly the cartilage and bone. The atrophy and
wearing away of the articular surfaces are accompanied by new
formation of cartilage and bone around their margins. The head of the
femur may acquire the shape of a helmet, a mushroom, or a limpet
shell, and from absorption of the neck the head may come to be sessile
at the base of the neck, and to occupy a level considerably below that
of the great trochanter (Fig. 120). These changes sometimes extend to
the upper part of the shaft, and result in curving of the shaft and
neck, suggesting a resemblance to a point of interrogation (Fig. 121).
The acetabulum may "wander" backwards and upwards, as in tuberculous
disease. It is usually deepened, and its floor projects on the pelvic
aspect; its margins may form a projecting collar which overhangs the
neck of the femur, or grasps it, so that even in the macerated
condition the head is imprisoned in the socket and the joint locked.
There is eburnation of the articular surfaces in those areas most
exposed to friction and pressure.

[Illustration: FIG. 120.--Upper End of Femur in advanced Arthritis
Deformans of Hip. The shaft is curved and the head of the bone is at a
lower level than the great trochanter.]

[Illustration: FIG. 121.--Femur in advanced Arthritis Deformans of Hip
and Knee Joints. The upper end of the bone shows the condition of coxa
vara; the lower end shows enlargement of the medial condyle and
alteration in the axis of the articular surface.]

These changes are necessarily associated with restriction of movement,
and in advanced cases with striking deformity, which consists in
shortening of the limb, usually with eversion and displacement of the
trochanter upwards and backwards in relation to Nélaton's line.

The _clinical features_ are usually so characteristic that there is
little difficulty in diagnosis. Restriction of the movements of
abduction and adduction, the presence of cracking and of grating of
the articular surfaces, and the aggravation of the pain and stiffness
after resting the limb, are characteristic of arthritis deformans. The
prominence of sciatic pain may lead to the disease being regarded as
sciatica.

The greatest difficulty is met with in cases in which the disease
occurs as mon-articular affection in adolescents, for the resemblance
to tuberculous disease of the hip and to coxa vara may be close.
Skiagrams do not always enable one to differentiate between them.

_Treatment_ is conducted on the same lines as in other joints. The
normal movements are maintained by suitable exercises, and an effort
is made to diminish the pressure on the articular surfaces in walking
by the use of sticks or crutches.

Shortening of the limb may be compensated by raising the sole of the
boot. When the X-rays show that the disability is mainly due to new
bone locking the head of the femur, such new bone may be removed by
operation, _cheilotomy_ (Sampson Handley). Excision of the joint has
in some cases yielded satisfactory results; it is indicated in young
patients who are otherwise healthy, and who are unable to walk on
account of pain and deformity.

#Osteo-chondritis Deformans Juvenilis.#--Under this term Perthes
describes an affection of the hip in children which differs in many
respects from the juvenile form of arthritis deformans. Islands of
cartilage appear in the epiphysis of the head of the femur, and the
epiphysis itself becomes flattened without involvement of the
articular surface or of the acetabulum.

The disease is met with in children between five and ten; there is a
limp in walking without pain or sensitiveness, so that the child
continues to take part in games. Abduction is markedly restricted and
the trochanter is elevated and prominent. There is no crepitation on
movement or other signs of involvement of the articular surfaces. The
X-rays show the deformity of the head and clear areas in the interior
of the upper epiphysis corresponding to the islands of cartilage;
these clear areas resemble those due to caseous foci in tuberculous
coxitis.

The disease runs a chronic course, and in the course of a year or two
the limp and the restriction of abduction disappear, so that no active
treatment is called for.

#Neuro-Arthropathies.#--_Charcot's disease_ is usually met with in men
over thirty who suffer from tabes dorsalis. One or both hip-joints may
be affected. Sometimes the first manifestation is a hydrops and a
fluctuating swelling in the upper part of Scarpa's triangle. In many
of the recorded cases, however, attention has first been directed to
the disease by the deformity and limp associated with disappearance of
the head of the femur, or by the occurrence of pathological
dislocation. The absence of pain and tenderness is characteristic.
When dislocation has occurred, the limb is short, and the upper end of
the femur is freely movable on the dorsum ilii. When both hips are
dislocated, the attitude and gait are similar to those observed in
bilateral congenital dislocation. The rotation arc of the great
trochanter may be much reduced as a result of the disappearance of the
head of the femur. There may be considerable formation of new bone,
giving rise to large tumour-like masses in relation to the capsular
ligament and the muscles surrounding the joint.

The _treatment_ consists in protecting and supporting the joint. When
the affection is unilateral, advantage may be derived from a Thomas'
or other form of splint, along with a patten and crutches; in
bilateral cases, from the use of crutches alone.

_Loose bodies in the hip_ are mostly the result of hypertrophy of
synovial fringes in arthritis deformans and in Charcot's disease, and
do not figure in the clinical features of these affections; Caird has
observed a case in which the cavity of the joint and the bursa beneath
the psoas were filled with loose bodies, many of which had undergone
ossification and gave a characteristic picture with the X-rays.

_Hysterical affections_ of the hip resemble those in other joints.


THE KNEE-JOINT

The knee is more often the seat of disease than any other joint in the
body.

The synovial membrane extends beneath the quadriceps extensor as a
cul-de-sac, which either communicates with the sub-crural bursa, or
forms with it one continuous cavity. When the joint is distended with
fluid, this upper pouch bulges above and on either side of the
patella, and this bone is "floated" off the condyles of the femur.
When there is only a small amount of fluid, it is most easily
recognised while the patient stands with his feet together and the
trunk bent forwards at the hip-joints, and the quadriceps completely
relaxed; the fluid then bulges above and on each side of the patella,
and its presence is readily detected, especially on comparison with
the joint of the other side.

On account of the great extent of the synovial membrane, a large
quantity of serous effusion may accumulate in the joint in a
comparatively short time, as a result either of injury or disease. The
villous processes and fringes may take on an exaggerated growth, and
give rise to pedunculated and other forms of loose body.

The bursæ in the popliteal space, especially that between the
semi-membranosus and the medial head of the gastrocnemius, as well as
the sub-crural bursa, frequently communicate with the synovial cavity
of the knee and may share in its diseases.

As the epiphyses at the knee are mainly responsible for the growth in
length of the lower extremity, and are late in uniting with their
respective shafts--twenty-one to twenty-five years--serious shortening
of the limb may result if their functions are interfered with, whether
by disease or injury. The epiphysial cartilages lie beyond the limits
of the synovial cavity, so that infective lesions at the ossifying
junctions are less likely to spread to the joint than is the case at
the hip or shoulder, where the upper epiphysis lies partly or wholly
within the joint; disease in the lower end of the femur is more likely
to implicate the knee-joint than disease in the upper end of the
tibia.

One of the commonest causes of prolonged disability and feeling of
insecurity in the knee, is to be found in the wasting and loss of tone
in the quadriceps extensor muscle; the feeling of insecurity is most
marked in coming down stairs. The instability of the joint is often
added to by stretching of the ligaments and lateral mobility. As a
result of both of these factors the joint is liable to repeated
slight strains or jars which irritate the synovial membrane and tend
to keep up the effusion and excite the overgrowth of its tissue
elements.


TUBERCULOUS DISEASE

While tuberculous disease of the knee is specially common in childhood
and youth, it may occur at any period of life, and is not uncommon in
patients over fifty. The disease originates in the synovial membrane
and in the bones respectively with about equal frequency.

When the synovial membrane is diseased, it tends to grow inwards over
the articular surfaces (Fig. 122), shutting off the supra-patellar
pouch and fixing the knee-cap to the femur, and diminishing the area
of the articular surfaces. The ingrowth of synovial membrane may fill
up the cavity of the joint, or may divide it up into compartments.
Ulceration of the cartilage and caries of the articular surfaces are
common accompaniments.

[Illustration: FIG. 122.--Tuberculous Synovial Membrane of Knee,
spreading over articular surface of femur.]

The femur and tibia are affected with about equal frequency, and the
nature and seat of the bone lesions are subject to wide variations.
Multiple small foci may be found beneath the articular cartilage of
the tibia, or along the margins of the femoral condyles--especially
the medial. Caseating foci are comparatively rare, but they sometimes
attain a considerable size--especially in the head of the tibia, where
they may take the form of a caseous abscess. Sclerosed foci, which
form sequestra, are comparatively common (Fig. 123).

[Illustration: FIG. 123.--Lower End of Femur from an advanced case of
Tuberculous Arthritis of the Knee. Towards the posterior aspect of the
medial condyle there is a wedge-shaped sequestrum, of which the
surface exposed to the joint is polished like porcelain.

(Anatomical Museum, University of Edinburgh.)]

#Clinical Types.#--(1) _Hydrops_ usually arises from a purely synovial
lesion, but the joint may suddenly become distended with fluid when an
osseous focus ruptures into the synovial cavity.

It is met with chiefly in young adults. As the fluid accumulates it
gradually stretches the capsule, and pushes the patella forwards, so
that it floats. There is little pain or interference with function;
the patient is usually able to walk, but is easily tired. The amount
of fluid diminishes under rest, and increases after use of the limb.
In a certain number of cases it may be possible to recognise localised
thickening of the synovial membrane, or the presence of floating
masses of fibrin or melon-seed bodies. This is best appreciated if the
knee is alternately flexed and extended by the patient while the
surgeon grasps and compresses it with both hands. If the joint is
opened, fibrinous material, often in the form of melon-seed bodies,
may be found lining the synovial membrane.

Tuberculous hydrops is to be diagnosed from the effusion that results
from repeated sprain, from the hydrops of loose body, gonorrhœa,
arthritis deformans, Charcot's disease, and Brodie's abscess in the
adjacent bone, and from the hæmarthrosis met with in bleeders.

(2) _Papillary or Nodular Tubercle of the Synovial Membrane._--This is
a condition in which there is a fringy, papillary, or polypoidal
growth from the synovial membrane. It is most often met with in adult
males. The onset and progress are gradual, and the chief complaint is
of stiffness and swelling which are worse after exertion. Sometimes
there are symptoms of loose body, such as occasional locking of the
joint, with pain and inability to extend the limb; but the locking is
easily disengaged, and the movements are at once free again. The
patient may give a history of several years' partial and intermittent
disability, with lameness and occasional locking, although he may have
been able to go about or even to continue his occupation.

There is a moderate degree of effusion into the joint, and when this
has subsided under rest it may be possible to feel ill-defined cords,
or tufts, or nodular masses, and to grasp between the fingers those in
the supra-patellar pouch. There is little wasting of muscles, and it
is exceptional to have signs of disease of the articular surfaces or
of cold abscess.

On opening the joint, there may escape fluid and loose bodies similar
to those described under hydrops, and if the finger is introduced into
the cavity, the upper pouch is felt to be occupied by fringes or
polypoidal processes derived from the synovial membrane.

The diagnosis is to be made from arthritis deformans, and in some
cases from loose body of other than tuberculous origin.

(3) _Cold abscess_ or _empyema_ of the knee is a rare condition, in
which the joint becomes filled with pus. It usually results from a
primary tuberculosis of the synovial membrane occurring in children
reduced in health and the subject of tuberculosis elsewhere.

(4) _Diffuse Thickening of the Synovial Membrane--White Swelling._--So
long as this form of the disease remains confined to the synovial
membrane, the chief feature is that of an indolent elastic swelling in
the area of the joint. The swelling tapers off above and below, so
that it acquires a fusiform shape, and from the wasting of the muscles
it appears greater than it really is. The range of movement is
moderately restricted.

At first the patient limps, keeps the knee slightly flexed, and
complains of tiredness and stiffness after exertion. As the articular
surfaces become affected, there is pain, which is readily excited by
jarring of the limb, or by any attempt at movement; the joint is held
rigid, and there may be startings at night. If untreated, flexion
becomes more pronounced--it may be to a right angle--the leg and foot
are everted, and, in children, the tibia may be displaced backwards
(Fig. 124). The wasting of muscles continues, the part becomes hot to
the touch, the swelling increases, and may show areas of softening or
fluctuation from abscess formation.

[Illustration: FIG. 124.--Advanced Tuberculous Disease of Knee, with
backward displacement of Tibia.]

White swelling is to be differentiated from peri-synovial gummata,
from myeloma and sarcoma of the lower end of the femur, and from
bleeder's knee. In the first of these the swelling is nodular and less
uniform, and there may be tertiary ulcers or depressed scars in the
neighbourhood of the patella. In tumours the swelling is more marked
on one side of the joint, it is uneven or nodular, it does not
correspond to the shape of the synovial membrane, and may extend
beyond the limits of the joint, and it involves the bone to a greater
extent than is usual in disease of the joint. Skiagrams show expansion
of the bone in central tumours, or abundant new bone in ossifying
sarcoma. The diagnosis of bleeder's knee is to be made from the
history.

(5) _Primary Tuberculous Disease in the Bones of the Knee._--So long
as the foci are confined to the interior of the bone, it is impossible
to recognise their existence, unless they are of sufficient size to
cause enlargement of the bone or to be discernible in a skiagram.

#The formation of peri-articular abscess# takes place in rather more
than fifty per cent. of cases. When left to themselves, such abscesses
tend to spread up the thigh, or down the back of the leg between the
superficial and deep layers of calf muscles, and numerous sinuses may
result from their rupture through the skin.

#Attitudes of the Limb in Knee-Joint Disease.#--The attitude most
often assumed is that of _flexion_, with or without _eversion of the
leg and foot_. The flexion is explained by its being the resting
attitude of the joint, and that which affords most ease and comfort to
the patient. Once the joint is flexed, the involuntary contraction of
the flexor muscles maintains the attitude, and if the patient is able
to use the limb in walking, the weight of the body is a powerful
factor in increasing it. The eversion of the leg is probably
associated with contraction of the biceps muscle. _Backward
displacement of the tibia_ is met with chiefly in neglected cases of
chronic disease of the knee when the child has walked on the limb
after it has become flexed.

In certain cases, _genu valgum_ or abduction of the leg is present
along with a slight degree of flexion. The valgus attitude is
associated with slight lateral displacement of the patella, with
prominence and apparent enlargement of the medial condyle, with
depression of the pelvis on the diseased side and apparent lengthening
of the limb.

#Treatment of Tuberculous Disease of the Knee.#--Conservative measures
are always indicated in the first instance, and are persevered with so
long as there is a prospect of obtaining a movable joint.

_Conservative Treatment._--If the joint is sensitive and tends to be
flexed, the patient is confined to bed, the limb is secured to a
posterior splint, and extension with weight and pulley persevered with
until these symptoms have disappeared; during this time, from three to
six weeks, methods of inducing hyperæmia and other anti-tuberculous
procedures are employed. If it is proposed to inject iodoform or other
drug, the needle is inserted into the interval between the bones on
the medial side of the ligamentum patellæ or into the upper pouch when
this is distended with fluid.

If there is no pain or tendency to flexion, or when these have been
overcome, the limb is put up in a Thomas' splint (Fig. 125) and the
patient allowed to go about. The splint is worn for a period varying
from six to twelve months; before being discarded it may be left off
at night; it is ultimately replaced by a bandage.

[Illustration: FIG. 125.--Thomas' Knee Splint applied. Note extension
strapping applied to affected leg, and patten under sound foot.]

The indications for _operative treatment_ are: (1) marked symptoms of
destruction of the articular cartilages; (2) a deformed attitude
incapable of being rectified without operation; (3) a condition of the
general health which requires that the disease should be got rid of as
speedily as possible; (4) progress or persistence of the disease in
spite of conservative treatment. When there is no prospect of recovery
with a movable joint it is a waste of time and a possible source of
danger to persevere with conservative measures. Operation permits of
the disease being eradicated and the restoration of a useful limb
within a reasonable time, averaging from three to six months.

In adults, the operation consists in excising the joint; in children
the aim is to remove the diseased tissues without damaging the
epiphysial cartilages.

Amputation is performed when the disease has relapsed after excision
and there is persistent suppuration, and when life is threatened by
the occurrence of tuberculosis in the lungs or elsewhere.

#Treatment of Deformities resulting from Antecedent Diseases of the
Knee.#--Flexion is the commonest of these; when due to contracture of
the soft parts, these are either stretched by degrees, the limb being
encased in plaster after each sitting, or they are divided by open
dissection in the popliteal space. If there is fibrous or osseous
ankylosis, the choice lies between arthroplasty, the removal of a
wedge of bone which includes the joint, or, in patients who are still
growing, of a wedge from the femur above the level of the epiphysial
cartilage. Backward displacement of the tibia, genu recurvatum, and
genu valgum also require operative treatment.


OTHER DISEASES OF THE KNEE-JOINT

#Pyogenic diseases# result from infection through the blood stream,
from one of the adjacent bones, or from a penetrating wound of the
joint. The commoner types include the _synovitis_ associated with
disease in the adjacent bone, _acute arthritis of infants_, joint
suppuration in _pyæmia_, _pyogenic arthritis_ following upon
penetrating wounds, and the affections which result from _gonorrhœal_
or _pneumococcal_ infection.

_Treatment._--The limb is immobilised on a posterior splint so padded
as to allow slight flexion at the knee, and extension applied with
sufficient weight to relieve the pain; it is also of benefit to induce
hyperæmia by one or other of the methods devised by Bier. To tap the
joint, the needle is introduced obliquely into the supra-patellar
pouch, and if it is necessary to open the joint, the incision is made
on one or on both sides of the patella, and Murphy's plan of inserting
formalin-glycerine may be employed. If the infection progresses and
threatens the life of the patient, it may be necessary to lay the
joint freely open from side to side, sawing across the patella, and,
the limb being flexed, the whole wound is left open and packed with
gauze. As the infection subsides, the limb is gradually straightened.
If these methods fail, amputation through the thigh may be the only
means of saving life.

#Arthritis deformans# affects the knee more frequently than any of the
other large joints. The changes related to the synovial membrane here
attain their maximum development, and may assume the form of hydrops
with or without fibrinous bodies, or of overgrowth of the synovial
fringes and the formation of pedunculated loose bodies. It is
suggested that these synovial changes follow upon repeated sprains or
upon a previous pyogenic infection of the joint. The effusion and
stretching of the ligaments that follow upon a sprain are incompletely
recovered from; the synovial membrane becomes puckered, the quadriceps
atrophies and no longer puts the ligamentum mucosum on the stretch;
and the infra-patellar pad of fat, not undergoing the normal
compression during extension, is readily nipped between the femur and
tibia. Each nipping implies a fresh sprain, with return of the
effusion, and so a vicious circle is set up which terminates in what
has been called a _villous arthritis_, with fringes and loose bodies;
in time, the articular cartilage at the line of the synovial
reflection undergoes fibrillation and conversion into connective
tissue, and the process spreading to the articular surfaces, the
picture of a rheumatoid arthritis is complete. Fibrillation of the
cartilage imparts a feeling of roughness when the joint is grasped
during flexion and extension, and lipping of the margins of the
trochlear surface of the femur may be felt when the joint is flexed;
it is also readily seen in skiagrams. When a portion of the "lipping"
is broken off, it may give rise to a loose body. In advanced cases
with destruction of the cartilages, there may be movement from side to
side, with grating of the articular surfaces.

In the early stages, treatment consists in limiting the movements of
extension by means of a splint provided with a hinge that locks at
thirty degrees from full extension and vigorous massage of the
quadriceps. In the dry, creaking forms of arthritis, the symptoms are
relieved by introducing liquid vaseline into the joint. When the
symptoms are due to the presence of fringes and loose bodies, these
may be removed by operation. When the disease is of a severe type, and
is confined to one knee, the question of excising the joint may be
considered.

_Bleeder's knee_, _Charcot's disease_, _hysterical knee_, and _loose
bodies_ in the joint have already been described.


THE ANKLE-JOINT

There is a common synovial cavity for the ankle and the inferior
tibio-fibular joints. The epiphysial cartilage of the tibia lies above
the level of this synovial cavity, but that of the fibula is included
within its limits (Fig. 93). The talus is related to three
articulations--the ankle above, the talo-navicular joint in front, and
the calcaneo-taloid joint below. The tendon sheaths, especially those
of the peronei and of the tibialis posterior, are liable to be
infected by the spread of infective disease from the joint.

#Tuberculous Disease.#--Tuberculous disease at the ankle is met with
at all ages. In the majority of cases the disease affects both bone
and synovial membrane. Gross lesions in the bones are comparatively
rare, and are chiefly met with in the head or neck of the talus.

_Primary synovial disease_ usually exhibits the features of white
swelling, projecting beneath the extensor tendons on the dorsum, and,
posteriorly, filling up the hollows on either side of the tendo
Achillis and below the malleoli (Fig. 126). The foot may retain its
normal attitude, or the toes may be pointed and adducted. The calf
muscles are wasted, there is little complaint of pain, and the
movements of the joint may be so little interfered with that the
patient can walk without a limp. When the disease involves the
articular surfaces, there is pain and sensitiveness, the movements are
restricted or abolished, and the patient is unable to put the foot on
the ground.

[Illustration: FIG. 126.--Tuberculous Disease in a man æt. 35, of six
weeks' duration.]

_A primary focus in the bone_ causes localised pain and tenderness,
and a limp in walking, but the first sign may be the formation of
abscess or the rapid development of articular symptoms. In such cases
skiagrams afford valuable information.

Abscess formation is an early and prominent feature, whether the
disease is of osseous or synovial origin, and sinuses are liable to
form around the joint. Outlying abscesses and sinuses are usually the
result of infection of the tendon sheaths in the neighbourhood.

_Diagnosis._--When teno-synovitis occurs independently of disease of
the ankle, the swelling is confined to one aspect of the joint. In
sarcoma of the lower end of the tibia, the swelling lacks the uniform
distribution of that met with in joint disease. In Brodie's abscess of
the lower end of the tibia there may be swelling of the ankle, but
there is an area of special tenderness on percussion over the bone.

_Treatment._--The foot is immobilised at a right angle to the leg by
splints or plaster of Paris; if articular symptoms are absent or have
subsided, a Thomas' knee splint should be applied to enable the
patient to move about without bearing his weight on the affected foot
(Fig. 125). To inject iodoform, the point of the needle is inserted
below either malleolus, and is then pushed upwards alongside of the
talus. If localised disease in one of the bones is recognised before
the joint is infected, it should be eradicated by operation.

When the disease is diffuse and resists conservative treatment,
excision should be performed, the articular surfaces of the
constituent bones being removed, and if necessary the whole of the
talus.

Amputation is only called for in adults with rapidly progressing
disease and diffuse suppuration, and in cases which have relapsed
after excision.

The other diseases of the ankle include _pyogenic_, _gonorrhœal_,
_rheumatic_, _gouty_, and _hysterical_ affections, _arthritis
deformans_, and _Charcot's disease_. The last-named is generally
associated with a rapid and painless disintegration of the bones of
the ankle and tarsus, resulting in great deformity and loss of the
arch of the foot--sometimes associated with perforating ulcer of the
sole.

Tuberculous disease in the #tarsus#, #metatarsus#, and #phalanges# has
been considered in the chapter on Diseases of Bone.




CHAPTER X

DEFORMITIES OF THE EXTREMITIES


The origin of deformities: (1) Those arising before birth; (2) those
    produced during birth; and (3) those acquired after birth.

Palsies of children: _Anterior Poliomyelitis_. Cerebral palsies:
    _Spastic paralysis_.

THE LOWER EXTREMITY: Congenital dislocation of hip--Snapping
    hip--Paralytic deformities--Contracture and ankylosis of hip--Coxa
    vara and coxa valga--Congenital dislocation of knee and
    patella--Genu recurvatum--Paralytic deformities--Contracture and
    ankylosis of knee--Genu valgum and genu varum--Congenital
    deformities of leg--Bow-leg--Club-foot: _Talipes equino-varus_;
    _Pes equinus_; _Pes calcaneus_; _Pes calcaneo-valgus and varus_;
    _Pes cavus_; Flat-foot and pes valgus--Painful affections of
    heel--Metatarsalgia--Hallux valgus and bunion--Hallux
    varus--Hallux rigidus and flexus--Hammer-toe--Hypertrophy of
    toes--Supernumerary toes--Webbed toes.

THE UPPER EXTREMITY: Congenital absence of clavicle--Elevation of
    scapula--Winged scapula--Congenital paralytic deformities of
    shoulder--Deformities of elbow--Club-hand--Deformities of
    wrist--Madelung's deformity--Deformities of fingers--Dupuytren's
    contraction--Polydactylism.

The surgery of the extremities is so largely concerned with the
correction of deformities that it is necessary at the outset to refer
briefly to some points relating to the time and mode of origin of
these.

1. _Congenital deformities_--that is, those which originate _in utero_
and are present at birth--are comparatively common and may be due to a
variety of causes. Some result from errors of development--for
example, supernumerary fingers or toes, and deficiencies in the bones
of the leg or forearm. A larger number are to be attributed to a
persistent abnormal attitude of the fœtus, usually associated with
want of room in the uterus--for example, the common form of club-foot
and congenital dislocation of the hip. Less frequently amniotic bands
so constrict the digits or the limbs as to produce distortion, or even
to sever the distal part--_intra-uterine amputation_. Lastly, certain
diseases of the fœtus, and particularly such as affect the
skeleton--for example, achondroplasia--cause congenital deformities.

2. _Deformities originating during birth_ are all traceable to the
effects of injuries sustained in the course of a difficult labour.
Examples of these are: wry-neck resulting from rupture of the
sterno-mastoid; lesions of the shoulder-joint and brachial plexus due
to hyper-extension of the arm; a spastic condition of the lower
limbs--Little's disease--resulting from tearing of blood vessels on
the surface of the brain with hæmorrhage and interference with the
function of the cortical motor area.

3. _Deformities acquired after birth_ arise from widely different
causes, of which diseases of bone, including rickets, diseases of
joints, and affections of the nervous system attended with paralysis,
are amongst the commonest. Other deformities are produced by
unsuitable clothing, such as a tight corset, or ill-fitting shoes
distorting the toes, prolonged standing in growing subjects
overstraining the mechanism of the foot and giving rise to the common
form of flat-foot.

The part played by the palsies of children in the surgical affections
of the extremities necessitates a short description of their more
important features.

#Anterior poliomyelitis# is the lesion underlying what was formerly
known as _infantile paralysis_--a name to be avoided, because the
condition is not confined to infants and it is not the only form of
paralysis met with in young children. Anterior poliomyelitis is
characterised by an illness attended with fever, in which the child is
found to have lost the power of one, less frequently of both lower
extremities; or, it may be, of one or both arms. After a period,
varying from six weeks to three months, the paralysis tends to
diminish both in extent and degree, and in the majority of cases it
ultimately persists only in certain muscles or groups of muscles. At
the onset of the paralysis the affected limb is helpless and relaxed,
the reflexes are lost, the muscles waste, and those that are paralysed
exhibit the reaction of degeneration. In severe cases, and especially
if proper treatment is neglected, the nutrition of the limb is
profoundly affected; its temperature is subnormal, the skin is bluish
in cold weather and readily becomes the seat of pressure sores. In
course of time the limb lags behind its fellow in growth, and tends to
assume a deformed attitude, which at first can easily be corrected,
but later becomes permanent.

[Illustration: FIG. 127.--Female child showing the results of
Poliomyelitis affecting the left lower extremity; the limb is short
and poorly developed, the pelvis is tilted and the spine is curved.]

When the acute stage of the illness is past, the chief question is to
what extent recovery of function can be looked for in the paralysed
muscles.

It would appear to be established that if a muscle reacts to faradism
it will recover, but the contrary proposition does not follow. It was
formerly accepted that a muscle which exhibits the reaction of
degeneration is incapable of recovery, but observation has shown that
this is not the case. Complete destruction of the motor cells in the
anterior horn of grey matter as a result of poliomyelitis is now known
to be exceptional; as a matter of fact, damage to the nerve cells is
usually capable of being repaired. The muscles governed by these cells
may appear to be completely paralysed, but with appropriate treatment
their functional activity can be restored. As functional disability is
frequently due to the affected muscle being _over-stretched_, it is of
the first importance, when the acute symptoms are on the wane, that
every care should be taken to prevent the weak muscular groups being
put upon the stretch, and the greatest attention should be paid to
_the posture of the limb during convalescence_. For example, if the
child is allowed to lie with the wrist flexed, the flexor muscles
undergo shortening, and the extensors are over-stretched and are
therefore placed at a mechanical disadvantage. As the inflammatory
changes in the anterior horn of the cord subside, the flexor tendons,
from their position of advantage, are in a condition to respond to the
first stimuli that come from their recovering motor cells, while the
extensors are not in a position to do so. If, on the other hand, the
wrist and fingers are maintained in the attitude of extreme
dorsiflexion, the extensors become shortened, and, relieved of strain,
they soon begin to respond to the stimuli sent them from the
recovering nerve cells. Similarly in the lower extremity, when, for
example, the muscles innervated through the peroneal (external
popliteal) nerve are paralysed, if the foot is allowed to remain in
the attitude of inversion with the heel drawn up--paralytic
equino-varus--an attitude which is rendered more pronounced by the
pressure of the bedclothes, the chance of the muscles recovering their
function is seriously diminished. Another potent factor in preventing
recovery, especially in the lower limbs, is _erroneous deflection of
the body weight_. If, for example, there is weakness in the tibial
group of muscles, and the child is allowed to walk, the eversion of
the foot will steadily increase, the tibial muscles will be more and
more stretched, the opposing peroneal muscles will shorten, and, in
time, the bones of the tarsus will undergo structural alterations
which will perpetuate the deformity. If, on the other hand, by some
alteration of the boot, the foot is maintained in the attitude of
inversion, the weakened or paralysed tibial muscles are placed in a
much more favourable condition for recovery.

It must be emphasised that no operation should be performed in these
cases until the question whether it be possible or not to restore the
apparently paralysed muscle is settled. The clinical test of the
recoverability of a muscle is to keep it for a long period--six or
even twelve months--in a condition of relaxation. This test should be
made, no matter how many months or years the muscle may have been
paralysed.

The first stage in the treatment, therefore, is the correction of
existing deformity, after which the limb should be kept immovable
until the ligaments, muscles, and even the bones have regained their
normal length and shape. The slightest stretching of a muscle which is
in process of recovery disables it again.

The age of the patient influences the method of treatment. In young
children in whom the structures are soft and yielding, gradual
correction of the deformity is to be preferred to the more rapid
methods employed in older children. The proper sequence consists in
correcting the deformity, providing the simplest apparatus to keep the
limb in good position, preventing erroneous deflection of body weight
during walking, and then allowing the child to grow and develop until
he has reached the age of five before considering such an operation as
transplanting tendons, and the age of ten before deciding to ankylose
a flail-like joint.

_Reposition, Manipulations, Supports._--An attempt is made to correct
the deformity by manipulation, and the proper attitude is maintained
by a mechanical support. If the foot has become rotated so that the
sole looks laterally, the medial side of the boot must be raised, and
an iron worn which extends from the knee down the lateral side of the
leg, to end, without a joint, in the heel of the boot. In pes equinus,
the iron is let into the back of the heel and extends forwards into
the waist of the boot, to keep the foot at right angles to the leg and
to relax the weak extensor muscles.

_Division of Contractions._--Bands of fascia and contracted tendons
which prevent correction of deformity may have to be divided or
lengthened. This is best done by the open method.

_Removal of Skin._--To assist in maintaining the desired attitude,
Jones recommends the plan of excising an area of the redundant skin on
the weaker aspect of the limb; in equinus, the skin is taken from the
dorsum; in equino-varus, from the front and lateral aspect of the
foot. When the edges of the gap have united, the foot is maintained in
the desired attitude for some months, even if parents carelessly
remove the iron support to let the child run about.

_Tendon transplantation_, a procedure introduced by Nicoladoni, is to
be considered in children of five and upwards. It may be employed for
different purposes: (1) To reinforce a weak muscle by a healthy
one--for example, by transplanting a hamstring tendon into the patella
to reinforce a weak quadriceps, or reinforcing the weak invertors of
the foot by a transplanted extensor hallucis longus. (2)
Transplantation may also be performed to replace a muscle which is
quite inactive and does not show any sign of recovery--for example,
the tibiales being paralysed, the peroneus longus may be implanted
into the navicular or first metatarsal to act as an invertor of the
foot.

Wherever possible a tendon should be transplanted directly into bone,
as, if it is attached to soft parts it rarely holds firmly enough. The
bone should if possible be tunnelled, and the tendon passed through
the tunnel and securely fixed. When bringing a tendon to its new point
of attachment, it should pass in as straight a line as possible,
avoiding any bend or angle which might impair its action. Fat is the
best medium for the transplanted tendon to traverse, as it acts as a
sheath and prevents the formation of adhesions which would interfere
with the function of the new tendon. All deformity must be corrected
before transferring the tendon; if the tendon is too short to admit of
this, it can be lengthened by means of silk threads (Lange).

According to Jones, the most successful transplantations are the
following, in order: (1) The tibialis anterior into the lateral tarsus
in paralysis of the peronei; (2) the peroneus longus into the
navicular in paralysis of the tibial group; (3) the extensor hallucis
longus into any part of the foot where it may be wanted; (4) the
hamstrings into the patella, to reinforce the quadriceps, provided the
strictest after-treatment can be secured; (5) deflection of part of
the tendo Achillis to one or other side of the foot.

_Arthrodesis._--This operation, first performed by Albert in 1877,
consists in removing the cartilage covering the articular surfaces of
bones with the object of producing a firm ankylosis. The procedure is
most successful in the ankle and mid-tarsal joints, and as a result of
it there is obtained a secure and firm base of support in walking.
Before performing arthrodesis, the surgeon must decide whether the
patient will be better off with a stiff joint or with a weak and
movable ankle supported by apparatus. This is often a matter of social
position; in the poor, an ankylosed joint is more useful and less
expensive. An arthrodesis should seldom be performed at the ankle
until the child has passed his eighth year, or at the knee until he
has reached his twentieth year. There is plenty to be done during the
period of waiting, and if this is done well, it is possible that the
operation may not be required. The existing deformities, for example,
will have to be corrected, areas of skin removed to relieve
functionless muscles of strain, the body weight appropriately
deflected, and the child must be taught to walk with the aid of a
support, swinging his limb about, and using it effectively in a
correct position. Such exercise is a powerful agent in promoting
physiological and functional development.

_Nerve anastomosis_, which seeks to provide a new channel for the
transmission of motor impulses to the paralysed muscles, has as yet a
restricted field of application--for example, the tibial and peroneal
nerves may be anastomosed when the muscles supplied by one of them are
paralysed. Stoffel of Heidelberg lays stress on regard being paid to
the anatomical arrangement of the nerve bundles within the nerve-trunk
so that motor fibres may be joined to motor ones and not to sensory.
It is necessary also to cut across some of the fibres of the healthy
nerve in order that they may grow into the nerve which is degenerated.

In extreme cases in which the limb is hopelessly paralysed and
useless, it may be _amputated_ to admit of an artificial limb being
worn; it must be borne in mind, however, that such limbs furnish poor
stumps, usually quite unable to bear pressure.

#Cerebral Palsies of Childhood--Spastic Paralysis.#--These may be due
to arrest of development of the brain, to injuries of the head at
birth, to meningeal hæmorrhage, or to other lesions of the brain, with
secondary degenerative changes in the spinal cord. The commonest cause
is hæmorrhage occurring during child-birth from the veins which ascend
from the middle part of the convexity of the hemisphere to open into
the superior sagittal (superior longitudinal) sinus. The blood is
poured out beneath the dura on one or on both sides of the falx
cerebri, and as it accumulates near the vertex, the damage to the
motor centres for the legs is usually more extensive than that to the
centres for the arms. The paralysis may affect one side of the
body--_hemiplegia_, or both sides--_diplegia_; less commonly one
extremity alone is involved--_monoplegia_. In diplegia, in which both
arms and both legs are affected in the first instance, the arms may
recover while the lower extremities remain in a spastic state, a
condition known as _Little's disease_. The mental functions may be
normal but more frequently they are imperfectly developed, the
impairment in some cases amounting to idiocy. The affected limbs
exhibit muscular rigidity or spasm, which is aggravated on movement
but disappears under an anæsthetic; the reflexes are exaggerated, and
sometimes there are perverted involuntary movements (_athetosis_). The
growth of the limb is impaired, and contracture deformities may
supervene (Fig. 131). The amount of power in the limb is often
astonishing, in marked contrast to what is observed to follow upon
anterior poliomyelitis. The degree of natural improvement is by no
means great, and normal function is almost never regained.

The _treatment_ is concerned in the first place with improving the
condition of the muscles by methodical exercises and massage. When
reflex irritability of the muscles with consequent spasm is a
prominent feature, the reflex arc may be interrupted by _resection of
the posterior nerve roots_ corresponding to the part affected. This
operation, first suggested by Spiller but chiefly popularised by
Foerster, has yielded the best results in cases of Little's disease,
in which there still remains a considerable amount of voluntary
movement, and yet there is inability to walk on account of involuntary
spasm. In the case of the lower extremities, three or more of the
lumbar and one or more of the sacral nerve roots are resected within
the vertebral canal. Sensation is diminished but not abolished in the
area of skin involved. Massage and exercises and, it may be, splints
or apparatus are essential factors in promoting the recovery of
function. It has not yet been decided whether the results of the
resection of nerve roots justify the risk.

Apart from Foerster's operation, or when it has failed, the spasm of
any individual muscle or group of muscles may be got rid of by
diminishing the nerve supply to the muscle or by lengthening the
tendon. Diminishing the nerve supply was suggested by Stoffel; it
consists in exposing the motor nerve as it enters the muscle and
resecting one-third or one-half of the fibres so as to reduce the
innervation to the required degree. The method is still on its trial.

_Lengthening the Tendons._--In spastic paraplegia, for example, Jones
resects the origins of the adductors longus and brevis, lengthens the
tendo Achillis, divides the popliteal fascia and hamstrings, and
transplants the biceps into the quadriceps; after which the limbs are
put up in the attitude of wide abduction for six weeks. It is
important that the patient should begin to walk with the legs wide
apart and learn to balance himself without any feeling of insecurity;
he should be taught to look at an object straight in front of him
rather than on the ground.


THE LOWER EXTREMITY


CONGENITAL DISLOCATION OF THE HIP

This is the commonest of all congenital dislocations. Its frequency
varies in different countries, being greater on the continent of
Europe than in this country. It is more often unilateral than
bilateral (about 4 to 1), and is about three times more common in
girls than in boys.

The dislocation takes place in the early months of intra-uterine life,
and may be associated with deficiency of the liquor amnii.

#Pathological Anatomy.#--_In the infant_, the anatomical changes in
the joint are less marked than they are after the child has borne its
weight on the limb. The acetabulum, never having been occupied by the
head of the femur, is imperfectly developed; it remains flat and
shallow, is partly filled with fibro-fatty tissue derived from the
synovial membrane, and is always too small for the head of the femur.
The cotyloid ligament being broader and thicker than usual, makes the
osseous portion of the socket appear deeper than it really is. In
unilateral cases the affected half of the pelvis is contracted, so
that the pelvic basin is narrowed and oblique. The head of the femur
is small, flattened, and, in some cases, conical; and the angle formed
by the neck with the shaft is altered, sometimes diminished, it may be
to a right angle--_coxa vara_ (Fig. 129); sometimes increased--_coxa
valga_. There is also a variable degree of torsion of the neck,
ante-torsion being of practical importance as it increases the
difficulty of retaining the head in the socket. The capsule is lax and
admits of the head passing upwards for a variable distance on to the
dorsum ilii. In unilateral cases the ligamentum teres is elongated and
thickened; in bilateral cases it is frequently absent.

[Illustration: FIG. 128.--Radiogram of Double Congenital Dislocation
of Hip in a girl æt. 4.]

[Illustration: FIG. 129.--Innominate Bone and upper end of Femur from
a case of Congenital Dislocation of Hip.]

In _children who have walked_, the head of the femur is pushed farther
upwards on the dorsum ilii; the capsule becomes lengthened by
supporting the weight of the body. That part of the capsule which
arises from the lower margin of the acetabulum stretches across the
socket and partly shuts it off from the rest of the joint cavity. In
course of time the capsule becomes greatly thickened, and may present
an hour-glass constriction about its middle, which may prove a serious
obstacle to reduction. The socket becomes small and triangular, and
there is almost no ledge against which the head of the femur can rest.
A superficial depression may form on the ilium where it is pressed
upon by the head of the femur, covered by the capsule; and in the
course of years, as the head changes its position, several secondary
sockets may be formed. No proper new bony socket forms like that in
traumatic dislocations that remain unreduced because in the congenital
variety the thickened capsule intervenes between the head of the bone
and the dorsum ilii. The displacement of the head is most frequently
backwards (dorsal luxation), and as the point of support thus falls
behind the acetabulum the pelvis tilts forwards, and the lumbar spine
becomes unduly concave (lordosis). The muscles of the hip and thigh
alter in consequence of the changed relations; the gemelli,
obturators, and piriformis are lengthened, the adductors, hamstrings,
and ilio-psoas are shortened, while the glutei and quadriceps are but
little altered. In rare cases the head is displaced upwards and lies
immediately above the acetabulum.

[Illustration: FIG. 130.--Congenital Dislocation of Left Hip in a girl
æt. 8. The patient is putting the whole weight on the dislocated
limb.]

_Clinical Features._--The condition rarely attracts attention until
the child begins to walk, but sometimes the unusual breadth of the
pelvis, the presence of a lump in the buttock, snapping about the hip,
or a peculiar way of holding the limb, leads the parents to seek
advice early. In _unilateral cases_, when the child has learned to
walk at the late age of two, three, or it may even be four years, it
is noticed that the back is hollow and the buttocks unduly prominent,
and that there is a peculiar and characteristic limp; each time the
weight of the body is put upon the affected limb, the trunk makes a
sudden dip towards that side. There is no pain on walking. The
affected limb is shortened, as is shown by the projection of the great
trochanter above Nélaton's line; the shortening gradually increases,
and in time may amount to several inches. It is partly compensated for
by resting the affected limb on the balls of the toes and flexing the
knee on the sound side. The gluteal fold is shorter, deeper, and
higher than on the healthy side, and on account of the obliquity of
the pelvis the spine shows a lateral curvature, with its concavity to
the affected side. The movements at the hip-joint are free in all
directions except abduction; on practising external rotation it is
often found to be abnormally free; lastly, in young children, if the
pelvis is fixed, the head of the bone may be made to glide up and down
on the ilium.

_In bilateral cases_ the trunk appears well grown in contrast to the
short lower limbs, the hollow of the back is exaggerated, the abdomen
protrudes, the perineum is broadened, and the buttocks are unduly
prominent. The gait is waddling like that of a duck, the trunk
lurching from one side to the other with each step. In untreated cases
the deformity and disability become more pronounced as the capsular
and round ligaments are further stretched, the shortening and limp
become more marked, the patient is easily fatigued by walking or
standing, and is usually unfitted for earning a living. We have had
under observation, however, an adult male with bilateral dislocation
and extroversion of the bladder, who efficiently performed the duties
of a carrier for many years.

Except in fat infants, the _diagnosis_ is not difficult; the absence
of pain and tenderness, the freedom of motion and the absence of the
head of the femur from its normal position, differentiate the
condition from tuberculous disease of the joint, and from coxa vara
and other deformities in the region of the hip. _Trendelenburg's test_
consists in noting the relative level of the buttocks when the patient
stands on the affected leg. Normally the buttocks remain on the same
level when the patient stands on one leg; in congenital dislocation
the buttock of the limb raised from the ground drops to a lower level;
in coxa vara it rises higher.

In paralytic conditions at the hip there may be considerable
resemblance to dislocation, but the muscles are slack and wasted, and
the normal attitude can easily be restored by pulling on the limb. The
most certain means of diagnosis is by the X-rays, which show the
position of the head of the bone in relation to the acetabulum, and
any torsion of the neck of the femur that may be present. This last
point is determined by taking a series of skiagrams in different
positions of the limb; these are also useful in correcting erroneous
impressions as to the angle of the neck of the femur.

_Treatment._--We are indebted to Paci, Schede, Calot, Lorenz, and
Hoffa for the rational treatment which seeks to reduce the dislocation
by manipulation.

#Reduction by Manipulation# (_Method of Lorenz_).--The child is
anæsthetised and placed on its back with the legs over the end of the
table. While an assistant steadies the pelvis, the surgeon pulls on
the limb so as to bring the trochanter down to Nélaton's line; this is
followed by forced rotation outwards and inwards and forcible
abduction to a right angle, and by kneading the adductors till they
are stretched and torn. The next step is to stretch the hamstrings,
and this is done by raising the foot, without bending the knee, until
the front of the thigh meets the abdomen, and the toes the face. To
stretch the anterior muscles, the patient is turned on the side or
face, and the hip is hyper-extended both in the straight and in the
abducted position. The stage is now reached at which attempts at
reduction may be made; the child is again laid on its back, the
surgeon grasps the knee, flexes the thigh to a right angle, rotates
laterally, and slowly flexes and abducts, while the thumb pushes from
behind on the trochanter, trying to guide and lift it over the rim of
the socket as the hip reaches the over-abducted position. Lorenz uses
a wedge of wood padded with leather about 3 inches high to rest the
trochanter upon while attempting to lift it forward. When reduction
takes place, there is generally a sound and a sudden jump, as in
reducing a traumatic dislocation.

To keep the head in the socket, the limb must be maintained in the
position of right-angled abduction and external rotation (90°) by a
plaster case, which includes the lower part of the trunk and both
limbs down to the knee. Under the plaster, stockinette drawers are
worn, and the bony prominences are padded with cotton wool. The
plaster should overlap the costal margin. The first case is worn for
two months or more, and is then renewed at shorter intervals, the
degree of abduction being diminished at each renewal until the limbs
are nearly parallel. The child is only kept in bed for a week or two,
and is then allowed up, being provided with a boot and high sole on
the affected side, but should not use crutches. At the end of six
months, by which time the capsule has become tightened up round the
head of the femur, the plaster is given up and massage and exercises
are employed.

_In bilateral cases_ both dislocations are reduced at one sitting if
possible, and a plaster case applied with both thighs abducted and
flexed to a right angle, the so-called "frog position."

In the event of failure to reduce a dislocation at the first attempt,
the limb should be fixed in plaster in the abducted attitude for ten
days or a fortnight, and then another attempt made. The greatest
number of successes in bilateral cases is met with under five years of
age, and in unilateral cases under seven. Reduction may sometimes be
accomplished, however, in older children.

If it is found impossible to restore the head of the femur to the
acetabulum, an attempt should be made by similar manipulations to
wedge it under the long head of the rectus femoris, or, failing this,
below the anterior iliac spine under the sartorius and tensor fasciæ
femoris. By thus converting a posterior into an anterior dislocation,
the tilting of the pelvis and the lordosis are greatly diminished.
This procedure, named by Lorenz _anterior transposition of the head of
the femur_, is specially applicable to cases in which relapse has
taken place after reduction, and to those above the age when reduction
should be attempted.

_Reduction by open operation_ may be had recourse to in cases in
which, after several attempts, reduction has failed, or in which
re-dislocation has occurred; it is, however, a serious operation.
Attempts have also been made by means of pegs and other contrivances
to fix the head of the bone and prevent it sliding upwards on the
ilium. When reduction is impossible by any means, a stiff leather
jacket with prolongations around the thighs may diminish the deformity
and improve the walking.

#Snapping Hip# (_Hanche à ressort_).--This is a rare affection, met
with in children and young adults, and characterised by the occurrence
of a sudden, snapping sound, sometimes attended with pain in the
region of the great trochanter. This usually occurs when the limb is
slightly flexed or adducted, and rotated either inwards or outwards.
On palpation a cord-like structure may be felt, which slips forwards
and backwards over the trochanter when the position of the limb is
altered.

The condition was formerly described as a voluntary dislocation of the
hip; it is now believed to be due to a cord-like band of tissue
slipping backwards and forwards over the trochanter. The band is
usually derived from the fascia lata, sometimes reinforced by the
anterior fibres of the gluteus maximus, sometimes by the tensor fasciæ
femoris. The condition seldom gives rise to any appreciable disability
and surgical treatment is rarely called for. In a number of cases the
muscle has been fixed by sutures with satisfactory results. In a
recent case, an extensive open dissection proved negative, but the
stitching of the gluteus to the trochanter was followed by the
disappearance of the snapping.

#Paralytic Deformities of the Hip.#--In anterior poliomyelitis the
paralysis of muscles may be so widespread that the limb is unable to
support the weight of the body, or certain groups of muscles only are
paralysed and the child may be able to walk with the help of
apparatus. Even if the ilio-psoas is paralysed, flexion is still
possible by the anterior fibres of the gluteus medius, the anterior
adductors, and when the leg is rotated out by the tensor fasciæ and
sartorius, the dislocation differs from the traumatic variety in that
the head, although it leaves the socket, remains within the capsule.
Dislocation tends to occur from the disturbance of muscular balance,
anterior dislocation being commoner than posterior in about the
proportion of two to one; the nature of the dislocation is best
demonstrated by means of the X-rays. Reduction is rarely possible
without an open operation. Tendon and nerve-transplantation are
scarcely possible, and arthrodesis is rarely to be recommended;
contracture deformities, however, are often benefited by tenotomy in
young children, and in older children by osteotomy through the
trochanter, and putting the limb up in the abducted position.

In _spastic paralysis_ of cerebral origin, the tendency is towards
contracture, usually in the attitude of flexion, with adduction and
inversion. This may result in dislocation backwards on to the dorsum
ilii, and may occur in patients confined to bed (Fig. 131).

[Illustration: FIG. 131.--Contracture Deformities of Upper and Lower
Limbs resulting from Spastic Cerebral Palsy in infancy.

(Photograph taken after death by Dr. Thomson of Norwich.)]

#Contractures and Ankyloses of the Hip.#--Various forms of contracture
are met with as a result of cicatricial contraction, or from
shortening of the fasciæ, muscles, and ligaments when the hip has been
maintained in the flexed position for long periods--for example, in
psoas abscess, chronic rheumatism, or hysteria. The majority, however,
result from tuberculous disease of the hip-joint. In osseous
ankylosis, an attempt may be made to restore movement by the operation
of Murphy, which consists in chiselling through the osseous junction
between the bones, deepening the acetabulum if necessary, and then
interposing between the bony surfaces a portion of fat-bearing fascia
derived from the fascia lata over the great trochanter. The operation
of Jones consists in detaching the great trochanter (the insertions of
the glutei into it being left intact), dividing the neck of the femur,
and then securing the separated portion of the trochanter to the
proximal end of the neck to prevent union of the fragments.


COXA VARA AND COXA VALGA

These deformities depend on abnormalities of the angle of the neck of
the femur; the average or normal elevation is 125° for the adult and
135° for the child; variations between 120° and 140° are considered
normal. If the angle is less than 120° the condition is one of coxa
vara; if greater than 140°, coxa valga. The angle of inclination of
the neck of the femur is dependent upon the adjustment of certain
forces, namely, the weight of the body, the action of muscles, and the
resistance of the bone. The most obvious cause of deviation of the
neck from the normal angle is some condition which causes softening
of the bone so that it yields under weight-pressure, the most common
being partial fractures, rickets, and other diseases of the bone.

#Coxa Vara--Incurvation of the Neck of the Femur.#--There may be a
simple adduction bend of the neck, the head sinking to, or even below,
the level of the great trochanter (Fig. 132); or this may be combined
with a curve of the neck, of which the convexity is upwards and
forwards, so that the lower border of the neck is greatly shortened
and the head approximated to the lesser trochanter. At the same time
the shaft of the femur is adducted and rotated outwards.

[Illustration: FIG. 132.--Rachitic Coxa Vara.

(Sir Robert Jones' case. Radiogram by Dr. Morgan.)]

_Adolescent Coxa Vara._--This, the most common clinical type, is met
with in boys between the ages of twelve and eighteen. The _unilateral_
form is nearly always the result of injury to the neck of the femur or
to the epiphysial junction, although the deformity may not show itself
for months or a year or two after the injury. The deformity may be the
first indication, or it is preceded by pain and stiffness; the patient
complains of being easily tired, of difficulty in kneeling and
sitting, difficulty in riding, and of an increasing limp in walking.
On examination, the limb is found to be shortened, the great
trochanter is displaced upwards and backwards and is unduly prominent,
and the muscles of the buttock and thigh are a little smaller and
softer than on the normal side. The limb is adducted, its normal range
of abduction, and sometimes also of flexion, is restricted, and there
is, as a rule, some degree of lateral rotation, so that the toes point
outwards. It should be noted that the same picture--shortening with
eversion and stiffness at the hip--results from the common fracture of
the neck of the bone in old people. The adduction element of the
deformity is partly compensated for by upward tilting of the pelvis on
the affected side and curvature of the spine with its concavity
towards the affected limb.

_When the condition is bilateral_ it is usually the result of disease
in the bone, rickets most frequently in this country. The attitude and
gait are highly characteristic, as the adducted and everted legs tend
to cross each other at the knee, the deformity being of the
scissors-like type (Fig. 134), and in extreme cases the patient is
only able to walk with the aid of crutches.

_Diagnosis._--Pain in the hip and a limp in walking suggest _hip-joint
disease_, but while in coxa vara the movements are chiefly restricted
in the direction of abduction, in hip disease they are restricted or
absent in all directions. From _congenital dislocation of the hip_
the diagnosis can usually be made by the history, the examination of
the joint and of its movements; and by the Trendelenburg test (p.
252). In _sacro-iliac disease_, the pain and tenderness are over the
sacro-iliac joint and the movements at the hip are free in all
directions. Valuable evidence is obtained from skiagrams.

_Treatment._--In the early stages, especially if there is pain and
tenderness, the patient must lie up and extension is applied in the
abducted position of the limb; after a fortnight or so recourse is had
to massage and exercises and the patient is allowed up for a little
each day, attention being paid to flat-foot, which is a common
accompaniment. When deformity is the prominent feature and interferes
with locomotion it must be corrected. The bloodless method is to be
preferred; under general anæsthesia, the shortened adductors are
stretched or divided, and forcible movements are carried out in all
directions, until the limb can be brought into an attitude of marked
abduction and internal rotation. A plaster-case is then applied, from
the pelvis to the middle of the calf, the knee being slightly flexed
for greater comfort; in a week or so the patient is able to go about,
and in a couple of months a second plaster-case is applied, this time
leaving the knee free. After another six weeks or so a moulded splint
is used, which can be removed at bedtime. The traumatic forms can
nearly always be corrected by this bloodless method. In advanced cases
the deformity can only be corrected by open operation, which consists
in dividing the femur obliquely downwards and medially through the
great trochanter, and, the adductor muscles having been ruptured or
divided, the limb is put up in the abducted position along with, if
required, powerful weight extension.

[Illustration: FIG. 133.--Coxa Vara, showing adduction curvature of
neck of femur associated with arthritis of the hip and knee.]

[Illustration: FIG. 134.--Bilateral Coxa Vara, showing scissors-leg
deformity.]

In cases of traumatic origin--epiphysial separation--Sprengel has
obtained good results by forcibly abducting and internally rotating
the limb under an anæsthetic, and then applying a plaster-case which
extends down to the knee.

#Other Forms of Coxa Vara.#--In _rickety children_, coxa vara is most
often associated with pronounced eversion of both lower extremities,
without the capacity for abduction being necessarily restricted, and
with but little impairment of function. The child should be treated
for rickets, and put up in a double long splint with the limbs
abducted and inverted.

In _arthritis deformans_ of the hip, it is not uncommon to have
considerable depression of the head of the bone and diminution in the
angle of its neck, with consequent restriction of abduction. Sometimes
the upper end of the shaft is also curved.

In _osteomyelitis fibrosa_, involving the upper end of the femur, a
gross form of coxa vara may be observed, of which a marked example is
shown in figures on pp. 476, 478, Volume I.

The _congenital variety_ of coxa vara is due to various intra-uterine
conditions, of which the chief is defective development of the upper
end of the femur; as it does not manifest itself until the child
begins to walk, the resemblance to congenital dislocation of the hip
is very close.

#Coxa Valga.#--Coxa valga is the reverse of coxa vara, the angle at
the neck of the femur being over 140°. It is not nearly so important
in practice as coxa vara. It may result from incomplete fractures or
epiphysial separations, rickets, or various forms of osteomyelitis,
but it is also a frequent accompaniment of other deformities, such as
congenital dislocation of the hip and paralysis following anterior
poliomyelitis. It is commoner in boys than in girls, and is more often
single than bilateral. The limb is lengthened, abducted, and rotated
outwards; there is flattening of the buttock, and the trochanter is
depressed so that it lies below Nélaton's line. The patient is unable
to adduct the limb, and shows a peculiar gait, which has frequently
caused the condition to be mistaken for unilateral congenital
dislocation at the hip.

In recent cases it may be possible under anæsthesia forcibly to adduct
the limb and rotate it inwards, and to retain it in this position with
a plaster bandage. In advanced cases the length of the limbs may be
equalised by a high sole on the sound side, or by performing an
osteotomy through the great trochanter.


THE REGION OF THE KNEE

#Congenital dislocation# at the knee-joint is rare; it is usually
incomplete, and the patella is sometimes absent. The dislocation may
be permanent, or may only occur from accidental movements of the limb.
In some cases it can be produced at will by the patient or the
surgeon. We have observed one such case in a professional cyclist in
whom this capacity of partially dislocating the knee entailed no
disability. When the child begins to walk, an apparatus which will
prevent hyper-extension and lateral motion should be fitted to the
limb.

#Congenital absence of the patella# usually complicates other
abnormalities of the knee-joint. The tubercle of the tibia is
prominent and the extensor tendon unusually thick. In flexion the
tendon rises on to the lateral condyle of the femur.

#Congenital Dislocation of the Patella Laterally.#--This may be
persistent or intermittent. In the _persistent form_ the dislocation
is present from birth; the patella rests on the trochlear surface of
the lateral condyle, and when the knee is flexed may pass farther
outwards and become completely dislocated, lying against the lateral
aspect of the condyle.

In _the intermittent_ or _recurrent_ form the patella lies in its
normal place, but is liable to be displaced outwards when the joint is
flexed; the displacement occurs suddenly and unexpectedly in walking,
and the patient may fall to the ground, suffering intense pain. The
knee-cap is readily replaced on extending the joint, but the sprain of
the joint is followed by effusion, and the patient is usually disabled
for a day or two. It is met with chiefly in girls, and there may be a
history that the child was late in walking and learned with
difficulty. On examination, the patella is found to have an abnormal
range of movement outwards, although it cannot be completely
dislocated without considerable pain. If the child is brought for
advice when there is fluid in the joint, the condition is liable to be
mistaken for tuberculous synovitis. The observation that the undue
mobility of the knee-cap is present in both knees is of assistance in
arriving at a diagnosis, and also the history that the girl has
repeatedly hurt her knee in falling.

The cause of the abnormal mobility of the patella varies in different
cases; in some there is congenital laxity of the ligaments, in others
a faulty formation of the lower end of the femur. Bade has observed
families in which several children were affected, and although there
was nothing abnormal in the shape of the bones, the knee was slender
and delicately formed.

The use of a strong knee-cap may prevent falling, but as a rule an
operation is required, and there is quite a number to choose from, the
principle of them all being to prevent displacement of the bone
without unduly restricting flexion of the joint. That devised by
Goldthwait consists in exposing, by means of a vertical incision, the
whole length of the patellar ligament, splitting it longitudinally,
separating the lateral half from the tibia, passing it under the
medial portion and suturing it to the periosteum; this gives the
quadriceps a straight line of pull. We have achieved the same result
by dividing the lax capsule and synovial membrane on the medial side
of the patella, and overlapping the edges with a double line of catgut
sutures.

Lateral dislocation of the patella is met with in extreme forms of
_knock-knee_, and after correction of this deformity by osteotomy, and
its possible occurrence should be guarded against at the time of the
operation.

#Genu Recurvatum.#--In this deformity the knee is hyper-extended, the
thigh and leg forming an angle which is open forwards; the attitude
may be permanent or may only appear on walking. It is an extremely
disabling and unsightly deformity.

There are several varieties. In the _congenital form_, which is
apparently due to a faulty attitude of the lower extremities _in
utero_, the patella may be imperfectly developed or absent; the knee
is convex backwards, and attempts to flex the joint cause pain. Other
deformities frequently coexist. The treatment consists in flexing the
joint to a right angle under an anæsthetic, and maintaining this
attitude by means of plaster-of-Paris or splints until the growth of
parts overcomes any tendency to relapse.

_Acquired Forms._--The most common acquired form is the result of
anterior poliomyelitis, and is described in the next section.

The deformity may also be due to rickets which has caused a backward
bend of the tibia immediately below its upper epiphysis--sometimes
combined with an exaggerated forward curve of the femur. If there is
no prospect of spontaneous rectification, the upper end of the tibia
should be divided with the osteotome, and the limb straightened.

It may result also from fracture or from separation of one of the
epiphyses in the region of the knee, or from cicatricial contraction
of the quadriceps. As a result of bone and joint disease, it is met
with chiefly in neuro-arthropathies when the knee has become
disorganised and flail-like.

#Deformities of the Knee resulting from Anterior Poliomyelitis and
from Spastic Paralysis.#--When there is paralysis of all the muscles
acting on the knee, the joint may be so flail-like that the patient is
unable to stand without the aid of a crutch, or when weight is put on
the limb, it assumes the attitude of genu recurvatum. The usefulness
of the limb may be improved by the application of a rigid apparatus
with a lock at the joint so that it can be used in the extended
position for walking or in the flexed position for sitting. The rigid
knee produced by arthrodesis affords good support but is inconvenient
in sitting.

When the _quadriceps alone_ is paralysed, the patient is obliged to
maintain the joint in the position of extreme extension, because the
least degree of flexion results in the limb giving way under him. In
course of time the posterior ligament is stretched, and the joint
becomes hyper-extended, acquiring the attitude of _genu recurvatum_.
When it is bilateral the gait is seriously impaired. The treatment
consists in applying an apparatus which prevents hyper-extension, in
improving the condition of the thigh muscles, and in wearing a splint
at night which secures the flexed position. Recourse may be had to
operative measures, such as transplanting one of the hamstrings into
the patella, so as to compensate for the loss of power in the
quadriceps, arthrodesis, or supra-condylar osteotomy of the femur.

When the quadriceps is overcome by a _contraction of the hamstrings_,
as in spastic paraplegia, the knee is fixed in the flexed position and
the child is unable to walk. The flexion may be corrected by
lengthening the hamstring tendons, bringing the divided biceps tendon
through an opening in the vastus lateralis, and attaching it to the
rectus and to the patella. If there is a combination of flexion and
genu valgum, the knee-joint should be resected and ankylosed in the
straight position.

#Contracture and Ankylosis at the Knee.#--In addition to the different
paralytic forms above described, contracture may result from
ulceration and suppuration in the popliteal space, and from disease
(osteomyelitis) in one of the adjacent bones. The greater number of
contractures and ankyloses are the result of disease in the joint, and
have already been described.


GENU VALGUM AND GENU VARUM

In the normal limb, a line drawn from the centre of the head of the
femur to a point midway between the malleoli passes through the
centre of the knee-joint. If the line passes outside the centre of the
knee-joint, the condition is one of genu valgum; if inside, it is one
of genu varum (Fig. 135).

[Illustration: FIG. 135.]

#Genu Valgum--Knock-knee.#--In this deformity the leg joins the thigh
at an angle which is open outwards, and when the affection is
bilateral, the projecting knees tend to knock against each other in
walking; the term X-legs is sometimes applied to it.

_Etiology._--The observations of Macewen and of Mikulicz, and
information afforded by the Röntgen rays, have shown that the primary
cause of the deformity is an inequality of growth at the ossifying
junction of the femur or tibia or of both. This inequality of growth
is nearly always due to rickets, and its direction is determined by a
faulty attitude of the limbs in standing and walking. The legs being
abducted, the weight of the body falls unequally on the medial and
lateral parts of the ossifying junctions, and inequality of growth
results.

_Pathological Anatomy._--Examination of the femur usually shows that
the lower third of the diaphysis is lengthened on its medial side and
shortened on its lateral side, and that the epiphysis, itself
unaltered, is fitted on to the diaphysis obliquely, so that the medial
condyle appears to be increased in length and to occupy a level
distinctly below that of the lateral condyle. In many cases the tibia
shows corresponding alterations. On section of the bones, the
epiphysial cartilage and the zone of ossification are found to be
unduly broad and irregular.

[Illustration: FIG. 136.--Female child with right-sided Genu Valgum,
the result of Rickets. The pelvis is tilted, and the spine is curved.]

The neck of the femur is shortened and its angle diminished. The bones
of the leg are sometimes bent inwards in their lower thirds, and this
compensates partly for the valgus deformity at the knee. The articular
cartilage of the lateral condyle and the lateral meniscus are usually
thickened. In pronounced cases the quadriceps tendon and the patella
are displaced laterally, and this may be so pronounced that on flexion
of the joint the patella is dislocated on to the lateral condyle of
the femur. The biceps tendon and ilio-tibial band are shortened and
more prominent as a result of the approximation of their attachments,
and they are also displaced laterally. The sartorius and gracilis are
displaced backwards, so that they descend behind instead of on the
medial side of the knee. The popliteal artery lies on the back of the
lateral condyle instead of in the hollow between the condyles, and the
tibial (internal popliteal) nerve is displaced even farther outwards.
The capsular and other ligaments are slack, so that the joint is
unstable and easily hyper-extended. There is often some effusion into
the joint.

[Illustration: FIG. 137.--Female child with Rickety deformities of
upper and lower extremities.

(Mr. D. M. Greig's case.)]

_Radiograms_ reveal the changes in the bones (Fig. 138); the shaft of
the femur or tibia, or both, which may also be curved, is set
obliquely on its epiphysis; and the clear zone, corresponding to the
epiphysial cartilage, is uneven and broader than normal. There are
also less obvious changes in the density of the shadow and in the
arrangement of the trabecular structure of the bones.

[Illustration: FIG. 138.--Radiogram of case of Double Genu Valgum in a
child æt. 4.]

_Clinical Features._--In the infantile form (Fig. 139) the knock-knee
is commonly associated with rickets in other parts of the skeleton,
and especially with bending of the tibia and femur, and in extreme
cases the child may be unable to walk.

[Illustration: FIG. 139.--Genu Valgum in a child æt. 4. Patient
standing.]

The deformity is about as frequently bilateral as unilateral. There
may be knock-knee on the one side and bow-knee on the other. If, as is
usually the case, the deformity is due to obliquity of the femur, it
disappears on flexing the joint (Fig. 140), because in flexion the
tibia glides behind the projecting median condyle; if the deformity
affects the tibia only, the influence of flexion in disguising it is
not so marked. It is usually possible to hyper-extend the joint, and,
in the extended position, to rotate the leg outwards to a greater
extent than is normal. In unilateral knock-knee, the affected limb is
a little shorter than its fellow, but the patient compensates for this
by depressing the pelvis on the affected side.

[Illustration: FIG. 140.--Genu Valgum. Same patient as Fig. 139.
Sitting, to show disappearance of deformity on flexion of knee.]

_Prognosis._--In children below the age of six, the bones naturally
tend to straighten if the child is kept off its feet. After this age,
there is no such prospect.

The _treatment of knock-knee in children_ is directed towards curing
the rickets and preventing the child from putting its feet to the
ground. If it cannot have the services of a nurse and the use of a
perambulator, a light padded splint is applied on the lateral side of
the limb, extending from the iliac crest to 3 inches beyond the foot.
The splint is fixed above and below by bandages, and the projecting
knee is drawn towards it by a few turns of elastic webbing. A method
specially applicable to hospital out-patients, is to straighten the
limbs as far as possible under anæsthesia, and apply a plaster
bandage; the bandage is renewed at intervals of three weeks until the
deformity is corrected. Whatever plan is adopted, it must be
persevered with for at least six months, until the rickety changes in
the bones have been entirely recovered from.

If the child is approaching the age of five or six before it comes
under treatment, or if the deformity does not yield to treatment by
splints, it is better to straighten the limb by _osteotomy_.

In _adolescent knock-knee_ the patient seeks advice because of the
deformity or of pain after exertion, especially at the medial side of
the epiphysial junctions, of being easily tired, and of incapacity for
any occupation involving standing. The bones are coarse and badly
formed, and there is frequently a spinous process projecting downwards
from the medial side of the tibia about three finger-breadths below
the joint.

When the deformity is bilateral, the patient abducts the thigh and
rotates the limb outwards at the hip to disguise the deformity, and to
allow the projecting knees to pass each other. He usually supinates or
inverts the foot, with the object of bringing the whole length of the
lateral border of the sole into contact with the ground. Flat-foot is
exceptional. The boots are usually more worn along the lateral than
along the medial border of the sole and heel.

No apparatus that allows of the patient walking is of any value. If
the deformity is marked, there should be no hesitation in having
recourse to operation by one or other of the various methods of
osteotomy.

In severe cases it may be found that when the deformity is corrected
by osteotomy, the patella shows a tendency to be dislocated laterally
on flexion of the knee. This may be prevented by putting up the limb
in the attitude of slight genu varum.

The most difficult cases to treat are those in which, owing to curving
of the lower part of the shaft of the femur with the convexity
forwards, the knee is permanently flexed and cannot be completely
extended.

#Other forms of genu valgum# are relatively rare. There is a
congenital form arising from faulty position of the limbs _in utero_;
a traumatic form following fracture or epiphysial separation in the
region of the knee; and a paralytic form, usually combined with
flexion, in cases of spastic paralysis. Finally, genu valgum may be a
result of various forms of osteomyelitis of the lower end of the
femur, or of disease in the knee-joint, such as tuberculosis,
arthritis deformans, or Charcot's disease.

#Genu Varum--Bow-knee.#--In this deformity, which is the converse of
genu valgum, the leg joins the thigh at an angle which is open
medially. It is almost invariably bilateral, is of rachitic origin,
and is frequently associated with bow-legs (Fig. 141). The tibia takes
a greater share in its production than the femur. Although an ungainly
deformity, it is much less frequently the source of complaint than
knock-knee, because it scarcely interferes with locomotion--as a
matter of fact, the subjects of bow-knee, although short in stature,
are unusually sturdy on their legs. An extreme example of the
deformity is shown in Fig. 141.

[Illustration: FIG. 141.--Bow-knee in Rickety Child.]

Treatment is carried out on the same lines as in genu valgum.

#Rickety Deformities of the Bones of the Leg--Bow-leg.#--These
deformities are common in children; are nearly always bilateral and
symmetrical, and may be associated with knock-knee or bow-knee. They
may occur before the child is able to walk, the bones bending in the
attitude in which the limbs are habitually placed--over the nurse's
knee, for example, or as they are crossed underneath the child in
sitting. In children who are able to walk, the curve is due to the
weight of the body acting on the softened bones. In either case, the
bending may be increased by the traction of muscles, and sometimes by
the occurrence of greenstick fracture. The most common deformity is a
uniform curvature of the bones laterally and forwards, or a more
acute bend in the lower thirds of their shafts. In some cases the
chief curvature is forwards. The ungainliness in walking may be added
to by flat-foot. Backward curving of the upper end of the tibia has
been already described as one of the causes of genu recurvatum. The
most extreme deformities are met with in rickety dwarfs.

_Treatment._--Under the age of six, and particularly in children, who
are actively growing, the bones will probably straighten if the child
is treated for rickets and kept off his feet; well-padded lateral
splints are applied as recommended for knock-knee, and these should be
taken off at intervals for massage and douching. Above the age of six,
the choice lies between osteoclasis and osteotomy. In performing
osteotomy the bone is either simply divided or a segment is resected.
The fibula can usually be forcibly straightened, but may require to be
divided through a separate incision. In aggravated cases it may also
be necessary to lengthen the tendo Achillis.

The deformities of the bones of the leg in _inherited syphilis_,
_ostitis deformans_, and _osteomalacia_ have already been described.

#Congenital Deficiencies of the Bones of the Leg.#--The _tibia_ may be
absent completely or in part, more often on one side than on both
sides. In either case the leg is short and stunted, the knee is
flexed, the foot occupies the position of extreme equino-varus, and
the limb is useless. The extent of the defects is demonstrated by the
Röntgen rays. Among other defects with which it may be associated,
absence or deficient development of the patella is the most frequent.
When the upper end of the tibia is absent, the fibula articulates with
the lateral condyle of the femur. The operative treatment aims at
correcting the flexion at the knee, the equino-varus deformity of the
foot, and at substituting the fibula for the absent tibia. The
deficiency of the upper end may be compensated for by implanting the
head of the fibula between the condyles of the femur, and that at the
lower end by splitting the fibula so as to form a socket for the
talus. Amputation should be avoided, as even a dwarfed leg and foot
improves the service of an artificial limb. A modification of the
O'Connor extension boot may be employed.

The _fibula_ may be absent completely or in part. The clinical
appearances depend upon the condition of the tibia. When the tibia is
normal, the most notable feature is the absence of the lateral
malleolus, and the extreme valgus attitude of the foot. More commonly
the tibia makes a sharp forward bend just below its middle, and the
overlying skin presents a dimple or scar-like depression. This has
usually been regarded as an evidence of intra-uterine fracture, but
the observations of Hoffa suggest that both the bend of the bone and
the depression on the skin are due to pressure exercised upon the leg
from without by an amniotic band or adhesion. The leg fails to grow,
the deformity becomes more pronounced, and the toes become pointed. If
the tibia is markedly bent, it may be straightened by osteotomy; and
the tendons, Achillis and peronei, may require to be lengthened. If
the ankle is unstable as a result of the absence of the lateral
malleolus, it may be artificially ankylosed, or the lower end of the
tibia may be split vertically so as to make a socket for the talus. In
either case, the foot is placed in the equinus attitude to compensate
for the shortening of the leg. Deficiency of the tibia is frequently
associated with imperfect development of the great toe; deficiency of
the fibula with absence of the lateral toes and their metatarsal
bones.

_Volkmann's Supra-malleolar Deformity._--This condition, which is
closely allied to that just described, consists in a congenital
deficiency in the development of the bones of the leg, and especially
of the fibula, as a result of which the articular surface is oblique
and the foot deviates to one or other side. The foot usually occupies
a valgus position, the sole looking laterally, and only its medial
border coming into contact with the ground. It is treated by
supra-malleolar osteotomy.


THE FOOT

Various deformities are met with in the region of the ankle and
tarsus. The term "talipes" is commonly used to include all these, but
here it will be restricted to that form in which the heel is more or
less elevated, and the foot supinated so that it rests on its lateral
border--_talipes equino-varus_. In _pes equinus_ the foot is in the
position of plantar-flexion, and the patient walks on the toes. In
_pes calcaneus_ the foot is dorsiflexed so that the tip of the heel
comes in contact with the ground; this deformity may be combined with
eversion of the foot, _pes calcaneo-valgus_, or with inversion, _pes
calcaneo-varus_. When the instep is unduly arched, the terms _pes
cavus_, _pes arcuatus_ or _hollow claw-foot_ are employed; while loss
of the arch constitutes _flat-foot_, and eversion of the sole, _pes
valgus_.


CLUB-FOOT

#Talipes Equino-varus.#--This deformity may be congenital or
acquired.

#Congenital talipes equino-varus# (Fig. 142) is a common malformation
which is sometimes associated with other deformities, such as hare-lip
or spina bifida, and may be met with in several members of one family.
It is nearly twice as common in boys as in girls, and is slightly more
frequently bilateral than unilateral. Its etiology is obscure, and
various hypotheses have been put forward to account for it, but no one
is convincing. It may be pointed out, however, that the fœtal foot is
very easily moulded into abnormal attitudes by external pressure such
as might be exercised by the wall of the uterus when the liquor amnii
is deficient. In a number of cases there are indications of such
pressure over the bony prominences of the foot, in the shape of
circumscribed scar-like areas in which the skin is atrophied; and in
the infant, the intra-uterine position can be reproduced, thus
demonstrating its method of origin. The occurrence of club-foot in
several generations is alleged to support the Mendelian law.

[Illustration: FIG. 142.--Bilateral Congenital Club-foot in an
infant.]

_Pathological Anatomy._--In well-marked cases the foot presents a
concavity towards the medial side, the maximum point of the curve
being opposite the mid-tarsal joint. When the patient attempts to
stand, only the lateral border of the foot touches the ground, and the
weight is borne on the fifth metatarsal, the cuboid, and the greater
process of the calcaneus.

[Illustration: FIG. 143.--Radiogram of Bilateral Congenital Club-foot
in an infant.]

The individual tarsal bones, especially the talus and calcaneus, are
altered in shape as well as in their relations to one another and to
the tibio-fibular socket. The navicular and cuboid are rotated
medially around the anterior ends of the talus and calcaneus
respectively, and the tubercle of the navicular comes to lie close to
the medial malleolus. The lower third of the tibia is twisted medially
on its vertical axis.

The changes in the soft parts follow the general law that tissues
which are relaxed become shortened, while those that are put on the
stretch are lengthened. All the tissues on the medial, concave side of
the foot are shortened, the structures most affected being the medial
and the posterior ligaments of the ankle, and the inferior
calcaneo-navicular ligament. There is also shortening of the muscles
inserted into the tendo Achillis, and to a less extent of the tibiales
anterior and posterior. The extensor tendons on the dorsum are
displaced medially.

_Clinical Features._--_In children who have not walked_, the degree of
deformity varies, sometimes being very slight; in pronounced cases,
the foot is turned medially, and in that position forms a right angle
with the leg; the sole looks backwards and the medial border upwards.
The foot appears shortened because it is curved on itself, the heel is
narrower and more vertical than normal, the medial malleolus is
obscured by the approximation of the navicular, and the lateral
malleolus is unduly prominent.

In extreme cases, the supinated foot forms an acute angle with the
leg, and there is frequently a deep transverse depression across the
sole, the result of contraction of the plantar fascia--a feature which
is distinctive of the congenital form of club-foot.

_In children who have walked_, the deformity becomes aggravated. The
dorsum of the foot is markedly uneven, partly because of the
prominence of the individual tarsal bones, and especially of the head
of the talus and greater process of the calcaneus, and partly because
of a depression over the neck of the talus. Instead of resting on its
lateral border, the foot may finally rest on the dorsum, the sole
looking upwards and backwards. While the skin over the heel remains
comparatively thin and delicate, that covering the lateral border and
dorsum of the foot becomes the seat of callosities, beneath which
adventitious bursæ are formed. These bursæ are liable to become
inflamed, and are then a source of great suffering, and if they
suppurate may cause persistent sinuses. The muscles of the leg and
foot, although not paralysed, undergo atrophy from disuse. In walking,
the patient lifts one foot over the other in an ungainly and laborious
manner, without any spring, as if walking on stilts.

_In adults_, these features are further aggravated, and there are
permanent changes in the bones (Fig. 144).

[Illustration: FIG. 144.--Congenital Talipes Equino-varus in a man æt.
24; seen from behind.]

_Treatment._--This should be commenced as soon as the viability of the
infant is beyond question, as the younger the patient the more easily
and completely is the deformity rectified. Manipulations to correct
the deformity should be carried out twice or thrice daily, and the
limbs are also massaged and douched. At the end of two or three
months, assistance may be derived from the use of a simple lateral
poroplastic or aluminium splint with a foot-piece, or more simply by a
strip of rubber plaster. The foot is held in the over-corrected
attitude and the plaster is applied so as to maintain this attitude.
If this regime is systematically persevered with from within a few
days after birth, by the time the child begins to walk the sole can be
brought into contact with the ground, and the weight of the body will
aid in correcting the deformity. If the equinus element resists
correction, the tendo Achillis should be lengthened.

The turning in of the toes may be overcome by strapping the feet at
night to a wooden board with the whole lower limb rotated laterally so
that the toes of each foot point directly outwards. On account of the
tendency towards relapse, the manipulations and massage must be
persevered with for at least a year.

_Tenotomy and Forcible Correction under Anæsthesia._--In more severe
cases we have to deal not only with the contracted soft parts, but
with changes in the bones resulting from their having grown in
adaptation to the deformed attitude. The majority of surgeons defer
operative measures until the child is about a year old.

The soft parts to be divided are the tendo Achillis, the medial and
posterior ligaments of the ankle, the plantar fascia, the
calcaneo-navicular ligaments, and the tibialis posterior tendon. The
varus deformity may then be corrected by laying the foot on its
lateral side on a padded triangular wooden block, and pressing
forcibly on the anterior and posterior ends of the foot so as to undo
the curve on its medial side and allow of abduction of the foot; this
is usually attended with cracking as the shortened ligaments give way.
The equinus element is next dealt with by forcibly dorsiflexing the
foot until the deformity is over-corrected. If it is preferred to
correct the deformity in stages instead of at one sitting, the equinus
element is left to the last. In older children, the strength of the
hands is usually insufficient to stretch the tissues, and mechanical
wrenches may be employed, such as those devised by Thomas, Bradford,
or Lorenz.

_Resection of a wedge from the tarsus_ (Davies Colley, 1876) is
reserved for the most severe cases in which the shape and rigidity of
the bones prevent correction of the deformity by any other means. The
base of the wedge is on the lateral aspect, and the bone removed
includes parts of the calcaneus, cuboid, talus, and navicular.

_Removal of the talus_ is an alternative operation to resection of the
tarsus, and may yield equally good results.

In children, before the tarsal bones have become completely ossified,
Ogston's method yields good results; instead of removing a wedge from
the tarsus, the osseous nucleus of each bone is gouged out, leaving
the cartilaginous shell. In this way the intertarsal joints are not
interfered with, and the cartilaginous tarsus can be moulded so that
when ossification is completed the bones differ but little from the
normal.

After any of these operative procedures, manipulations, massage,
exercises, electrical stimulation of the muscles, and the wearing of
some apparatus must be persevered with for at least twelve months.
Failures are due to not sufficiently over-correcting the deformity in
the first instance, and to neglect of after-treatment; in hospital
practice it is difficult to ensure continuous supervision over long
periods.

Finally, _amputation_ may be called for when other methods have
failed, and the patient is unable to put the foot to the ground
because of suppurating bursæ and ulceration of the skin.

#Acquired Talipes Equino-varus.#--In the great majority of cases this
condition results from anterior poliomyelitis. It especially affects
the peronei and the extensors of the toes, and is unilateral. The
patient is unable to dorsiflex and abduct the foot, which hangs with
the toes pointed and the sole turned medially.

At first the joints are flaccid, and the attitude can easily be
corrected by manipulation. In course of time, however, the opposing
muscles--those inserted into the tendo Achillis, the tibialis
posterior, and the long flexors of the toes--become shortened, and
there is secondary contraction of the plantar fascia and of the
ligaments on the medial side of the foot, and the deformity is thus
rendered permanent. The bones also are altered in their shape and
mutual relations, the talus being rotated forwards so that a large
portion of its trochlear surface protrudes from the tibio-fibular
socket. The skin is cold and livid, and readily suffers from pressure
sores. The whole limb is ill-developed, and may be shorter than its
fellow, and the paralysed muscles are wasted and exhibit for a time
the reaction of degeneration.

A similar deformity may result from section of the peroneal (external
popliteal) nerve, from the peroneal form of progressive muscular
atrophy, and from peripheral neuritis.

The _treatment_ of paralytic equino-varus, short of operation, has
been referred to under anterior poliomyelitis (p. 242). If tendon
transplantation is indicated, the tendon of the tibialis anterior is
attached to the cuboid, and a strip of the tendo Achillis to the
dorsal aspect of the tarsus. Jones displaces the tibialis anterior
into the base of the fifth metatarsal.

If the paralysis is widely distributed, and the joints are flail-like,
it is better to ankylose the ankle and mid-tarsal joints. It may be
necessary to divide in several places the plantar fascia and other
structures that have undergone secondary shortening.

As using the limb hastens the restoration of function, the child
should be got on to his feet as soon as possible.

The spastic form of talipes equino-varus is comparatively rare. The
plantar flexors and invertors distort the foot into the equino-varus
attitude. The heel is drawn up, the anterior part of the foot is
adducted and inverted at the mid-tarsal joint. The muscles are tense
and rigid, and the reflexes exaggerated. The condition is frequently
bilateral, and is often associated with other deformities of the lower
limb and with a characteristic spastic gait. Considerable improvement
may be brought about by lengthening the tendons of the shortened
muscles. In severe cases it may be necessary to resect a portion of
the tarsus.

The occurrence of #varus without equinus# is so exceptional as not to
call for separate description.

#Pes Equinus.#--This deformity, in which the foot is in the position
of plantar-flexion with the heel drawn up and the toes pointed, is
nearly always acquired as a result either of poliomyelitis or of
spastic paralysis. In typical cases the patient walks on the balls of
the toes (Fig. 145). It is seldom met with as a congenital condition.
Occasionally it is due to nerve lesions such as peripheral neuritis,
or to injuries and diseases in the region of the ankle, when the foot
has been allowed to remain for long periods in the attitude of
plantar-flexion. In a limited number of cases the equinus attitude is
assumed to compensate for shortening of the limb.

[Illustration: FIG. 145.--Bilateral Pes Equinus in a boy æt. 7, the
result of Spastic Paralysis.]

In _poliomyelitis_ the deformity is most often unilateral (Fig. 146),
while in _spastic paralysis_ it is frequently bilateral (Fig. 145),
and is usually accompanied by excessive arching of the foot--pes
cavus--as a result of plantar-flexion at the mid-tarsal joint, and
hyper-extension of the first phalanges and plantar-flexion of the
second and third phalanges of the toes--"clawing of the toes."

[Illustration: FIG. 146.--Extreme form of Pes Equinus in a girl æt. 8,
the result of Anterior Poliomyelitis.]

_Clinical Features._--In the mildest cases the patient is able to
bring the foot to a right angle. In average cases the heel is raised
off the ground, and the foot rests on the balls of the toes. In
extreme cases, and especially when the extensors are completely
paralysed, the toes may be flexed towards the sole, and the weight is
borne on the dorsum of the foot (Fig. 146). The patient suffers from
painful corns and callosities, and from inflammation of bursæ which
form over the points of pressure. When unilateral, the patient
compensates for the lengthening of the limb by flexing the knee and
throwing the limb outwards in walking. In severe cases, especially
when both limbs are affected, the patient may be dependent on
crutches.

The talus projects on the dorsum, the anterior part of its trochlear
surface escapes from the tibio-fibular socket, and the calcaneus is
drawn up so that it comes into contact with the bones of the leg (Fig.
147).

[Illustration: FIG. 147.--Skeleton of Foot from case of Pes Equinus
due to Poliomyelitis.]

Shortening of the soft parts affects chiefly the muscles inserted into
the tendo Achillis, the posterior ligament, and posterior parts of the
lateral ligaments of the ankle. The fasciæ, ligaments, and muscles of
the sole of the foot are also shortened. The flexors of the toes, the
tibialis posterior, and the peroneus longus are shortened to a less
degree.

_Treatment._--Of all the deformities of the foot, pes equinus is that
most easily rectified. In recent cases a great deal may be done by
regular manipulations, and by the wearing of some corrective splint or
apparatus between times.

In well-marked cases it is necessary to lengthen the shortened
structures, and especially the tendo Achillis. When the equinus is
corrected, the excessive arching of the foot (pes cavus) and the
clawing of the toes usually disappear, but it may be necessary to
lengthen the flexor tendons, especially that of the great toe, and
also the plantar fascia.

Jones divides the tendo Achillis and the flexors of the toes
subcutaneously, and maintains the dorsiflexion by excising an oval
flap of skin from the front of the ankle.

In aggravated cases, the bones must be attacked, for example by
excising the talus. Arthrodesis of the ankle alone or along with the
mid-tarsal joint may be indicated when these joints are flail-like.
Amputation is reserved for cases which are otherwise hopeless, such as
that shown in Fig. 147.

When the deformity is compensatory to shortening of the limb, it is
usually said to be a mistake to correct the equinus. Experience shows,
however, that in young patients growth is stimulated by walking on the
limb after the deformity has been corrected; the sole of the boot is
then raised to the necessary extent.

#Pes Calcaneus.#--In this deformity the foot is dorsiflexed at the
ankle-joint. It is sometimes combined with eversion of the foot--_pes
calcaneo-valgus_, or with inversion--_pes calcaneo-varus_.

Pes calcaneus may be congenital or acquired. In the _congenital form_
the deformity is frequently bilateral. There is dorsiflexion at the
ankle-joint, and if an attempt is made to flex the foot towards the
sole, the extensor tendons stand out prominently. In marked cases the
long axis of the calcaneus is vertical, the tendo Achillis lies in
close contact with the tibia, and the hollows on either side of the
tendon are absent. The peronei are displaced from their grooves, and
may lie in front of the lateral malleolus.

Corrective manipulations are commenced within a few days after birth,
and a malleable splint is worn between times. When the child begins to
walk there is a natural tendency towards recovery. In severe cases it
may be necessary to lengthen the contracted tendons--the extensor
digitorum, the extensor hallucis, and, it may be also, the peroneus
tertius and tibialis anterior; the tendo Achillis may require to be
shortened.

In the _acquired form_, the appearances are different, because the
anterior part of the foot is usually flexed towards the sole, thus
disguising to a certain extent the dorsiflexion at the ankle. This
form is nearly always due to poliomyelitis, but it may also result
from accidental division of the tendo Achillis. The anterior part of
the foot is flexed towards the sole by the contraction of the plantar
fascia and short muscles of the sole, the balls of the toes are
approximated to the heel, and a deep transverse groove is formed in
the sole opposite the mid-tarsal joint. The deformity presents a
combination of the hollow foot--pes cavus--with pes calcaneus, and
resembles that of a Chinese lady's foot. The foot rests on the heel
and on the balls of the great and little toes, the sole of the foot
being so deeply hollowed that even the lateral border does not touch
the ground.

In paralysis of the calf muscles alone, the tendons of the peronei or
flexor digitorum longus may be divided and stitched to the calcaneus,
to take the place of the tendo Achillis. If the calf muscles are not
completely paralysed and the tendo Achillis is merely stretched, this
tendon may be shortened by splitting it longitudinally and making the
ends overlap, or its insertion may be displaced downwards. When the
ankle is flail-like, it may be necessary to perform arthrodesis.

Jones gets rid of the cavus deformity by resecting a wedge with its
base towards the dorsum from the middle of the tarsus; the foot is
then placed in a position of extreme calcaneus, the dorsum coming into
contact with the front of the leg. Four weeks later a wedge is taken
from the posterior part of the talus large enough to bring the foot
down to a right angle with the leg; the articular surfaces of the
tibia and fibula being denuded of cartilage, ankylosis takes place in
a good position.

#Pes Calcaneo-valgus.#--This deformity, which consists in a
combination of dorsiflexion at the ankle and eversion of the foot, is
as common as pure calcaneus (Figs. 148 and 149); the heel is
depressed, the sole looks laterally, and its medial border is convex.
Although it may be congenital, it is usually acquired as a result of
poliomyelitis. The calf muscles are paralysed while the peronei retain
their power, and, along with the tibialis anterior and the extensors
of the toes, become secondarily contracted. Treatment is conducted on
the same lines as in pes calcaneus, and the valgus may be controlled
by implanting the peroneus brevis into the navicular.

[Illustration: FIG. 148.--Pes Calcaneo-valgus with excessive arching
of foot.]

[Illustration: FIG. 149.--Pes Calcaneo-valgus, the result of
Poliomyelitis.]

#Pes Calcaneo-varus.#--In this rare deformity the heel is depressed
and the sole of the foot looks inwards.

#Pes Cavus.#--In this deformity, which is known also as _hollow
claw-foot_, _pes arcuatus_, or _pes excavatus_, the longitudinal arch
of the foot is exaggerated as a result of the approximation of the
balls of the toes to the heel (Fig. 150). It is most frequently met
with as an addition to pes equinus or pes calcaneus of paralytic
origin, and has already been described. There is a mild form which is
congenital, and which is quite independent of paralysis; another
variety occurs in diseases of the spinal cord, such as Friedreich's
ataxia.

The name hollow claw-foot appropriately indicates the clinical
appearances. The arch is exaggerated and the instep abnormally high;
there is hyper-extension of the toes at the metatarso-phalangeal
joints, and plantar-flexion at the inter-phalangeal joints; the
plantar fascia and muscles are shortened. The footprint shows that
neither border of the foot touches the ground. The patient complains
of pain in the instep, of painful corns over the heads of the
metatarsal bones, and of difficulty in getting properly fitting
boots.

_Treatment_ should first be directed towards the equinus or calcaneus
element of the deformity, for if these are corrected the cavus
condition tends to disappear. Exercises and massage should be
persevered with, and boots without heels should be worn. The
contracted structures in the sole may require to be divided, either
subcutaneously or by the open method, as a preliminary to forcible
correction, and the hallucis tendon may be brought through the head of
the first metatarsal. In aggravated cases the talus and the heads of
the metatarsal bones may be excised.


FLAT-FOOT--PES PLANUS AND PES VALGUS

Flat-foot or splay-foot is that deformity in which there is loss of
the arch, and the foot tends to be pronated and abducted. The term
_pes planus_ is applicable when there is merely loss of the arch; _pes
valgus_ when the foot is pronated and the sole looks laterally. Of all
deformities of the foot, flat-foot is the one for which advice is most
frequently sought; it is also a common complication of other
disabilities of the foot and of the lower extremity. It is usually
bilateral, and is about twice as common in the male as in the female.
Various types are met with; they are known according to their cause,
as static, congenital, traumatic, paralytic, rachitic, rheumatic,
arthritic, 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 the
changes in the bones in Pes Cavus.]

#Static or Adolescent Flat-foot.#--This, by far the most common and
important variety (Fig. 152), generally develops between the ages of
fourteen and twenty. It is called static because the essential factor
in its production is a disproportion between the weight of the body
and the supporting power of the arch of the foot.

[Illustration: FIG. 152.--Adolescent Flat-foot.]

It is met with in rapidly growing children or adolescents of feeble
muscular development and with long narrow feet, and those especially
who, after leaving school, begin some occupation which entails much
standing--such as that of a factory hand, message boy, or domestic
servant. To enable him to stand with the least effort for long
periods, the patient adopts an attitude which makes little demand on
the muscles, and throws nearly all the strain of the body weight on
the ligaments and bones of the feet. This, which has been called "the
attitude of rest," consists in standing with the limbs apart, the
knees slightly flexed, the legs slightly rotated laterally at the
knee, and the feet pronated, with the toes pointing laterally. The
most important local factors predisposing to flat-foot are weakness of
those muscles which normally support the ankle and the tarsal arches,
especially the tibiales; weakness of the ligaments of the foot; and
softness of the tarsal bones. When these conditions are present and a
faulty method of standing and walking is adopted, the undue strain to
which the tendons and ligaments are exposed results in their being
stretched; the bones are altered in position, and flat-foot results.
The head of the talus is displaced medially, and is protruded between
the calcaneus and navicular, tending to separate them from one
another, stretching the inferior calcaneo-navicular ligament and
causing the anterior part of the foot to be abducted. The plantar
ligaments--especially the inferior calcaneo-navicular--are stretched
and lengthened. In something like 80 per cent. there is the combined
deformity--pes plano-valgus--in those who apply for treatment.

[Illustration: FIG. 153.--Flat-foot, showing loss of arch.]

_Clinical Features._--The patient complains of being easily tired, and
of pain in the foot after walking or standing. There is generally more
pain before the appearance of the deformity than when it has
developed, and at this stage it is not so easily recognised, and is
apt to be called "rheumatism." The most common seat of pain is at the
medial border of the foot behind the tubercle of the navicular, and
this is due to stretching of the inferior calcaneo-navicular ligament.
Pain is also complained of in the middle of the dorsum across the
instep, from stretching of the interosseous ligaments. Later, there is
pain over the greater process of the calcaneus in front of the lateral
malleolus, from these bones coming into contact. There may be
nocturnal cramp in the muscles of the leg and foot.

The faulty attitude of the foot in standing and walking is usually
evident. The foot appears longer and broader than normal, and when the
body weight is put on it, it spreads out with the toes extended until
the entire sole is in contact with the ground. In advanced cases, the
medial border of the foot may be actually convex. Below and in front
of the prominent medial malleolus, the head of the talus forms a
rounded eminence, and a little farther forwards and lower still is the
projection of the tubercle of the navicular. The eversion of the foot
as a whole is best seen from behind; if the central axis of the leg is
prolonged downwards, it approaches the medial border of the heel
instead of passing through its centre; or, stated differently, instead
of the axis of the calcaneus being a continuation of that of the leg,
it deviates laterally and the medial malleolus is abnormally
prominent. When the eversion is more pronounced, the sole looks
laterally and the tendons of the peronei stand out in relief. The
anterior part of the foot is displaced laterally. Flat-foot is
frequently associated with stiff great toe; the patient having lost
the power of dorsiflexing the toe, the first phalanx and first
metatarsal are in a straight line, instead of forming an angle open
towards the dorsum.

The muscles of the leg are flabby and poorly developed. When the
patient is seated and asked to move the foot in different directions,
there is a characteristic stiffness, ungainliness, and restriction in
the range of movement. The feet are usually cold and sweat
excessively. The gait is slouching, and there is a want of spring and
elasticity. The lengthening of the foot results in the tendons,
especially the flexors, being too short, hence hammer-like contraction
of the toes may be brought about. The boots, after being worn, show a
bulging of the instep towards the sole, greater wearing away of the
sole along the medial border, and, when there is stiff great toe, an
absence of the transverse crease on the dorsum opposite the balls of
the toes. Footprints may be obtained by wetting the soles of the feet.
The print of a normal foot shows only the heel, the lateral border of
the foot, and the balls and tips of the toes. In flat-foot the medial
border appears in the print to a greater or less extent (Fig. 154). If
a record is wanted to estimate the progress of treatment, the sole of
the foot is painted with a 5 per cent. solution of ferro-cyanide of
potassium, and the patient stands on paper painted with the liquor of
the perchloride of iron diluted one-half; the print appears dark blue
on a yellow ground.

[Illustration: FIG. 154.--Imprint of Normal and of Flat Foot.]

_Skiagrams_ are useful for showing displacement of bones and
differences between sitting and standing, and for recording the
results of treatment.

_Prophylaxis of Flat-foot._--Stress is to be laid on a supervised
training of the whole muscular system, and especially of that of the
legs. In walking and standing, the feet should be kept parallel and
not pointed outwards, as was formally taught in schools of gymnastics
and insisted upon by drill instructors. Children should be taught to
walk properly, rising on the balls of the toes with each foot in
succession. Attention should also be directed to the boots, which
should be so fashioned that the medial side of the boot is kept
straight and the end of the boot is opposite the big toe.

_Treatment._--This is directed towards restoring and maintaining the
arch of the foot. As the measures adopted necessarily vary with the
extent to which the condition has progressed, it is convenient for
purposes of treatment to recognise the following four degrees. A first
degree, in which the arch reappears when the weight is taken off the
foot or the patient rises on the balls of the toes; a second, in which
the normal attitude can be restored by manipulation; a third, in which
this is only possible under anæsthesia; a fourth, in which the bones
are so displaced and altered in shape that correction is impossible
without operation.

_Cases of the First Degree._--If there is marked pain and tenderness,
the patient must lie up. The general health is improved by a
nourishing diet and by cod-liver oil and tonics; and the legs and feet
are douched and massaged thrice daily. When pain and tenderness have
disappeared, the patient is instructed how to walk and exercise the
feet. In walking, the medial edges of the feet should be parallel with
one another, first the heel should touch the ground and then the balls
of the toes. He should neither stand nor walk long enough to cause
fatigue, and in standing he should alter the attitude of the feet from
time to time, and occasionally rise on the balls of the toes. The
following exercises, devised by Ellis of Gloucester, should be
practised: (1) Rising on the balls of the toes, the toes being
directed straight forwards; (2) rising on the balls of the toes, with
the points of the great toes touching each other, and the heels
directed out, so that the medial borders of the feet meet in front at
a right angle; (3) in the same attitude, after rising on to the balls
of the toes, the knees are flexed and then extended before the heels
descend again; (4) while seated in a chair, one leg crossed over the
other, circumduction movements of the foot are carried out; (5) while
standing, the medial border of the foot is raised off the ground
several times, then the patient walks to and fro on the lateral border
of the foot, and in the same attitude lifts one foot over the other.
These exercises should be carried out slowly and deliberately, with
the feet bare, and they should be carefully supervised until the
patient thoroughly understands what is aimed at. The movements should
be performed a definite number of times at regular intervals, but
should not be pushed so as to cause pain or fatigue. The patient
should be fitted with well-made lacing boots, with the heel and sole
raised about half an inch on the medial side so that the foot rests
mainly on its lateral border. The additional leather, which can be
applied by any bootmaker, is in the form of a wedge, with its base to
the medial side, one on the sole and one on the heel. The wedge fades
away towards the lateral border, and also forwards towards the tip. In
time, the limbs are further strengthened by sea-bathing, cycling,
skipping, and other exercises.

In _cases of the second degree_, the patient should be provided with a
metal plate inside the boot. That known as Whitman's spring is the
most popular. A plaster cast is taken of the sole while the foot is
held in its proper position, and on this a metal plate, preferably of
aluminium bronze, is modelled. This is covered with leather and
inserted into the boot. We have found the supports devised by Scholl
simple and efficient. The treatment described for cases of the first
degree is carried out in addition.

In _cases of the third degree_, the deformity is corrected under an
anæsthetic. The foot is forcibly moved in all directions so as to
stretch the shortened ligaments and to break down adhesions, it is
then rotated into an extreme varus position, and fixed in
plaster-of-Paris or to a Dupuytren's splint. It may be necessary to
have recourse to the Thomas' wrench, employed in the correction of
club-foot. When the reaction consequent upon this procedure has
subsided, the question of shortening or of reinforcing the tendons
concerned in the support of the arch of the foot may be considered;
one of the peronei, for example, may be attached to the tubercle of
the navicular. We have not found it necessary to employ this
procedure.

In _cases of the fourth degree_, in which the displacement and
alterations in shape of the bones constitute an insuperable bar to
correction, operative treatment may be considered, either resection of
a wedge including the talo-navicular joint or forward displacement of
the tuberosity of the calcaneus.

#Spasmodic Flat-foot.#--There are cases of flat-foot in which pain and
spasm of the peronei muscles are the predominant features. If the
spasm is not allayed by rest in bed and hot fomentations, the foot
should be inverted under an anæsthetic; and in this position it is
encased in plaster-of-Paris. Jones resects an inch of each of the
peroneal tendons about 2-1/2 inches above the tip of the lateral
malleolus; Armour and Dunn claim to have obtained better results from
crushing the peroneal nerve in the substance of the peroneus longus.

#Paralytic Flat-foot# (Fig. 155).--In typical cases this results from
poliomyelitis affecting the tibial muscles. When other groups of
muscles are affected at the same time, compound deformities, such as
pes calcaneo-valgus, are more likely to result.

[Illustration: FIG. 155.--Bilateral Pes Valgus and Hallux Valgus in a
girl æt. 15, the result of Anterior Poliomyelitis.]

In paralytic valgus the medial border of the foot is depressed and
convex towards the sole, and although the foot can readily be restored
to the normal position by manipulation, it at once resumes the valgus
attitude. The leg is wasted, the skin is cold and livid, and the ankle
is flail-like. The treatment consists in reinforcing the paralysed
tibial muscles by attaching the peronei, or a strip of the tendo
Achillis, to the scaphoid, or in bringing about an ankylosis of the
joints above and in front of the talus.

#Traumatic flat-foot# is that form which results directly from injury.
It is most often due to a fall from a height on to the feet; the
ligaments supporting the arch are ruptured, and the bones are
displaced, either at the time of the injury or later when the patient
gets out of bed. The arch can only be restored by a wedge-resection of
the tarsus. Loss of the arch may follow as a result of walking on the
everted foot after injuries about the ankle, especially a badly united
Pott's fracture; the foot may be displaced laterally and pronated, the
sole looking laterally. This variety is very unsightly and disabling;
it is treated by supra-malleolar osteotomy of the tibia and fibula.

#Other Forms of Flat-foot.#--Flat-foot is sometimes met with in
rickety children, in association with knock-knee or curvature of the
bones of the leg, and is treated on the same lines as other rickety
deformities. It may follow upon an attack of acute rheumatism or upon
diseases in the region of the ankle and tarsus, such as gonorrhœa,
arthritis deformans, tuberculosis, and Charcot's disease; the
gonorrhœal flat-foot is extremely resistant to treatment. There is a
congenital form in which the sole is convex and the dorsum concave,
the result of the persistence of an abnormal attitude of the fœtus _in
utero_. Lastly, there is a racial variety, chiefly met with in the
negro and in Jews, which is inherited and developmental, and which,
although unsightly, is rarely a cause of disability.

#Pes Transverso-planus.#--Lange describes under this head a sinking or
flattening of the anterior arch formed by the heads of the metatarsal
bones, of which normally only the heads of the first and fifth rest on
the ground. In this condition all may be on the same level or the arch
is actually convex towards the sole. It may coexist along with the
common form of flat-foot, or it may be associated with the neuralgic
pain known as metatarsalgia.

#Painful Affections of the Heel.#--These include inflammation of the
bursa between the posterior aspect of the calcaneus and the lower end
of the tendo Achillis, inflammation of the tendon itself and its
sheath of cellular tissue, and the presence of a spur of bone
projecting from the plantar aspect of the tuberosity of the calcaneus.
The spur of bone is the source of considerable pain on standing and
walking, and tenderness is elicited on making pressure on the plantar
aspect of the heel; it is well demonstrated by the X-rays (Fig. 156).
The condition is usually bilateral. Complete relief is obtained by
removing the spur by operation.

Sever of Boston calls attention to a painful condition of the heel met
with in children, and associated with changes in the epiphysial
junction, allied to those met with in the epiphysis of the tubercle of
the tibia in Schlatter's disease. The changes in the epiphysial
junction can be demonstrated in skiagrams. Treatment is conducted on
the same lines as in teno-synovitis of the tendo Achillis.

#Metatarsalgia.#--This affection, which was first described by Morton
of Philadelphia (1876), is a neuralgia on the area of the anterior
metatarsal arch, specially located in the region of the heads of the
third and fourth metatarsal bones. It is most often met with in adults
between thirty and forty, is commoner in women than in men, and is
often combined with flat-foot. The patient complains of a dull aching
or of intense cramp-like pain in the anterior part of the foot. The
pain is usually relieved by rest and by taking off the boot. It may be
excited by pressing the heads of the metatarsals together or by
grasping the fourth metatarso-phalangeal joint between the finger and
thumb. In advanced cases the pain may be so severe as to cripple the
patient, so that she is obliged to use a crutch. On examination, the
sole may be found to be broadened across the balls of the toes, and
there may be corns over the heads of the third and fourth metatarsals.
Skiagrams may show a downward displacement of the head of one or other
of these bones, and prints of the foot may show an increased area of
contact in the region of the balls of the toes. The affection is of
insidious development, and is usually ascribed to sinking of the
transverse arch of the foot--pes transverso-planus--the result of
weakness or of wearing badly fitting boots. The intense pain is
believed to be due to stretching of, or pressure upon, the
interdigital nerves or the communicating branch between the medial and
lateral plantar nerves; Whitman believes it is due to abnormal side
pressure on the depressed articulations.

[Illustration: FIG. 156.--Radiogram of Spur on under aspect of
Calcaneus.]

_Treatment._--Great improvement usually results from treating
coexisting flat-foot, and pain is relieved by rest, massage, and
douching. A tight bandage or strip of plaster applied round the
instep before putting on the stocking may relieve pain. Boots should
be made from a plaster cast of the foot, high and narrow at the instep
so as to compress the bases of the metatarsals, and with the medial
edge of the sole and heel slightly raised; a support may be worn in
the sole, like that used for flat-foot, with both the longitudinal and
transverse arches exaggerated. Scholl has devised a support for the
anterior arch which we have used with benefit. When the head of one of
the metatarsals is displaced, it may be removed through a dorsal
incision running parallel with the tendon of the long extensor.

#Hallux Valgus and Bunion.#--_Hallux valgus_ is that deformity in
which the great toe deviates towards the middle line of the foot and
comes to lie on the top of, or beneath, the second toe (Figs. 155,
157). The head of the first metatarsal projects on the medial border
of the foot, and, as a result of the pressure of the boot, an
adventitious bursa is formed, which, when thickened by chronic
inflammation, constitutes a prominent swelling or _bunion_. It is a
common affection in civilised and especially in urban communities, and
reaches its acme of development in adult women. It may occur on one or
on both sides, and is sometimes associated with flat-foot.

[Illustration: FIG. 157.--Radiogram of Hallux Valgus. The sesamoid
bone is seen displaced towards middle line of the foot.]

The deformity develops slowly, and is usually attributed to the
wearing of stockings which are unduly tight at the toes, and of
improperly made boots. The boot that favours the occurrence of hallux
valgus is one which is too short and has pointed toes, with the apex
in the middle line of the foot instead of being in line with the great
toe. The pressure of the boot displaces the great toe into the valgus
position, especially if a high heel is worn, as the toes are then
driven forward into the apex of the boot. Once the great toe is
abducted by the pressure of the boot, the deformity is increased by
bearing unduly on the medial side of the ball of the great toe, and by
pointing the foot outwards in walking.

Arthritis deformans is rarely the cause of hallux valgus, but the
changes characteristic of that affection are commonly present in the
joint of the great toe. In pronounced cases, the base of the first
phalanx is displaced on to the lateral aspect of the head of the first
metatarsal, the exposed head of which frequently shows fibrillation
and wearing away of the cartilage, and is often surrounded by new
bone, sometimes amounting to an exostosis. There are also fringes from
the synovial membrane that may be caught between the articular
surfaces. The distal end of the first metatarsal is displaced
medially, broadening the tread of the foot, and in severe cases its
shaft is rotated on its long axis, so that its dorsal surface looks
medially; the great toe is then similarly rotated (Fig. 157). The
flexor and extensor tendons and the sesamoid bones are displaced
laterally. The ligaments and other soft parts on the medial side are
elongated, while those on the lateral side are contracted.

In women, the chief complaint may be of the disfigurement of the boot;
in others, of pain and disability resulting from the sensitiveness of
the joint and of the enlarged bursa over the head of the first
metatarsal. The inflamed bursa, which sometimes communicates with the
joint, may suppurate, and the infection may spread to the joint.

The _treatment_ varies with the severity of the deformity. In mild
cases, a great deal can be done by wearing properly made boots and
stockings with a separate compartment for the great toe, or a pad of
cotton wool or tent of rubber between the great and second toes. The
patient should practise manipulations and exercises of the toes and
feet, and putting the foot to the ground properly in walking. In
pronounced cases, the pain and tenderness must first be got rid of by
rest and soothing applications. At night, the attitude of the toe may
be corrected by a moulded splint fixed to the medial aspect of the
foot by strips of plaster; the toe is then bandaged to the distal end
of the splint. Scholl has devised a prop, made of rubber, to be worn
between the great and second toes. If there is flat-foot, this must
receive appropriate treatment.

In aggravated cases, the deformity can only be corrected by an
operation which consists in resecting the head of the metatarsal bone,
and the tendon of the long extensor may be detached from its
insertion and secured to the medial side of the first phalanx. A bar
may be placed across the sole just behind the balls of the toes, and
the boot should also comply with the anatomical shape of the foot.

#Hallux Varus or Pigeon-toe# (Fig. 158).--In this deformity, which is
extremely rare, the great toe deviates from the middle line of the
foot; it occurs chiefly in children in conjunction with other
deformities, and interferes with the wearing of boots. Treatment
consists in straightening the toe and retaining it in position by a
splint or plaster of Paris. The medial collateral ligament and the
tendon of the abductor hallucis may require to be divided.

[Illustration: FIG. 158.--Radiogram of Hallux Varus or Pigeon-toe.]

#Hallux Rigidus and Hallux Flexus# (Fig. 159).--These terms indicate
two stages of an affection of the metatarso-phalangeal joint of the
great toe, first described by Davies Colley. In the earlier
stage--_hallux rigidus_--the toe is stiff and incapable of being
dorsiflexed, although plantar-flexion is, as a rule, but little
restricted. When the joint, in addition to being stiff, is painful,
sensitive, and swollen, the term _hallux dolorosus_ is applied.

[Illustration: FIG. 159.--Hallux Rigidus and Flexus in a boy æt. 17.
There is a suppurating corn over the head of the first metatarsal
bone.]

As the disease progresses, the toe is drawn towards the sole and
becomes permanently flexed--_hallux flexus_--and any attempt at
dorsiflexion is attended with pain.

The condition is met with chiefly in adolescent males, is nearly
always associated with flat-foot, and is then usually bilateral. The
patient's gait, in addition to having the characteristic features
associated with flat-foot, is peculiarly wooden and inelastic, as
instead of rising on the balls of the toes with each step, he puts
down and lifts the sole as if it were a rigid plate. The pain is
increased by walking. The boot tends to become worn away at the point
of the toes and at the posterior edge of the heel, and the usual
crease across the dorsum is absent.

On dissection it is found, especially in hallux flexus, that the
inferior portions of the collateral ligaments are contracted, and that
the cartilage of that part of the head of the metatarsal which is
exposed on the dorsum is converted into fibrous tissue; there may also
be other changes characteristic of arthritis deformans. Bony ankylosis
has not been observed.

_Treatment._--In early cases, great benefit results from measures
directed towards the cure of the accompanying flat-foot, and
especially the wearing of the support of the anterior arch devised by
Scholl. If the joint of the big toe is painful and sensitive, absolute
rest should be enforced until these symptoms have disappeared. The
patient must wear a properly shaped boot with a pliable sole, and be
instructed how to manipulate and exercise the toe. Later, when the toe
is already rigid or flexed towards the sole, the above treatment is
not feasible. It is then best to correct the deformity either by
wrenching the toe into the dorsiflexed position, under anæsthesia, and
fixing it with a plaster-of-Paris bandage; or, when this is
impossible, by excising the articular end of the metatarsal bone and
interposing a layer of fatty or bursal tissue between the distal end
of the metatarsal and the base of the first phalanx. When these
measures are impracticable, the suffering may be relieved by inserting
in the boot a rigid metal plate which will prevent any attempt at
dorsiflexion in walking.

#Hammer-toe.#--This is a flexion-contracture which generally involves
the second, but sometimes also other toes. It may be congenital and
inherited, but usually develops about puberty, and is then, as a rule,
bilateral, and often associated with flat-foot.

The first phalanx is dorsiflexed, and the second is plantar-flexed,
while the third varies in its attitude, sometimes being in line with
the second (Fig. 160), sometimes even more plantar-flexed, and
sometimes dorsiflexed. When the second toe alone is affected, as is
commonly the case, it is partly buried by those on either side of it,
only the knuckle of the first inter-phalangeal joint projecting above
the level of the other toes (Fig. 160). The skin over the head of the
first phalanx being pressed upon by the boot usually presents a corn,
under which a bursa forms (Fig. 161). Both the corn and the bursa are
subject to attacks of inflammation, which cause suffering and
disability in walking. The soft parts at the distal extremity of the
toe are flattened out by contact with the sole of the boot--hence the
supposed resemblance to the head of a hammer.

[Illustration: FIG. 160.--Hammer-toe.]

On dissection, it is found that the contracture is maintained by
shortening of the plantar portions of the collateral ligaments of the
first inter-phalangeal joint and of the glenoid ligament upon which
the head of the first phalanx rests.

Hammer-toe is usually ascribed to the use of tight socks and of
ill-fitting boots, especially those which are median-pointed and are
too short for the feet, but in some persons there appears to be an
inherited predisposition to the deformity.

[Illustration: FIG. 161.--Section of Hammer-toe.

    _a_, Corn.
    _b_, Bursa over first inter-phalangeal joint.]

While corrective manipulations, strapping, and the use of splints may
be of service in slight cases, it is usually necessary to perform an
operation in order to extend the toe permanently. Before operating,
any infective condition, such as a suppurating corn or bursa, must be
corrected. The collateral and glenoid ligaments are divided
subcutaneously--Spitzy also divides the flexor tendons and
capsule--and if the toe can then be straightened, the foot is secured
to a metal splint moulded to the sole and provided with longitudinal
slots opposite the intervals on either side of the toe affected. The
toe is drawn down to the splint by passing a loop of cotton or elastic
bandage round the toe and through the slots. In many cases the
contraction of all the tissues on the plantar aspect, including the
skin, prevents the toe being straightened even after division of the
ligaments, and it is then necessary to remove the head and neck of the
first phalanx through a lateral incision. This is more satisfactory
than amputation of the affected toe at the metatarso-phalangeal
joint, as after this the adjacent toes tend to fall together and
favour hallux valgus. If amputation is performed, a pad of cotton wool
or rubber prop should be worn to fill up the vacant space.

The term _Gampsodactyly_ has been applied to a deformity in which all
the toes assume the position of hammer-toe, usually from a spastic
condition of the muscles controlling the toes.

#Hypertrophy of the Toes.#--One or more of the toes may be the seat of
hypertrophy or local giantism. This is usually present at birth or
appears in early childhood, and may form part of an overgrowth
involving the entire lower extremity (Fig. 162). The overgrowth may
involve all the tissues equally, or the subcutaneous fat may be
specially affected. The medial toes are those most commonly
hypertrophied. In addition to being enlarged, the toe may be displaced
from its normal axis. The hypertrophy may affect two or more toes
which are fused together or webbed (Fig. 162). The treatment consists
in amputating as much of the toe as will allow of an ordinary boot
being worn.

[Illustration: FIG. 162.--Congenital Hypertrophy of Left Lower
Extremity in a boy æt. 5. The second and third toes are fused.]

#Supernumerary Toes# (_Polydactylism_).--These vary from mere
appendages of skin to fully developed toes (Fig. 163); if they
interfere with the wearing of boots they should be removed.

#Webbing of the Toes# (_Syndactylism_).--This may affect two or more
toes, which may be united merely by a web of skin, or so completely
fused that the individual digits are only indicated by the nails; the
degree of fusion is shown by means of skiagrams. Unless associated
with congenital hypertrophy, no treatment is called for.

[Illustration: FIG. 163.--Supernumerary Great Toe.

(Photograph lent by Sir George T. Beatson.)]


THE UPPER EXTREMITY

#Congenital Absence of the Clavicle.#--Both clavicles may be absent,
and it is possible for the patient voluntarily to bring his shoulders
into contact with one another in front of the chest; there is little
or no impairment of function.

#Displacements of the Scapula.#--_Congenital Elevation of the Scapula_
(Sprengel's shoulder, 1891).--This abnormality is rare, and is not
usually recognised till several years after birth. In one variety
there is a bridge of bone or fibrous tissue connecting the superior
angle of the scapula with the spinous process of one of the cervical
vertebræ, and there may be a false joint at one end of the bridge
permitting a certain amount of movement of the scapula. Associated
abnormalities in the vertebræ and in the ribs are shown in skiagrams.
In the more common type, the scapula seems to be held in its elevated
position by shortening of the muscles attached to its body, and it is
often rotated so that its lower angle is close to the spine and its
axillary border nearly horizontal, or the axillary border may lie in
close to the ribs, and the vertebral border project from the chest
wall. The shoulder is generally higher and farther forward on the
affected side, and there is a moderate degree of scoliosis. There is a
want of purchase in the movements of the shoulder and upper arm.

[Illustration: FIG. 164.--Congenital elevation of Left Scapula in a
girl: also shows hairy mole over Sacrum.

(Mr. D. M. Greig's case.)]

When the deformity is bilateral, which is rare, the neck is short and
thick, the chin lies close to the sternum, and the arms can scarcely
be raised to the horizontal.

Gymnastic exercises and the wearing of a brace to hold the shoulders
back and down may be followed by some improvement, but, as a rule, it
is necessary to mobilise the scapula by operation. An X-ray photograph
should first be taken, because, when the scapula is connected with the
spine by a bridge of bone, this must be resected. The muscles attached
to the vertebral border and spine of the scapula are divided, the
bone is drawn down to its proper position, and the parts are fixed by
plaster bandages.

_Winged Scapula._--This condition consists in a marked displacement
backwards of the lower angle and vertebral border of the scapula, when
the patient attempts to raise the arm from the side (Fig. 165). Under
normal conditions, in making this movement the serratus and rhomboid
muscles pull forward the vertebral border and inferior angle of the
scapula, and so fix the bone firmly against the chest wall. When these
muscles are paralysed, as a result of anterior poliomyelitis,
neuritis, or injury of the long thoracic nerve of Bell, or of the
fifth and sixth cervical nerve-roots through which they receive their
supply, the patient is unable to abduct the arm, and the deltoid
having lost its _point d'appui_, its contraction merely results in
tilting the angle of the scapula backward (Fig. 165).

[Illustration: FIG. 165.--Winged Scapula; the patient is holding the
arms out in front.]

_Treatment._--In the majority of recent cases the condition yields to
the administration of strychnin and other muscle and nerve tonics, and
the use of massage and the faradic current. The application of a
carefully adjusted padded belt is sometimes useful. The method of
treatment by stitching the latissimus dorsi over the lower angle of
the scapula is based on the erroneous assumption that the displacement
is due to the slipping of that muscle off the bone; at the same time,
it must be admitted that the operation sometimes diminishes the
deformity and adds to the patient's comfort.

A more efficient method consists in detaching the clavicular portion
of the pectoralis major from its insertion, and stitching it to the
serratus anterior so as to make it take on the function of this
muscle, or stitching it to the axillary border of the scapula. Success
has also followed suture of the vertebral border of the scapula to the
subjacent ribs (Eiselsberg).

_Displacement of the scapula upwards and laterally_ has been observed
as a result of partial paralysis of the trapezius when the nerves
supplying it have been divided in removing tuberculous glands from the
neck. In these acquired displacements, treatment is directed towards
the nerve lesion and towards the improvement of the muscles by
electricity, massage, and exercises; when the paralysis of the
trapezius is permanent, the disability is gradually overcome by the
compensatory hypertrophy of the levator muscle.

#Congenital Dislocation of the Shoulder.#--This rare condition is
usually bilateral, and is associated with other congenital defects.
The glenoid cavity is deformed or absent, and the dislocation may be
sub-coracoid, sub-acromial, or sub-spinous. The movements of the arm
are restricted, and the development of the extremity as a whole is
imperfect. It is sometimes possible to reduce the dislocation by
manipulation, or, if this fails, by operation. Unilateral dislocation
is sometimes mistaken for dislocation that has occurred during
delivery and _vice versa_.

#Habitual Dislocation# is described on p. 65.

#Paralytic Deformities--Paralytic Dislocation of the Shoulder.#--The
muscles in the region of the shoulder may have their innervation
interfered with as a result of various conditions, of which
poliomyelitis and injuries of the brachial plexus at birth are the
most important. The capsular ligament of the shoulder-joint, being no
longer kept tense by the scapular muscles--especially the deltoid and
lateral rotators--becomes relaxed, and is gradually stretched by the
weight of the arm. The appearances are characteristic; the muscles of
the shoulder are wasted, the acromion is prominent, and between it and
the upper end of the humerus there is a marked hollow into which one
or more fingers may be inserted. The arm hangs flaccid by the side,
rotated medially and pronated, and moves in a flail-like fashion in
all directions, the patient having little control over it. The best
results are obtained by the transplantation of muscles, the trapezius
being detached from the clavicle and stitched to the surface of the
deltoid, and the upper arm fixed in the position of horizontal
abduction with the arm rotated laterally and supinated. Bradford
inserts a portion of the trapezius into the humeral insertion of the
deltoid. When these methods are impracticable, the upper arm may be
fixed to the trunk by some form of apparatus, or arthrodesis is
performed so that the movements of the scapula are communicated to the
upper arm; the best attitude for ankylosis is one of abduction with
medial rotation, so that the hand can be brought to the mouth.

In cases of poliomyelitis, when all the muscles governing the elbow
are paralysed while the muscles of the hand have escaped, it may be of
great service to fix this joint permanently at rather less than a
right angle. This may be effected by arthrodesis, or by removing an
extensive diamond-shaped portion of skin from the flexor aspect of the
joint and bringing the raw surfaces together, commencing the stitching
at the lateral apices of the gap.

[Illustration: FIG. 166.--Arrested Growth and Wasting of Tissues of
Right Upper Extremity, the result of Anterior Poliomyelitis in
childhood.]

#Congenital Dislocations at the Elbow.#--_The head of the radius_ may
be dislocated forwards, backwards, or laterally--usually in
association with imperfect development of the radius and of the
lateral condyle of the humerus. When the displaced head of the bone
interferes with supination, or with extension, it should be removed.
Congenital dislocation of both bones of the forearm is extremely rare.

#Cubitus Valgus# and #Cubitus Varus#.--When the normal arm hangs by
the side with the palm of the hand directed forward, the forearm and
upper arm form an angle which is open outwards--known as the "carrying
angle"; it is usually more marked in women in association with the
greater breadth of the pelvis and the relative narrowness of the
shoulders. When this angle is increased, the attitude is described as
one of _cubitus valgus_. This deformity may be acquired as a result of
rickets, but more commonly it is due to fracture of the lateral
condyle of the humerus, in which the separated fragment has been
displaced upwards.

_Cubitus varus_ is the reverse of cubitus valgus. It is more common,
is always pathological, and is nearly always a result of fracture of
the lower end of the humerus or separation of the lower humeral
epiphysis and subsequent interference with growth. These deformities
may be corrected by supra-condylar osteotomy of the humerus.

[Illustration: FIG. 167.--Lower end of Humerus from case of Cubitus
Varus.]

#Synostosis of the superior radio-ulnar joint# is a rare congenital
condition, in which the hinge movements at the elbow are free, but
supination is impossible; an attempt may be made by operation to form
a new joint.

#Volkmann's ischæmic contracture# of the muscles of the forearm,
resulting in the production of claw-hand, is described in Volume I.,
p. 415.

#Deformities of the Forearm and Hand.#--The _radius_ may be absent
completely or in part, frequently in combination with other
malformations. The most evident result is a deviation of the hand to
the radial side--one variety of _club-hand_. The forearm is
shortened, the ulna thickened and often bent, and the thumb and its
metacarpal bone are often absent, so that the usefulness of the hand
and arm is greatly impaired (Fig. 171). For this condition Bardenheuer
devised an operation which consists in splitting the lower end of the
ulna longitudinally and inserting the proximal bones of the carpus
into the cleft.

Congenital deficiency of the _ulna_ is extremely rare.

#Intra-uterine amputation# by constriction of amniotic bands sometimes
occurs (Figs. 168, 169).

[Illustration: FIG. 168.--Intra-uterine Amputation of Forearm.]

[Illustration: FIG. 169.--Radiogram of Arm of patient shown in Fig.
168.]

#Drop Wrist from Anterior Poliomyelitis.#--In this condition the
capacity of extending the fingers is deficient or absent. Recovery can
be confidently predicted if, on still further flexing the fingers,
they can be voluntarily extended towards the point from which they are
flexed (Tubby and Jones). Considerable improvement may result from
fixing the hand by means of a splint in the attitude of dorsal
flexion. The splint is removed at frequent intervals to allow of
massage and other treatment being carried out, and it has usually to
be worn for a period of one to two years. In some cases recourse
should be had to arthrodesis.

[Illustration: FIG. 170.--Congenital absence of Left Radius and Tibia
in a child æt. 8.

(Mr. D. M. Greig's case.)]

In _spastic paralysis_ the most pronounced deformity is flexion of the
forearm and pronation and flexion of the hand (Fig. 166). Gradual
extension at the wrist may be brought about by the use of a malleable
splint, in which the angle is gradually increased, over a period of at
least twelve months. Failing success by this method, operation may be
had recourse to, and this consists in lengthening of tendons, and
tendon transplantation. Tubby has devised an operation for converting
the pronator radii teres into a supinator, and Robert Jones another in
which the flexors of the carpus are made to take the place of the
extensors. "These operations, combined if necessary with elongation of
the flexors of the fingers, pave the way for diminution of the angle
of flexion at the elbow, lessening of the pronator spasm, increase of
the supinating power, reduction of the carpal flexion, and addition to
the extensor power at the wrist" (Tubby and Jones).

#Congenital Club-hand.#--This rare deformity corresponds to congenital
club-foot, and probably arises in the same way. The hand and fingers
are rigidly flexed to the ulnar or radial side, so that the patient is
incapable of moving them. Treatment is carried out on the same lines
as for club-foot.

A deformity resembling this, _acquired club-hand_, is brought about
when the growth of either of the bones of the forearm has been
arrested as a result of disease or of traumatic separation of its
lower epiphysis. The hand deviates to the side on which the growth has
been arrested--_manus valga_ or _vara_. The treatment consists in
resecting a portion of the longer bone.

[Illustration: FIG. 171.--Club-hand, the result of imperfect
development of radius. The thumb is absent.

(Photograph lent by Sir George T. Beatson.)]

#Madelung's Deformity of the Wrist.#--In 1878, Madelung called
attention to a deformity also called sub-luxation of the hand, in
which the lower articular surface of the radius is rotated so that it
looks towards the palm; there is palmar displacement of the carpus,
and the lower end of the ulna projects on the dorsum. The cause of the
condition is obscure, but it is met with chiefly in young women with
slack ligaments, whose laborious occupation or athletic pursuits
subject the hand and wrist to long-continued or repeated strain. It is
as frequently unilateral as bilateral and may recur in successive
generations. There is a good deal of pain, the grasping power of the
hand is impaired, and dorsiflexion is considerably restricted. The
deformity disappears on forcible traction, but at once reappears when
the traction is removed. A wristlet of poroplastic or leather
extending from the mid-forearm to the knuckles is moulded to the limb
in the corrected position, and is taken off at intervals for massage
and exercises.

When _operative treatment_ is called for, it takes the form of
osteotomy of the radius and ulna about an inch or more above their
articular surfaces.

#Congenital dislocation of the wrist# is rare.

#Deformities of the Fingers.#--Various forms of _congenital
dislocation_ of the fingers are met with, but they are of little
clinical importance, as they interfere but slightly with the
usefulness of the digit affected.

_Congenital lateral deviation of the phalanges_ is more unsightly than
disabling; it is met with chiefly in the thumb, in which the terminal
phalanx deviates to the radial or to the ulnar side in extension; the
deviation disappears on flexion.

_Congenital contraction of the fingers_ is comparatively common. It is
an inherited deformity, and is often met with in several members of
the same family. It most frequently affects the little or the ring and
little fingers (Fig. 172), and is usually bilateral. The second and
third phalanges are flexed towards the palm; the first phalanx is
dorsiflexed, this being the reverse of what is observed in Dupuytren's
contraction. Duncan Fitzwilliams suggests that it should be called
"hook-finger," and that it is probably due to imperfect development of
the anterior ligament of the first inter-phalangeal joint. He has
observed it in association with laxity of the ligaments of the other
joints of the body.

[Illustration: FIG. 172.--Congenital Contraction of Ring and Little
Fingers.]

The affection is usually disregarded in infancy and childhood as being
of no importance. In young children, the deformity is corrected by
wearing a light splint fixed with strips of plaster, or a piece of
whalebone or steel inside the finger of a glove. In older children,
the finger may be straightened by subcutaneous division of the
ligament over the palmar aspect of the base of the middle phalanx, or
failing this by lengthening the flexor tendons and resecting a wedge
from the dorsal aspect of the first phalanx close to the
inter-phalangeal joint.

#Dupuytren's Contraction.#--This is an acquired deformity resulting
from contraction of the palmar fascia and its digital prolongations
(Fig. 173). It is rare in childhood and youth, but is common after
middle life, especially in men. It is often hereditary, and is said to
occur in those who are liable to gout and to arthritis deformans.
While it is met with in the working-classes and attributed to the
pressure of some hard object on the palm of the hand--such as a hammer
or shovel or whip--its greater frequency in those who do no manual
work, and the fact that it is very often bilateral, indicate that the
constitutional factor is the more important in its causation.

[Illustration: FIG. 173.--Dupuytren's Contraction.]

In the initial stage there is a localised induration in the palm
opposite the metacarpo-phalangeal joint, and the skin over it is
puckered and closely adherent to the underlying fascia. After a
variable interval, the finger is gradually and progressively flexed at
the metacarpo-phalangeal joint. The ring finger is usually the first
to be affected, less often the fifth, although both are commonly
involved. It is rarest of all in the index. The flexion may be
confined to the metacarpo-phalangeal joint, or the middle and distal
phalanges may also be flexed; and as the deformity becomes more
pronounced, the nail of the affected finger may come into contact with
the skin of the palm. Dissections show that the flexion of the finger
is the result of a chronic interstitial overgrowth or fibrositis and
subsequent contraction of the palmar fascia and of its prolongations
on to the sides of the fingers. The digital processes of the fascia
are thickened and shortened, and come to stand out like the string of
a bow. The adipose tissue in the skin of the palm disappears, and the
skin and fascia thus brought into contact become fused. The tendons
and their sheaths are not implicated; they are found lying deeply in
the concavity of the curve of the flexed digit. There is no pain, but
the grasp of the hand is interfered with, the patient is unable to
wear an ordinary glove, and he may be incapacitated from following his
occupation.

The condition is easily diagnosed from congenital contraction by the
fact that in the latter the proximal phalanx is dorsiflexed.

_Treatment._--When seen in the initial stage, contraction may be
prevented by passive movements of the finger and by massage of the
indurated fascia; we have observed cases in which these measures have
held the malady in check for many years, but when flexion has already
occurred, they are useless, and according to the social position,
habits, or occupation of the patient, the condition is left alone or
the deformity is corrected by operation.

Adam's operation consists in multiple subcutaneous division of the
contracted fascia in the palm and of its prolongations on to the
finger; in addition to dividing the fascia, the tenotomy knife should
be used also to separate the skin from the fascia. The finger is then
forcibly extended, and a well-padded splint secured to the hand and
forearm. The skin on the palmar aspect opposite the first
inter-phalangeal joint may give way when the finger is extended;
should this occur, the resulting gap may be covered by a skin graft.

After healing has occurred, massage and movements must be persevered
with, and a splint (Fig. 174) worn at night, as there is an inveterate
tendency to recurrence of the contraction. In view of this tendency
there is much to be said in favour of the radical operation which
consists in removal of the fascia by open dissection. Owing to the
long time required for healing and the sensitiveness of the scar, the
results of excision of the fascia are sometimes disappointing. Greig
has obtained good results by resecting the head of the metacarpal
bone. When the little finger is completely flexed towards the palm it
may be amputated, as it is always in the way.

[Illustration: FIG. 174.--Splint used after Operation for Dupuytren's
Contraction.]

#Supernumerary Fingers (Polydactylism).#--These may coexist with
supernumerary toes, and the condition is often met with in several
members of the same family. Sometimes the extra finger is represented
by a mere skin appendage, the nature of which may only be indicated by
the presence of a rudimentary nail; sometimes it contains bone
representing one or more phalanges, or it may be fully formed (Fig.
175). In the majority of cases the superfluous finger should be
removed.

[Illustration: FIG. 175.--Supernumerary Thumb.

(Photograph lent by Sir George T. Beatson.)]

#Congenital Deficiencies in the Number of Fingers.#--One or more
fingers may be absent, such deficiency being often associated with
imperfect development of the radius or ulna; or they may be
represented by short rounded stumps, which are ascribed to the
strangulation of the digits by amniotic bands _in utero_--the
so-called intra-uterine amputation.

#Webbing of Fingers (Syndactylism).#--Congenital webbing or fusion of
the fingers may be associated with polydactylism or with congenital
hypertrophy, and, like other digital deformities, may affect several
members of the same family. The degree of fusion ranges from a web of
skin joining the fingers to a fusion of the bones, the latter being
well seen in skiagrams. If an operation is decided upon, it should not
be performed until the age of five or six years. In the simplest cases
it is only necessary to divide the web and to unite the cut edges of
skin along each finger by sutures, a skin graft being inserted into
the angle between the fingers. An operation in which the skin is
dissected up in the form of flaps may be required, but it should not
be lightly entered upon, as in young children it has been known to be
followed by gangrene of one or more of the digits.

#Congenital Hypertrophy of the Fingers.#--This is a form of local
giantism affecting one or more digits, and involving all the tissues.
The finger is usually of abnormal size at birth, and continues to
grow more rapidly than the others, and it may also come to deviate
from its normal axis. Such a finger should be trimmed down or removed,
to permit of the use of the other digits.

#Trigger Finger# (Fig. 176).--This is an acquired condition in which
movement of a finger or thumb, either in flexion or extension, is
arrested, and is only completed with the assistance of the other hand.
The obstacle to movement is usually overcome with a jerk or snap
suggesting a resemblance to the trigger of a gun or the blade of a
clasp-knife. The commonest cause is a disproportion between the size
of the tendon and its sheath, such as may result from a localised
thickening of the tendon. Recovery usually takes place under massage
and passive movements. Failing this, the thickened portion of the
tendon is pared down to its normal size; if it is the sheath of the
tendon that is narrow, it is laid freely open.

[Illustration: FIG. 176.--Trigger Finger.

(Photograph lent by Sir George T. Beatson.)]

#Drop# or #mallet finger# is described on p. 121.




CHAPTER XI

THE SCALP


Surgical Anatomy--Injuries: _Contusion_; _Hæmatoma_;
    _Cephal-hæmatoma_; _Wounds_; _Avulsion_--Diseases: _Infective
    conditions_; Cystic and solid tumours; Air-containing swellings;
    Vascular tumours.

#Surgical Anatomy.#--The _skin_ of the scalp is intimately united to
the _epicranial aponeurosis_ by a network of firm fibrous tissue
containing some granular fat, and representing the subcutaneous
connective tissue. These three layers constitute the scalp proper, and
they are so closely connected as to form a single structure which can
be moved to a certain extent by the action of the epicranius muscle.
The epicranius (occipito-frontalis) muscle with its aponeurosis
extends from the superciliary ridge in front to the superior nuchal
(curved) line of the occipital bone behind, and laterally to the level
of the zygoma where it blends with the temporal fascia. Between the
scalp proper and the _pericranium_ is a quantity of loose areolar
tissue, in the meshes of which extravasated blood or inflammatory
products can rapidly spread over a wide area. Blood extravasated under
the pericranium is limited by the attachments of this membrane at the
sutures.

The _blood supply_ of the frontal region is derived from the internal
carotid arteries through their supra-orbital branches; the remainder
of the scalp is supplied from the external carotids through their
temporal, posterior auricular and occipital branches. The vessels,
which run in the subcutaneous tissue, superficial to the epicranial
aponeurosis, anastomose freely with one another and across the middle
line. The main branches run towards the vertex, and incisions should,
as far as possible, be directed parallel with them.

The _venous return_ is through the frontal, temporal, and occipital
veins. These have free communications, through the _emissary veins_,
with the intra-cranial sinuses, and by these routes infective
conditions of the scalp may readily be transmitted to the interior of
the skull. The most important of the emissary veins are: the
_mastoid_, _condyloid_, and _occipital_, passing to the transverse
(lateral) sinus; the _parietal_, which enters the superior sagittal
(longitudinal) sinus; and a branch from the nose which traverses the
foramen cæcum and enters the anterior end of the superior sagittal
sinus.

The supra-trochlear, supra-orbital and auriculo-temporal branches of
the trigeminal nerve, together with the greater and lesser occipital
nerves, supply the scalp with sensation, while the muscles are
supplied from the facial nerve.

The _lymph vessels_ pass to the parotid, occipital, mastoid, and
submaxillary groups of glands, the different areas of drainage being
ill-defined.


INJURIES OF THE SCALP

#Subcutaneous Injuries.#--_In simple contusion_ of the superficial
layers, owing to the density of the tissues, the blood effused is
small in quantity and remains confined to the area directly injured,
which is firm and tender to the touch, swollen and discoloured. The
disappearance of the swelling may be hastened by elastic pressure and
massage.

_Hæmatoma of the scalp_ results when lacerated vessels bleed into the
sub-aponeurotic space. Owing to the laxity of the connective tissue in
this area, the effused blood tends to diffuse itself widely, and,
according to the position assumed by the patient, gravitates to the
region of the eyebrow, the occiput, or the zygoma. When a large artery
is torn the swelling may pulsate. A hæmatoma of the scalp may readily
be mistaken for a depressed fracture of the skull, owing to the fact
that the margins of the effusion are often raised and of a firm
resistant character. A differential diagnosis can usually be made by
observing that the swelling is on a higher level than the rest of the
skull; that the raised margin can to a large extent be dispersed by
making firm, steady pressure over it with the finger; and that, on
doing so, the smooth and intact surface of the skull can be
recognised. When a fracture exists, the finger sinks into the
depression and the irregular edge of the bone can be felt. In doubtful
cases, if cerebral symptoms are present, an exploratory incision
should be made.

Even a large hæmatoma is usually completely absorbed, but the
dispersion of the clot may be hastened by massage and elastic
pressure. Any excoriation or wound of the skin must be disinfected.

Sometimes a blood-cyst, consisting of a connective-tissue capsule
filled with a yellowish-red fluid, remains, and may require to be
emptied with a hollow needle.

These effusions are to be distinguished from the _cephal-hæmatoma_, in
which the blood collects between the pericranium and the bone. This is
oftenest seen in newly born children as a result of pressure on the
head during delivery, and is characterised by its limitation to one
particular bone--usually the parietal--the further spread of the blood
being checked by the attachment of the pericranium at the sutures.
Occasionally a permanent thickening of the edges of the bone remains
after the absorption of the extravasated blood. This condition is to
be diagnosed from traumatic cephal-hydrocele (p. 390).

#Wounds of the Scalp.#--So long as a scalp wound, however extensive,
is kept free from infection, it involves comparatively little risk,
but the introduction of organisms to even the most trivial wound is
fraught with danger, on account of the ease and rapidity with which
the infection may spread along the emissary veins to the meninges and
intra-cranial sinuses.

The deeper the wound, the greater is the risk. If the epicranial
aponeurosis is divided, the "dangerous area" between it and the
pericranium is opened, and if infection occurs, it may lead to
widespread suppuration. Should the wound extend through the
pericranium, infection is more liable to spread to the bone and to the
cranial contents.

The usual varieties of wounds--incised, punctured, contused, and
lacerated--are met with in the scalp, and they vary in degree from a
simple superficial cut to complete avulsion. For medico-legal purposes
it is important to bear in mind that a scalp wound produced by the
stroke of a blunt weapon, such as a stick or baton, may closely
simulate a wound made with a cutting instrument.

On account of the density of the integument and its close connection
with the aponeurosis, scalp wounds do not gape unless the epicranial
aponeurosis is widely divided. This facilitates union in incised
wounds, but interferes with drainage in the long narrow tracts which
result from punctures, and which are so liable to be infected and to
implicate the sub-aponeurotic space, the pericranium, or even the
bone. It also favours the inclusion in the wound of a foreign body,
such as the broken point of a knife, or a piece of glass. The bleeding
from scalp wounds is often profuse and difficult to control, because
the vessels, fixed as they are in the dense subcutaneous tissue,
cannot retract and contract so as to bring about the natural arrest of
hæmorrhage, and it is difficult to apply forceps or ligatures to their
cut ends, suture ligatures are more efficient. On account of the free
arterial anastomosis in the deeper layers of the integument, large
flaps of scalp will survive when replaced, even if badly bruised and
torn, and it is never advisable to cut away any un-infected portion of
the scalp, however badly it may be lacerated or however narrow may be
the pedicle which unites it to the head.

_Gun-shot wounds_ of the scalp are usually associated with damage to
the skull and brain. A spent shot, however, may pierce the scalp, and
then, glancing off the bone, lodge in the soft parts.

_Complete Avulsion._--In women, the scalp is sometimes torn from the
cranium as a result of the hair being caught in revolving machinery.
The portion removed, as a rule, consists of integument and aponeurosis
with portions of muscle attached. In a few cases the pericranium also
has been torn away. So long as any attachment to the intact scalp
remains, the parts should be replaced, and, if asepsis is maintained,
a satisfactory result may be hoped for. When the scalp is entirely
separated, recourse must be had to skin-grafting.

_Treatment of recent Scalp Wounds._--To ensure asepsis, the hair
should be shaved from the area around the wound, and the part then
purified. Gross dirt ground into the edges of lacerated wounds is best
removed by paring with scissors. Undermined flaps must be further
opened up and drained--by counter-openings if necessary. When there is
reason to suspect their presence, foreign bodies should be sought for.
Bleeding is arrested by forci-pressure or by ligature; when, as is
often the case, these measures fail, the hæmorrhage may be controlled
by passing a needle threaded with catgut through the scalp so as to
include the bleeding vessel. The wound is stitched with horse-hair or
silk, and, except in very small and superficial wounds, it is best to
allow for drainage. With the use of iodine as a disinfectant, it is
often advantageous to dispense with dressings altogether.

#Complications of Scalp Wounds.#--The most common complications are
those due to infection, which not only aggravates the local condition,
but is apt to lead to spreading cellulitis, osteomyelitis, meningitis,
or inflammation of the intra-cranial sinuses. These dangerous sequelæ
are liable to follow infection of any scalp wound, but more especially
such as implicate the sub-aponeurotic area, or the pericranium. In the
integument, a small localised abscess, attended with pain and œdema of
surrounding parts, may form. Pus forming under the aponeurosis is
liable to spread widely, pointing above the eyebrow, in the occipital
region, or in the line of the zygoma. Suppuration under the
pericranium tends to be limited by the inter-sutural attachments of
the membrane. Necrosis of the outer table, or even of the whole
thickness of the skull, may follow, although it is by no means
uncommon for large denuded areas of bone to retain their vitality.

The onset of infection is indicated by restlessness, throbbing pain
and heat in the wound, a feeling of chilliness or the occurrence of a
rigor, and tension of the stitches from œdema of the surrounding
tissues. The œdema often extends to the eyelids and face; a puffiness
of the eyelids, indeed, is not infrequently the first evidence of the
occurrence of infection in the wound.

_Treatment._--When suppuration ensues, the stitches should be removed,
the wound opened up and purified with eusol, and packed. A dressing of
ichthyol and glycerine should be employed for a few days.

_Erysipelas of the scalp_ may originate even in wounds so trivial as
to be almost invisible, or from suppurative processes in the region of
the frontal sinuses or nasal fossæ. It tends to be limited by the
attachments of deep fasciæ, and seldom spreads to the cheek or neck.
Symptoms of cerebral complications, in the form of delirium or coma,
and of meningitis may supervene. Cellulitis beneath the aponeurosis
from mixed infection is a dangerous complication.


DISEASES OF THE SCALP

#Infective Conditions.#--It is not uncommon for _localised abscesses_
to occur in the subcutaneous cellular tissue in delicate children, and
such collections are not infrequently associated with pediculi,
impetigo, or chronic dermatitis. They develop slowly and painlessly,
and are only covered by a thin, bluish pellicle of skin. It is not
improbable that they result from a mixed infection by pyogenic and
tuberculous organisms. As a rule they heal quickly after incision and
drainage, but when they are allowed to burst, tedious superficial
ulcers may form. Localised abscesses may also form in connection with
disease of the cranial bones. _Suppuration_ following upon injuries
has already been referred to.

_Boils and carbuncles_ are not common on the hairy part of the scalp.
_Lupus_ rarely originates on the scalp, although it may spread thither
from the face. _Syphilitic_ lesions are common and present the same
characters as elsewhere. Gummata may develop in the soft parts, but
more commonly they take origin in the pericranium or bone. _Eczema
capitis_ is of surgical importance only in so far as it often forms
the starting-point of infection of lymph glands by pyogenic and other
organisms.

#Cystic and Solid Tumours.#--A great variety of swellings is met with
in the scalp.

_Sebaceous cysts_ or _wens_ are of frequent occurrence, and have been
described in Volume I.

A _dermoid cyst_ is most commonly situated over the position of the
anterior fontanelle, in the region of the occipital protuberance, or
at the lateral angle of the orbit. As it frequently lies in a gap in
the skull, it may be connected by a pedicle with the dura mater, and
is liable to be mistaken for a meningocele.

[Illustration: FIG. 177.--Multiple Wens.

(Photograph lent by Sir George T. Beatson.)]

_Serous cysts_ are occasionally found in the occipital region, and are
believed to be meningoceles that have become shut off from the
interior of the skull before birth.

_Adenomas_ originating in the sebaceous or sweat glands are sometimes
multiple, of a purplish colour, and the skin covering them is thin and
glistening. They show a tendency to ulcerate and fungate, giving rise
to a fœtid discharge, and may be mistaken for epithelioma; they are
also liable to become the seat of epithelioma. They are treated by
excision.

Large, flat _papillomas_ or warts may be single or multiple; they are
of slow growth, and as they may also become the starting-point of
epithelioma, they should be removed.

[Illustration: FIG. 178.--Adenoma of Scalp.]

The _plexiform neuroma_ forms a loose soft tumour situated in the
course of one or more branches of the trigeminal nerve, especially
the supra-orbital branch. In its most aggravated form the tumour hangs
over the face or neck in large pendulous masses, and is described as a
_pachydermatocele_ (V. Mott).

A _sarcoma_ usually has its origin in the bones of the skull, and only
implicates the scalp secondarily.

_Epithelioma_ of the scalp may originate in relation to a wart, an
ulcerated wen or sebaceous adenoma, or the cicatrix of a burn. It may
affect comparatively young persons, may spread over a wide area, or
pass deeply and involve the bone. Free and early removal is indicated.

_Rodent cancer_ may originate on the scalp, but usually spreads
thither from the face.

In operating for extensive tumours of the scalp the hæmorrhage is
sometimes formidable. It may be controlled by an elastic tourniquet
applied horizontally round the head, or if, on account of the position
of the tumour or from other causes, this is not practicable, by
ligation or temporary clamping of the external carotid on one or on
both sides.

#Air-containing Swellings#--_Pneumatocele Capitis._--Cases have been
recorded in which, as a result of pathological or traumatic
perforations of the mastoid, and less frequently of the frontal cells,
air has passed under the pericranium and given rise to a tense rounded
tumour, resonant on percussion, and capable of being emptied by firm
pressure. Such swellings exhibit neither pulsation nor fluctuation;
and as they are painless, and give rise to almost no inconvenience,
they do not call for treatment.

_Emphysema of the scalp_ may follow fractures implicating any of the
air sinuses of the skull, the air infiltrating the loose cellular
tissue between the pericranium and the aponeurosis, and on palpation
yielding a characteristic crepitation. It usually disappears in a few
days.

#Vascular Tumours.#--_Nævi_ on the scalp present the same features as
elsewhere. If placed over one of the fontanelles, a nævus may derive
pulsation from the brain, and so simulate a meningocele.

_Cirsoid aneurysm_ is usually met with in the course of the temporal
artery, and may involve the greater part of the scalp. Large,
distended, tortuous, bluish vessels pulsating synchronously with the
heart are seen and felt. They can be emptied by pressure, but fill up
again at once on removal of the pressure. The patient complains of
dizziness, headache, and a persistent rushing sound in the head.
Ulceration of the skin over the dilated vessels, leading to fatal
hæmorrhage, may take place.

They may be treated by excision, after division and ligation of the
larger vessels entering the swelling; or the dilated vessels may be
cut across at several points and both ends ligated. Krogius recommends
the introduction of a series of subcutaneous ligatures so as to
surround the whole periphery of the pulsating tumour, and interrupt
the blood flow. Ligation of the main afferent vessels, or of the
external or common carotid, has been followed by recurrence, owing to
the free anastomatic circulation in the scalp. In some cases
electrolysis has yielded good results.

_Traumatic aneurysm_ of the temporal artery was comparatively common
in the days when the practice of bleeding from this vessel was in
vogue, but it is seldom met with now.

_Arterio-venous aneurysm_ may also occur in the course of the temporal
artery, as a result of injury, and is best treated by complete
extirpation of the segments of the vessels implicated.




CHAPTER XII

THE CRANIUM AND ITS CONTENTS


Anatomy and physiology--Cerebral localisation--Lumbar puncture. HEAD
    INJURIES--Concussion--Cerebral irritation--Compression--Contusion
    and laceration of the brain, and traumatic intra-cranial
    hæmorrhage: _Middle meningeal hæmorrhage_; _Hæmorrhage from
    internal carotid and venous sinuses_--Intra-cranial hæmorrhage of
    the newly born. Cerebral œdema--Wounds of brain--After-effects of
    head injuries--Traumatic epilepsy and insanity--Infective
    complications.

#Anatomy and Physiology.#--The _Cranium_ is irregularly ovoid in
shape, and its floor is broken up by various projections to form three
separate fossæ--anterior, middle, and posterior--in which rest
respectively the frontal, the temporal, and the occipital lobes of the
brain; the cerebellum, pons, and medulla oblongata also occupy the
posterior fossa.

The _outer_ table is the most elastic layer of the calvarium, and it
varies greatly in thickness in different skulls and in different parts
of the same skull. It is nourished chiefly from the pericranium which
is firmly bound down along the lines of the sutures. The _inner_ or
vibreous table is thin and fragile, and its smooth internal surface is
grooved by the middle meningeal and other arteries of the dura mater,
and by the large venous sinuses. The intermediate layer--the
_diploë_--is highly vascular, branches of the meningeal vessels
anastomosing freely in its open porous substance with branches derived
from the pericranial vessels. Some of its veins open into the external
veins, and others into the intra-cranial sinuses, and they communicate
with the emissary veins as these pass through the bone, which explains
the spread of infective processes from the structures outside the
skull to those within. The possibility of withdrawing blood from the
interior of the skull by leeching, bleeding, or cupping depends on the
existence of the emissary veins.

_The Membranes of the Brain._--The _dura mater_ is a fibro-serous
membrane, the outer, fibrous layer constituting the endosteum of the
skull, the inner, serous layer forming one of the coverings of the
brain. Between the fibrous layer and the bone the meningeal vessels
ramify; and along certain lines the two layers split to form channels
in which run the cranial venous sinuses. Inside the dura, and
separated from it by a narrow space--the _sub-dural space_--lies the
_arachno-pial membrane_, consisting of an outer (_arachnoid_) layer
which envelops the brain but does not pass into the sulci, and a
highly vascular inner layer--the _pia mater_--which closely invests
the brain and lines its entire surface.

The space between these layers--the _sub-arachnoid space_--is
traversed by a network of fine fibrous strands, in the meshes of which
the cerebro-spinal fluid circulates. Each nerve-trunk as it leaves the
skull or spinal canal carries with it a prolongation of each of these
membranes and their intervening spaces. The membranes gradually become
lost in the fibrous sheaths of the nerves, and the sub-dural and
sub-arachnoid spaces become continuous with the lymph spaces of the
nerves.

The _cerebro-spinal fluid_ is secreted by the choroid plexuses and
fills the cerebral ventricles, the central canal of the cord, the
sub-dural and sub-arachnoid spaces, and the sheaths of the
intra-cerebral blood vessels. At the base of the brain, particularly
in the posterior fossa, the sub-arachnoid space is wider than
elsewhere, forming "cisterns" filled with cerebro-spinal fluid which
supports the cerebral structures. Through the foramen of Magendie in
the roof of the fourth ventricle the sub-arachnoid fluid of the
cranial cavity communicates with that of the vertebral canal.

Although it differs in its chemical constitution from true lymph, the
cerebro-spinal fluid seems to functionate as lymph, in addition to
acting as a lubricating agent, and playing a part in regulating the
vascular supply of the brain. In cases of cerebral hæmorrhage,
abscess, tumour, or depressed fracture, room is made up to a certain
point for the extraneous matter by displacement of cerebro-spinal
fluid.

_Vascular supply._--The free anastomosis between the vessels entering
into the formation of the circulus arteriosus (circle of Willis)
ensures an abundant supply of blood to the brain. The larger arteries
run in the sub-arachnoid space and give off branches which ramify in
the pia mater before entering the cerebral substance. Within the
brain, each artery being more or less terminal, there is no free
anastomosis between adjacent vessels, with the result that if any
individual artery is obstructed the vitality of the area supplied by
it is seriously impaired. The venous arrangements are also peculiar in
that the veins are thin-walled and valveless, and open into the rigid,
incompressible sinuses which run between the layers of the dura mater.
Most of the blood passes to the internal jugular vein, and any
increase in the pressure of this vessel is immediately transmitted
back to the cerebral veins. As the blood vessels project into a rigid
case filled with incompressible material, and as the total _volume_ of
blood in the brain is constant (Munro and Kelly), any alteration in
the supply of blood to the cerebral tissue must be due to an increased
_velocity_ of flow, and this in turn depends upon changes in the
aortic and vena cava pressure. Thus, if the aortic pressure rises,
more blood will enter the cerebral vessels and will move along more
rapidly; while if the pressure in the vena cava rises there is
obstruction to the passage of blood in the arteries and diminished
velocity of flow. The ebb and flow of cerebro-spinal fluid in and out
of the spinal canal may also help to control the pressure.

#Nerve Elements.#--The nervous system is composed of a multitude of
units, called _neurones_, each neurone consisting of a nucleated cell,
with branching protoplasmic processes or _dendrites_ and one
_axis-cylinder_ or _axon_. The nutrition of an axis cylinder depends
on its continuity with a living cell. If the cell dies, the axis
cylinder degenerates. If the axis cylinder is severed at any point, it
degenerates beyond that point, and the nucleus of the nerve-cell
disintegrates--chromatolysis.

The axis cylinder of one cell ends in a number of fine filaments which
arborise around another nerve-cell, thus bringing it into
physiological, if not anatomical, relationship with the first cell.
The termination is called a cell-station or _synapsis_. In this way
the various sections of the nervous system are kept in association
with one another and with the rest of the body.

_Motor Functions and Mechanism._--The nerve centres, which together
make up the motor area, and govern the voluntary muscular movements of
the body, are situated in the grey matter of the præcentral or
ascending frontal gyrus, and of the frontal aspect of the central
sulcus (fissure of Rolando). The upper limit of the motor area reaches
on to the mesial aspect of the paracentral lobule, and the lower limit
stops short of the lateral cerebral fissure (fissure of Sylvius) (Fig.
179).

[Illustration: FIG. 179.--Relations of the Motor and Sensory Areas to
the Convolutions and to Chiene's Lines.

(After Cunningham.)]

Each group of muscles has its own regulating centre, the size of the
area representing any group depending upon the character and
complexity of the movements performed by the muscles, rather than upon
the amount of muscular tissue that is governed by the centre--for
example, the centre for the mouth, tongue, and vocal cords is larger
than that for the muscles of the trunk.

The motor centres have been localised on the surface of the brain with
approximate accuracy. For example, above the superior genu of the
præcentral gyrus, the centres governing the hip, knee, and toes are
grouped; opposite the genu are the centres for the movements of the
trunk; between the superior and middle genua lie the centres for the
upper extremity; opposite the middle genu, those for the neck, and
below it, those for the face, jaws, and tongue, pharynx and larynx.

#The Motor Tracts.#--It is now generally accepted that there are two
paths by which motor impulses pass from the brain: one--the
_rubro-spinal tract_--which controls the more elemental movements of
the body, such as standing, walking, breathing, etc.; the other--the
_pyramidal tract_--developed later in the evolution of the nervous
system, and concerned with the finer and more skilled movements.

The pyramidal tract is the more important clinically. From the
pyramidal cells in the cortex of the Rolandic area, the axis cylinders
pass through the centrum ovale towards the base of the brain. They
converge at the internal capsule, and pass through the anterior
two-thirds of its posterior limb (Figs. 180 and 195). The fibres for
the eyes, face, and tongue lie farthest forward, and next in order
from before backward, those for the arm and the leg.

From the internal capsule, the motor fibres pass as the _pyramidal
tract_ through the crusta of each crus cerebri, the pons and the
medulla oblongata. Throughout this part of its course, numerous axons
leave the tract, and enter the mid-brain, pons, and medulla in which
lie the nuclei of the motor cranial nerves.

At the _decussation of the pyramids_ in the lower third of the
medulla, the main mass of the motor fibres crosses the middle line,
and enters the lateral column of the spinal cord as the _crossed
pyramidal tract_. The remaining fibres pass down as the _direct
pyramidal tract_, and decussate in the cord near their termination.

The fibres forming the second path pass through the red nucleus in the
cerebral peduncle (crus cerebri) and thence by way of the rubro-spinal
tract in the lateral column of the cord.

The existence of this double motor path explains how after a
hemiplegic stroke in which the pyramidal tract is destroyed while the
rubro-spinal tract escapes, the patient is able to perform such
primitive movements as are involved in walking or standing, while he
is unable to carry out finer movements that require higher education.

The pyramidal and rubro-spinal tracts, in addition to conveying motor
impulses, convey impulses that influence muscle tonus and the deep
reflexes. The pyramidal tract conveys impulses that inhibit muscle
tonus, while the rubro-spinal tract is the path by which excitatory
impulses travel. When the inhibitory influences are cut off, as in a
lesion of the internal capsule, the paralysed muscles become spastic,
and the deep reflexes are exaggerated. When the excitatory impulses
are also lost, as in a total transverse lesion of the cord, the
paralysed muscles are flaccid and the deep reflexes disappear. In
destructive lesions of the lower neurones, the muscles are always
flaccid.

The axons passing from the cerebral cortex terminate at different
levels in the cord by breaking up into dendrites which arborise around
the cells on the grey matter of the posterior horns--this system of
cells, axons, and dendritic processes forming an _upper neurone_. From
this synapsis the _lower neurone_ proceeds, its axons travelling to
the anterior horn and arborising around the motor cells. The axis
cylinders pass out in the anterior nerve roots to the spinal nerves
and are continued in them to their distribution in voluntary muscles.

If the continuity of any group of these lower neurones is interrupted,
not only do the nerve fibres degenerate, but the nutrition of the
muscles supplied by them is interfered with and they rapidly
degenerate and waste, and after an interval show the reaction of
degeneration. In addition, the reflex arc is disturbed, and reflexes
are lost. As these changes do not occur in lesions of the upper
neurones, an appreciation of the differences enables us to distinguish
between lesions implicating the upper and the lower neurones.

#Sensory Functions and Mechanism.#--Three kinds of sensory impulses
pass from the periphery to the brain; (1) deep, or muscular
sensibility, (2) protopathic sensibility, and (3) epicritic
sensibility.

_Deep sensibility_ includes the recognition of (_a_) deep pressure,
say by the blunt end of a pencil; (_b_) the position of a joint on
passive movement (joint sense); (_c_) active muscular contraction
(kinesthetic sense). The fibres that convey these impulses to the
spinal cord pass in the afferent nerves from the muscles, tendons, and
bones, and so long as these nerves are intact these sensations are
retained, even if the surface of the skin is quite anæsthetic.

_Protopathic sensibility_ is of a lower order than epicritic. It
consists in the recognition of painful cutaneous stimuli and of
extreme degrees of heat and cold. The fibres concerned are
non-medullated and regenerate comparatively quickly after injury, so
that protopathic sensibility is regained before epicritic.

_Epicritic sensibility_ is the most highly specialised and permits of
the recognition of light touch, _e.g._, with a wisp of cotton wool, of
fine differences of temperature, and of discriminating as separate the
points of a pair of compasses 2 cm. apart. These sensations are
carried by medullated nerve fibres, and are slow to return after
injury to the nerves.

The sensory nerve fibres conveying these different impulses pass to
the ganglionic cells of the posterior nerve roots. From each of these
cells a process passes into the cord and bifurcates into an ascending
and a descending branch. In the cord the fibres rearrange themselves
and pass to the brain by a double path. Those that convey sensations
of pain and of temperature pass by the spino-thalamic route by way of
the tract of Gowers and the fillet to the optic thalamus; those that
are concerned with the muscular sense, the joint sense, and tactile
discrimination pass up the posterior columns in the tracts of Goll and
Burdach to the nuclei gracilis and cuneatus in the medulla, whence
they pass to the optic thalamus.

From the cell station in the optic thalamus the fibres proceed to the
_cortical sensory centres_, that for tactile sensation being situated
in the post-central (ascending parietal) gyrus; that for muscular and
stereognostic sense lying probably in the adjacent portions of the
parietal lobe.

In a unilateral lesion of the cord, pain and the temperature sense may
be disturbed in one limb, and motor power and tactile sensibility in
the other, as the fibres that convey impressions of pain, and those
that subserve the discrimination of temperature, pass up and decussate
in the cord a few segments above their point of entrance.

[Illustration: FIG. 180.--Diagram of the Course of Motor and Sensory
Nerve Fibres.]

#Effects of Lesions of the Motor and Sensory Mechanisms.#--Lesions of
the _motor mechanism_ differ in their fundamental characters according
as they affect the upper or the lower neurones. The signs also vary
according as the affected area is _destroyed_ or merely _irritated_,
say by the pressure of a tumour. Irritative lesions in general produce
muscular spasms or convulsions, while destructive lesions cause
paralysis. The essential differences in the effects of destructive
lesions of upper and lower neurones may be indicated thus:--

    _Upper Neurone Lesion._           _Lower Neurone Lesion._

    Spastic paralysis of voluntary    Flaccid paralysis of voluntary
       muscles.                          muscles.
    No marked wasting of paralysed    Marked wasting of paralysed
       muscles.                          muscles.
    No reaction of degeneration.      Reaction of degeneration.
    Exaggeration of reflexes.         Loss of reflexes.

Irritative lesions of the sensory mechanism cause numbness and
tingling (paræsthesia); more extensive paralytic lesions produce
anæsthesia, astereognosis, loss of muscle sense, loss of pain, or
inability to distinguish temperature, according to the tracts that are
affected.

_Lesions of the Upper Motor Neurone_ may occur in any part of its
course. _Localised lesions of the motor cortex_ of an irritative kind,
for example, a patch of meningitis, a tumour, meningeal hæmorrhage, or
a spicule of bone, produce spasms in those groups of muscles on the
opposite side of the body that are supplied by the centres
implicated--Jacksonian epilepsy. The cortical discharge may overflow
into neighbouring centres and cause more widespread convulsive
movements, or, if strong and long-continued, may even lead to general
convulsions. Consciousness is usually lost before the whole of one
side becomes implicated in the spasms; always before they spread to
the opposite side. Contracture may occur in the muscles affected after
the spasms cease.

If an area of the cortex is destroyed by the lesion, paralysis is
produced of the corresponding muscles on the opposite side of the
body. At first the paralysed muscles are flaccid, but spasticity soon
develops. In some cortical lesions, for reasons not yet understood,
the paralysis remains of the flaccid type. The seat and extent of the
paralysis depend upon the area of the cortex destroyed. In rare cases
the whole motor area is destroyed--_cortical hemiplegia_; more
generally the lesion affects one or more groups of muscles, and
occasionally all the muscles of one limb are paralysed--_cortical
monoplegia_. Lesions are often both irritative and destructive, and
lead to paralysis of one or more groups of muscles associated with
spasms and convulsions of the muscles governed by neighbouring areas
of the cortex. Irritation or destruction of the sensory centres may
also exist, giving rise to areas of paræsthesia and anæsthesia.

Lesions in the _centrum ovale_, which destroy the fibres proceeding
from the overlying cortex, produce a corresponding spastic paralysis
on the opposite side of the body. No irritative phenomena are
associated with such a sub-cortical lesion.

Lesions in the region of the _internal capsule_ often produce complete
spastic hemiplegia of the opposite side of the body. When the
posterior part of the capsule is involved, there are, in addition,
hemianæsthesia and hemianopia, and sometimes disturbances of hearing,
smell, and taste.

A lesion of the _crus_ may in like manner produce spastic hemiplegia
and hemianæsthesia of the opposite side, often associated with a lower
neurone paralysis of the third and fourth nerves of the same side
(crossed paralysis). The optic tract, which crosses the crus, may also
be affected, and hemianopia result.

Lesions of the _corpora quadrigemina_ cause interference with the
reaction of the pupil, disturbance of the functions of the oculo-motor
nerve and of mastication, ataxia, and inco-ordination of the movements
of the limbs.

The symptoms produced by lesions of the _pons and medulla_ vary
according to the position of the lesion. If it is unilateral, there
may be spastic hemiplegia and hemianæsthesia of the opposite side; if
it is situated in the lower part of the pons or in the medulla, there
is often also a lower neurone paralysis of one or more of the cranial
nerves on the same side as the lesion (crossed paralysis). Paralysis
of the external rectus of one eye and of the internal rectus of the
other (conjugate paralysis) is frequently found in pontine, and in
cortical and internal capsule lesions.

_Cerebellar_ lesions are associated with special symptoms. In ataxia,
there is inco-ordination of muscular movements, especially of the
coarse movements, such as walking. The gait becomes irregular and
staggering, with a tendency to fall, sometimes to the side on which
the lesion is situated, sometimes to the opposite side. In patients
who cannot walk, ataxia may be tested by ordering repeated pronation
and supination of the forearm. Paresis or asthenia may be found in the
trunk muscles, or evidenced by weakness of the grip, or drooping of
the head to one side. Changes in muscle tone may arise and lead to
exaggerated or decreased reflexes, often varying from day to day.
Vertigo and nystagmus may also be present, in addition to occipital
headache and tenderness on percussion. When one lateral lobe is
implicated, the symptoms are referred to the same side; when the
median lobe is involved, they are bilateral, and there may be
retraction of the neck with extension of the legs, probably as the
result of the associated internal hydrocephalus.

A unilateral lesion of the _spinal cord_ causes a lower neurone
paralysis of the muscles supplied from the cord at the level of the
lesion, with spastic paralysis of the muscles of the same side of the
body supplied from a lower level of the cord. The sensory symptoms are
variable. Typically there is some anæsthesia in the structures
supplied from the damaged section of the cord--incomplete owing to the
overlapping by other sensory nerves. Just above the lesion there is
irritation of spinal nerves, and hyperæsthesia and pain referred to
their distribution. On the same side below the lesion, there is a loss
of epicritic, stereognostic and deep sensibility, and on the opposite
side below the lesion, loss of the sense of pain and the
discrimination between heat and cold. Ordinary tactile sensibility,
which is governed by a double path, may or may not be lost on either
side below the lesion.

#Other Special Centres.#--The cortical centres for _vision_ lie on the
median surfaces of the occipital lobes in the neighbourhood of the
calcarine fissure. Each half-vision centre--for there is one in each
occipital lobe--receives the fibres from the same side of both retinæ.
Destruction of one half-vision centre produces the condition known as
_homonymous hemianopia_, in which the medial (nasal) half of one
visual field and the lateral (temporal) half of the other is affected,
so that there is an inability to see objects situated on the side
opposite to the lesion.

_Auditory impulses_ are received in the posterior part of the superior
temporal convolution.

_Aphasia._--The use of language, spoken or written, as a means of
expression depends upon the co-ordination of four different centres:
the visual, the auditory, the graphic, and the articulatory. These are
situated in different parts of the brain and are connected by
sub-cortical association tracts, the main pathway of which lies in the
vicinity of the upper end of the fissure of Sylvius. Marie has proved
that aphasia results from lesions in this area.

The _olfactory_ and _gustatory_ centres are situated in the uncus
close to the pituitary fossa.

Lesions of the frontal cortex anterior to the motor centres, even if
extensive, may produce few or no symptoms, and in consequence this
region has been called a "silent" area. Occasionally there results a
change in temperament or intelligence, and the region is on this
account supposed to be concerned with the higher psychical functions.
There is evidence that the pre-frontal cortex has a centre for the
conscious initiation of movements, and that lesions produce "apraxia,"
_i.e._, inability to perform, or clumsiness in voluntarily performing
fine movements such as touching the nose with the finger, though such
movements may be perfectly carried out unintentionally. This centre is
probably situated in the superior and middle left frontal convolutions
in right-handed people. The fibres from the centre to the right motor
area cross in the anterior part of the corpus callosum.

#Cerebral Localisation.#--The various parts of the brain can be
localised in relation to the surface by various methods. That devised
by Professor Chiene has been found reliable.

#Relation of Cerebral Centres to the Surface.#--Numerous attempts have
been made to formulate rules for locating the different parts of the
brain in relation to the surface of the head. The method devised by
Chiene is free from many of the difficulties and fallacies common to
most other methods, inasmuch as the results obtained do not depend
upon making definite measurements in inches, or determining particular
angles. Certain fixed and easily recognised bony landmarks--the
glabella, the external occipital protuberance, the lateral angular
process, and the root of the zygoma--are taken, and connected by
lines, which are further subdivided--_always being bisected_. Figs.
179 and 181 explain the method. The head being shaved, a line (GO) is
drawn along the vertex from the glabella (G) to the external occipital
protuberance (O). This line is bisected in M, which constitutes the
"mid-point." The posterior half of the line MO is bisected in T,
constituting the "three-quarters point," and the posterior half TO is
bisected in S--"the seven-eighths point." The lateral angular process
(E) is next connected to the root of the zygoma (P) by a line EP, and
the root of the zygoma with the seven-eighths point by PS; the line
EPS thus forms the base line. The lateral angular process is now
joined to the three-quarters point by ET. The two segments of the base
line EP and PS are bisected in N and R respectively, and these points
connected with the mid-point (M) by lines NM and RM. These lines cut
off a part of ET--AB, which is now bisected in C, and from C the line
CD is drawn parallel to AM.

[Illustration: FIG. 181.--Chiene's Method of Cerebral Localisation.]

In this way practically all the points of the brain which are wanted
for operative purposes may be mapped out. Thus the quadrilateral space
MDCA contains the Rolandic area. MA represents the præcentral sulcus,
and if it be trisected in K and L, these points will correspond to the
origins of the superior and inferior frontal sulci. The pentagon ABRPN
corresponds to the temporal lobe. The apex of the temporal lobe
extends a little in front of N. The supra-marginal convolution lies in
the triangle HBC. The angular gyrus is at B. A is over the anterior
branch of the middle meningeal artery, and the bifurcation of the
lateral or Sylvian fissure; AC follows the horizontal limb of the
lateral fissure. The transverse or lateral sinus at its highest point
touches the line PS at R (Fig. 181).

The _fissure of Rolando_ or _central sulcus_ may be marked out by
taking a point half an inch behind the mid-point (M) (Fig. 181), and
drawing a line downwards and forwards for a distance of about three
and a half inches, at an angle of 67.5° with the line GO. The angle of
67.5° can be readily determined by folding a square piece of paper on
itself so as to make a triangle. The angle at the fold equals 45°. By
folding the paper again upon itself in the same direction, the right
angle of the paper is divided into four angles of 22.5° each. Three of
these angles taken together make up the 67.5°. If the straight edge of
the paper be placed along the sagittal suture with the angle of
folding over the upper end of the fissure of Rolando, the folded edge
falls over the line of the fissure (Chiene).

[Illustration: FIG. 182.--To illustrate the site of various operations
on the skull.]


LUMBAR PUNCTURE

Quincke, in 1891, first suggested the withdrawal of cerebro-spinal
fluid from the theca in the lumbar region, as a means of relieving
excessive intra-cranial tension in tuberculous meningitis, and to
obtain specimens of the fluid for diagnostic purposes. The scope of
the procedure, both as a therapeutic and as a diagnostic measure, has
since been widely extended.

_Technique._--The puncture may be made with the patient either lying
on his left side, the spine being fully flexed by approximating the
knees and shoulders; or sitting on the table with the knees drawn up
and the body bent forward. The upper edge of the fourth lumbar spine
is identified by drawing a horizontal line across the back at the
level of the highest part of the iliac crests (Fig. 183). The space
between the fourth and fifth lumbar vertebræ being the widest, is that
usually selected. The skin having been purified, an exploring needle,
about three inches long, is introduced about half an inch below the
fourth lumbar spine in the middle line, and passed for about two
inches in a direction forwards and slightly upwards. The needle
usually encounters some resistance as it pierces the interspinous
ligament, and then enters the sub-arachnoid space. If bone is struck,
the needle should be withdrawn and introduced at a different level. If
the cerebro-spinal fluid does not escape at once, a stylet should be
passed through the needle to clear it of blood-clot or shreds of
tissue. When the intra-thecal tension is normal, the fluid trickles
away drop by drop, but if it is increased, as, for example, in
meningitis, intra-cranial tumour, hydrocephalus, or uræmia, it may
escape in a jet.

[Illustration: FIG. 183.--Localisation of site for introduction of
needle in Lumbar Puncture.]

The _normal cerebro-spinal fluid_ is clear and colourless, has a
specific gravity of 1004-1008, and contains a trace of serum globulin
and albumose, some chlorides, and a substance which reduces Fehling's
solution. Microscopically, it may contain some large endothelial cells
and a few lymphocytes, or may be entirely devoid of cells. It does not
contain the antitoxins and opsonins which are normally found in the
plasma and lymph, hence the liability to infective meningitis after
injuries and operations on the central nervous system. With a view to
diminishing these risks, hexamine, which is excreted into the
cerebro-spinal fluid, is administered for its antiseptic properties in
cases of head injury and before intra-cranial operations.

_Diagnostic Puncture._--Examination of the fluid withdrawn has proved
useful in diagnosis in cases of intra-cranial and intra-spinal
hæmorrhage, in various forms of meningitis, in cerebral abscess, and
in some cases of cerebral tumour.

The first few drops should be discarded, as they may be stained with
blood from the puncture, and about 5 c.c. collected in each of two
sterile tubes. To determine whether blood in the fluid is due to the
puncture or to a pre-existing intra-cranial or intra-thecal
hæmorrhage, the fluid should be centrifugalised; in the former case
the supernatant fluid is clear and limpid, in the latter it retains a
yellow tinge. In extra-dural hæmorrhage there is no blood in the
cerebro-spinal fluid.

In acute meningitis the fluid is turbid, and contains an excess of
albumin. Organisms also are present, such as the diplococcus
intracellularis in acute cerebro-spinal meningitis; staphylococci,
streptococci, and pneumococci, particularly in the intra-cranial
complications of middle ear disease. In all cases of acute microbic
infection, and especially in the suppurative forms, polynuclear
leucocytes are found in the fluid; while in chronic affections, such
as tubercle and syphilis, there is an excess of lymphocytes (Purves
Stewart). The detection of the tubercle bacillus is confirmatory of a
diagnosis of tuberculous meningitis, but, as it is often difficult to
find, its absence does not negative this diagnosis. In tuberculous
meningitis the clot which forms floats in the centre of the fluid, and
is translucent, grey, and flaky; in the pyogenic forms it is yellow,
and sticks to the side of the vessel.

In a few cases of malignant tumour of the spinal cord and its
membranes, characteristic cells have been found in the fluid after
centrifugalising.

In uræmia there is a diminution of chlorides, and an increase of
phosphates and sulphates.

The Wasserman test is sometimes positive in the cerebro-spinal fluid,
when it is negative in the blood.

_Therapeutic Puncture._--In certain cases of cerebral tumour, and of
tuberculous meningitis associated with an excessive quantity of fluid
in the arachno-pial space, temporary relief of such symptoms of
increased intra-cranial tension as headache, vertigo, blindness, or
coma, has followed the withdrawal of from 30 to 40 c.cm. of the fluid.
Terrier and others have found this measure useful in relieving pain in
the head, delirium, and even coma, in cases of basal fracture.
Carrière has found it beneficial in some cases of uræmia. The quantity
withdrawn must not exceed 40 c.cm., lest the ventricles be emptied and
pressure be exerted directly on the basal ganglia (Tuffier). In a
number of cases sudden death has followed the withdrawal of
cerebro-spinal fluid.

This route is sometimes selected for the induction of spinal
anæsthesia, and for the injection of antitoxin in cases of tetanus.


HEAD INJURIES

The brain is protected from injury by moderate degrees of violence
applied to the head, by the dense and mobile scalp, the dome-like
shape of the skull, the elasticity of its outer table and the
buffer-like sutural membrane between the numerous bones of which it is
composed, and the various internal osseous projections with the
membranes attached to them, all of which tend to diminish vibrations
and to disperse forces so that they expend themselves before they
reach the brain. Further protection is provided by the water-bed of
cerebro-spinal fluid, and by the external buttresses formed by the
zygomatic arch and the thick muscular pads related to it, as well as
by the mobility of the skull upon the spine.

In all cases of head injury, the questions that dominate the whole
clinical outlook are, whether the brain is directly damaged or not,
and whether it is likely to become the seat of infection.

It is impossible to consider separately in their clinical aspects
injuries of the cranium and injuries of the brain. It seldom happens
that one is seriously damaged without the other suffering to a greater
or less extent. Sometimes the skull suffers comparatively little,
while the brain is severely damaged, but it is rare for a serious
injury to the bone to be unaccompanied by definite brain lesions. In
any case it is the damage to the brain, however slight, that gives to
the injury its clinical importance. It is an old and a true saying
that "no injury of the head is so trivial as to be despised or so
serious as to be despaired of." Injuries at first sight apparently
slight may prove fatal from hæmorrhage or infection; on the other
hand, recovery has followed injuries of great severity--for example,
the famous "American crowbar case," in which a bar of iron three and a
half feet long and one and a half inches thick passed through the
head, and yet the patient recovered.

It is convenient to consider the injuries of the brain before those of
the skull.


TRAUMATIC LESIONS OF THE BRAIN

It is probable that in all cases of injury to the head in which a
patient loses consciousness, there is some definite damage to the
cerebral tissue. This takes the form of a greater or less degree of
contusion or laceration, and the lesions are usually most severe and
dangerous when the skull is fractured and fragments are driven in upon
the brain, but they may exist--indeed they may be very extensive--in
the absence of fracture.

Several degrees are recognised.

(1) Numerous minute _petechial hæmorrhages_ may be found widely
scattered throughout the brain substance, as a result of a diffused
blow on the head, which has shaken up the brain and caused symptoms of
cerebral shock or "concussion." We have found, on microscopic
examination in such cases, in addition to these small extravasations,
collections of colloid bodies, patches of miliary sclerosis, and
chromatolysis and vacuolation of nerve-cells.[3]

[3] Miles, _Laboratory Reports, Royal College of Physicians,
Edinburgh_, vol. iv.

(2) In more severe cases there are often several _visible areas of
extravasation_, most commonly in the grey matter of the cortex (Fig.
184). These foci vary in size from a split-pea to a hazel-nut, and
consist of a dark central zone of extravasated blood, surrounded by an
area of "red softening" of the brain matter, beyond which are numerous
minute capillary hæmorrhages. These intra-cerebral lesions may be
accompanied by an effusion of blood into the meshes of the
arachno-pial membrane, and they may occur either at the part of the
head struck, or at the opposite pole of the axis of percussion--the
so-called point of _contre-coup_. The symptoms vary with the size and
site of the extravasations. It is probable that the phenomena of
"cerebral irritation" are to be explained by the occurrence of such
hæmorrhages widely scattered through the cerebral cortex. Effusions
into the cortical motor areas give rise to irritation or paralysis of
the muscles governed by the affected centres. Different forms of
aphasia and interference with vision or with hearing follow
implication of the centres governing these functions. In the
pre-frontal and in the lower temporal convolutions no special symptoms
seem to follow. When the hæmorrhages are extensive and numerous,
symptoms of compression may ensue, and these are aggravated when œdema
of the brain is superadded.

Localised hæmorrhages also occur, although less frequently, in the
crura cerebri, the pons, the floor of the fourth ventricle, and the
cerebellum. In these situations they usually prove fatal by causing
rapidly advancing coma and interference with the respiratory and
cardiac centres. The temperature immediately rises to 106° or even
108° F., and a modified form of Cheyne-Stokes respiration is present.

(3) Still more gross lesions, in the form of distinct _lacerations_,
are comparatively common at the tips of the frontal, temporal, and
occipital lobes, on the surface of the cerebellum, and at the base of
the brain. These are usually associated with symptoms of compression
in its most typical form, and as a rule prove fatal. The grey matter
is torn, and extensive effusion of blood takes place into the brain
substance, and on the surface, filling up the sulci, and distending
the arachno-pial space (Fig. 184). In a compound fracture, brain
matter may be extruded through the opening in the skull.

(4) The extravasated blood may burst _into the lateral ventricles_,
in which case the pulse becomes small and rapid--130, 160, or even
170. The respiration also is rapid--45 to 60--and greatly embarrassed,
and the temperature suddenly rises to 103° or 104° F., and continues
to rise till death ensues.

(5) _Traumatic Œdema._--It is not uncommon for a diffuse œdematous
infiltration of the brain substance or of the arachno-pial membrane to
take place in the vicinity of the injured portion of brain. This
serous exude, on account of the natural adhesions of the arachno-pia,
usually remains limited to the damaged area, but it may become
generalised.

_Mechanism._--The explanation of these widespread hæmorrhages is to be
found, according to Duret, in the disturbance of the cerebro-spinal
fluid which accompanies a severe blow on the head. This fluid not only
surrounds the brain, but it also fills the ventricles, and permeates
its substance in every direction in the peri-vascular and
perilymphatic spaces. As the brain tissue is incompressible, if an
area of the skull is momentarily depressed by a localised blow, space
is provided for it by displacement of a quantity of cerebro-spinal
fluid, which sets up a fluid wave, and this by hydrostatic pressure
increases the tension of the fluid throughout the entire brain.
Vessels may be lacerated at any point, either by the flow of this wave
or during the ebb which follows the recoil. Hence it is that the
lesion is not always at the seat of impact, but may be at the opposite
side of the skull or at other remote points.

[Illustration: FIG. 184.--Contusion and Laceration of Brain. Note
limited lesion at point of impact on left side, and more extensive
damage at point of _contre-coup_ on right.

(After Sir Jonathan Hutchinson.)]

_Repair._--As the disintegrated brain matter is replaced by
cicatricial tissue, neither the nerve cells nor the fibres being
regenerated, the loss of function of the parts destroyed is usually
permanent. A localised extravasation of blood may become encapsulated,
and constitute a "hæmorrhagic cyst." We have experimentally confirmed
Duret's observations and agree with his conclusions.


CLINICAL MANIFESTATIONS OF INJURIES TO THE BRAIN

For convenience, the clinical manifestations of cerebral injury are
usually described under the terms "concussion," "cerebral irritation,"
and "compression," but no precise pathological significance attaches
to these terms, they are essentially clinical. As the conditions so
described do not occur as independent entities and may overlap or
merge into one another their differentiation is more or less
arbitrary, and cases are frequently met with that do not run the
course characteristic of any of these groups.

#Concussion of the Brain or Cerebral Shock.#--The symptoms associated
with concussion of the brain are to all intents and purposes those of
surgical shock (Volume I., p. 250), the activity of the vital centres
being disturbed by violence acting directly upon the brain tissue
instead of by impulses transmitted to it by way of the afferent
nerves. Various theories have been put forward to account for the
depression of the vital functions in concussion. According to Duret,
with whose views we agree, the wave of cerebro-spinal fluid set in
motion by the impact of the blow on the skull, passes, both in the
ventricles and in the sub-arachnoid space, towards the base, where it
impinges upon the pons and medulla, stimulating the restiform bodies
and so inducing a fall in the blood pressure and a profound anæmia of
the brain. The disturbance of the cerebro-spinal fluid may at the same
time produce the microscopic lesions in the brain tissues described on
p. 341.

The symptoms of shock may be the only evidence of injury, or they may
be superadded to those of fracture of the skull, or laceration of the
brain.

The _clinical features_ vary according to the severity of the
violence. In the slightest cases the patient does not lose
consciousness, but merely feels giddy, faint, and dazed for a few
seconds. His mind is confused, but he rapidly recovers, and, perhaps
after vomiting, feels quite well again, save for a slight shakiness in
his limbs.

In more severe cases, immediately on receiving the blow the patient
falls to the ground unconscious. Sometimes he suffers from a general
tetanic seizure associated with arrest of respiration, which is
usually of short duration and is frequently overlooked, but may prove
fatal. The pulse is slow, small, and feeble, and is sometimes
irregular in force and frequency. The respirations are short, shallow,
slow, and frequently sighing in character. The temperature falls to
97° F., or even lower. The skin is cold and pallid and covered with
clammy sweat, and the features are pinched and pale.

In uncomplicated cases the pupils are usually equal, moderately
dilated, and react sluggishly to light. The patient can be partially
roused by shouting or by other forms of external stimulation, but he
soon subsides again into a lethargic condition. Although voluntary
movement and the deep reflexes are abolished, there is no true
muscular paralysis.

After a period, varying from a few minutes to several hours, he
rallies, the first evidence often being vomiting, which is usually
repeated. Sometimes reaction is ushered in by a mild epileptiform
seizure. He then turns on his side, the face becomes flushed, and
gradually the symptoms pass off and consciousness returns. The
temperature rises to 99° or 100° F., and in some cases remains
elevated for a few days. In most cases it falls again to 97° or 97.5°,
and remains persistently subnormal for one or two weeks. During
reaction the pulse becomes quick and bounding, but after a few hours
it again becomes slow, and usually remains abnormally slow (40 to 60)
for ten or fourteen days. There is sometimes a tendency to
constipation, and for the bladder to become distended, although he has
no difficulty in passing water. Very commonly the patient complains of
pain in the head for some days after the return of consciousness.
Children often sleep a great deal during the first few days, but
sometimes they are very fretful.

In cases complicated by gross brain lesions the symptoms of concussion
may imperceptibly merge into those of compression or there may be a
"lucid interval" of some hours duration.

_After-Effects of Concussion._--The majority of patients recover
completely. A number complain for a time of headache, languor,
muscular weakness, and incapacity for sustained effort--_traumatic
neurasthenia_. Sometimes there is a condition of mental instability,
the patient is easily excited, and is unduly affected by alcohol or
other stimulants. Occasionally there is permanent mental impairment.
It is not uncommon to find that the patient has entirely forgotten the
circumstances of the injury and of the events which immediately
preceded it. In some instances the memory is permanently impaired. On
the other hand, it has occurred that a patient, after concussion, has
recovered his memory of a foreign language long since forgotten.

As it is never possible to determine the precise extent of the damage
to the brain, the immediate prognosis, even in the mildest cases of
concussion, should always be guarded. If the patient has been actually
unconscious, the condition should be looked upon as a serious one, and
treated accordingly.

_Treatment._--The immediate treatment is the same as that of shock.
Absolute rest and quietness are called for. When the symptoms begin to
pass off, the head should be raised on pillows to prevent congestion
and to diminish the risk of bleeding from damaged blood vessels in the
brain. The value of applying an ice-bag or Leiter's tubes with a view
to arresting hæmorrhage inside the skull, is more than doubtful.
Lumbar puncture, venesection, or the application of leeches over the
temple or behind the ear may be employed with benefit. The use of
small doses of atropin and ergotin was recommended by von Bergmann.
The bowels should be thoroughly opened by calomel, croton oil, or
Henry's solution, and a light milk diet given. The patient is kept in
a shaded room, and should be confined to bed for from fourteen to
twenty-one days. It is often difficult to convince the patient of the
necessity for such prolonged confinement, but the responsibility for
curtailing it must rest upon him or his friends. Reading,
conversation, and argument must be avoided to ensure absolute rest to
the brain.

#Cerebral Irritation.#--In some cases of injury to the
head--particularly of the anterior part and the parietal region--as
the symptoms of concussion are passing off, the patient begins to
exhibit a peculiar train of symptoms, which was graphically described
by Erichsen under the name of cerebral irritation. "The attitude of
the patient is peculiar, and most characteristic: he lies on one side
and is curled up in a state of general flexion. The body is bent
forwards and the knees are drawn up on the abdomen, the legs bent, the
arms flexed, and the hands drawn in. He does not lie motionless, but
is restless, and often, when irritated, tosses himself about. But,
however restless he may be, he never stretches himself out nor assumes
the supine position, but invariably maintains an attitude of flexion.
The eyelids are firmly closed, and he resists violently every effort
made to open them; if this be effected, the pupils will be found to be
contracted. The surface is pale and cool, or even cold. The pulse is
small, feeble, and slow, seldom above 70. The sphincters are not
usually affected, and the patient will pass urine when the bladder
requires to be emptied; there may, however, though rarely, be
retention.

"The mental state is equally peculiar. Irritability of mind is the
prevailing characteristic. The patient is unconscious, takes no heed
of what passes, unless called to in a loud tone of voice, when he
shows signs of irritability of temper or frowns, turns away hastily,
mutters indistinctly, and grinds his teeth. It appears as if the
temper, as much as or more than the intellect, were affected in this
condition. He sleeps without stertor.

"After a period varying from one to three weeks, the pulse improves in
tone, the temperature of the body increases, the tendency to flexion
subsides, and the patient lies stretched out. Irritability gives place
to fatuity; there is less manifestation of temper, but more weakness
of mind. Recovery is slow, but though delayed, may at length be
perfect...."

The _treatment_ consists in keeping the patient quiet, in a darkened
room, on much the same lines as for concussion.

#Compression of the Brain.#--This term is used clinically to denote
the train of symptoms which follows a marked increase of the
intra-cranial tension produced by such causes as hæmorrhage, œdema,
the accumulation of inflammatory exudate, or the growth of tumours
within the skull. The only pathological idea the term conveys is that
there is more inside the skull than it can conveniently hold.

_Clinical Features._--The following description refers to compression
due to hæmorrhage within the skull as a result of injury. In a
majority of such cases, the symptoms of compression supervene on those
of concussion; in certain conditions, notably hæmorrhage from the
middle meningeal artery, there is an interval, during which the
patient regains complete consciousness, in others the symptoms of
concussion gradually and imperceptibly merge into those of
compression. The rapidity of onset of the symptoms and their course
and duration vary widely according to the nature and extent of the
brain lesion. Death may occur in a few hours, or recovery may take
place after the patient has been unconscious for several weeks.

The first symptoms are of an irritative character--dull pain in the
head, restlessness, and hyper-sensitiveness to external stimuli. The
face is suffused, and the pupils at first are usually contracted. The
temperature falls to 97°, or even to 95° F. Vomiting is not
infrequent.

As the pressure increases, paralytic symptoms ensue. The patient
gradually loses consciousness, and passes into a condition of coma.
The face is cyanosed, and the distension of the veins of the eyelids
furnishes an index of the severity of the intra-cranial venous stasis
(Cushing). The pulse becomes slow, full, and bounding. The respiration
is slow and deep, and eventually stertorous or snoring in character
from paralysis of the soft palate, and the lips and cheeks are puffed
out from paralysis of the muscles of these parts. The temperature,
which at first falls to 97° or even 95° F., in the course of three or
four hours usually rises (100.5° or 102.5° F.). If the temperature
reaches 104° F., or higher, the condition usually proves fatal.
Sometimes it rises as high as 106° or 108° F.--_cerebral hyperpyrexia_
(Fig. 185). Retention of urine from paralysis of the bladder, and
involuntary defecation from paralysis of the sphincter ani, are
common.

[Illustration: FIG. 185.--Two Charts of Pyrexia in Head Injuries.]

During the progress of the symptoms there is frequently evidence of
direct pressure upon definite cortical centres or cranial nerves,
giving rise to _focal symptoms_. Particular groups of muscles on the
side opposite to the lesion may first show spasmodic jerkings or
spasms (unilateral monospasm), and later the same groups become
paralysed (monoplegia). The paralysis frequently affects the whole of
one side of the body (hemiplegia) and the oculo-motor nerve is often
paralysed at the same time.

The pupils vary so widely in different cases that their condition does
not form a reliable diagnostic sign. Perhaps it is most common for the
pupil on the same side as the lesion to be contracted at first and
later to become fully dilated, while that on the opposite side remains
moderately dilated. As a rule, they are irresponsive to light.
Ophthalmoscopic examination shows swelling of the disc, and the
vessels of the papilla are distended and tortuous.

In cases which go on to a fatal termination, the coma deepens and the
muscular and sensory paralyses become general and complete. The vital
centres in the medulla oblongata gradually become involved, and death
results from paralysis of the respiratory centre. The fatal issue is
often hastened by the onset of hypostatic pneumonia. Not infrequently
a modified type of Cheyne-Stokes respiration is observed for some time
before death ensues.

A similar train of symptoms may ensue in cases of head injury as a
result of _pyogenic infection_ having given rise to meningitis or
abscess with accumulation of inflammatory exudate.

_Pathology._--When any addition is made to the bulk of matter inside
the cranial cavity, room is gained in the first instance by the
displacement into the vertebral canal of a certain amount of
cerebro-spinal fluid. The capacity of the spinal sheath, however, is
limited, and as soon as the tension oversteps a certain point, the
pressure comes to bear injuriously on the cerebral capillaries,
disturbing the circulation, and so interfering with the nutrition of
the brain tissue. As the intra-cranial tension still further
increases, the pressure gradually comes to affect the cerebral tissue
itself, and so the extreme symptoms of compression are produced. The
vagus and vaso-motor centres are irritated, and this causes slowing of
the pulse, contraction of the small arteries, and increase of the
arterial tension which tends to maintain an adequate circulation in
the vital centres in the medulla. The Cheyne-Stokes respiration is due
to rhythmical variations in the arterial tension: during the period of
fall the centres become anæmic and the respiration fails; during the
rise the medulla is again supplied with blood, and breathing is
resumed (Eyster).

The parts of the brain directly pressed upon become anæmic, while the
other parts become congested, and the nutrition of the whole brain is
thus seriously interfered with. Different parts of the brain and cord
show varying powers of resistance to this circulatory disturbance. The
cortex is the least resistant part, and next in order follow the
corona radiata, the grey matter of the spinal cord, the pons, and,
last, the medulla oblongata. Hence it is that the respiratory and
cardiac centres hold out longest.

_Depressed Bone as a Cause of Compression._--It is more than doubtful
whether a depressed portion of bone is of itself capable of inducing
symptoms of compression of the brain. When such symptoms accompany
depressed fracture, they are to be attributed either to associated
hæmorrhage, or to interference with the circulation and consequent
œdema which the displaced bone produces. Fragments of bone may,
however, aggravate the symptoms by irritating the cerebral tissue on
which they impinge.

_Foreign Bodies._--The rôle of foreign bodies, such as bullets, in the
production of compression symptoms is similar to that of depressed
bone. That foreign bodies of themselves are not a cause of compression
seems evident from the fact that it is not uncommon for them to become
permanently embedded in the brain substance without inducing any
symptoms. Not only have bullets, the points of sharp instruments, and
other substances remained embedded in the brain for years without
doing harm, but in many cases the patients have continued to occupy
important and responsible positions in life.

_Differential Diagnosis._--It not infrequently happens that a patient
is found in an insensible condition under circumstances which give no
clue to the cause of his unconsciousness. He is usually removed to the
nearest hospital, and the house-surgeon under whose charge he comes
must exercise the greatest care and discretion in dealing with him. In
attempting to arrive at the cause of the condition, numerous
possibilities have to be borne in mind, but it is often impossible to
make a definite diagnosis. The chief of these causes are trauma,
apoplexy or cerebral embolism, epileptic coma, alcohol and opium
poisoning, uræmic and diabetic coma, sunstroke, and exposure to cold.
The commonest error is to mistake a case of cerebral compression for
one of drunkenness. It is scarcely necessary to say that a man who
smells of alcohol is not necessarily intoxicated; the drink may have
been given with the object of reviving him. It may be that one or
other of the above-named conditions has caused the patient to fall,
and in his fall he has incidentally sustained an injury to the head,
which, however, is in no way responsible for his unconsciousness.
Whenever there is the least doubt, therefore, the patient should be
admitted to hospital.

In the first instance, careful search should be made for any sign of
injury, especially on the head. The discovery of a severe scalp wound
or of a fracture of the skull, in association with the symptoms of
concussion or compression, will in most cases raise the presumption
that the unconsciousness is due to some traumatic intra-cranial
lesion. Examination of the fluid withdrawn by lumbar puncture may
furnish useful information (p. 338).

In the absence of evidence of a head injury, the stomach should be
washed out and its contents examined to see if any narcotic poison is
present. The urine also should be drawn off and examined for albumin
and sugar.

In hæmorrhage due to the rupture of diseased cerebral arteries
(apoplexy), or to embolism, the symptoms are essentially those of
compression, and, in the absence of a definite history of injury to
the head, it is seldom possible to arrive at an accurate diagnosis as
to the cause of the condition. The history that the patient has
previously had "an apoplectic shock," and the fact that he is up in
years and shows signs of arterial degeneration and of cardiac
hypertrophy which would favour such hæmorrhage, are presumptive
evidence that the lesion is not traumatic.

If a history is forthcoming that the patient is an epileptic, there is
a strong presumption that the symptoms are those of _epileptic coma_.

In _alcoholic poisoning_ the examination of the stomach contents will
furnish evidence. The patient is not completely unconscious, nor is he
paralysed; the pupils are usually contracted, but react; and the
temperature is often markedly subnormal. Improvement soon takes place
after the stomach has been emptied.

In _opium poisoning_ the general condition of the patient is much the
same as in poisoning by alcohol. The pupils, however, are markedly
contracted, and do not react to light. When the poison has been taken
in the form of laudanum, this may be recognised by its odour.

In the _coma_ of _uræmia_ or of _diabetes_ there is no true paralysis,
nor is there stertor. The urine contains albumin or sugar, and there
may be œdema of the feet and legs.

_Prognosis._--The prognosis depends so much on the nature and extent
of the injury to the brain that it is impossible to formulate any
general statements with regard to it. It may be said, however, that
the symptoms which indicate a bad prognosis are immediate rise of
temperature, particularly if it goes above 104° F., the early onset of
muscular rigidity, extreme and persistent contraction of the pupils,
with loss of the reflex to light, conjugate deviation of the eyes, and
the early appearance of bed-sores.

In the majority of cases compression ends fatally in from two to seven
days. On the other hand, recovery may ensue after the stuporous
condition has lasted for several weeks.

The _treatment_ of compression is considered with the different
lesions which cause it; the principle in all cases being to remove, if
possible, the cause of the increased pressure within the skull.

#Traumatic Œdema.#--In practice, cases are frequently met with,
particularly in children, that do not conform to the classical
description of either concussion, cerebral irritation, or compression.
The injury may be followed by a varying degree of concussion which
soon passes off but leaves the patient in a listless, drowsy state
that may persist for days or even for weeks. The cerebration is
disturbed, so that while the patient is not unconscious, he is
apathetic and has lost his bearings and fails to recognise where or
with whom he is. He complains of headache, there is tenderness on
percussion over the skull, the knee jerks are diminished or absent,
but there is no motor paralysis. In some cases there are localised
jerkings, in others generalised convulsive attacks during which the
patient becomes deeply cyanosed. The condition differs from
compression due to middle meningeal hæmorrhage in that it is less
severe and is not steadily progressive.

When the symptoms are localised, the condition is probably due to
œdematous infiltration of the injured portion of brain; when
generalised, to increased intra-cranial tension from serous effusion
into the arachno-pial space.

The _treatment_ consists in diminishing the intra-cranial tension by
purgation, leeches, bleeding, or lumbar puncture, or if life is
threatened, by opening the skull over the seat of injury, or failing
evidence of this, by a decompression operation in the temporal region.


INTRA-CRANIAL HÆMORRHAGE

Apart from the hæmorrhage that accompanies laceration of brain tissue,
bleeding may occur inside the skull, either from arteries or from
veins. The effused blood may collect either between the dura mater and
the bone (_extra-dural hæmorrhage_), or inside the dura (_intra-dural
hæmorrhage_).

#Middle Meningeal Hæmorrhage.#--The commonest cause of extra-dural
hæmorrhage is laceration of the middle meningeal artery. This
artery--a branch of the internal maxillary--after entering the skull
through the foramen spinosum, crosses the anterior inferior angle of
the parietal bone, and divides into an anterior and a posterior branch
which supply the meninges and calvaria (Fig. 186). Either branch may
be injured in association with fractures, or from incised, punctured,
or gun-shot wounds. The vessel may be ruptured without the skull being
fractured, and sometimes it is the artery on the side opposite to the
seat of the blow that is torn. The most common situations for rupture
are at the anterior inferior angle of the parietal bone, in which case
the anterior branch is torn (90 to 95 per cent.); and on the inner
aspect of the temporal bone, where the posterior branch is torn (5 to
10 per cent.).

[Illustration: FIG. 186.--Relations of the Middle Meningeal Artery and
Lateral Sinus to the surface as indicated by Chiene's Lines.

(After Cunningham.)]

It is probable that the size of the hæmorrhage depends on the nature,
extent, and severity of the injury to the head. The recoil of the
skull after the blow separates the dura from the bone, and if the
meningeal artery is lacerated or punctured, blood is effused into the
space thus formed (Fig. 187). A localised blow therefore results in a
small area of separation and a correspondingly small clot; while a
diffuse blow is followed by more extensive lesions. It is believed
that, once the dura is partly separated, the force of the blood poured
out from the lacerated artery is--on the principle of the hydraulic
press--sufficient to continue the separation.

[Illustration: FIG. 187.--Extra-Dural Clot resulting from hæmorrhage
from the Middle Meningeal Artery.]

_Clinical Features._--The typical characteristics of middle meningeal
hæmorrhage are met with only when the bleeding takes place between the
dura and the bone. Under these conditions the symptoms of concussion
are usually most prominent at first, and those of compression only
ensue after a varying interval, during which the patient as a rule
regains consciousness. In some cases, indeed, he is able to continue
his work, or to walk home or to hospital, before any evidence of
intra-cranial mischief manifests itself. This "lucid interval" helps
to distinguish the symptoms due to middle meningeal hæmorrhage from
those of laceration of the brain substance, as in the latter the
symptoms of concussion merge directly into those of compression.
Lumbar puncture may aid in the differential diagnosis between
extra-and intra-dural hæmorrhage, as blood is present in the fluid
withdrawn in the latter, but not in the former.

A few hours after the accident the patient experiences severe pain in
the head, and he usually vomits repeatedly. For a time he is restless
and noisy, but gradually becomes drowsy, and the stupor increases
more or less rapidly until coma supervenes. The pulse usually becomes
slow and full. The respiration is rapid (30 to 50), and becomes
greatly embarrassed and stertorous. The temperature progressively
rises, and before death may reach 106° F., or even higher. Monoplegia,
usually beginning in the face or arm on the side opposite to the
lesion, gradually comes on, and is followed by hemiplegia, from
pressure on the motor areas, underlying the clot. The condition of the
pupils is so variable as to have no diagnostic value; but if both are
widely dilated and irresponsive to light, the prognosis is grave.
Death usually ensues in from twenty-four to forty-eight hours, unless
the pressure within the skull is relieved by operation; even after
removal of the clot death may ensue if the brain has been lacerated,
or if there is hæmorrhage at the base.

When the hæmorrhage takes place from the anterior branch, the clot
tends to spread towards the base, and may press upon the cavernous
sinus, causing congestion and protrusion of the eye, with paralysis of
the oculo-motor nerve and wide dilatation of the pupil.

In some cases of middle meningeal hæmorrhage there is no gross injury
to the brain; the area underlying the clot is merely compressed and
emptied of blood, and, on being exposed, the brain is found flattened,
or even deeply indented by the blood-clot, and it does not pulsate. If
the clot is removed, the brain may regain its normal contour and its
pulsation return. The mortality is over 50 per cent.

If the fracture is compound, the blood can escape, and therefore the
pressure symptoms are less evident or may be entirely absent.

It is a fact of some medico-legal importance that hæmorrhage from the
middle meningeal may not take place till some days, or even weeks,
after an injury, which at the time was only attended with symptoms of
concussion. This condition is known as _traumatic apoplexy_.

_Treatment._--Immediate operation is imperatively called for, not only
to arrest the hæmorrhage and remove the clot, but also to ward off the
œdema of the brain, which is often responsible for the fatal issue.
When there is no external wound, the point at which the skull is to be
opened is determined by the symptoms; for example, paralysis of the
arm and face on one side indicates trephining over the centres
governing these parts on the side opposite to the paralysis.

If the bleeding cannot otherwise be arrested it may be necessary to
ligate the external carotid artery. It has been suggested by J. B.
Murphy that, when the patient is seen while the symptoms of
compression are coming on, instead of trephining, the hæmorrhage from
the meningeal vessels should be arrested by applying a ligature to the
external carotid, under local anæsthesia.

Injury to the #internal carotid# artery within the skull may result
from penetrating wounds, or may be associated with a fracture of the
base. It is almost invariably fatal. In some cases a communication is
established between the artery and the cavernous sinus, and an
arterio-venous aneurysm is thus produced. Ligation of the internal
carotid in the neck or of the common carotid is the only feasible
treatment.

Injuries of the #venous sinuses# may occur apart from gross lesions of
the skull, but as a rule they accompany fractures and penetrating
wounds. The transverse (lateral), superior sagittal (longitudinal),
and cavernous sinuses are those most frequently damaged. On account of
the low pressure in the sinuses, spontaneous arrest of extra-dural
hæmorrhage usually takes place, and recovery ensues. In some cases,
however, the amount of blood extravasated is sufficient to cause
compression. If the dura mater is torn, and the blood passes into the
sub-arachnoid space, it may spread over the whole surface of the
brain. Sometimes the bleeding only commences after a depressed
fracture has been elevated.

In the presence of an open wound, the venous source of the bleeding is
recognised by the dark colour of the blood and the continuous
character of the stream. It may be arrested by pressure with gauze
pads or by packing a strand of catgut into the sinus (Lister), or, if
this fails, by grasping the sinus with forceps and leaving these in
position for twenty-four or forty-eight hours. A small puncture in the
outer wall of the sinus may be closed with sutures. Signs of
increasing compression call for trephining and opening of the dura if
this is necessary to admit of the clot being removed.

#Intra-cranial Hæmorrhage in the Newly-Born.#--An extravasation of
blood into the arachno-pial space frequently occurs during birth. The
observations of Cushing seem to show that this is usually due to
tearing of the delicate cerebral veins which pass from the cortex to
the superior sagittal sinus, from the strain put upon them by the
overlapping of the parietal bones, in the moulding of the head. It may
sometimes be due to an excessive degree of asphyxia during birth. The
extravasation is usually most marked over the central area of the
cortex near the middle line, and it is often bilateral.

This condition is most frequently met with in a first-born child--and
more often in boys than in girls--the labour having been prolonged and
difficult, and the presentation abnormal. There is usually a history
that the infant was deeply cyanosed when born, and that there was
difficulty in getting it to breathe. As a rule, there is no external
evidence of trauma. The anterior fontanelle is tense and does not
pulsate, the pulse is slow, and for several days the child appears to
have difficulty in sucking and swallowing, and is abnormally still. In
the course of a few days definite symptoms of localised pressure
appear. It is noticed that one leg or arm, or one side of the body is
not moved, or both sides may be affected; when the paralysis is
bilateral, the absence of movement is more liable to be overlooked.
The infant may suffer from convulsions; there may be paralysis of
certain of the ocular muscles, and inequality of the pupils; sometimes
there is blindness. Persistent rigidity of the limbs, with turning of
the thumbs towards the palm, is present in some cases. Lumbar puncture
may reveal the presence of blood corpuscles in the cerebro-spinal
fluid, and increase in the tension of the fluid.

If untreated, the condition is usually followed by the development of
spastic paralysis of one or more limbs, on one or on both sides of the
body (Little's disease), by blindness, deafness, and varying degrees
of mental deficiency, or by Jacksonian epilepsy.

_Treatment._--To obviate these after-effects the clot may be removed
by raising an osteo-plastic flap, including nearly the whole of the
parietal bone. The operation should be undertaken within the first
week or two, and great care must be taken to keep up the body-warmth,
and to prevent undue loss of blood. It may be necessary to operate on
both sides, an interval being allowed to elapse between the two
operations.

For the immediate relief of increased intra-cranial tension, the daily
withdrawal of 10-12 c.c. of cerebro-spinal fluid by lumbar punctures
may be employed, or a sub-temporal decompression operation may be
performed.


WOUNDS OF THE BRAIN

#Wounds of the Brain.#--_Incised_ wounds of the brain usually result
from sabre-cuts, hatchet blows, or circular saws. A portion of the
scalp and cranium may be raised along with a slice of brain matter,
and in some cases the whole flap is severed. The extent of the injury,
the conditions under which it is received, and the liability to
infection, render such wounds extremely dangerous.

_Punctured wounds_ may be inflicted on the vault by stabs with a knife
or dagger, or by other sharp objects, such as the spike of a railing.
More frequently a pointed instrument, such as a fencing foil, the end
of an umbrella, or a knitting needle, is thrust through the orbit into
the base of the brain. Occasionally the base of the skull has been
perforated through the roof of the pharynx, for example, by the stem
of a tobacco-pipe. All such wounds are of necessity compound, and the
risk of infection is considerable, particularly if the penetrating
object is broken and a portion remains embedded within the skull. The
infective complications of such injuries are described later.

_Bullet wounds_ have many features in common with punctured wounds.
There is more contusion of the brain substance, disintegrated brain
matter is usually found in the wound of entrance, and the bullet often
carries in with it pieces of bone, cloth, or wad, thus adding to the
risk of infection.

Aseptic foreign bodies, especially bullets, may remain embedded in the
brain without producing symptoms.

The _treatment_ of punctured wounds consists in enlarging the wounds
in the soft parts, trephining the skull, and removing any foreign body
that may be in it, purifying the track, and establishing drainage.


AFTER-EFFECTS OF HEAD INJURIES

Various after-effects may follow injuries of the head. Thus, for
example, _chronic interstitial changes_ (sclerosis) may spread from an
area of cicatrisation in the brain; or _softening_ may ensue, either
in the form of pale areas of necrosis (white softening) or of
hæmorrhagic patches (red softening). The symptoms vary with the area
implicated. _Adhesions_ between the brain and its membranes may
produce severe headache and attacks of vertigo, especially on the
patient making sudden exertion.

After a head injury, the patient's whole mental attitude is sometimes
changed, so that he becomes irritable, unstable, and incapacitated for
brain-work--_traumatic neurasthenia_. In some cases self-control is
lost, and alcoholic and drug habits are developed.

#Traumatic epilepsy# may ensue as a result of some circumscribed
cortical lesion, such as a spicule of bone projecting into the
cortex, the presence of adhesions between the membranes and the brain,
a cicatrix in the brain tissue leading to sclerosis or a hæmorrhagic
cyst in the membranes or cerebral tissue.

The convulsive attacks are of the Jacksonian type, beginning in one
particular group of muscles and spreading to neighbouring groups till
all the muscles of the body may be affected. The convulsions may begin
soon after the injury, for example, when the cause is a fragment of
bone irritating the cortex; in other cases it may be several years
before they make their appearance. The onset is usually sudden, and
the "signal symptom"--for example, jerking of the thumb, conjugate
deviation of the eyes, or motor aphasia--indicates the seat of the
lesion. At first the attacks only recur at intervals of, it may be
weeks or months, but as time goes on they become more and more
frequent, until there may be as many as forty or fifty in a day.
Sometimes the patient loses consciousness during the fit; sometimes he
remains partly conscious. In course of time the same degenerative
changes as occur in other forms of epilepsy ensue: certain groups of
muscles may become paralysed; the patient may pass into a state of
idiocy, or into what is known as the "status epilepticus," in which
the fits succeed one another without remission, the breathing becomes
stertorous, the temperature rising, the pulse becoming very rapid;
finally coma supervenes, and the patient dies.

_Treatment._--The administration of bromides is only palliative.
Operation is indicated only when the "signal symptom" indicates a
limited and accessible portion of the brain as the seat of the lesion,
or when there is a depression of the skull or other definite evidence
of cranial injury. The more recent the injury the better is the
prospect, as secondary changes are less likely to have taken place,
and the peculiarly irritable state of the brain--sometimes referred to
as the "epileptic habit"--has not developed. The operation consists in
opening the skull freely, and removing any discoverable cause of
irritation--depressed bone, thickened and adherent membranes, a cyst,
or sclerosed patch of cortex; it may be necessary to interpose a layer
of tissue, a flap of fascia lata, for example, between the bone and
the cortex of the brain. The point at which the skull is opened is
determined by the seat of the injury and the focal brain symptoms.

The return of fits within a few days of the operation does not
necessarily mean failure, as they often pass off again. Complete and
permanent cure is not common, but the number and severity of the
attacks are usually so far diminished that life is rendered bearable.

#Traumatic insanity# may follow injury to any part of the brain, and
it may come on either immediately or after an interval. It may or may
not be associated with epilepsy. Any form of insanity may occur,
either as a direct result of the trauma, or from the resistance of the
brain being lowered by the injury in a patient predisposed to
insanity. When insanity follows as a direct consequence of injury, the
organic lesion is usually a superficial one, and the disturbance of
brain function is generally due to reflex irritation of the dura mater
(Duret). These facts possibly explain the immediate improvement which
occasionally follows the opening of the skull at the point of injury
and removal of the exciting cause. Cases occurring within a few days
of the injury usually recover within a month or two. The later the
condition is in developing the less obvious is the relationship
between the trauma and the insanity, and therefore the worse is the
prognosis.

_Meningitis_, _sinus thrombosis_, and _cerebral abscess_ may follow
upon any form of head injury attended with infection. The clinical
features--save for the history of a trauma--correspond so closely with
those of the same conditions occurring apart from injury, that they
are most conveniently considered together (p. 374).




CHAPTER XIII

INJURIES OF THE SKULL


Contusions--FRACTURES--Of the vault: _Varieties_--Of the Base:
    _Anterior fossa_--_Middle fossa_--_Posterior fossa_.

The bones of the skull may be contused or fractured. These injuries
are not in themselves serious: their clinical importance is derived
from the injury to the intra-cranial contents with which they are
liable to be associated.

#Contusion# of the skull may result from a fall, a blow, or a gun-shot
injury. In the majority of cases the damage to soft parts--scalp,
meningeal vessels, or brain--overshadows the osseous lesion, which of
itself is comparatively unimportant.


FRACTURES OF THE SKULL

While it is convenient to consider separately fractures of the vault
and fractures of the base of the skull, it is to be borne in mind that
it is not uncommon for a fracture to involve both the vault and the
base. Fractures in either situation may be simple or compound.


FRACTURES OF THE VAULT

#Mechanism.#--When the skull is broken by _direct_ violence, the
fracture takes place at the seat of impact, and its extent varies with
the nature of the impinging object and the degree of violence exerted.
If, for example, a pointed instrument, such as a bayonet, a foil, or a
spike, is forcibly driven against the skull, the weapon simply crashes
through the bone, disintegrating it at the point of entrance, and
cracking or splintering it for a variable, but limited, distance
beyond. On the other hand, when the head is struck by a "blunt"
object--for example, a batten falling from a height--the force is
applied over a wider area and the elastic skull bends before it. If
the limits of its elasticity are not exceeded, the bone recoils into
its normal position when the force ceases to act; but if the bone is
bent beyond the point from which it can recoil, a fracture takes
place--"_fracture by bending_." The bone gives way over a wide area,
the affected portion may be comminuted, and one or more of the
fragments may remain depressed below the level of the rest of
the skull. Cracks and fissures spread widely in different
directions--often (70 to 75 per cent.) extending into the base. In
almost all fractures of the vault the inner table splinters over a
wider area than the outer, partly because it is more brittle and is
not supported from within, but also because the diffusion of the force
as it passes inwards affects a wider area. If a bullet traverses the
cranial cavity the inner table is more widely shattered at the
aperture of entrance, and the outer table at the aperture of exit. Von
Bergmann reported thirty cases in which the inner table alone was
fractured by a blow on the head.

Fractures by _indirect_ violence--that is, fractures in which the bone
breaks at a point other than the seat of impact--are almost always due
to violence inflicted with a blunt object, and acting over a wide
area--such, for example, as when the head strikes the pavement. Much
discussion has taken place as to the method of their production. It
has been shown that when the skull is depressed at one point by a
force impinging on it, it bulges at another, so that its whole contour
is altered. But the elasticity of the bone varies at different parts
of the skull, owing to differences in thickness and in structure. If,
therefore, the part which is depressed--that is, the part directly
struck--happens to be less elastic than the part which bulges, it
gives way, and a fracture by "bending" results; but if the bulging
part is the less elastic, it bursts outwards--_fracture by_
"_bursting_." The term "fracture by _contre-coup_" has been
incorrectly applied to such fractures when the area of bulging happens
to be opposite to the seat of impact. _Contre-coup_, properly
so-called, is only possible in a perfectly spherical body, which, of
course, the skull is not.

When a high-velocity bullet penetrates the head, it exerts on the
incompressible, semi-fluid brain an explosive (hydro-dynamic) force,
which is transmitted to all points on the inner surface of the skull
and leads to shattering of the bone.

_Repair._--The repair of fractures of the skull is usually attended
with an exceedingly small amount of callus. Except in the presence of
infection, separated fragments live and become reunited, but they may
unite in such a manner as to project towards the brain and, by
irritating the cortical centres, cause traumatic epilepsy. In
comminuted fractures, the lines of fracture remain permanently visible
on the bone, but fissured fractures may leave no trace. Gaps left in
the skull by injury or operation are, after a time, filled in by a
fibrous membrane, which may undergo ossification from the periphery
towards the centre, but unless the aperture is a small one it is
seldom completely closed by bone. The new bone which forms is derived
from the old bone at the margins of the opening. Permanent defects in
the skull are chiefly injurious if they are accompanied by lesions of
the underlying dura, such as adhesions to the brain; large gaps may
cause giddiness on stooping, or on forcible expiration, as in blowing
the nose or playing a wind instrument.

#Varieties.#--For descriptive purposes, fractures of the vault are
divided into the fissured, the punctured, the depressed, and the
comminuted varieties. Clinically, however, these varieties are often
combined. The practical importance of a given fracture depends upon
whether it is simple or compound, rather than upon the exact nature of
the damage done to the bone. Compound fractures which open the dura
mater are the most serious. Simple fractures result, as a rule, from
diffuse forms of violence, and are liable to spread far beyond the
seat of impact. Compound fractures result from severe and localised
violence--for example, the kick of a horse or the blow of a
hammer--and tend to be limited more or less to the seat of impact. In
gun-shot injuries, however, there are usually numerous fissures
radiating from the point at which the missile enters the skull.

#Fissured fractures# generally result from blows by blunt objects or
from falls, and they usually extend far beyond the area struck, in
most cases passing into the base. The fissure may pass through the
bone vertically or obliquely, and it may implicate one or both tables.
So long as the fracture is simple, it can scarcely be diagnosed except
by inference from the associated symptoms of meningeal or cerebral
injury. When compound, the crack in the bone can be seen and felt. It
is recognised by the eye as a split in the bone, filled with red
blood, which, as often as it is sponged away, oozes again into the
gap. In fractures by bursting a tuft of hair may be caught between the
edges of the fracture, and this adds to the difficulty of purifying
the wound.

_Diagnosis._--A normal suture may be mistaken for a fissured fracture.
A suture, however, may generally be recognised by its position, the
irregularity of its margins, and the absence of blood between its
edges. At the same time, it is not uncommon, especially in children,
for a suture to be sprung by violence applied to the head, or for a
fissured fracture to enter a suture and, after running in it for some
distance, to leave it again. The edges of a clean cut in the
periosteum may be mistaken for a fissure in the bone, especially if
reliance is placed on the probe for diagnosis. This error can be
avoided by raising the edge of the periosteum from the bone, with the
gloved finger. On combined auscultation and percussion a peculiar
"hollow-cask" sound may be detected in some cases of fissured fracture
of the vault.

Fissured fractures as such call for no _treatment_. When compound, the
wound must be disinfected; and intra-cranial complications, such as
meningeal hæmorrhage, laceration of the brain, or infection, are to be
treated on the lines already described.

#Punctured fractures# are of necessity compound, and on account of the
risks of infection are to be looked upon as serious injuries. They
result from the localised impact of a sharp, and usually infected
object the point of which is not infrequently left either in the bone
or inside the skull. Fragments of bone are often driven into the
brain, and short fissures frequently pass in various directions from
the central aperture.

_Diagnosis._--When the instrument impinges on the head obliquely,
after piercing the scalp it may pass for some distance under it before
perforating the skull, so that on its withdrawal a valvular wound is
left, and at first sight it appears that only the scalp is involved.
Sometimes a foreign body left in the gap so fills it up that it is
difficult to detect the fracture with a probe or even with the finger.
In all doubtful cases the scalp wound should be sufficiently enlarged
to exclude such errors. We have known of a case of a man who died of
meningitis resulting from a punctured fracture of the vault caused by
the spoke of an umbrella, the fracture having escaped recognition
until the meningeal symptoms developed.

_Treatment._--The scalp wound must be purified, being opened up as far
as necessary for this purpose. The infected portion of bone should be
removed to render possible the purification of the membranes and
brain, and to permit of drainage.

#Depressed and Comminuted Fractures.#--As these varieties almost
always occur in combination, they are best considered together. The
terms "indentation fracture," "gutter fracture," "pond fracture," have
been applied to different forms of depressed fracture, according to
the degree of damage to the bone and the disposition of the fragments
(Figs. 188, 189, 190). These fractures may be simple or compound.

[Illustration: FIG. 188.--Depressed Fracture of Frontal
Bones--involving the air sinus on both sides--with a fissured fracture
radiating from it.

(From Professor Harvey Littlejohn's collection.)]

[Illustration: FIG. 189.--Depressed and Comminuted Fracture of Right
Parietal Bone: Pond Fracture. The patient sustained the injury twenty
years before death.]

[Illustration: FIG. 190.--Pond Fracture of Left Frontal Bone, produced
during delivery.

(From a photograph lent by Mr. J. H. Nicoll.)]

As a rule the whole thickness of the skull is broken, and, as usual,
the inner table suffers most. In infants the bones may be merely
indented, the fracture being of the greenstick variety. All degrees of
severity are met with, from a simple, localised indentation of the
bone, to complete smashing of the skull into fragments.

_Diagnosis._--When compound, the nature of these fractures is readily
recognised on exploring the wound, but their extent is not always easy
to determine, and it is not uncommon for extensive fissures to pass
into the base.

A hæmatoma of the scalp may readily be mistaken for a depressed
fracture. The condensation of the tissues round the seat of impact and
the soft coagulum in the centre, closely simulate a depression in the
bone; but if firm pressure is made with the finger, the irregular edge
of the bone can be recognised, and the depressed portion is felt to be
on a lower level. On the other hand, a depression in the bone is
sometimes obscured by an overlying hæmatoma, and unless great care is
taken the fracture may be overlooked.

_Treatment._--All are agreed that compound depressed and comminuted
fractures--whether associated with cerebral symptoms or not--should
be operated on to enable the wound to be purified, and the normal
outline of the skull to be restored by elevating or removing depressed
or separated fragments. Except in young children, in whom considerable
degrees of depression are frequently righted by nature, most surgeons
recommend operative interference even in simple fractures with the
object of elevating the depressed bone, and to anticipate subsequent
complications such as persistent headache, attacks of giddiness,
traumatic epilepsy, or insanity. Others, including von Bergmann and
Tilmanns, consider that the risk of such sequelæ ensuing is not
sufficient to justify a prophylactic operation of such severity as
trephining.

The operation is described in _Operative Surgery_, p. 93.


FRACTURES OF THE BASE

The base of the skull may be fractured by a pointed object, such as a
fencing foil, a knitting pin, or the end of an umbrella, being forced
through the orbit, the nasal cavities, or the pharynx. These injuries
will be referred to in describing fractures of the anterior fossa.

The majority of basal fractures result from such accidents as a fall
from a height, the patient landing on the vertex or on the side of the
head, or from a heavy object falling on the head. The violence is
therefore indirect in so far as the bone breaks at a point other than
the seat of impact.

In other cases the base is broken by the patient falling from a height
and landing on his feet or buttocks, the force being transmitted
through the spine to the occiput, and the bone giving way around the
foramen magnum. Sometimes the condyle of the lower jaw is driven
through the base of the skull by a blow or fall on the chin, and
fissures radiate into the base from the glenoid cavity. It is usual to
describe these also as fractures by indirect violence, but as the
skull gives way at the point where it is struck, these are really
fractures by direct violence. Von Bergmann, Bruns, and Messerer have
done much to elucidate the mechanism of basal fractures.

In the consideration of the mode of production of basal fractures by
indirect violence, the irregular shape of the cavity, the varying
strength and thickness of its different parts, and the existence of
the foramina through the bone are to be borne in mind. The force
acting on the skull tends to increase one diameter of the cavity, and
to diminish the opposite diameter. The resulting fracture, therefore,
is due to bursting of the skull, and tends to take place at the part
which has least elasticity--that is, at the base. It has been found
that the site and direction of basal fractures bear a fairly constant
relation to the direction of the force by which they are produced.
When, for example, the skull is compressed from side to side, the line
of fracture through the base is usually transverse, and it may
implicate one or both sides (Fig. 191). On the other hand, when the
pressure is antero-posterior, the fracture tends to be longitudinal;
and when oblique, it tends to be diagonal.

[Illustration: FIG. 191.--Transverse Fracture through Middle Fossa of
Base of Skull.]

Fractures of the base usually take the form of a single fissure, or a
series of fissures, which, as a rule, run through the foramina in
their track. Small portions of bone are sometimes completely
separated. It is common for a fissure through the base to be
continued for a considerable distance on to the vault.

The fracture may involve only one fossa, but as a rule fissures
radiate into two or all of them. Fractures of the anterior and middle
fossæ are usually rendered compound by tearing of the mucous membrane
of the nose, the pharynx, or the ear.

Basal fractures are frequently associated with contusion and
laceration of the brain, and also with injuries of one or more of the
cranial nerves.

#Fracture of the anterior fossa# may result from a blow on the
forehead, nose, or face; or from a punctured wound of the orbit or of
the nasal cavity. Often the injury is at first considered trivial, and
it is only when infective complications, in the form of meningitis or
cerebral abscess, develop, that its true nature is suspected. This
fossa may also be implicated in fractures of the vault, fissures
extending from the vertex to the orbital plate of the frontal bone, or
to the lesser wing of the sphenoid.

_Clinical Features._--Unless the fracture is compound through opening
into the nose or pharynx, there are few symptoms by which it can be
recognised. When compound, there may be bleeding from the pharynx or
nose from tearing of the periosteum and mucous membrane related to the
basi-sphenoid and ethmoid respectively. When the hæmorrhage is
profuse, it is probable that the meningeal vessels or even the venous
sinuses have been torn. Cerebro-spinal fluid may escape along with the
blood, but it is seldom possible to recognise it. If the flow is long
continued, the patient may be conscious of a persistent salt taste in
the mouth, due to the large proportion of sodium chloride which the
fluid contains. In very severe injuries, brain matter may escape
through the nose or mouth.

Fracture of the anterior fossa is often accompanied by extravasation
of blood into the orbit, pushing forward the eyeball and infiltrating
the conjunctiva (_sub-conjunctival ecchymosis_). This occurs
especially when the orbital plate of the frontal bone is implicated.
The blood which infiltrates the conjunctiva passes from behind
forwards, appearing first at the outer angle of the eye and spreading
like a fan towards the cornea. Later it spreads into the upper eyelid.
When the orbital ridge is chipped off, without the cavity of the skull
being opened into, the hæmorrhage shows at once both under the
conjunctiva and in the upper lid. If the frontal sinus is opened, air
may infiltrate the scalp.

The olfactory, optic, oculo-motor, pathetic, ophthalmic division of
the trigeminal, and the abducens nerves are all liable to be
implicated.

_Diagnosis._--It is scarcely necessary to state that bleeding from the
nose or mouth may occur after a blow on the face without the
occurrence of a fracture of the skull. It is only when it is long
continued and profuse that the bleeding suggests a fracture. Similarly
effusion of blood in the region of the orbit may be due to a simple
contusion of the soft parts ("black eye"), or to gravitation of blood
from the forehead or temple. Sub-conjunctival ecchymosis also may
occur independently of a fracture implicating the anterior fossa--for
example, in association with an ordinary black eye, or with fracture
of the orbital ridge or of the zygomatic (malar) bone.

Finally, paralysis of the cranial nerves may result from pressure of
blood-clot, or from the nerves being torn without the skull being
fractured.

#Fracture of the middle fossa# is usually the result of severe
violence applied to the vault, as, for example, when a man falls from
a height, or is thrown from a horse and lands on his head.

_Clinical features._--The most conclusive sign of fracture of the
middle fossa is the escape of dark-coloured blood in a steady stream
from the ear, followed by oozing of cerebro-spinal fluid. The bleeding
from the ear may go on for days, the blood gradually becoming lighter
in colour from admixture with cerebro-spinal fluid. Finally the blood
ceases, but the clear fluid continues to drain away, sometimes for
weeks, and in such quantity as to soak the dressings and the pillow.
In our experience, the escape of cerebro-spinal fluid is much less
common than is generally supposed. In most cases, on examining the ear
with a speculum, the tympanic membrane is found to be ruptured; when
it is intact, the blood and cerebro-spinal fluid may pass down the
Eustachian tube into the pharynx. The escape of brain matter from the
ear is exceedingly rare. Emphysema of the scalp sometimes results when
the fracture passes through the mastoid cells. The facial and acoustic
nerves and the maxillary and mandibular divisions of the trigeminal
are frequently implicated. Deafness is a serious and not uncommon
accompaniment of fracture of the middle fossa, as the fracture
involves the labyrinth and is attended with hæmorrhage and the
formation of new bone.

_Diagnosis._--Care must be taken not to mistake blood which has passed
into the ear from a scalp wound, or which has its origin in a
fracture of the wall of the external auditory meatus or a laceration
of the tympanic membrane, for blood escaping from a fracture of the
base. Under these conditions the blood is usually bright red, is not
accompanied by cerebro-spinal fluid, and the flow soon stops. It is on
record[4] that blood and cerebro-spinal fluid may escape along the
sheath of the acoustic nerve without the bone being broken.

[4] Miles, _Edinburgh Medical Journal_, 1895.

#Fracture of the posterior fossa# is produced by the same forms of
violence as cause fracture of the middle fossa; it is specially liable
to result if the patient falls on the feet or buttocks.

_Clinical Features._--Sometimes a comparatively limited fracture of
the occipital bone results, and in the course of a few days blood
infiltrates the scalp in the region of the occiput and mastoid, or may
pass down in the deeper planes of the neck. As a rule, however, there
is no immediate external evidence of fracture. The patient is
generally unconscious, and shows signs of injury to the pons and
medulla, causing interference with respiration, which soon proves
fatal. The rapidly fatal issue of these cases usually prevents the
manifestation of any injury to the posterior cranial nerves.

_Diagnosis of Basal Fractures._--In the diagnosis of fractures of the
base, reliance is to be placed chiefly upon: (1) the nature of the
injury; (2) the diffuse character of the cerebral symptoms; (3) the
evidence of injury to individual cranial nerves; (4) the occurrence of
persistent bleeding from the nose, mouth, or ear; (5) the
extravasation of blood under the conjunctiva or behind the mastoid
process; and (6) the presence of blood in the cerebro-spinal fluid
withdrawn by lumbar puncture. In rare cases the diagnosis is made
certain by the escape of cerebro-fluid or of brain matter from the
nose, mouth, or ear.

It must be admitted, however, that in a large proportion of cases
which end in recovery, the diagnosis of fracture of the base is little
more than a conjecture. The external evidence of damage to the bone is
so slight and so liable to be misleading, that little reliance can be
placed upon it. The associated cerebral and nervous symptoms also are
only presumptive evidence of fracture of the bone. In all cases,
however, in which there is reason to suspect that the base is
fractured, the patient should be treated on this assumption. It is
often found that, when there are no cerebral symptoms present, it is
difficult to convince the patient of the necessity for undergoing
treatment, and of the risk involved in his leaving his bed and
resuming work.

_Prognosis in Basal Fractures._--The prognosis depends upon the
severity of the cerebral lesions, and on the occurrence of traumatic
œdema or infective intra-cranial complications. Many cases prove fatal
within a few hours from the associated injury to the brain, the
patient dying from cerebral compression due to hæmorrhage. If the
patient survives two days, the prognosis is more hopeful (Wagner). It
is possible that the free escape of blood from the nose or ear may in
some cases prevent compression, and to a certain extent render the
prognosis more favourable. Punctured fractures are frequently fatal
from infective complications--meningitis, sinus thrombosis, and
cerebral abscess. These complications are also liable to occur in
fractures rendered compound by opening into the nose, pharynx, or ear,
but they are less common than might be expected.

_Treatment._--The general treatment includes that for all head
injuries. In a number of cases attended with symptoms of compression,
benefit has followed the relief of intra-cranial tension by a
decompression operation. The withdrawal of 30 or 40 c.c. of
cerebro-spinal fluid by lumbar puncture has also proved beneficial in
the same way; Quenú strongly recommends repeated puncture in serious
cases. In a few cases this procedure has been followed by sudden
death.

Steps must be taken to prevent infection from the mucous surfaces
implicated. This is exceedingly difficult in fractures opening into
the pharynx and nose. Owing to the general condition of the patient,
it is usually impossible to employ nasal douching or mouth washes, but
spraying the cavities with peroxide of hydrogen or other antiseptics
may be employed with benefit. In fractures of the middle fossa, the
ear should be gently sponged out and the meatus plugged with gauze,
retained in position by adhesive plaster or a bandage. When there is a
persistent escape of blood or cerebro-spinal fluid, the dressing
requires to be changed frequently.

In compound fractures of the anterior fossa due to perforation through
the orbit, the frontal bone should be trephined to admit of the
removal of loose fragments or of any foreign body that may have
entered the skull and to provide for drainage.




CHAPTER XIV

DISEASES OF THE BRAIN AND MEMBRANES


Pyogenic diseases--Meningitis: _Varieties_--Abscess:
    _Varieties_--Sinus phlebitis--Intra-cranial tuberculosis.
    Cephaloceles--_Meningocele_--_Encephalocele_--
    _Hydrencephalocele_--Traumatic cephal-hydrocele--Hydrocephalus;
    _Varieties_--Micrencephaly. Cerebral tumours. Tumours of the
    pituitary body. Epilepsy--Hernia cerebri. Surgical affections of
    cranial nerves--Cervical sympathetic.


PYOGENIC DISEASES

The most important intra-cranial conditions that result from infection
with pyogenic bacteria are: meningitis, abscess of the brain, and
phlebitis of the venous sinuses.

The organisms most frequently associated with these conditions are the
staphylococcus aureus and the streptococcus, but it is not uncommon
to meet with mixed infections in which other bacteria are
present--particularly the pneumococcus, the bacillus fœtidus, the
bacillus coli, the bacillus pyocyaneus, and the diplococcus
intracellularis.

By far the most common source of intra-cranial infection is chronic
suppuration of the middle ear and mastoid antrum, the organisms
passing from these cavities to the interior of the skull directly
through a perforation of the tegmen tympani or of the wall of the
sigmoid groove, or being carried in the blood stream by the emissary
veins. In some cases the infection travels along the sheaths of the
facial and acoustic nerves.

Less frequently infective conditions of the nasal cavity and its
accessory air sinuses, and compound fractures of the skull,
particularly punctured fractures, are followed by intra-cranial
complications; or infection is conveyed to the inside of the skull, by
way of the emissary veins, from wounds of the scalp, or from such
conditions as erysipelas of the face and scalp, malignant pustule,
carbuncles, or boils.

At the bedside there is often difficulty in discriminating between the
various pyogenic intra-cranial complications, because many of the
symptoms are common to all the members of this group, and because
more than one condition is frequently present. Thus a localised
meningitis spreading to the brain may set up a cerebral abscess; a
sinus phlebitis may give rise to a purulent lepto-meningitis; or a
cerebral abscess bursting into the sub-arachnoid space may produce
meningitis.


MENINGITIS

#Pachymeningitis.#--This term is applied when the infection involves
the dura mater--a condition which is usually due to the spread of
infection from a localised osseous lesion, such as erosion of the
tegmen tympani in chronic suppuration of the middle ear, of the wall
of the sigmoid groove in mastoid disease, or of the posterior wall of
the frontal sinus in suppuration of that cavity. It also occurs in
relation to septic lesions of the cranial bones such as a broken-down
gumma, after operations on the cranial bones, and in cases of compound
fracture attended with a mild degree of infection and with imperfect
drainage. In contusion of the skull without an external wound, the
infection may take place through the blood stream.

The layer of the dura in contact with the affected portion of
bone is inflamed, thickened, and covered with a layer of
granulations--_external pachymeningitis_--and between it and the bone
there is an effusion of fluid. Up to this point the process is largely
protective in its effects, and gives rise to no symptoms, beyond
perhaps some pain in the head.

In the majority of cases, however, suppuration occurs between the dura
and the bone--_suppurative pachymeningitis_--and leads to the
formation of an _extra-dural abscess_ (Fig. 192). When this happens
in association with disease in the middle ear or frontal sinus, it is
attended with severe headache referred to the seat of the abscess, a
sudden rise of temperature preceded by shivering, and other evidence
of the absorption of toxins. Over the situation of the abscess, the
scalp becomes swollen and œdematous--a condition which Percival Pott,
in 1760, first observed to be characteristic of extra-dural
suppuration, hence the name, _Pott's puffy tumour_, applied to it
(Fig. 193). Under these circumstances the abscess is seldom of
sufficient size to cause a marked increase in the intra-cranial
tension, or to give rise to localised cerebral symptoms by pressing on
the brain.

[Illustration: FIG. 192.--Diagram of Extra-Dural Abscess.]

[Illustration: FIG. 193.--Pott's Puffy Tumour in case of extra-dural
abscess following compound fracture of orbital margin; infected with
road-dust; operation; recovery. At the time of the photograph the man
was unconscious.]

When associated with a punctured wound implicating the skull, an
extra-dural abscess may develop within a few days of the injury, or
not till after the lapse of several weeks, and it may spread over a
wide area and come to encroach on the cranial cavity sufficiently to
raise the intra-cranial tension and cause symptoms of compression, or
even to press upon cortical centres and produce localised paralyses.
As discharge can escape from the wound in the scalp, the puffy tumour
does not necessarily form.

_Treatment._--When the abscess is secondary to middle ear disease, the
mastoid must be opened, the eroded bone exposed, and sufficient of it
removed with rongeur forceps to admit of free drainage. When the
infection has spread from the frontal sinus, the skull is trephined in
the frontal region, the precise site being indicated by the œdematous
area in the scalp, and the diseased bone is removed. In cases of
compound fracture, drainage is established by enlarging the scalp
wound, and removing loose, depressed, or inflamed portions of bone; if
the bone is comparatively intact, it must be trephined, and further
bone is removed with rongeur forceps over the entire area in which the
dura has been separated.

#Lepto-meningitis.#--If the infection spreads to the adjacent
arachno-pia (_localised lepto-meningitis_), adhesions usually form,
and shut off the infected area from the general arachno-pial space.

Pus may form among these adhesions, constituting a _sub-dural
abscess_, and may infiltrate the superficial layers of the cortex
(_purulent encephalitis_, or _meningo-encephalitis_) (Fig. 194). The
symptoms are similar to those of extra-dural abscess, but may be more
severe; and it is seldom possible to distinguish between them before
exposing the parts by operation. The treatment is carried out on the
same lines.

[Illustration: FIG. 194.--Diagram of Sub-Dural Abscess.]

_Acute General Lepto-Meningitis._--In bone lesions, particularly
compound fractures, infection of the arachno-pia may take place
before protective adhesions form, and a diffuse lepto-meningitis
results. The open structure of the arachno-pial membrane favours the
rapid spread of the infection, which may extend over the surface of
the hemispheres, or downwards towards the base (_basal meningitis_),
or in both directions. The process is at first attended with a copious
effusion of cerebro-spinal fluid into the arachno-pial space and into
the ventricles (_serous lepto-meningitis_), but this fluid tends to
become purulent, the pus forming in a thin layer over the surface of
the brain, and in the sulci between the convolutions (_purulent
lepto-meningitis_). The membranes are congested and thickened, the
veins of the arachno-pia engorged, and the superficial layers of the
cortical grey matter may share in the process (_encephalitis_).

_Clinical features._--The earliest and most prominent symptom is
violent pain in the head, often referred to the frontal region, or, in
cases starting from middle ear disease, to the temporal region. This
is accompanied by a sudden rise of temperature, usually without an
antecedent rigor; the temperature remains persistently elevated (102°
to 105° F.), and the pulse is small, rapid, and irregular both in rate
and force. The patient, especially if a child, is extremely irritable,
all his sensations are hyper-acute, and he periodically utters a
peculiarly sharp, piercing cry.

Vomiting of the cerebral type--that is, unattended with nausea and not
related to the taking of food or to gastric disturbance--is common,
and persists through the illness. The bowels are usually constipated.
There is an increase in the number of leucocytes in the cerebro-spinal
fluid, and organisms also are found in the fluid. As this does not
occur in cerebral abscess, examination of the cerebro-spinal fluid may
be useful in differential diagnosis. There is a higher leucocytosis in
the blood in meningitis than in cerebral abscess.

When the inflammation is most marked over the cerebral hemisphere,
there may be paralysis of the side of the body opposite to the seat of
the original lesion; sometimes there is erratic rigidity of the limbs,
sometimes clonic spasms of groups of muscles. The superficial reflexes
disappear early on both sides; the abdominal reflexes being lost
sooner than the knee-jerks. In basal meningitis, temporary squinting
due to irritation of the ocular muscles, retraction of the head, and
an excessively high temperature are usually prominent features. The
pupils at first are equally contracted; later they become dilated and
fixed. Both optic discs are œdematous and swollen.

Gradually the patient becomes unconscious, shows signs of increasing
intra-cranial tension, slowing of the pulse, and laboured respiration,
and the condition almost always proves fatal within three or four
days.

_Treatment._--The treatment consists in removing the source of
infection when this is possible, but as a rule little can be done to
arrest the spread of the meningitis or to ward off its effects. In
cases resulting from a sub-dural abscess in relation to a compound
fracture, a sinus phlebitis, or an erosion of the tegmen tympani, an
attempt should be made, after exposing this, to purify and drain the
meningeal spaces. Temporary relief of symptoms sometimes follows the
withdrawal of cerebro-spinal fluid by repeated lumbar puncture,
bleeding by leeches or cupping, or the use of an ice-bag or Leiter's
tubes. The bowels should be freely moved by purgatives or enemata.

_Cerebro-spinal Meningitis._--This form of meningitis, which is due to
the _diplococcus intracellularis_, may occur sporadically, but is more
frequently met with in an epidemic form. It is attended with the
formation of a profuse sero-purulent exudate, which covers the brain,
the cord, the nerves, and the membranes.

The clinical features are similar to those of acute general
lepto-meningitis, and in sporadic cases the diagnosis is only
completed by discovering the diplococcus intracellularis in the fluid
withdrawn by lumbar puncture. Although recovery sometimes takes place,
the disease is attended with a high mortality. In the early stages,
before the exudate has become too thick, repeated lumbar puncture
followed by the injection of Flexner's serum has proved beneficial.
Recovery may be attended with paralysis of one or other of the cranial
nerves.


CEREBRAL AND CEREBELLAR ABSCESS

#Abscess due to Middle Ear Disease.#--The most common cause of abscess
in the brain is chronic middle ear disease, and the majority of
cerebral abscesses are therefore situated in the temporal lobe. Some
are due to direct spread from a collection of pus in relation to an
erosion of the tegmen tympani, either inside or outside the dura,
others to infection carried by the veins, and in this way the
infective material reaches the white matter; less frequently infection
from the middle ear takes place along the peri-vascular lymph spaces.
Macewen has pointed out that cerebral abscess never occurs from
pyogenic organisms passing from the middle ear by way of the internal
auditory meatus, although lepto-meningitis may do so. Cerebral abscess
is much more frequently met with in the white matter of the centrum
ovale than in the cortex, and in the majority of cases the abscess is
single.

The _pus_ is often of a greenish-yellow colour, or it may be dark
brown from admixture with broken-down blood-clot; in some cases it is
thin and serous and contains sloughs of brain matter, and it
frequently has a fœtid odour. In quantity it varies from a few drops
to several ounces.

The _arachno-pia_ over an abscess usually has a turbid and milky
appearance.

In an acute abscess the surrounding _brain tissue_ is engorged and
infiltrated with pus; in a chronic abscess it is condensed, and the
pus may be encapsulated by the formation of a zone of young fibrous
tissue round its periphery. In this condition the abscess may remain
"latent," giving rise to no symptoms for many weeks or even months.

_Clinical features._--The _initial_ formation of pus in the cerebral
tissue is associated with the sudden onset of severe pain in the head,
shivering and well-marked cutis anserina, and vomiting of the cerebral
type. The discharge from the ear usually diminishes or may even cease.

As a _localised abscess_ develops the patient gradually passes, into a
stuporous condition; he does not lose consciousness, but, his
cerebration is slow, he seems unable to sustain his attention, for any
length of time, and he answers questions "slowly, briefly, but, as a
rule, correctly" (Macewen). The pain in the region of the ear becomes
less intense, but the mastoid and temporal areas on the affected side
are tender on percussion. The temperature falls, and, as a rule,
remains subnormal. Rigors are unusual: their occurrence usually
indicating the development of some complication such as sinus
phlebitis. The pulse is full, regular, and slow (40 to 60). Vomiting
frequently occurs, and the bowels are often obstinately constipated.

There is no actual paresis, but there is a "gradual diminution of the
ability to apply his strength." The superficial reflexes are late of
disappearing and the disturbance is unilateral. The optic discs are
moderately swollen. "The face is expressionless, passive, and cloudy.
It may assume a meaningless smile, with which the features are not
lit; it is too mechanical" (Macewen).

_Differential Diagnosis._--In the early stages it is often difficult
to distinguish between meningitis and cerebral abscess. The chief
points on which reliance is to be placed are that in meningitis the
pulse shows an irregularity, both in rate and force, which is wanting
in cases of uncomplicated abscess. In meningitis the temperature is
raised, while in abscess it is persistently subnormal. The
superficial reflexes, particularly the abdominal reflexes, disappear
early in meningitis and the disturbance is bilateral; in abscess they
are slower to disappear, and one side only is affected. Retraction of
the neck, when present, is a characteristic sign of meningitis. In
meningitis the optic discs are highly œdematous and are more swollen
than in abscess, and the condition is equally marked on the two sides.

_Localisation of Cerebral Abscess--Temporal Abscess._--The existence
of middle ear disease is always presumptive evidence that the abscess
is in the temporal lobe on the same side. A small abscess in this lobe
may produce no localising symptoms; one of large size may press
indirectly on the motor cortex, on the fibres passing through the
internal capsule, or on individual cranial nerves.

It is important to observe the order in which paralysis of the
opposite side of the body comes on. When it begins in the face and
passes successively to the arm and leg, the pressure is on the
cortical centres. When the paralysis progresses in the opposite
direction--leg, arm, face--the pressure is on the nerve fibres passing
through the internal capsule (Fig. 195). The paralysis may be spastic
in lesions of the cortex or internal capsule; if it is flaccid the
lesion is almost certainly cortical.

[Illustration: FIG. 195.--Diagram illustrating Sequence of Paralysis,
caused by abscess in temporal lobe. (After Macewen.)]

Motor aphasia may result from pressure on the left inferior frontal
convolution; auditory aphasia from abscess in the posterior part of
the superior temporal convolution. Ptosis and lateral squint, with a
fixed and dilated pupil, indicates pressure on the oculo-motor nerve
of the same side.

Abscess in the _parietal lobe_ gives rise to paralysis of the face and
limbs on the opposite side of the body. Abscess in the _occipital
lobe_ produces interference with the visual functions. An abscess in
the _frontal lobe_ may give rise to no localising symptoms, but if it
is on the left side, the power of making co-ordinated movements may be
lost--apraxia--or the motor speech centre may be implicated.

_Terminal Stage._--If left to itself, a cerebral abscess usually ends
fatally by causing gradually increasing stupor and coma, or by
bursting, either into the ventricles or into the sub-arachnoid space,
and setting up a diffuse purulent lepto-meningitis.

When the _abscess bursts into the ventricles_, the patient suddenly
becomes much worse and dies within a few hours. "The pupils become
widely dilated, the face livid, the respiration greatly hurried, and
either shallow or stertorous. The temperature rises within a few hours
with a bound from subnormal to 104° to 105° F.; the pulse from 40 or
50 per minute quickly reaches 120 and over. There are muscular
twitchings all over the body, possibly associated with convulsions and
tetanic seizures, and these are followed by coma and speedy death"
(Macewen).

Spontaneous evacuation of a temporal abscess may take place through
the middle ear.

#Cerebellar Abscess.#--Next to the temporal lobe, the cerebellum is
the most common seat of abscess. Cerebellar abscess is usually due to
spread of infection from a thrombosed sigmoid sinus, either directly
from a sub-dural abscess formed in relation to the walls of the sinus,
or by extension of the thrombotic process along the cerebellar veins.
While the abscess is small, it may give rise to few symptoms, and the
patient may be able to go about, but as it increases in size serious
symptoms develop. There may be nystagmus, and the patient suffers from
vertigo, and is unable to co-ordinate his movements. If he attempts to
walk, he reels from side to side; even when sitting up in bed, he may
feel giddy and tend to fall, usually towards the side opposite to that
on which the abscess is situated. The head and neck are retracted, the
pulse is slow and weak, and the temperature subnormal. There is
frequent yawning, and the speech is slow, syllabic, and jerky. There
may be optic neuritis and blindness. There is sometimes unilateral or
even bilateral spastic paralysis of the limbs from pressure on the
medulla oblongata. The respiration may assume the Cheyne-Stokes
character, occasionally being interrupted for a few minutes, while the
heart continues to beat vigorously. This arrest of respiration is
especially liable to occur during anæsthesia.

_Treatment._--The abscess having been localised, the skull must be
opened and the pus removed.

#Abscess from causes other than Middle Ear Disease.#--From the _nasal
passages_, infection may spread to the interior of the skull directly
through the walls of the frontal, ethmoidal, or sphenoidal air
sinuses, or indirectly by way of the veins, and give rise to a
cerebral abscess, usually in the frontal lobe. The symptoms are
similar to those of abscess following middle ear disease, but focal
symptoms are seldom present. When the abscess is on the left side,
apraxia and motor aphasia may be present. Spontaneous evacuation may
take place by the abscess bursting into the nose through the
cribriform plate.

The treatment consists in trephining through the frontal bone or
through the temporal fossa, according to the site of the abscess and
its seat of origin. The primary focus of infection must also be dealt
with.

In _infected compound fractures_, an abscess may form in the cortical
grey matter within a few days of the injury from direct spread of
infection from the bone and membranes. This is usually associated with
a spreading lepto-meningitis, the symptoms of which predominate. The
condition usually proves fatal, but by opening up the original wound,
removing depressed fragments of bone, and establishing drainage, the
patient's life may be saved.

There is evidence that an abscess may form in the brain after a simple
contusion without fracture or other external injury (Ehrenvooth).

An abscess may develop in the white matter of the centrum ovale some
weeks, or even months, after an injury, particularly if a fragment of
bone or a foreign body has been driven into the brain. If the
infection has spread along the track of the missile, the abscess is
usually near to the seat of the brain injury, but if it is due to
spread of a thrombo-phlebitis it may be a considerable distance from
it, even on the opposite side of the head. These chronic abscesses are
usually in the parietal or frontal lobes, and as the pus is
encapsulated they may remain latent for long periods, during which
they may cause some degree of headache, neuralgic pains in the
distribution of the trigeminal nerve, and occasional rises of
temperature. When the abscess becomes active, general symptoms similar
to those of other forms of abscess develop, and there may be localised
paralysis of the opposite side of the body, the distribution of which
depends upon whether the cortical centres or the motor fibres are
implicated.

The treatment consists in opening up the original wound, removing any
depressed bone or foreign body that may be present, and establishing
drainage.

_Bronchiectasis_ and other infective diseases of the lungs are less
common causes of cerebral abscess, which is usually single, and may
occur in any part of the brain.

_Disease of the bones of the skull_, such as osteomyelitis or
syphilis, may be followed by cerebral abscess.

Abscesses of _pyæmic_ origin are usually multiple, and may occur both
in the cerebrum and in the cerebellum; they are not amenable to
surgical treatment.


SINUS PHLEBITIS

Inflammation of the intra-cranial venous sinuses is due to the spread
of infection from a local focus of suppuration; by far the most
frequent cause is chronic suppuration in the middle ear. Less common
sources of infection are erysipelas of the face or scalp, infective
conditions of the mouth or nose, and diseases of the bones of the
skull.

The organisms may reach the affected sinus directly by continuity of
tissue, as, for instance, when the transverse (lateral) sinus becomes
infected from a focus of suppuration in the mastoid process spreading
through the bone to the sigmoid groove and involving the walls of the
vessel; or they may reach it by extension of thrombosis in a tributary
vein--for example, when the superior sagittal (longitudinal) sinus is
infected from an anthrax pustule of the lip, which has caused
thrombosis of the emissary vein that passes through the foramen cæcum.

The pathological changes are the same as occur in the suppurative form
of thrombo-phlebitis in the peripheral veins (Volume I., p. 285). The
soft clot that forms adheres to the inflamed wall of the sinus, and,
being infected with pyogenic bacteria, it soon undergoes purulent
disintegration.

The infective process may spread backward along tributary vessels, and
so give rise to cerebral or cerebellar abscess, or to purulent
meningitis; or it may spread into the internal jugular vein and lead
to the development of a diffuse purulent cellulitis along its course.

General pyæmic infection may take place from pus or bacteria getting
into the circulation, either directly or by reversed flow through
tributary veins. Infective emboli are liable to lodge in the lung or
pleura, and set up pulmonary abscess, gangrene of the lung, or
empyema.

_Clinical Features._--In all cases, pain in the head, referred to the
region of the affected sinus, and so severe as to prevent sleep, is an
early and prominent feature. The patient is usually excited,
hypersensitive, and irritable in the early stages, and becomes dull
and even comatose towards the end. Rigors, followed by profuse
perspiration, occur early and increase in frequency as the disease
progresses. The temperature is markedly remittent, varying from 103°
to 106° F. (Fig. 196). The pulse is rapid, small, and thready. Loss of
appetite, vomiting, and diarrhœa are almost constant symptoms.

[Illustration: FIG. 196.--Chart of case of Sinus Phlebitis following
middle ear disease in a boy æt. 13.]

#Phlebitis of Individual Sinuses.#--The _transverse_ (_lateral_ or
_sigmoid sinus_), from its proximity to the middle ear and mastoid air
cells, is that most commonly affected, especially in young adults.
With the onset of the phlebitis the discharge from the ear stops;
there is severe pain in the ear and violent headache. The temperature
rises, but shows marked remissions, and rigors are common. Vomiting is
frequently present. Turgescence of the scalp veins draining into this
sinus, and œdema over the mastoid, are occasionally observed; but as
these signs may accompany various other conditions, they are of little
diagnostic value. Not infrequently phlebitis spreads to the internal
jugular vein, which may then be felt as a firm, tender cord running
down the neck, and the head is held rigid, sometimes in the position
characteristic of wry-neck.

Three clinical types of sinus phlebitis are recognised--pulmonary,
abdominal, and meningeal--but it is often impossible to relegate a
particular case to one or other of these groups. Many cases present
symptoms characteristic of more than one of the types.

In the _pulmonary type_ evidence of infection of the lungs appears
towards the end of the second week, in the form of dyspnœa, cough, and
pain in the side, coarse moist râles, and dark fœtid sputum. Death
usually takes place from gangrene of the lung. The brain functions may
remain active to the end.

In the _abdominal type_ the symptoms closely resemble those of typhoid
fever, for which the condition may be mistaken. The absence of a rash
and the coexistence of middle ear disease are important factors in
diagnosis.

When the disease is of the _meningeal type_, symptoms of general
purulent lepto-meningitis assert themselves, and soon come to dominate
the clinical picture. Evidence of the presence of meningitis may be
obtained by lumbar puncture. The mind at first is clear, but the
patient is irritable; later he becomes comatose.

The _prognosis_ is always grave, on account of the risk of general
infection.

_Treatment._--The primary focus of infection must first be removed,
and this usually involves clearing out the middle ear and mastoid
process. The sigmoid sinus is then exposed, and after any granulation
tissue or pus that may be in the groove has been cleared away, the
sinus is opened and the thrombus removed. With the object of
preventing the dissemination of infective material, a ligature should
be applied to the internal jugular vein in the neck before the sinus
is opened, as was first recommended by Victor Horsley. If the
phlebitis is accompanied by other intra-cranial infections, these are,
of course, treated at the same time.

The _superior sagittal_ or _longitudinal sinus_ is liable to be
infected from pyogenic lesions of the scalp. There are no symptoms
that are pathognomonic, but œdema of the scalp with turgescence of its
veins, epistaxis, and convulsions followed by paralysis, are those
most likely to be met with.

The _cavernous sinus_ is usually implicated by spread of the process
from other sinuses--for instance, from the petrosal or transverse
(lateral) sinuses--or from the ophthalmic veins in cases of orbital
cellulitis. Although at first unilateral, the thrombosis usually
spreads across the middle line to the sinus of the opposite side. The
special symptoms--exophthalmos, œdema of the eyelids, and paralysis of
the ocular nerves--are due to pressure on the structures entering the
orbit.

Operative interference is seldom feasible in phlebitis of the superior
sagittal (longitudinal) or cavernous sinuses.

#Intra-cranial Tuberculosis.#--_Tuberculous meningitis_ is most
frequently met with in patients below the age of twenty, and the
infection takes place by the blood stream from some focus elsewhere in
the body or from the spinal membranes. In cases of tuberculous disease
of the middle ear infection may spread to the membranes by way of the
internal auditory meatus (Macewen). The arachno-pia, especially at the
base, is studded over with miliary tubercles, and an excess of fluid
collects in the arachno-pial space and in the ventricles (_acute
hydrocephalus_).

At first the _symptoms_ of irritation of the brain predominate: severe
headache, photophobia, inequality of the pupils, stiffness of the
neck, cutaneous hyperæsthesia, vomiting and convulsions. Kernig's
sign--pain on flexing the hip while the knee is extended, and
inability to extend the knee while in the sitting posture--is present.
There is usually obstinate constipation, and the abdomen is retracted.
Later, signs of increased intra-cranial tension develop:
unconsciousness deepening into coma, paralysis of ocular muscles,
rapid pulse, Cheyne-Stokes respiration, and sometimes hyperpyrexia. An
excess of mono-nuclear lymphocytes and, sometimes, tubercle bacilli
may be discovered in the cerebro-spinal fluid withdrawn by lumbar
puncture. The absence of the diplococcus intracellularis helps to
differentiate the disease from cerebro-spinal meningitis, which it may
closely simulate.

The only surgical measure that is justifiable is lumbar puncture,
which often affords marked relief of symptoms, although the benefit is
only temporary.

_Localised tuberculous nodules_ sometimes develop in the brain and
form definite tumours. They vary in size from a pea to a hen's egg,
are rounded and encapsulated. Sometimes the centre is caseous,
sometimes fibrinous or calcified. In children they are usually
multiple; in adults they may be single--the so-called "solitary
tubercle." They are most common in the pons, basal ganglia, and
cerebellum, but occur also in the cerebral cortex and sometimes in the
centrum ovale. They usually originate in the pia and invade the brain
substance, but do not as a rule involve the dura. The membranes in the
vicinity of the growth are often the seat of tuberculous disease.

As these nodules give rise to the same symptoms as other forms of
cerebral tumour, and as their nature can be diagnosed only in
exceptional cases, their clinical features and treatment are described
with tumours of the brain.

#Intra-cranial Syphilis.#--_Syphilitic meningitis_ is usually
secondary to cario-necrosis of the bones of the vault or to a
localised gumma of the brain. When primary, it usually affects the
inter-peduncular region of the base, and takes the form of a diffuse
gummatous infiltration of the membranes which gives rise to symptoms
referable to the parts pressed upon, and especially paralysis of one
or other of the cranial nerves. As in other intra-cranial syphilitic
lesions, the symptoms show a variability in intensity which is
characteristic. The diagnosis is made by the history, and the
treatment is carried out on the same lines as in other syphilitic
lesions.

_Localised gummata_ are described with tumours of the brain.


CEPHALOCELES

The term "cephalocele" is applied to a protrusion of a portion of the
cranial contents through a congenital deficiency in the bones of the
skull. This malformation is believed to be due to an irregularity in
development, whereby a portion of the primary cerebral vesicle remains
outside the mesoblastic layer of the embryo. It is usually associated
with adhesion of the membranes in the region of the fourth ventricle,
and with internal hydrocephalus. Cephaloceles are covered by the
scalp, and are most commonly met with in the occipital region and at
the root of the nose; less frequently at the anterior inferior angle
of the parietal bone, and in the line of the sagittal suture. Very
rarely they occur at the base of the skull and project into the
pharynx, the mouth, or the nose, where they are liable to be mistaken
for polypi. Cephaloceles vary greatly in size, some being so small as
almost to escape detection, while others are larger than a child's
head. In many cases the condition is incompatible with life.

Several varieties are recognised. They are known as (1)
_meningocele_, which consists of a protrusion of a cul-de-sac of the
arachno-pial membrane, containing cerebro-spinal fluid; (2)
_encephalocele_, in which a portion of the brain is protruded in
addition to the membranes; and (3) _hydrencephalocele_, in which the
protruded portion of brain includes a part of one of the ventricles.

_Clinical Features._--The _meningocele_ is commonest in the occipital
region, where it escapes through a cleft in the bone between the
foramen magnum and the occipital protuberance (Fig. 197). It forms a
tense, smooth, translucent globular swelling, which may be sessile or
pedunculated, and is usually covered by thin, smooth skin in which the
vessels are dilated and nævoid. The tumour does not pulsate, but
increases in size and tension when the child cries or coughs. It may
be diminished in size or even made to disappear by pressure, and so
permit of the opening in the bone being felt. This manipulation,
however, may be followed by slowing of the pulse, vomiting, loss of
consciousness, or convulsions.

[Illustration: FIG. 197.--Occipital Meningocele.

(From a photograph lent by Sir George T. Beatson.)]

Small meningoceles may remain stationary for a long time, or may even
undergo spontaneous cure. Those of larger size usually progress till
they eventually burst, and death results from the escape of the
cerebro-spinal fluid or from meningitis. Infection may also occur
from eczema or from excoriation of the overlying skin.

_Encephaloceles_ are much commoner than meningoceles, and usually
occur in the frontal region, where they form broad-based, elastic, and
pulsatile tumours, which vary greatly in size.

The _hydrencephalocele_ is usually met with in the occipital region,
and is generally so large and associated with such great cerebral
deformity as to be inconsistent with life. It does not as a rule
pulsate (Fig. 198).

[Illustration: FIG. 198.--Frontal Hydrencephalocele.

(From a photograph lent by Sir George T. Beatson.)]

Cephaloceles have to be diagnosed from dermoid cysts, nævi (Fig. 199),
cephal-hydrocele, and cephal-hæmatoma. Their recognition is seldom
attended with difficulty. If the margins of the gap in the skull can
be distinctly felt, or the gap in the bone can be shown by the X-rays,
the diagnosis is greatly simplified.

[Illustration: FIG. 199.--Nævus at Root of Nose, simulating
Cephalocele.

(From a photograph lent by Sir George T. Beatson.)]

_Treatment._--Only small cephaloceles are amenable to surgical
treatment; those that are large and contain brain substance are best
left alone, being merely protected from irritation and infection.

While the immediate effects of operation are, on the whole,
satisfactory, the ultimate results are disappointing, as the essential
cause of the intra-cranial pressure persists, and the child develops
hydrocephalus. The method of tapping the sac and injecting iodine has
nothing to recommend it.

#Traumatic Cephal-hydrocele.#--Certain rare cases of simple fracture
of the vault occurring in early childhood have been followed by the
development beneath the scalp of a localised fluid swelling, which
varies in size from time to time and is partly reducible by pressure.
The swelling results from laceration of the membranes, and sometimes
of the brain substance, so that the cerebro-spinal fluid of the
sub-arachnoid space, or even of the lateral ventricle, escapes through
the opening in the skull and bulges beneath the scalp. In a majority
the swelling pulsates synchronously with the heart, and becomes tense
on exertion. A distinct opening in the skull may sometimes be felt.
When associated, as it frequently is, with mental deficiency or the
occurrence of fits, the cyst may be tapped or its neck ligated
(Hogarth Pringle). Otherwise it should be left alone.


HYDROCEPHALUS

An excess of cerebro-spinal fluid may collect in the arachno-pial
space surrounding the brain, or in the interior of the ventricles,
constituting in the former case an _external_, and in the latter an
_internal hydrocephalus_. Hydrocephalus may be acute or chronic.

#Acute hydrocephalus# is practically synonymous with tuberculous
meningitis, although it may result from other forms of meningeal
infection. The excess of fluid is found both in the arachno-pial space
and in the ventricles. This condition only calls for mention here as
attempts have been made to treat it by surgical measures, such as
lumbar puncture, or drainage through the occipital fossa. The results,
however, have not been encouraging.

#Chronic Hydrocephalus.#--_Chronic external hydrocephalus_ is rare,
and usually results from some definite intra-cranial lesion, such as
meningitis, tumour, or cerebral atrophy. It is not amenable to
surgical treatment.

_Chronic internal hydrocephalus_, on the other hand, is a
comparatively common condition. It may be of congenital origin, or may
develop in young rickety children, usually as a result of some chronic
inflammatory process in the membranes at the base, the choroid
plexuses, or the ependyma of the ventricles, causing obstruction to
the outflow of blood through the internal cerebral veins of Galen. In
the acquired form the communication between the ventricles and the
sub-arachnoid space, by way of the foramen of Magendie, is obstructed,
so that the cerebro-spinal fluid is pent up in the ventricles and
gradually distends them. The pressure causes the head to enlarge, the
fontanelles to bulge, and the bones to be separated from one another,
the interval between the bones being occupied by a thin translucent
membrane.

The cerebral tissue is greatly thinned out, but the cerebellum and
cranial nerves usually remain unaffected.

The appearance of the patient is characteristic (Fig. 200). The
enormous dome of the skull surmounts a puny and preternaturally old
face; the eyes are pushed downwards and forwards by the pressure on
the orbital plates, and the eyebrows are displaced upwards. The head
rolls helplessly from side to side; the child moans and cries a great
deal; and vomiting is often a prominent symptom. In most cases the
intelligence is defective, and epileptic seizures and other functional
disturbances of the brain may be present.

[Illustration: FIG. 200.--Hydrocephalus in a child æt. 3-1/2.]

In mild cases, especially when associated with rickets or syphilis,
recovery sometimes takes place, but in the majority the condition
progresses, and death results either from convulsions or from some
intercurrent disease. Few hydrocephalic subjects reach adult life.

_Treatment._--Hydrocephalus being a symptom rather than a disease, no
method of treatment which does not remove the primary cause can be
permanently curative. Anti-syphilitic treatment should be tried in the
hydrocephalus of infants and young children. The rachitic element,
when present, must also be treated.

In congenital hydrocephalus, as there is no blocking of the passages
at the fourth ventricle, the foramina being as a rule much larger than
normal, no form of drainage is beneficial. Ligation of the common
carotids, one some weeks after the other, has been successful in
restoring the balance which normally exists between the secretion and
absorption of the cerebro-spinal fluid (H. J. Stiles). In acquired
hydrocephalus, puncture of the ventricles is sometimes followed by a
remarkable improvement in the symptoms, and may even result in
apparent cure. An exploring needle is introduced at the lateral angle
of the anterior fontanelle, to avoid the superior sagittal
(longitudinal) sinus, and from a half to one ounce of cerebro-spinal
fluid withdrawn. This is repeated once a week for several weeks.
Continuous drainage of the fourth ventricle through an opening made in
the occipital region (Parkin), and the establishment of a
communication between the ventricle and sub-arachnoid space
(Watson-Cheyne), or between the sub-arachnoid space of the spinal cord
and the peritoneal cavity, or the retro-peritoneal space (Cushing),
have been tried, with little more than temporary benefit in the
majority of cases. Operative treatment, if it is to do good, must be
undertaken early, before permanent changes in the brain have taken
place.

#Micrencephaly.#--This condition is due to defective development of
the brain, and not to premature closure of the cranial sutures and
fontanelles, and as the subjects of it are mentally deficient, and
often blind, deaf and dumb, the removal of segments of the skull with
a view to enable the brain to develop have proved futile.


CEREBRAL TUMOURS

As a comparatively small proportion of tumours of the brain--using the
term "tumour" in its widest sense--are amenable to surgical treatment,
it is only necessary here to refer to those aspects of this subject
that have a distinctively surgical bearing.

Various forms of growth occur in the brain, the most common being
tuberculous nodules, syphilitic gumma, endothelioma, glioma, and
sarcoma. Less frequently fibroma, osteoma, and parasitic, hæmorrhagic,
and other cysts are met with. The growth may originate in the brain
tissue primarily, or may spread thence from the membranes, or from the
skull. In relation to operative treatment, it is an unfortunate fact
that those forms that are well defined and do not tend to infiltrate
the brain tissue, usually occur at the base, where they are difficult
to reach; while those that develop in more accessible regions are for
the most part infiltrating growths of a gliomatous or sarcomatous
nature, and are therefore irremovable.

_Clinical Features._--The presence of a tumour in the brain inevitably
results sooner or later in an increase in the intra-cranial tension,
and to this the symptoms are chiefly due.

The earliest and most prominent of the _general symptoms_ are severe
paroxysmal headache, optic neuritis, with choked disc and limitation
of the field for blue, amounting sometimes to blue-blindness
(Cushing). The relative degree of neuritis in the two eyes is a
reliable guide to the side on which the tumour is situated (Horsley).
The symptoms are seldom absent, and are common to all forms of tumour,
wherever situated. Vomiting, which is without relation to the taking
of food and is usually unattended by nausea, is a characteristic
symptom when present, but it is wanting in two-thirds of the cases
(Cushing). Vertigo, general convulsions, and signs of mental
deterioration are also present in a considerable proportion of cases.

In addition, certain _localising symptoms_ may be present. When, for
example, the tumour is situated in the _cortex of the Rolandic area_,
attacks of Jacksonian epilepsy, preceded by an aura, which is usually
referable to the centre primarily implicated, are common. The group of
muscles first involved, and the order in which other groups become
affected, are important localising factors. As the tumour increases in
size, these irritative phenomena are replaced by localised paralyses.
The tactile and muscular sensations are also disturbed, and motor and
sensory aphasia may be present. In some cases localised tenderness on
percussing the skull may be of assistance in indicating the site of
the tumour.

When the tumour is _sub-cortical_, that is, in the centrum ovale,
there are no Jacksonian spasms, the motor paralysis is more
widespread, and sensation also is lost on the opposite side of the
body. There is no special tenderness on percussion. It is not always
possible, however, to distinguish between cortical and sub-cortical
tumours, and in many cases both areas are invaded.

Tumours situated in the region of _the internal capsule_, and _in the
deeper parts of the brain_, are not attended with Jacksonian spasms,
paralysis develops more rapidly than in cortical and sub-cortical
tumours, and there is complete loss of sensation on the opposite side
of the body. The cranial nerve-trunks also are liable to be pressed
upon.

Tumours and cysts _in the cerebellum_ give rise to symptoms similar to
those of cerebellar abscess (p. 381).

Tumours _in the cerebello-pontine angle_, in addition to the special
symptoms associated with cerebellar lesions, give rise to symptoms of
interference with nerve-roots of the same side. The facial and
acoustic nerves are most frequently affected, resulting in facial
weakness, tinnitus, loss of perception for high-pitched notes, as
tested by Galton's whistle, or absolute unilateral deafness. Any of
the other cranial nerves from the fifth to the twelfth may be either
irritated or paralysed. Pressure on the pons may produce hemiplegia of
the opposite side, with spasticity and exaggeration of reflexes.
Sudden death may occur from crowding of the cerebellum into the
foramen magnum.

With the growth of the tumour the symptoms become aggravated, the
optic neuritis is followed by optic atrophy and blindness, the patient
gradually becomes stuporous, and finally dies in a state of coma. The
severity of the symptoms depends to a large extent on the rapidity of
growth of the tumour; thus an osteoma growing slowly from the inner
table of the skull and implicating the brain may reach a considerable
size without producing cerebral symptoms, while a comparatively small
sarcoma or syphilitic gumma of rapid growth may endanger life. A
sudden and serious aggravation of symptoms may result from hæmorrhage
into a soft tumour, such as glioma.

The _diagnosis_ of the pathological nature of a cerebral tumour is
generally "hardly more than a guess" (Gowers). At the same time it may
be borne in mind that _syphilitic gummata_ occur in adults, from forty
to sixty years of age, who have suffered from acquired syphilis, and
who may present other evidence of the disease. They tend to increase
somewhat rapidly. A negative Wassermann reaction does not necessarily
exclude a diagnosis of brain syphilis. Severe nocturnal pain which
interferes with sleep is often a prominent symptom. Gummata are
generally situated on the surface of the brain; they often originate
in the dura mater, and when exposed are easily enucleated. Improvement
in the symptoms may follow the administration of iodides and mercury,
or organic arsenical salts of the salvarsan group, but in many cases
the growth is very resistant to anti-syphilitic treatment.

_Tuberculous masses_ occur most frequently in children and
adolescents, and other signs of tuberculosis are usually present. The
cerebellum is a common seat of these tumours, and they are often
multiple. Their growth may be rapid at first, and then become arrested
for a time. Spasmodic growth of a tumour strongly suggests its
tuberculous nature, and superadded signs of basal meningitis confirm
the diagnosis.

_Endothelioma_ grows from the dura mater, and in so far as it is a
well-defined and non-infiltrating growth it lends itself to removal by
operation. Unfortunately, however, it is usually located at the base
of the brain and is not readily accessible.

_Glioma_ is usually met with in the young; it tends to grow slowly at
first, but may take on a rapid growth at any time, and hæmorrhage is
liable to occur into the substance of the tumour, causing a sudden
aggravation of the symptoms.

_Sarcoma_ occurs between puberty and middle life; it grows slowly, and
compresses rather than destroys the brain tissue. It is sharply
defined from the surrounding cerebral tissue, and is therefore more
favourable for operation than glioma.

The _prognosis_ is grave in all forms of brain tumour. Even in
syphilitic growths, although the more urgent symptoms may be
ameliorated by the use of drugs, recurrence is liable to occur, and
the structural changes induced in the cerebral tissue, and the
contraction of the cicatrix which results, may permanently interfere
with the functions of the brain, or may induce Jacksonian epilepsy.
Tuberculous tumours also may become arrested, and may cease for a time
to cause symptoms, but permanent cure is extremely rare. We have known
a sarcoma to recur as late as five years after removal. Death
sometimes occurs suddenly from hæmorrhage, from acute œdema, or from
implication of vital centres.

_Treatment._--It is to be borne in mind that gummatous growths in the
brain are seldom influenced to any extent by anti-syphilitic remedies,
and time should not be wasted in trying this form of treatment.

The question of removal by operation arises in cases in which there is
reason to believe that the tumour is situated near the surface of the
brain and that it is circumscribed and of moderate size. Unfortunately
it is only in a small proportion of cases that these conditions are
present and can be recognised before opening the skull.

In many cases in which there is no hope of being able to remove the
tumour, it is advisable to relieve symptoms due to excessive
intra-cranial tension, such as blindness, severe headache, and
persistent vomiting, by performing a "decompression operation"
(_Operative Surgery_, p. 108). The relief that follows such operations
is often remarkable.

Lumbar puncture, frequently repeated, has also been practised for the
relief of tension in inoperable cases, but it is not free of danger
and is not to be looked upon as a substitute for a decompression
operation.

When surgical treatment is contra-indicated, all that can be done is
to palliate the symptoms by bromides, opium, phenacetin, caffein, and
other drugs.

#Tumours of the Pituitary Body# or #Hypophysis Cerebri#.--The tumours
most frequently met with in the pituitary body are of the nature of
adenoma with hyperplasia and cystic degeneration; carcinoma and
sarcoma also occur. They develop slowly and give rise to comparatively
slight increase in the intra-cranial tension. When the anterior lobe
is implicated and there is a pathological increase in the functional
activity of the gland (_hyperpituitarism_), signs of acromegaly may
ensue. Diminution of function (_hypopituitarism_) is attended with
infantilism, a rapid deposition of fat in the subcutaneous tissue, and
a decrease or loss of the genital functions. In women, amenorrhœa is
an early and constant symptom. Intense drowsiness is a marked feature
in some cases.

From their position close to the back of the optic chiasma these
growths affect the fibres passing to the nasal half of each retina,
and so give rise to bilateral temporal hemianopsia, and although there
is no choked disc, the optic nerves undergo primary atrophy from
pressure, and there is failure of sight.

Marked temporary benefit has followed the administration of thyreoid
extract. Operative treatment has been successful in a number of cases,
but as the anterior lobe is essential to life, the operation is merely
directed towards the relief of pressure on the optic chiasma with a
view to preventing loss of vision. We have seen marked relief follow a
temporal decompression operation.

#Epilepsy.#--The surgical aspects of Jacksonian epilepsy following
head injuries have already been considered (p. 358). For the cure of
those forms of epilepsy in which there is no gross lesion of the
brain, numerous surgical procedures have been suggested, but from none
of these have the results been encouraging.

#Hernia Cerebri.#--This term is applied to a protrusion of brain
substance through an acquired opening in the skull and dura mater,
such as may result from a compound fracture or a gun-shot wound. The
protrusion is due to increased intra-cranial tension, and is almost
invariably associated with infection of the brain and its membranes,
and with the presence of a foreign body or fragments of bone. Other
things being equal, a hernia is more likely to occur through a small
than through a large opening in the skull.

So long as the extruded portion of brain matter is small, it pulsates,
but as it increases in size and is pressed upon by the edges of the
opening through which it escapes, the pulsation ceases, and the
herniated portion may become strangulated and undergo necrosis.

In cases of compound fracture, and in other conditions associated with
necrosis of bone, masses of redundant granulation tissue growing from
the soft parts outside the skull may simulate a hernia cerebri.

The _treatment_ consists in counteracting the septic infection by
purifying the protruding mass, and if necessary by enlarging the
opening in the skull with rongeur forceps to admit of the removal of
foreign bodies or bone fragments and to relieve the inter-cranial
tension. Steps must also be taken to prevent meningitis, which, if it
occurs, is usually fatal. Pressure over the hernia, with the object
of returning it to the skull, is to be avoided, and the herniated
portion should not be cut away unless it is sloughing, or has become
pedunculated. It may be got rid of by painting it with 40 per cent.
formalin, which causes a dry, horny crust to form on the surface; this
is picked off, and the formalin re-applied.

After the hernia has disappeared and the wound is aseptic, steps
should be taken to close the gap in the skull. This may be done by an
osteo-plastic operation in which a flap, comprising a segment of the
outer table, is raised from an adjacent part of the skull and placed
in the gap; or by transplanting a portion of periosteum-covered bone
from the scapula, tibia, or other suitable source. An alternative
method is to implant a plate of celluloid, silver or other metal, or a
portion of the fascia lata, in the gap. When a permanent hole is left
in the bone, the patient should wear over it a leather or metal shield
to protect the brain.

The protrusion of brain resulting after a decompression operation
deliberately performed for the relief of intra-cranial tension, unless
it becomes infected, has nothing in common with a hernia cerebri.


SURGICAL AFFECTIONS OF THE CRANIAL NERVE

Irritation, or paralysis, of one or more of the cranial nerves may
result from lesions implicating their centres or trunks.

When the trunk of the nerve is affected, the paralysis is on the same
side as the lesion, and is of the lower neurone type; when the
cortical centre or the upper axons are involved, it is on the opposite
side, and is of the upper neurone type (p. 334). The lesions of the
cerebral centres with which nerve symptoms are most frequently
associated are: laceration of the brain, hæmorrhage, meningitis,
tumour, and syphilitic gumma.

The nerve-trunks may be contused or torn across, especially in basal
fractures which traverse their foramina of exit; blood may be effused
into their sheaths as a result of injuries not attended with fracture;
or they may be pressed upon by an inflammatory effusion, a tumour, a
gumma, or an aneurysm invading the base of the skull. When the nerve
is merely contused, or pressed upon by blood-clot, the paralysis tends
to pass off in the course of a few days. When it is torn across, or
compressed by a new growth, the paralysis is permanent. In some
traumatic cases paralysis does not come on until a few days after the
injury, and is then due either to gradually increasing pressure from
blood-clot, or more probably to the onset of meningitis or of
ascending neuritis.

I. The branches of the _Olfactory Nerve_ may be ruptured as they pass
through the cribriform plate in fractures implicating the anterior
fossa of the skull, and there results complete and permanent loss of
smell (_anosmia_). Hæmorrhage into the nerve sheath or contusion of
the nerve may cause a transitory loss of smell. The trunk of the nerve
may be implicated also in tumours and meningitis in the anterior
fossa. In all cases in which anosmia results there is also
interference with the power of recognising different flavours, thus
greatly impairing the sense of taste.

II. _Optic Nerve._--Temporary paralysis of one or both optic nerves is
a comparatively common result of traumatic effusion of blood into
their sheaths; the resulting blindness may pass off in a few days, or
may last for some weeks. When a large effusion takes place, the
prolonged pressure on the nerve may result in optic atrophy and
permanent blindness. Complete severance of the nerve by a bullet, the
point of a sharp instrument, or a fragment of bone, results in loss of
sight in the eye on the same side. In cellulitis of the orbit,
intra-orbital tumour, gumma and aneurysm in the region of the
cavernous sinus, also, the optic nerve may be implicated.

Lesions implicating the cortical centre for sight in the occipital
lobe give rise to hemianopia--that is, loss of sight in the lateral
halves of the fields of vision of both eyes--colour-blindness,
subjective sensations of light and colour, and other eye symptoms.

Double optic neuritis, followed by optic atrophy, is one of the most
constant effects of the growth of a tumour within the skull, and is
not uncommon in cases of cerebral abscess and meningitis. Pressure on
the optic chiasma, for example by a tumour of the pituitary body, is
associated with bilateral temporal hemianopsia.

III. _Oculo-Motor Nerve._--One or more of the branches of this nerve
may be compressed by extravasated blood, or be contused and lacerated
in fractures implicating the region of the sphenoidal fissure. Fixed
dilatation of one pupil may result from pressure by blood-clot,
without other functional disturbance of the nerve. A tumour or an
aneurysm growing in this region also may press upon the nerve.
Sometimes both nerves are involved--for example, in fracture
implicating both sides of the anterior fossa, and in tumours,
particularly gumma, growing in the region of the floor of the third
ventricle. In lesions of the cerebral hemispheres the third nerve is
frequently paralysed. Its cortical centre lies in close proximity to
the centre for the face (Fig. 179).

The most prominent symptoms of complete paralysis are ptosis or
drooping of the upper eyelid, lateral strabismus, and slight downward
rotation of the eye with diplopia. There are also dilatation of the
pupil from paralysis of the circular fibres of the iris, and loss of
accommodation and reaction to light from paralysis of the ciliary
muscle.

Paralysis of the muscle supplied by the third nerve is frequently
associated with paralysis of other ocular muscles. When all the
muscles of the eye are paralysed, the condition is known as
"opthalmoplegia externa"; it is usually due to syphilitic disease in
the floor of the third ventricle.

IV. The _Trochlear_ or _Patheticus Nerve_, which supplies the superior
oblique muscle, may suffer in the same way as the oculo-motor nerve.
When it is paralysed, there is defective movement of the eye downward
and medially, and the patient may complain of diplopia when he looks
downward.

V. _Trigeminal Nerve._--The most important surgical affection of this
nerve is "trigeminal neuralgia," which has already been described
(Volume I., p. 373). One or other of the divisions of the nerve may be
torn in fractures of the base of the skull, and there results
anæsthesia in the area supplied by it. In fractures crossing the apex
of the petrous portion of the temporal bone, the great and small
superficial petrosal nerves may be ruptured, and the soft palate and
uvula are paralysed and there is difficulty in swallowing; there are
also painful sensations in the ear. When the ophthalmic division is
implicated, the conjunctiva is rendered insensitive, and
conjunctivitis, which may be followed by ulceration of the cornea,
results from exposure to dust and other foreign bodies, which, on
account of the anæsthetic condition of the eye, are allowed to remain
and cause irritation.

VI. _Abducens Nerve._--This nerve, which supplies the lateral rectus
muscle, has the longest course within the skull of any of the cranial
nerves. In spite of this fact, it is comparatively seldom torn in
basal fractures; but it is prone to be pressed upon by tumours,
gummas, or aneurysms in the region of the base of the brain. When it
is paralysed, medial strabismus results.

VII. _Facial Nerve._--Paralysis of the facial muscles, more or less
complete, is the most characteristic symptom of lesions of this nerve.

_Paralysis of the Cerebral Type._--When the fibres of the nerve are
implicated in any part of their course between the cortical centre
and the nucleus in the lower part of the pons, the paralysis is of the
upper neurone (cerebral) type. It affects the side of the face
opposite to that of the lesion, and the defective movement is more
marked in the lower than in the upper half of the face.

This form of facial paralysis may be due to the pressure of an
intra-cranial tumour, abscess, or hæmorrhage, or to degenerative
processes in the cerebral tissue, and as a rule other cranial nerves
are also affected. Its recognition is chiefly of diagnostic and
localising importance.

_Paralysis of the Peripheral Type._--When the trunk of the nerve is
implicated between the pontine nucleus and its peripheral
distribution, the paralysis is of the lower neurone (peripheral) type,
the muscles on the same side as the lesion being flaccid and
atrophied.

The majority of cases are of the so-called "rheumatic" variety, and
are attributed to exposure to cold. Others result from fractures
implicating the middle fossa of the skull, or are associated with
chronic suppuration in the middle ear.

In fractures passing across the petrous temporal, the nerve may be
torn at the time of the injury, or may become pressed upon by a
traumatic effusion or by callus later, but considering the frequency
of these fractures it is comparatively seldom damaged.

Suppurative disease of the middle ear is a more common cause of facial
paralysis. The nerve, as it traverses the facial canal (aqueductus
Fallopii), may be pressed upon by inflammatory effusions or
granulations, or may be destroyed by the suppurative process,
particularly in young children, as in them the osseous wall of the
aqueduct is very thin. It may also be involved in tuberculous and in
malignant disease of the middle ear.

The nerve may be injured also in the course of operations on the
mastoid or middle ear, or in the removal of tumours or glands in the
parotid region. As the nerve breaks up into numerous branches soon
after it leaves the stylo-mastoid foramen, the paralysis may be
confined to one or more of its branches.

Temporary paralysis may result from inflammatory conditions such as
parotitis, or from blows or pressure over the nerve, for example by
the forceps in delivery.

_Symptoms._--In complete unilateral _facial paralysis_ (Bell's
paralysis) the affected side of the face is expressionless and devoid
of voluntary or emotional movement. The muscles are flaccid, the cheek
is flattened and smooth, all its folds and wrinkles being
obliterated. When the patient speaks or smiles, the face is drawn to
the sound side (Fig. 201). The eye on the affected side cannot be
closed, and on making the attempt the eyeball rolls upwards and
outwards. The lower lid droops, the patient cannot wink, and the
conjunctiva therefore becomes dry, and is irritated by exposure to
cold and dust. The tears run over the cheek. From paralysis of the
buccinator muscle there is inability to whistle or to puff out the
cheeks and food collects between the cheek and the gums. The
orbicularis oris being also paralysed, the patient is unable to show
his upper teeth, and the labial consonants are pronounced
indistinctly. The sense of taste is often impaired from involvement of
the chorda tympani nerve.

[Illustration: FIG. 201.--Patient suffering from left facial
Paralysis. Note smoothness of left side of face, imperfect closure of
left eye, and deviation of face to right side.

(From a photograph lent by Dr. Edwin Bramwell.)]

When the paralysis is bilateral, the symmetrical appearance of the
face renders the condition liable to be overlooked.

_Treatment._--In addition to removing the cause, when this is
possible, recovery of function may be promoted by the administration
of drugs, such as potassium iodide, strychnin, or iron, by the
application of blisters, or by massage and electricity. These measures
are most useful in cases due to blows or exposure to cold. When the
nerve is accidentally divided in the course of an operation on the
face, it should immediately be sutured. So long as the electrical
reactions of the affected muscles indicate an incomplete lesion,
recovery may be confidently expected (Sherren). When the reaction of
degeneration is present and the paralysis has lasted for more than six
months, there is little hope of recovery, and recourse should be had
to operation, to restore the function of the nerve by grafting its
distal end on to the trunk of the hypoglossal nerve. To prevent
paralysis of the tongue the lingual nerve may be divided, and its
proximal end anastomosed with the distal end of the hypoglossal.

The facial may be grafted on the accessory nerve, but the associated
movements of the face which then accompany movements of the shoulder
often prove inconvenient.

_Facial Spasm._--Clonic contraction of the facial muscles (histrionic
spasm) occasionally results from irritative lesions in the cortex or
pons. Sometimes all the muscles are involved, sometimes only one, for
example the orbicularis oculi (palpebrarum)--blepharospasm. This
condition may be induced reflexly from irrigation of the trigeminal
nerve, notably of branches that supply the nasal cavities and the
teeth.

The _treatment_ consists in removing any source of peripheral
irritation that may be present, in employing massage, and in
administering nerve tonics, bromides, and other drugs. In severe
cases, the facial nerve may be stretched with benefit, either at its
exit from the stylo-mastoid foramen or on the face.

VIII. _Acoustic_ or _Auditory Nerve_.--The acoustic nerve is liable to
be damaged along with the facial in tumours of the cerebello-pontine
angle, and in fractures which traverse the internal auditory meatus.
Both nerves also may be torn across just before they enter the meatus
in severe brain injuries apart from fracture. Complete and permanent
deafness results. Effusion of blood into the nerve sheath, or into the
internal or middle ear, causes transitory deafness, and the patient
suffers from noises in the ear, giddiness, and interference with
equilibration.

IX. The _Glosso-pharyngeal Nerve_ is comparatively seldom injured.
When it is compressed by a tumour in the region of the medulla, there
is interference with speech and deglutition, ulcers form on the
tongue, and œdema of the glottis may supervene.

X. The _Vagus_ or _Pneumogastric Nerve_ is seldom injured within the
cranial cavity.

In the neck, it is liable to be divided or ligated in the course of
operations for the removal of malignant or tuberculous glands, for
goitre, or for ligation of the common carotid. Division of the nerve
on one side, or even removal of a portion of it, is not as a rule
followed by any change in the pulse or respiration. If it is
irritated, however, for example by being grasped with an artery
forceps, there is inhibition of the heart, and if it is accidentally
ligated, there may be persistent vomiting.

Division of the main trunk, or of its recurrent branch on one side,
results in paralysis of the corresponding posterior crico-arytænoid
muscle--the muscle that opens the glottis. This condition is known as
unilateral _abductor paralysis_, and is accompanied by interference
with inspiration and phonation. If both nerves are divided, bilateral
abductor paralysis results: the vocal cords flap together, producing a
crowing sound on inspiration and embarrassment of breathing, and
tracheotomy may be necessary to prevent asphyxia.

The vagus and recurrent nerves have been successfully sutured after
having been divided accidentally.

XI. _Accessory_ or _Spinal Accessory Nerve_.--This nerve is seldom
damaged within the skull. It supplies the sterno-mastoid and
trapezius; but as these muscles usually have an additional nerve
supply from the cervical plexus, the accessory may be divided, or a
considerable portion of it resected, as, for example, in the treatment
of spasmodic torticollis, without any serious disablement resulting.
It is liable to be accidentally divided in excising malignant or
tuberculous glands in the neck. When, however, the accessory is the
only source of supply to these muscles, its division is followed by
considerable disablement, which appears to depend almost entirely on
the _paralysis of the trapezius_. The head is inclined slightly
forward, the shoulder is depressed, the arm hangs heavily by the side
and is slightly rotated forward, the scapula is drawn away from the
spine and rotated on its horizontal axis, and there is slight cervical
scoliosis with the concavity towards the affected side. The trapezius
is markedly wasted, and is, therefore, less prominent in the neck than
normally, and the functions of the arm and shoulder are impaired,
especially in making overhead movements. In time other muscles
compensate in part for the loss of the trapezius.

When divided accidentally, the nerve should be immediately sutured.
Even when the paralysis has lasted for some time, secondary suture
should be attempted; if this is impossible, the peripheral end should
be anastomosed with the anterior primary divisions of the third and
fourth cervical nerves (Tubby). Massage, electricity, and the
administration of tonics are also indicated.

XII. _Hypoglossal Nerve._--This nerve has been ruptured in fractures
passing through the canalis hypoglossi (anterior condylar foramen). It
is also liable to be divided in wounds of the submaxillary region--for
example, in cut throat, or during the operation for ligation of the
lingual artery, or the removal of diseased lymph glands.

The paralysed half of the tongue undergoes atrophy. When the tongue is
protruded, it deviates towards the paralysed side, being pushed over
by the active muscles of the opposite side. Speech and mastication are
interfered with, the tongue feeling too large for the mouth; in time
this disability is to a large extent overcome.

#The Cervical Sympathetic.#--The cervical sympathetic cord and its
ganglia may be injured in the neck by stabs or gun-shot wounds, or in
the course of deep dissections in the neck; and in injuries of the
lower part of the cervical enlargement of the spinal cord (p. 417) or
of the first dorsal nerve root.

Paralysis of the cervical sympathetic is characterised by diminution
in the size of the pupil on the affected side. The pupil does not
dilate when shaded, nor when the skin of the neck is pinched--"loss of
the cilio-spinal reflex." The palpebral fissure is smaller than its
fellow, and the eyeball sinks into the orbit. There is anidrosis or
loss of sweating on the side of the face, neck, and upper part of the
thorax, and on the whole upper extremity of the affected side.




CHAPTER XV

DISEASES OF THE CRANIAL BONES


Suppurative periostitis and osteomyelitis--Tuberculosis--
    Syphilis--Tumours.

#Suppurative Periostitis and Osteomyelitis.#--These conditions may be
the result of infection through the blood stream, but as a rule they
follow upon a breach of the surface caused by a wound, a severe burn
as in epileptics, a tertiary syphilitic ulcer, or a compound fracture
that has become infected. Sometimes they follow suppuration in the
middle ear and mastoid or in the frontal sinus, and epithelioma and
rodent cancer that has ulcerated and become infected after spreading
from the face towards the vertex. They are occasionally associated
with acute cellulitis of the scalp. When the infection is blood-borne
suppuration occurs on both aspects of the bone--a point of importance
in treatment.

The illness is usually ushered in by a rigor, and this is soon
followed by other signs of suppuration--high temperature, pain and
tenderness, and the formation of a fluctuating swelling in relation to
the bone. When pus forms between the bone and the dura, there is a
characteristic œdema of the overlying area of the scalp--spoken of as
_Pott's puffy tumour_--which is of value as indicating the extent of
the disease in the bone, and of the collection of pus between it and
the dura. When suppuration occurs under the pericranium, an incision
gives exit to a quantity of pus, and exposes an area of bare bone. If
the incision is made early, this bone may soon be covered by
granulations and recover its vitality; but if operation is delayed, it
usually undergoes necrosis. The sequestrum that forms includes, as a
rule, only the outer table, but in some cases the whole thickness of
the bone undergoes necrosis. In either case the separation of the
sequestrum is an exceedingly slow process, and is not accompanied by
the formation of new bone. When the whole thickness of the skull is
lost, there may be a protrusion of the contents of the skull--hernia
cerebri; should the patient survive, the gap becomes filled in by a
dense fibrous membrane which is fused with the dura mater.

Serious complications, in the form of meningitis, cerebral abscess,
sinus phlebitis, and general pyæmia, are liable to develop at any time
during the progress of the infection, and we have seen pyæmia develop
after the suppuration in the skull had been recovered from.

_Treatment._--Early, free, and, if necessary, multiple incisions are
indicated to admit of disinfection of the affected area, and of the
establishment of drainage. If the symptoms point to suppuration having
occurred between the bone and the dura, the skull should be trephined
and further bone removed with the rongeur forceps as may be required.

Time may be saved by separating the sequestrum with the aid of an
elevator or sharp spoon, or by chiselling away the dead part till
healthy vascular bone is reached.

#Tuberculosis# of the cranial vault is usually met with in children.
The disease commences in the diploë, and results in the formation of a
central sequestrum, around and beneath which the tuberculous process
spreads. Granulations form between the skull and the dura, and on the
outer aspect lifting up the pericranium. The sequestrum is slowly
thrown off, and when separated is circular like a coin and presents
worm-eaten edges.

A circumscribed, tender swelling forms, at first yielding an obscure
sensation of fluctuation, but later, when the pus is no longer
confined under the pericranium, assuming the characters of a cold
abscess, which gradually becomes superficial, and eventually bursts
through the scalp, forming one or more sinuses.

The abscess should be laid open, all tuberculous granulations scraped
away, and the sequestrum removed, with the aid of the chisel if it has
not already become loose. On inserting the finger through the opening,
it appears to penetrate to an alarming extent; this is due to the
accumulation of tuberculous material between the skull and the dura
mater, depressing the latter. After healing is completed, a depression
or gap in the bone remains.

#Syphilis.#--Syphilitic affections occur during the tertiary period of
the disease, and usually implicate the frontal and parietal bones
(Fig. 202). They are described in Volume I., p. 462.

[Illustration: FIG. 202.--Skull of woman illustrating the appearances
of Tertiary Syphilis of Frontal Bone--Corona Veneris--in the healed
condition.]

#Tumours.#--_Osteoma_ of the skull has been described with diseases of
bone (Volume I., p. 481).

_Sarcoma._--All forms of sarcoma are met with, implicating the bones
of the skull. They may originate in the pericranium, in the diploë, or
in the dura mater, and usually involve the bones of the vault. They
sometimes occur in children (Fig. 203).

[Illustration: FIG. 203.--Sarcoma of Orbital Plate of Frontal Bone in
a child at age of 11 months, and 18 months.

(Mr. D. M. Greig's case.)]

The tumour grows chiefly towards the surface, but it also tends to
invade the cranial cavity, and may thus assume the shape of a
dumb-bell. Its growth is usually rapid, and results in the formation
of a diffuse soft swelling, which sometimes pulsates, and sooner or
later fungates through the skin. On account of its rapid growth the
tumour is liable to be mistaken for an abscess, and in some cases the
nature of the disease is only discovered after making an exploratory
incision, and finding that the finger passes through a softened area
in the bone.

When the cranial cavity is encroached upon, signs of compression
ensue. After the tumour has fungated, infective complications within
the skull are liable to develop. In all cases the prognosis is
extremely unfavourable.

If diagnosed sufficiently early, an attempt may be made to remove the
tumour, but often the operation has to be abandoned, either on account
of the hæmorrhage which attends it, or because of the extent of the
disease.

The bones of the skull may become the seat of _secondary growths_ by
the direct spread of cancer from the soft parts, _e.g._ rodent cancer
(Fig. 204), or by metastasis of cancer or sarcoma from distant parts
of the body, or of thyreoid tumours. Metastatic cancer would appear to
be conveyed by the blood stream; it may occur in a diffuse
form--cancerous osteomalacia--softening the calvaria so that at the
post-mortem examination it may be removed with the knife instead of
the saw; or it occurs in a discrete or scattered form, and then the
macerated skull presents a number of circular and oval perforations.

[Illustration: FIG. 204.--Destruction of Bones of Left Orbit, caused
by Rodent Cancer. The patient died of septic meningitis.

(Mr. D. M. Greig's case.)]




CHAPTER XVI

THE VERTEBRAL COLUMN AND SPINAL CORD


Surgical Anatomy--Injuries of the spinal cord: _Concussion_;
    _Traumatic hæmatorrachis_; _Traumatic hæmatomyelia_; _Total
    transverse lesions at different levels_; _Partial lesions_;
    "_Railway spine_"--Injuries of the vertebral column: _Sprain_;
    _Isolated dislocation of articular processes_; _Isolated fracture
    of arches and spinous processes_; _Compression fracture of
    bodies_--Traumatic spondylitis--Fracture-dislocation--Penetrating
    wounds.

#Surgical Anatomy.#--The veretebral column is the central axis of the
skeleton, and affords a protecting casement for the spinal cord.

The spine is movable in all directions--flexion, extension, lateral
flexion, and rotation around the long axis of the column. Flexion is
accompanied by compression of the intervertebral discs, and by a
slight forward movement of each vertebra on the one below it. This
forward movement is checked by the tension of the ligamenta flava
which stretch between the laminæ.

In the infant, the spine is either straight or presents one long
antero-posterior curve with its convexity backwards. With the
assumption of the erect posture the normal S-shaped curve is
developed, the cervical and lumbar segments arching forward, while the
thoracic and sacral segments arch backward.

Through the skin it is often difficult to identify with certainty the
individual spinous processes. The spine of the seventh cervical
vertebra,--vertebra prominens--and that of the first thoracic, are
those most readily felt. While the arm hangs by the side, the root of
the spine of the scapula is opposite the third thoracic spine, and the
lower angle of the scapula is on the same level as the seventh. The
twelfth thoracic vertebra may be recognised by tracing back to it the
last rib. A line joining the highest points of the iliac crests
crosses the fourth lumbar spine; and the second sacral spine is on the
same level as the posterior superior iliac spine. The bodies of the
upper cervical vertebræ may be felt through the posterior wall of the
pharynx. The cricoid cartilage corresponds in level to that of the
lower border of the sixth cervical vertebræ and its transverse
process.

It is important for surgical purposes to bear in mind that most of the
spinous processes do not lie on the same level as their corresponding
bodies. The tips of the spines of the cervical and first two or three
thoracic vertebræ lie, roughly speaking, opposite the lower edge of
their respective bodies; those of the remaining thoracic vertebræ lie
opposite the body of the vertebræ below; while the spines of the
lumbar vertebræ lie opposite the middle of their corresponding bodies.

The _vertebral canal_ contains the spinal cord so suspended within its
membranes that it does not touch the bones, and is not disturbed by
the movements of the vertebral column.

The _membranes_ of the cord are continuous with those of the brain.
The arachno-pia invests the cord and furnishes a sheath to each of the
spinal nerves as it passes out through the intervertebral foramen. The
arachno-pial space is filled with cerebro-spinal fluid, which forms a
water-bed for the cord, continuous with that at the base of the brain.
The dura mater constitutes the enveloping sheath of the cord. It hangs
from the edge of the foramen magnum as a tubular sac, and is connected
to the bones only opposite the intervertebral foramina, where it is
prolonged on to each spinal nerve as part of its sheath. Between the
dura and the bony wall of the canal is a space filled with loose
areolar tissue and traversed by large venous sinuses. The dura extends
as far as the upper edge of the sacrum.

The _spinal cord_ extends from the foramen magnum to the level of the
disc between the first and second lumbar vertebræ. The cervical
enlargement, which includes the lower four cervical and the upper two
thoracic segments, ends opposite the seventh cervical spine. The
lumbar enlargement lies opposite the last three thoracic spines.

One pair of spinal nerves leaves each "segment" of the cord. On
leaving the cord the nerves incline slightly downwards towards the
foramina by which they make their exit from the canal. The obliquity
of the nerves gradually increases, till in the lower part of the
canal--from the second lumbar vertebra onward--they run parallel with
the filum terminale and together constitute the cauda equina.

It is to be borne in mind that owing to the fact that the cord is
relatively shorter than the canal, the tips of the spinous processes
lie a considerable distance lower than the segments of the cord with
which they correspond numerically. To estimate the level of the
segment of the cord which is injured: in the cervical region add one
to the number of the vertebra counted by the spines; in the upper
thoracic region add two, in the lower thoracic region add three, and
this will give the corresponding segment. The lower part of the
eleventh thoracic spinous process and the space below it are opposite
the lower three lumbar segments. The twelfth thoracic spinous process
and the space below it are opposite the sacral segments (Chipault).

_Functions._--The essential function of the spinal cord is to transmit
motor and sensory impulses between the brain and the rest of the body.
The general course of the fibres by which these impulses travel has
already been described (p. 331).

In the grey matter there are groups of nerve-cells--"centres"--which
govern certain reflex movements. The most important of these--the
centres for the rectal, the vesical, and the patellar reflexes--are
situated in the lumbar enlargement.

In the great majority of cases of spinal disease or injury coming
under the notice of the surgeon the symptoms are bilateral, that is,
are of the nature of paraplegia, and the whole of the body below the
level of the segment affected is involved in the paralysis. Lesions
affecting only one-half of the cord are rare and give rise to symptoms
which are exceedingly complicated. When the lesion implicates the
nerve-roots only, the symptoms are confined to the area supplied by
the affected nerves.


INJURIES OF THE SPINAL MEDULLA OR CORD

As the clinical importance of a spinal injury depends almost entirely
on the degree of damage done to the cord, we shall consider injuries
of the cord before those of the vertebral column. They will be
described under the headings: Concussion of the Cord; Traumatic Spinal
Hæmorrhage; Total Transverse Lesions; Partial Lesions of the Cord and
Nerve Roots; and "Railway Spine."

#Concussion of the Spinal Cord.#--Concussion of the cord is now
regarded as a definite entity closely resembling concussion of the
brain. In some cases, the underlying lesion is of a temporary
character, usually in the form of a vascular disturbance such as œdema
or vascular engorgement, and possibly an arterial anæmia; in other
cases there is definite evidence of injury, of the nature of
contusion, minute hæmorrhages and blood-staining of the cerebro-spinal
fluid. It must be clearly stated, that concussion of the cord may be
attended with an immediate arrest of all its functions closely
resembling the condition following upon complete crushing of the
cord--total transverse lesion,--and it may be impossible to
differentiate between the two conditions until two or more days have
elapsed after the accident; it is usual, however, in concussion, as
contrasted with crushing of the cord, that although motor conduction
may be completely abolished, sensation is only impaired and evidence
of sensory conduction can usually be elicited. If the lesion is merely
a concussion, the functions of the cord will be restored within a day
or two, first to full sensation and then to full motor power.

A classical instance is that of a late Governor-General of India, who
on being thrown in the hunting-field was found to be paralysed in all
four extremities; Paget diagnosed a total transverse lesion of the
cervical cord with the necessary inference that it would inevitably
have a fatal termination. The fact that the patient recovered
completely, and was later able to fill two Viceroyalties, proved that
the lesion must have been of the nature of a concussion of the cord.

The _treatment_ consists in adopting the same measures as in crushing
of the cord, while careful watch is observed for the signs of recovery
of conduction. The usual order of recovery is first the reflexes, then
sensation, and lastly, the motor functions.

#Traumatic Spinal Hæmorrhage.#--Hæmorrhage into the vertebral canal is
a common accompaniment of all forms of injury to the spine, but the
lower cervical region is the common seat of the severe type of
hæmorrhage resulting from acute flexion of the spine such as occurs
especially in a fall on the head from a horse or a vehicle in motion.
The blood may be effused around the cord--between it and the
dura--(extra-medullary), or into its substance (intra-medullary).

_Extra-medullary Hæmorrhage--Hæmatorrachis._--The symptoms associated
with extra-medullary hæmorrhage are at first of an irritative
kind--muscular cramps and jerkings, radiating pains along the course
of the nerves pressed upon, and hyperæsthesia. It is only when the
blood accumulates in sufficient quantity to exert definite pressure on
the cord that symptoms of paralysis ensue, and it is characteristic of
extra-medullary hæmorrhage that the paralysis comes on gradually. When
the effusion is in the cervical region--the commonest situation--the
arms are more affected than the legs. The paralysis of the arms is of
the lower neurone type, and the muscles are flaccid and undergo
atrophy; the legs may exhibit a more complete degree of paralysis of
the upper neurone type, with exaggeration of the knee-jerks. Blood may
trickle down the canal and collect at a level lower than that of the
lesion which causes the bleeding, and produce paralysis which slowly
spreads from below upwards--_gravitation paraplegia_ (Thorburn). There
is blood in the cerebro-spinal fluid.

The _treatment_ is on the same lines as in total transverse lesions.
When there is evidence of progressive pressure on the cord, the blood
is removed by spinal puncture if possible, or by laminectomy performed
at the level suggested by the symptoms; operation is, however, rarely
called for.

_Intra-medullary Hæmorrhage--Hæmatomyelia._--Traumatic hæmorrhage into
the substance of the cord occurs almost invariably in the lower
cervical region, and results from forcible stretching of the cord by
acute flexion of the neck. The blood is usually effused into the
anterior cornua of the grey matter and into the central canal, and
there is a varying degree of laceration of the nerve tissue, in
addition to pressure exerted by the extravasated blood.

The severity of the _clinical features_ depends upon the extent of the
lesion. In contrast with what results in extra-medullary hæmorrhage,
the symptoms are paralytic from the outset.

When the hæmorrhage is only sufficient to cause _pressure_ on the
cord, the paralysis is usually most marked in the lower extremities
because the conducting fibres are pressed upon. This is associated
with evanescent anæsthesia for temperature and pain, while tactile
sensibility is preserved. There is retention of urine and fæces, and
in young men, priapism. As the fibres which supply the dilator pupillæ
are involved, the pupils are contracted. The symptoms gradually
subside as the extravasated blood is re-absorbed, sensation being
restored before motion, and recovery may be comparatively rapid.

When the blood extravasated in the cord causes disintegration of its
substance, there is complete paralysis with atrophy, and anæsthesia in
the area supplied by the segments of the cord directly implicated. The
paralysis in the parts below the lesion assumes the spastic form. As
the lesion is usually in the upper part of the cord, it is the arms
that are most frequently affected. In less severe degrees of damage
the paralysis of the most distant parts, _e.g._ the feet, may be
transitory. Even in cases in which the loss of function below the
level of the lesion has been complete, recovery may take place, but it
is apt to be marred by a spastic condition of the muscles concerned,
due to sclerotic changes in the cord.

Except that operative treatment is contra-indicated, the _treatment_
is the same as for extra-medullary hæmorrhage, and at a later period
measures may be employed to relieve the spastic condition of the
muscles.

#Total Transverse Lesions.#--Total transverse lesions, that is, those
in which the cord is completely crushed or torn across, are much more
common than partial lesions, being an almost invariable accompaniment
of a complete dislocation or of a fracture-dislocation of the spine.
Even when the displacement of the vertebræ is only partial and
temporary, the cord may be completely torn across. Similar lesions may
result from stabs or bullet-wounds.

From the records of cases in which the vertebræ were injured by modern
rifle bullets, even although the bony walls of the spinal canal had
not been fractured and no hæmorrhage had occurred within the spinal
canal, the cord in the vicinity was degenerated into a "custard-like
material" incapable of any conducting power (Makins). According to
Stevenson, "this must have been due to the vibratory concussion
communicated to it by the passage of the bullet at a high rate of
velocity." The importance of this observation lies in the fact that in
such cases no benefit can follow operative interference.

The _clinical features_ vary with the level at which the cord is
injured, and the diagnosis as to the nature and site of the lesion is
to be made by a careful analysis of the symptoms. By gently passing
the fingers under the patient's back as he lies recumbent, any
irregularity in the spinous processes or laminæ may be detected, but
movement of the patient to admit of a more direct examination of the
spine is attended with considerable risk, and should be avoided.
Skiagrams are indispensable, as they show the exact site and nature of
the lesion.

_Immediate Symptoms._--At whatever level the cord is damaged there is
immediate and complete paralysis of motion and sensation (paraplegia)
below the seat of injury, and the paralysed limbs at once become
flaccid. On careful examination, a narrow zone of hyperæsthesia may be
mapped out above the anæsthetic area, and the patient may complain of
radiating pain in the lines of the nerves derived from the segments of
the cord directly implicated. In complete transverse lesions the
paralytic symptoms are symmetrical; any marked difference on the two
sides indicates an incomplete lesion.

Retention of urine and retention or incontinence of fæces are constant
symptoms. In young men priapism is common--the corpus cavernosum penis
is filled with blood without actual erection. There is other evidence
of vaso-motor paralysis in the form of dilatation of the subcutaneous
vessels, and local elevation of temperature in the paralysed parts.
The deep reflexes, including the tendon reflexes, are permanently
lost.

Unless regularly emptied by the catheter, the bladder becomes
distended, and there is dribbling of urine--the overflow from the full
bladder. As the bladder is unable to empty itself, and its trophic
nerve supply is interfered with, the use of the catheter involves
considerable risk of infection, unless the most rigid precautions are
adopted. Hypostatic pneumonia is liable to develop. Great care in
nursing is necessary to prevent trophic sores occurring over parts
subjected to pressure, such as the sacrum, the scapulæ, the heels, and
the elbows.

_Later symptoms_ are the result of descending degeneration taking
place in the antero-lateral columns of the cord. There are often
violent and painful jerkings of the muscles of the limbs; the muscles
become rigid and the limbs flexed.

_Treatment._--When the cord is completely divided, no benefit can
follow operative interference, and treatment is directed towards the
prevention of infective complications from cystitis and bed-sores.

#Injuries of the Cord at Different Levels.#--_Cervical
Region._--Complete lesions of the _first four cervical segments_--that
is, above the level of the disc between the third and fourth cervical
vertebræ--are always rapidly, if not instantaneously, fatal, as
respiration is at once arrested by the destruction of the fibres
which go to form the phrenic nerve. It is from this cause that death
results in judicial hanging.

In lesions between the _fifth cervical and first thoracic segments
inclusive_, all four limbs are paralysed. Sensation is lost below the
second intercostal space. The parts above this level retain sensation,
as they are supplied by the supra-clavicular nerves which are derived
from the fourth cervical segment (Fig. 205). Recession of the
eyeballs, narrowing of the palpebral fissures, and contraction of the
pupils result from paralysis of the cervical sympathetic. Respiration
is almost exclusively carried on by the diaphragm, and hiccup is
often persistent. There is at first retention of urine, followed by
dribbling from overflow, and sugar is sometimes found in the urine.
Priapism is common. The pulse is slow (40 to 50) and full; and the
temperature often rises very high--a symptom which is always of grave
omen.

[Illustration: FIG. 205.--Distribution of the Segments of the Spinal
Cord.

(After Kocher.)]

When the lesion is confined to the _sixth cervical segment_, the arms
assume a characteristic attitude as a result of the contraction of the
muscles supplied from the higher segments. The upper arm is abducted
and rotated out, the elbow is sharply flexed, and the hand supinated
and flexed (Fig. 206). Sensation is retained along the radial side of
the limb.

[Illustration: FIG. 206.--Attitude of Upper Extremities in Traumatic
Lesions of the Sixth Cervical Segment. The prominence of the abdomen
is due to gaseous distension of the bowel.]

Total lesions of the lower cervical segments are usually fatal in from
two to three days to as many weeks, from embarrassment of respiration
and hypostatic pneumonia.

When the lesion is confined to _the first thoracic segment_, the
attitude of the arms is usually that of slight abduction at the
shoulder and flexion at the elbow, the forearms lie semi-pronated on
the chest or belly, and there is slight flexion of the fingers. There
is complete anæsthesia as high as the level of the second interspace,
and along the distribution of the ulnar nerve (Fig. 205); the
respiration is entirely diaphragmatic; and the ocular changes
depending on paralysis of the cervical sympathetic are present.

_Thoracic Region._--In injuries of the thoracic region--second to
eleventh thoracic segments inclusive--the anæsthesia below the level
of the lesion is complete and its upper limit runs horizontally round
the body, and not parallel with the intercostal nerves. Above the
anæsthetic area there is a zone of hyperæsthesia, and the patient
complains of a sensation as if a band were tightly tied round the
body--"girdle-pain."

The motor paralysis and the anæsthesia are co-extensive. The
intercostal muscles below the seat of the lesion and the abdominal
muscles are paralysed. The respiratory movements are thus impeded,
and, as the patient is unable to cough, mucus gathers in the
air-passages and there is a tendency to broncho-pneumonia. As the
patient is unable to aid defecation or to expel flatus by straining,
the bowel is liable to become distended with fæces and gas, and the
meteorism which results adds to the embarrassment of respiration by
pressing on the diaphragm. There is retention of urine followed by
dribbling from overflow. As the reflex arc is intact there may be
involuntary and unconscious micturition whenever the bladder fills.

If infection of the bladder and the formation of bed-sores are
prevented, the patient may live for months or even for years. At any
time, however, infection of the bladder may occur and spread to the
kidneys, setting up a pyelo-nephritis; or the patient may develop an
ascending myelitis, and these conditions are the most common causes of
death.

_Lumbo-sacral Region._--All the spinal segments representing the
lumbar, sacral, and coccygeal nerves lie between the level of the
eleventh thoracic and first lumbar vertebræ. Injuries of the lower
thoracic and upper lumbar vertebræ, therefore, may produce complete
paralysis within the area of distribution of the lumbar and sacral
plexuses. The anæsthesia reaches to about the level of the umbilicus.
There is incontinence of urine and fæces from the first. Priapism is
absent. Bed-sores and other trophic changes are common, and there is
the usual risk of complications in relation to the urinary tract.

_Conus Medullaris._--A lesion confined to the conus medullaris may
result from a fall in the sitting position. It is attended with slight
weakness of the legs, anæsthesia involving a saddle-shaped area over
the buttocks and back of the thighs, the perineum, scrotum, and penis.
The urethra and anal canal are insensitive, and there is paralysis of
the levatores ani, the rectal and the vesical sphincters. The testes
retain their sensation.

_Cauda Equina._--As the cord terminates opposite the lower border of
the first lumbar vertebra, injuries below this level implicate the
cauda equina. The extent of the motor and sensory paralysis varies
with the level of the lesion and with the particular nerves injured.
Sometimes it is complete, sometimes, selective. As a rule all the
muscles of the lower extremity are paralysed, except those supplied by
the femoral (anterior crural), obturator, and superior gluteal nerves.
The perineal and penile muscles are also implicated. There is
anæsthesia of the penis, scrotum, perineum, lower half of the buttock,
and the entire lower extremity, except the front and lateral aspects
of the thigh, which are supplied by the lateral cutaneous nerve and
the cutaneous branches of the femoral (anterior crural). There is
incontinence of urine and fæces. The prognosis is more favourable than
in lesions affecting the cord itself, and the only risk to life is the
occurrence of infective complications.

#Partial Lesions of the Cord and Nerve Roots.#--Partial lesions, such
as bruises, lacerations, or incomplete ruptures, are always attended
with hæmorrhage into the substance of the cord, and usually result
from distortions or incomplete fractures and dislocations of the
spine, or from bullet wounds. They are comparatively rare.

When the _nerve roots_ alone are injured, sensory phenomena
predominate. Formication, radiating pains, and neuralgia are present
in the area of distribution of the nerves implicated. There is motor
paresis or paralysis, which may disappear either suddenly or
gradually, or may persist and be followed by atrophy of the muscles
concerned. In contrast to what is observed from pressure by tumours
and inflammatory products, twitchings and cramps are rare.

In _partial lesions of the cord_ the motor phenomena predominate.
Paresis extends to the whole of the motor area below the seat of the
lesion, but the weakness is more marked on one side of the body. The
distal parts--feet and legs--suffer more than the proximal--arms and
hands, and the extensors more than the flexors. The paresis develops
slowly, varies in extent and degree, and may soon improve. Vaso-motor
disturbances accompany the motor symptoms. Irritative phenomena, such
as twitchings or contractures, may come on later.

The deep reflexes, particularly the knee-jerks, may be absent at
first, but they soon return, and are usually exaggerated; a
well-marked Babinski response may appear later. Abolition of the
reflexes, therefore, does not necessarily indicate complete
destruction of the cord, but their return is conclusive evidence that
the lesion is a partial one. It is necessary, therefore, to defer
judgment until it is determined whether the abolition of the reflexes
is temporary or permanent.

Sensory disturbances may be entirely absent. When present, they are
incomplete, and are chiefly irritative in character. They may not
reach the same level as the motor phenomena, and the different sensory
functions are unequally disturbed in the areas corresponding to the
several nerve roots. There is sometimes a combination of hyperæsthesia
on one side and anæsthesia on the other.

Retention of urine is not always present even in those cases in which
the limbs are completely paralysed, as the fibres of one side of the
cord are sufficient to maintain the functions of the bladder. The
patient may be aware that the bladder is full, although he is unable
to empty it. Similarly, sensation in the rectum and anus may be
retained although the control of the sphincters is lost. Priapism may
be present, but tends to disappear.

In partial lesions, the difficulties of diagnosis are sometimes
increased by the occurrence of hæmorrhage into the substance of the
cord, so that symptoms of generalised pressure are superadded to those
of the partial lesion. In time the symptoms due to the intra-medullary
hæmorrhage pass off, but those due to the tearing of the cord persist.

The _prognosis_ is generally favourable, but must be guarded, as
permanent organic changes in the cord may take place, causing a
spastic condition of the muscles. When recovery is taking place the
first signs are the return of the knee-jerks, and a gradual change in
the limbs from the flaccid to the spastic condition. Sensibility
returns in the order--touch, pain, temperature, and the parts supplied
by the lowest sacral segments usually become sentient first. Voluntary
power returns earlier in the flexors than in the extensors, and
flexion of the toes is almost invariably the earliest voluntary
movement possible. Infection from bed-sores or from the urinary tract
is the most common cause of death in cases that terminate fatally.

The _treatment_ is carried out on the same lines as for total lesions.
Laminectomy, however, is indicated when there is reason to believe
that the pressure is due to some cause, such as a blood-clot or a
displaced fragment of bone, which is capable of being removed.

In practice when a person has lost the power of the lower extremities
as the result of an accident, there are three conditions requiring
ultimate differentiation--a concussion of the cord alone, a total
transverse lesion and a partial lesion of the cord together with
concussion. It must again be emphasised that it may not be possible to
differentiate between these immediately after the accident. Two or
three days may elapse before it is possible to give a definite
opinion.

"#Railway Spine.#"--This term is employed to indicate a disturbance of
the nervous system which may develop in persons who have been in
railway accidents, but a similar group of symptoms is met with in men
engaged in laborious occupations such as coal-miners, who, after an
injury to the back, develop symptoms referable to the nervous system
on account of which they claim compensation not infrequently in the
law-courts. It is a remarkable fact that it seldom occurs in railway
employees, or in passengers who sustain gross injuries, such as
fractures or lacerated wounds.

_Clinical Features._--The patient usually gives a history of having
been forcibly thrown backwards and forwards across the carriage at the
time of the accident. He is dazed for a moment and suffers from shock
or, it may be, is little the worse at the time, and is able to
continue his journey. On reaching his destination, however, he feels
weak and nervous, and complains of pain in his back and limbs. There
is rarely any sign of local injury. For a few days he may be able to
attend to business, but eventually feels unfit, and has to give it up.

The symptoms that subsequently develop are for the most part
subjective, and it is difficult therefore either to corroborate or to
refute them; it will be observed that while some of them are referable
to the cord the greater number are referable to the brain. They
usually include a feeling of general weakness, nervousness, and
inability to concentrate the attention on work or on business matters.
The patient is sleepless, or his sleep is disturbed by terrifying
dreams. His memory is defective, or rather selective, as he can
usually recall the circumstances of the accident with clearness and
accuracy. He becomes irritable and emotional, complains of sensations
of weight or fullness in the head, of temporary giddiness, is
hypersensitive to sounds, and sometimes complains of noises in the
ears. There are weakness of vision and photophobia, but there are no
ophthalmoscopic changes. He has pain in the back on making any
movement, and there is a diffuse tenderness or hyperæsthesia along the
spine. There is weakness of the limbs, sometimes attended with
numbness, and he is easily fatigued by walking. There may be loss of
sexual power and irritability of the bladder, but there is seldom any
difficulty in passing urine. The patient tends to lose weight, and may
acquire an anxious, careworn expression, and appear prematurely aged.
Special attention should be directed to the condition of the deep
reflexes and to the state of the muscles, as any alteration in the
reflexes or atrophy of the muscles indicates that some definite
organic lesion is present.

As the symptoms are so entirely subjective, it is often extremely
difficult to exclude the possibility of malingering; it is essential
that the patient should be examined with scrupulous accuracy at
regular intervals and careful notes made for purposes of comparison,
and also that the doctor should retain an impartial attitude and not
develop a bias either in favour of or against the patient's claim for
compensation.

So long as litigation is pending the patient derives little benefit
from treatment, but after his mind is relieved by the settlement of
his claim--whether favourable to him or not--his health is usually
restored by the general tonic treatment employed for neurasthenia.


INJURIES OF THE VERTEBRAL COLUMN

_Partial_ lesions include twists or sprains, isolated dislocations of
articular processes, isolated fractures of the arches and spinous
processes, and isolated fractures of the vertebral bodies. The most
important _complete_ lesions are total dislocations and
fracture-dislocations.

In partial lesions, the continuity of the column as a whole is not
broken, and the cord sustains little damage, or may entirely escape;
in complete lesions, on the other hand, the column is broken and the
cord is always severely, and often irreparably, damaged.

Twists and dislocations are most common in the cervical region, that
is, in the part of the spine where the forward range of
movement--flexion--is greatest. Fractures are most common in the
lumbar region, where flexion is most restricted. Fracture-dislocations
usually occur where the range of flexion is intermediate, that is, in
the thoracic region.

In all lesions accompanied by displacement, the upper segment of the
spine is displaced forwards.

#Twists# or #sprains# are produced by movements that suddenly put the
ligamentous and muscular structures of the spine on the stretch--in
other words, by lesser degrees of the same forms of violence as
produce dislocation. When the interspinous and muscular attachments
alone are torn, the effects are confined to the site of these
structures, but when the ligamenta flava are involved, blood may be
extravasated and infiltrate the space between the dura and the bone
and give rise to symptoms of pressure on the cord. The nerve roots
emerging in relation to the affected vertebræ may be stretched or
lacerated, and as a result radiating pains may be felt in the area of
their distribution.

In the _cervical_ region, distortion usually results either from
forcible extension of the neck--for example from a violent blow or
fall on the forehead forcing the head backwards--or from forcible
flexion of the neck. The patient complains of severe pain in the neck,
and inability to move the head, which is often rigidly held in the
position of wry-neck. There is marked tenderness on attempting to
carry out passive movements, and on making pressure over the affected
vertebræ or on the top of the head. The maximum point of tenderness
indicates the vertebra most implicated. In diagnosis, fracture and
dislocation are excluded by the absence of any alteration in the
relative positions of the bony points, and by the fact that passive
movements, although painful, are possible in all directions.

In the _lumbar_ region sprains are usually due to over-exertion in
lifting heavy weights, or to the patient having been suddenly thrown
backwards and forwards in a railway collision. The attachments of the
muscles of the loins are probably the parts most affected. The back is
kept rigid, and there is pain on movement, particularly on rising from
the stooping posture.

_Treatment._--Unless carefully treated, a sprain of the spine is
liable to cause prolonged disablement. The patient should be kept at
rest in bed, and, when the injury is in the cervical region, extension
should be applied to the head with the nape of the neck supported on a
roller-pillow. Early recourse should be had to massage, but active
movements are forbidden till all acute symptoms have disappeared. In
patients predisposed to tuberculosis, the period of complete rest
should be materially prolonged.

#Isolated Dislocation of Articular Processes.#--This injury, which is
most frequently met with in the cervical region and is nearly always
unilateral, is commonly produced by the patient falling from a vehicle
which suddenly starts, and landing on the head or shoulders in such a
way that the neck is forcibly flexed and twisted. The articular
process of the upper vertebra passes forward, so that it comes to lie
in front of the one below.

The pain and tenderness are much less marked than in a simple twist,
as the ligaments are completely torn and are therefore not in a state
of tension. The patient often thinks lightly of the condition at the
time of the accident, and may only apply for advice some time after
on account of the deformity. The head is flexed and the face turned
towards the side opposite the dislocation, the attitude closely
resembling that of ordinary wry-neck, only it is the opposite
sterno-mastoid that is tight. The bony displacement is best recognised
by palpating the transverse process of the dislocated vertebra. In the
case of the upper vertebræ this is done from the pharynx, in the lower
between the sterno-mastoid and the trachea. There is pain on
attempting movement, and tenderness on pressure, particularly on the
side that is not displaced, as the ligaments there are on the stretch.
There are often radiating pains along the line of the nerves emerging
between the affected vertebræ. As the bodies are not separated, damage
to the cord is exceptional. The lesion can usually be recognised in a
radiogram.

_Treatment._--Reduction should be attempted at once, before the
vertebræ become fixed in their abnormal position. Under anæsthesia
gentle extension is made on the head by an assistant, and the abnormal
attitude is first slightly exaggerated to relax the ligaments and to
restore mobility to the locked articular processes. The head is then
forcibly flexed towards the opposite side, after which it can be
rotated into its normal attitude (Kocher). Haphazard movements to
effect reduction are attended with risk of damaging the cord. After
reduction has been effected, the treatment is the same as that of a
sprain.

#Isolated Fractures of the Arches, Spinous and Transverse
Processes.#--Fractures of the arches and spinous processes usually
result from direct violence, such as a blow or a bullet wound, and are
accompanied by bruising of the overlying soft parts, irregularity in
the line of the spines, and by the ordinary signs of fracture.
Skiagrams are useful in showing the exact nature of the lesion. These
fractures are most common in the lower cervical and in the thoracic
regions, where the spines are most prominent and therefore most
exposed to injury.

In many cases there are no symptoms of damage to the cord or spinal
nerves, but when both laminæ give way the posterior part of the arch
may be driven in and cause direct pressure on the cord, or blood may
be effused between the bone and the dura. In such cases immediate
operation is indicated. When there are no cord symptoms, the treatment
consists in securing rest, with the aid of extension, if necessary,
for several weeks until the bones are reunited.

The use of the X-rays has shown that one or more of the _transverse
processes of the lumbar vertebræ_ may be chipped off by direct
violence. The symptoms are pain and tenderness in the region of the
fracture, and marked restriction of movement, especially in the
direction of flexion. This lesion may explain some of the cases of
persistent pain in the back following injuries in workmen. It is
important to remember, however, that in a radiogram an un-united
epiphysis may simulate a fracture.

#Isolated Fracture of the Bodies--"Compression Fracture."#--The
"compression fracture" consists in a crushing from above downwards of
the bodies--and the bodies only--of one or more vertebræ. It is due to
the patient falling from a height and landing on the head, buttocks,
or feet in such a way that the force is transmitted along the bodies
of the vertebræ while the spine is flexed.

If the patient lands on his head, the compression fracture usually
involves the lower cervical or upper thoracic vertebræ. When he lands
on his buttocks or feet it is usually the lumbar or the lower thoracic
vertebræ that are fractured (Fig. 207).

[Illustration: FIG. 207.--Compression Fracture of Bodies of Third and
Fourth Lumbar Vertebræ. Woman, æt. 28, who fell three storeys and
landed on the buttocks.]

As a rule, there are no external signs of injury over the spine. The
sternum, however, is often fractured, and irregularity and
discoloration may be detected on examining the front of the chest. The
recognition of a fracture of the sternum should always raise the
suspicion of a fracture of the spine. On examination of the back a
more or less marked projection of the spinous processes of the damaged
vertebræ may be recognised. In the cervical and lumbar regions this
projection may merely obliterate the normal concavity. The spinous
process which forms the apex of the projection belongs to the vertebra
above the one that is crushed. The cord usually escapes, but the
nerves emerging in relation to the damaged vertebræ may be bruised,
and this gives rise to girdle-pain.

Local tenderness is elicited on pressing over the affected vertebræ.
As might be expected from the nature of the accident producing this
lesion, it is often associated with serious injuries to the head,
limbs, or internal organs which gravely affect the prognosis.

The _treatment_ consists in taking the pressure off the injured
vertebræ in order that the reparative material may be laid down in
such a way as to restore the integrity of the column. In the cervical
region, extension is applied to the head, and a roller-pillow placed
beneath the neck. In the lumbar region, the extension is applied
through the lower limbs, and the pillow placed under the loins. The
patient is confined to bed for six or eight weeks, and before he gets
up a poroplastic or plaster-of-Paris jacket is applied. This is worn
for a month or six weeks.

#Traumatic Spondylitis.#--This condition is liable to develop in
patients who have sustained a severe injury to the back. It is
believed to originate in a compression fracture which has not been
recognised, and is probably due to the callus thrown out for the
repair of the fracture being subjected to strain and pressure too
early, or to a progressive softening of the injured vertebra and of
the bodies of those adjacent to it. This leads to an alteration in the
shape of the affected bones, which can be demonstrated by means of the
X-rays. The usual history is that some considerable time after the
patient has resumed work he suffers from pain in the back, and
radiating pains round the body and down the legs. He becomes more and
more unfit for work, and a marked projection appears in the back and
may come to involve several vertebræ. While the condition is
progressive, the prominent vertebræ are painful and tender. In course
of time the softening process is arrested, and the affected bones
become fused, so that the area of the spine involved becomes rigid and
permanent deformity results. So long as the condition is progressive
the patient should be kept in the recumbent and hyper-extended
position over a roller-pillow and, when he gets up, the spine should
be supported by a jacket.

#Dislocation and Fracture-Dislocation.#--It is seldom possible at the
bedside to distinguish between a complete dislocation of the spine and
a fracture-dislocation. _Fracture-dislocation_ is by far the more
common lesion of the two, and is the injury popularly known as a
"broken back." It may occur in any part of the column, but is most
frequently met with in the thoracic and thoracico-lumbar regions. It
usually results from forcible flexion of the spine, as, for example,
when a miner at work in the stooping posture is struck on the
shoulders by a heavy fall of coal. The spine is acutely bent, and
breaks at _the angle of flexion and not at the point struck_. The
lesion consists in a complete bilateral dislocation of the articular
processes, together with a fracture through one or more of the bodies.
This fracture is usually oblique, running downwards and forwards. The
upper fragment with the segment of the spine above it is displaced
downwards and forwards, and the cord is crushed between the posterior
edge of the broken body and the arch of the vertebra above it (Fig.
208). In almost every case the cord is damaged beyond repair.

[Illustration: FIG. 208.--Fracture--Dislocation of Ninth Thoracic
Vertebra, showing downward and forward displacement of upper segment,
and compression of cord by upper edge of lower segment.

(Anatomical Museum, University of Edinburgh.)]

_Total dislocation_, in which the articular processes on both sides
are displaced and the contiguous intervertebral disc separated, is
rare, and is met with chiefly in the lower cervical region.

_Clinical Features._--The outstanding symptoms of total lesions are
referable to the damage inflicted on the cord. The diagnosis should
always be made by a consideration of the mechanism of the injury and
the condition of the nerve functions below the lesion. On no account
should the patient be moved to enable the back to be examined, as this
is attended with risk of increasing the displacement and causing
further damage to the cord. On passing the fingers under the back as
the patient lies recumbent, it is usually found that there is some
backward projection of the spinous processes, the most prominent
being that of the broken vertebra. The spinous process immediately
above it is depressed as the upper segment has slipped forward. Pain,
tenderness, swelling and discoloration may be present over the injured
vertebræ. It is usually possible to have skiagrams taken without risk
of further damage to the spine. There is complete loss of motion and
sensation below the seat of the lesion. The symptoms of total
transverse lesions of the cord at different levels have already been
described (p. 416).

_Treatment._--An attempt may be made to reduce the displacement under
anæsthesia, gentle traction being made in the long axis of the spine
by assistants, while the surgeon attempts to mould the bones into
position. No special manipulations are necessary, as the ligaments are
extensively torn, and the bones are, as a rule, readily replaced. A
roller-pillow is placed under the seat of fracture to allow the weight
of the body above and below to exert gentle traction, and so to
relieve pressure on the cord. Operative treatment is almost never of
any avail, as the cord is not merely pressed upon, but is severely
crushed, or even completely torn across. Even when the cord is only
partially torn, operative treatment is not likely to yield better
results than are obtained by reduction and extension. The usual
precautions must be taken to prevent cystitis and bed-sores.

Total fracture-dislocation between the _atlas_ and _epistropheus_
(axis), if attended with displacement, is instantaneously fatal (Fig.
209). This is the osseous lesion that occurs in judicial hanging.
Fracture of the odontoid process may occur, however, without
displacement, the transverse ligament retaining the fragment in
position and protecting the cord from injury. The patient complains of
stiff neck and pain, and the lesion may be recognised in a radiogram.
A number of cases are recorded in which death took place suddenly
weeks or months after such an injury, from softening of the transverse
ligament and displacement of the bones.

[Illustration: FIG. 209.--Fracture of Odontoid Process of Axis
Vertebra.]

#Penetrating Wounds.#--These result from stabs or gun-shot accidents,
and are practically equivalent to compound fractures of the spine;
their severity depends on the extent of the damage done to the cord,
and on whether or not the wound is infected. In many cases the
condition is complicated by injuries of the pleural or peritoneal
cavities and their contained viscera, or by injury of the trachea,
œsophagus, or large vessels and nerves of the neck. When the membranes
of the cord are opened, the profuse and continued escape of
cerebro-spinal fluid may prove a serious complication.

_Treatment._--The wound of the soft parts is treated on the usual
lines. When the spinous processes and laminæ are driven in upon the
cord, they must be elevated at once by operation. In injuries
involving the lumbo-sacral region it is sometimes advisable to perform
laminectomy for the purpose of suturing divided nerve cords.

When there is evidence that the spinal cord is completely divided,
operation is contra-indicated. Attempts have been made to unite the
two ends of the divided cord by sutures, but there is as yet no
authentic record of restoration of function following the operation.




CHAPTER XVII

DISEASES OF THE VERTEBRAL COLUMN AND SPINAL CORD


POTT'S DISEASE: _Pathology_; _Clinical features_--Pott's disease as it
    affects different regions of the spine--Disease of the sacro-iliac
    joint; Syphilitic disease of spine; Tumours of vertebræ;
    Hysterical spine; Acute osteomyelitis; Rheumatic spondylitis;
    Arthritis deformans; Coccydynia; Tumours of cord and
    membranes--Spinal meningitis; Spinal myelitis--Congenital
    deformities: _Spina bifida_; _Congenital sacro-coccygeal tumours_.
    Congenital sacro-coccygeal sinuses and fistulæ.


TUBERCULOUS DISEASE OF THE SPINE--POTT'S DISEASE

Percival Pott, in 1779, first described a disease of the vertebral
column which is characterised by erosion and destruction of the bodies
of the vertebræ. It is liable to produce an angular deformity of the
spine, and to be associated with abscess formation and with nervous
symptoms referable to pressure on the cord. This disease is now known
to be tuberculous. It may occur at any period of life, but in at least
50 per cent. of cases it attacks children below the age of ten and
rarely commences after middle life.

#Morbid Anatomy.#--The tuberculous process may affect any portion of
the spine, and as a rule is limited to one region; several vertebræ
are usually simultaneously involved. The disease may begin either in
the interior of the bodies of the vertebræ--tuberculous
osteomyelitis--or in the deeper layer of the periosteum on the
anterior surface of the bones--tuberculous periostitis.

_Osteomyelitis_ is the form most frequently met with in children. The
disease commences as a tuberculous infiltration of the marrow, which
results in softening of the bodies of the affected vertebræ,
particularly in their anterior parts, and, as the disease progresses,
caseation and suppuration ensue, and the destructive process spreads
to the adjacent intervertebral discs. In some cases a sequestrum is
formed, either on the surface or in the interior of a vertebra. The
pus usually works its way towards the front and sides of the bones,
and burrows under the anterior longitudinal (common) ligament. Less
frequently it spreads towards the vertebral canal and accumulates
around the dura, causing pressure on the cord.

The compression of the diseased vertebræ by the weight of the head and
trunk above the seat of the lesion, and by the traction of the muscles
passing over it, produces angling of the vertebral column. The
anterior portions of the bodies being more extensively destroyed, sink
in, while the less damaged posterior portions and the intact articular
processes prevent complete dislocation. In this way the integrity of
the canal is maintained, and the cord usually escapes being pressed
upon. The spinous processes of the affected vertebræ project and form
a prominence in the middle line of the back. When, as is usually the
case, only two or three vertebræ are implicated, this prominence takes
the form of a sharp angular projection, while if a series of vertebræ
are involved, the deformity is of the nature of a gentle backward
curve (Fig. 210).

[Illustration: FIG. 210.--Tuberculous Osteomyelitis affecting several
vertebræ at Thoracico-lumbar Junction.]

The _periosteal form_ of vertebral tuberculosis is that most
frequently met with in adults. The disease begins in the deeper layer
of the periosteum on the anterior aspect of the vertebræ, and extends
along the surface of the bones, causing widespread superficial caries.
It may attack the discs at their margins, and spread inwards between
the discs and the contiguous vertebræ. Owing to the comparatively
wide area of the spine implicated, this form of the disease is not
attended with angular deformity, but rather with a wide backward
curvature which corresponds in extent to the number of vertebræ
affected. The accumulation of tuberculous pus under the periosteum and
anterior longitudinal ligament is the first stage in the formation of
the large abscesses with which this form of spinal tuberculosis is so
commonly associated.

_Effects on the Spinal Cord and Nerve Roots._--In some cases the cord
and nerve roots are pressed upon by an œdematous swelling of the
membranes; in others, the tuberculous process attacks the dura mater
and gives rise to the formation of granulation tissue on its outer
aspect--_tuberculous pachymeningitis_. Less frequently a collection of
pus forms between the bone and the dura, and presses the cord back
against the laminæ. The cord is rarely subjected to pressure as a
result of curving of the spine alone, but occasionally, especially in
the cervical region, a sequestrum becomes displaced backward and
exerts pressure on it, and it sometimes happens, also in the cervical
region, that the cord is nipped by sudden displacement of diseased
vertebræ--a condition comparable to a fracture-dislocation of the
spine.

The severity of the symptoms is aggravated by the occurrence of
inflammation of the cord--_myelitis_--which is not due to tuberculous
disease, but to interference with its blood-supply from the associated
meningitis.

_Repair._--When the progress of the disease is arrested, the natural
cure of the condition is brought about by the bodies of the affected
vertebræ becoming fused by osseous ankylosis (Fig. 211). While this
reparative process is progressing, the cicatricial contraction renders
the angular deformity more acute, and it may go on increasing until
the bones are completely ankylosed; this reparative process can be
followed in successive skiagrams. An increase in the projection in the
back, therefore, is not necessarily an unfavourable symptom, although,
of course, it is undesirable.

[Illustration: FIG. 211.--Osseous Ankylosis of Bodies (_a_) of Dorsal
Vertebræ, (_b_) of Lumbar Vertebræ following Pott's disease. There is
marked kyphosis at the seat of the disease and compensatory lordosis
above and below.

(Museum of the Royal College of Surgeons, Edinburgh.)]

[Illustration: FIG. 212.--Radiogram of Museum Specimen of Pott's
disease in a Child; the disease is located at the thoracico-lumbar
junction.

(Dr. Hope Fowler.)]

In rare cases the disease affects only the articular or the spinous
processes, producing superficial caries and a localised abscess.

#Clinical Features.#--The clinical features of Pott's disease vary so
widely in different regions of the spine, that it is necessary to
consider each region separately. To avoid repetition, however, certain
general features may be first described.

_Pain._--In the earliest stages, the patient complains of a feeling of
tiredness, which prevents him walking far or standing for any length
of time. Later, there is a constant, dull, gnawing pain in the back,
increased by any form of movement, particularly such as involves
jarring or bending of the spine. If the patient is a child, it is
noticed that he ceases to play with his companions, and inclines to
sit or lie about, usually assuming some attitude which tends to take
the weight off the affected segment of the spine (Figs. 214, 217). If
he is going about, the pain increases as the day goes on, but may pass
off during the night. It is often referred along the course of the
nerves emerging between the diseased vertebræ, and takes the form of
headache, neuralgic pains in the arms or side, girdle-pain, or
belly-ache, according to the seat of the lesion. Tenderness may be
elicited on pressing over the spinous or transverse processes of the
diseased vertebræ, or on making pressure in the long axis of the
spine. These tests, however, are not of great diagnostic value, and
they should be omitted, as they cause unnecessary suffering. It is to
be borne in mind that in some cases the disease is not attended with
any pain.

_Rigidity._--The pain produced by movement of the diseased portion of
the spine causes reflex contraction of the muscles passing over it,
and the affected segment of the column is thus rendered rigid. If the
palm of the hand is placed over the painful area while the patient
attempts to make movements of stooping, nodding, or turning to the
side, it is found that the vertebræ implicated move _en bloc_ instead
of gliding on one another. This rigidity of the diseased portion of
the column with "boarding" of the muscles of the back is one of the
earliest and most valuable diagnostic signs of Pott's disease.

_Deformity._--The most common and characteristic deformity is an
abnormal antero-posterior curvature, with its convexity backwards. The
situation, extent, and acuteness of the bend vary with the region of
the spine affected, the situation of the disease in the bone, and the
number of vertebræ implicated. When the disease has destroyed the
bodies of one or two vertebræ, a short, sharp, angular deformity
results; when it affects the surface of several bones, a long, wide
curvature.

Lateral deviation is occasionally met with in the early stages of the
disease as a result of unequal muscular contraction, and in the later
stages from excessive destruction of one side of a vertebra, or from
partial luxation between two diseased vertebræ.

_Abscess Formation._--Spinal abscesses occur with greater frequency
and at an earlier stage in adults than in children, because in adults
the disease usually begins on the surface of the vertebræ. Pyogenic
infection of such abscesses after they have burst externally
constitutes one of the chief risks to life in Pott's disease.

_X-Ray Appearances._--These, when considered along with the clinical
signs, usually afford valuable information as to the exact seat and
nature of the lesion and the number of vertebræ involved. It is
recommended to compare the skiagram with that of the normal spine from
the same region and from a patient of approximately similar age. The
outlines of the bodies are woolly or blurred; in the early stage there
may be clear areas corresponding to cheesy foci. In progressive cases
the bodies may be altered in shape and in size, and from destruction
and collapse of the bones there is altered spacing, both of the bodies
and of the ribs. In the interpretation of skiagrams, help is often
obtained from an alteration in the axis of bodies, an angular
deviation often drawing attention to the lesion which is located at
the "angle." In children (Fig. 213) there is often a spindle-shaped
shadow, outlined against the vertebral column, which is due to a cold
abscess, and which extends above and below the bodies actually
involved in the tuberculous process. The fusion of the bodies by new
bone, which accompanies repair, can be followed in skiagrams taken at
intervals.

[Illustration: FIG. 213.--Radiogram of Child's Thorax, showing
spindle-shaped shadow at site of Pott's disease of fourth, fifth, and
sixth thoracic vertebræ.]

_Cord and Nerve Symptoms._--When the spinal cord is pressed upon, the
motor fibres are first affected as they lie superficially on the
antero-lateral aspects of the cord, and are more sensitive to
pressure. There is at first weakness or paresis of the muscles
supplied from the part of the cord below the seat of pressure. The
knee-jerks and plantar reflexes are exaggerated, and there is marked
ankle clonus. Later, there is paralysis of the spastic type, varying
in extent and sometimes amounting to complete paraplegia, and this may
come on gradually or quite suddenly. There is wasting of muscles from
disuse, and later a tendency to contracture and the development of
deformities, as a result of sclerosis or descending degeneration of
the cord.

The sensory fibres usually escape, although in some cases there is
partial anæsthesia and perversion of sensation. When there is also
myelitis, loss of sensibility to pain (analgesia) below the level of
the lesion is one of the most characteristic symptoms. In severe cases
there is incontinence of urine and of fæces, as the patient loses
control of the sphincters. Acute bed-sores are not uncommon.

The symptoms referable to pressure on the _nerve roots_ at their
points of emergence are pain and hyperæsthesia along the course of the
nerves that are pressed upon, and occasionally weakness and wasting of
the muscles supplied by them; girdle-pain is often a prominent symptom
in adults.

In the #diagnosis# of Pott's disease in young children, chief stress
is laid on the demonstration of rigidity of the affected portion of
spine; the child is laid prone and is lifted by the legs and feet so
as to hyper-extend the spine; in Pott's disease the spine is held
rigid, while in the rickety and other conditions that resemble it, the
movements are normal.

#Treatment of Pott's Disease.#--In addition to the general treatment
of tuberculosis, the essential factor consists in _immobilising
the spine in the recumbent posture and in the attitude of
hyper-extension_; this must be persisted in until the diseased
vertebræ become fused together or ankylosed by new bone, a result
which is estimated partly by the disappearance of all symptoms and
more accurately by observing the formation of the new bone in
successive skiagrams.

Under conservative measures it is estimated that this reparative
process entails an immobilisation of the spine of from one to three
years; the _operative procedures introduced by Albe and Hibbs_ bring
about a bony ankylosis of the vertebræ in as many months, and may be
accepted as reducing the period of spinal immobilisation in the
recumbent posture to one year at the most.

The immobilisation of the recumbent spine in the attitude of
hyper-extension is most efficiently carried out by an apparatus on the
lines of the _Bradford frame_; this is made of gas-piping covered by
canvas, and is easily bent as may be required in the progress of the
case towards convalescence. The frame does not interfere with such
_extension_ as may be necessary, to the head, for example, in recent
cervical caries, or to the lower extremities where flexion at the hip
from spasmodic contraction of the psoas muscle may be efficiently
relieved by weight-extension.

_Gauvain's "wheel-barrow" splint_ and the _double Thomas' splint_
(Fig. 215) are efficient substitutes, but _Phelps' box_ has been
discarded because it fails to secure immobilisation of the spine.

When the stage of _convalescence_ is arrived at, and recumbency is no
longer essential, the child is allowed to sit up, stand, and go
about, with the restraint, however, of some apparatus that will
prevent movement of the spine, except to a limited extent. The
_plaster-of-Paris jacket_, applied over a woollen jersey, as
introduced by Sayre of New York, is probably the best; the jacket is
accurately moulded to the trunk while the child is partly suspended by
means of a tripod and the necessary strings under the chin, occiput,
and armpits. Poroplastic felt, celluloid, papier mâché, and other
materials, reinforced by strips of metal, may be substituted for the
plaster of Paris. Various forms of _jury-masts_ and _collars_ have
been employed to diminish the weight of the head in children with
cervical caries, but have been very properly discarded as failing to
perform the function expected of them.

_Correction of the Angular Projection._--In cases in which the angular
projection or gibbus, as it is called by continental authors, is of
recent origin, it may be corrected by the method so successfully
employed by Calot of Berck-sur-Mer--a plaster jacket is accurately
moulded to the trunk, and a diamond-shaped window is cut in the jacket
opposite the gibbus; a series of layers of cotton-wool are then
applied, one on top of the other, so as to exert firm pressure on the
gibbus, a plaster or elastic webbing bandage being employed to retain
them and reinforce the pressure. The padding is renewed at intervals
of three weeks or a month; in successful cases the projection may
ultimately be replaced by a hollow.

_Treatment of Abscess._--If a spinal abscess is causing symptoms or is
approaching the surface, and there appears to be a risk of mixed
infection, the abscess should be asperated and injected with iodoform
emulsion.

_Treatment of Cord-Complications._--Extension is applied, in the first
instance, to the head or to the lower limbs, or to both, while some
form of pillow is inserted at the seat of the disease; if the
condition is merely one of œdema, the symptoms usually yield with
remarkable rapidity; if they persist, in spite of extension, for three
to six weeks, recourse should be had to _laminectomy_; it is usual to
find evidence of mechanical pressure by granulation tissue, pus, or
displaced bone, the relieving of which is followed by disappearance of
the nerve symptoms. Some authors are lukewarm in their advocacy of
this operation, but we can cite a number of cases in which, after
laminectomy, an apparently hopeless paraplegia has been entirely got
rid of.

#Prognosis.#--As regards the _survival of persons who have suffered
from Pott's disease_, and as having an important bearing on prognosis,
it may be noted that surgical museums contain many specimens
illustrating the "cured" stage of the disease, in which the bodies of
the vertebræ, formerly the seat of tuberculous destruction or caries,
are represented by a ridge-shaped mass of new bone, forming a solid
union between the segments above and below (Fig. 211), or the remains
of the original bodies may still be identifiable, although they are
surrounded and fused together by new bone. The latter condition is the
more liable to a recrudescence of the tuberculous infection. Further,
it may be inferred from the number of "cured" cases of Pott's disease
met with in everyday life, that the malady is one from which recovery
may be expected.

The cervical cases are recognised by the "telescoping" of the neck,
the head and thorax being unduly approximated; the dorsal cases by the
well-known _hump_ or _hunch-back_, in which the spinous processes of
the collapsed vertebræ constitute the apex of the hump; the thorax is
telescoped from above downwards, the ribs are crowded together, the
lower ones, it may be, inside the iliac crests, and the sternum
projected forwards. The hunch-back from Pott's disease is often a
remarkably capable person, both physically and intellectually.


POTT'S DISEASE AS IT AFFECTS DIFFERENT REGIONS OF THE SPINE

#Upper Cervical Region, including Atlo-axoid Disease.#--When the
disease affects the first and second cervical vertebræ, the atlo-axoid
articulation becomes involved, and as a result of the destruction of
its component bones and ligaments, the atlas tends to be dislocated
forward. When this occurs suddenly, the odontoid process may impinge
on the medulla and upper part of the cord and cause sudden death. When
the displacement occurs gradually, the atlas and axis may be separated
to a considerable extent without the cord being pressed upon, and
recovery with ankylosis may ensue. When the third, fourth, and fifth
vertebræ are affected, the tendency to dislocation and compression of
the cord is not so great, but a portion of bone may be displaced
backwards and exert pressure on the cord.

The patient complains of a fixed pain in the back of the neck, and of
radiating pains along the course of the sub-occipital and other
cervical nerves. The neck is held rigid, and to look to the side the
patient turns his whole body round. As the disease advances the head
may be bent to one side as in wry-neck, or it may be retracted and the
chin protruded. To take the weight of the head off the diseased
vertebræ the patient often supports the chin on the hands (Fig. 214).

[Illustration: FIG. 214.--Attitude of patient suffering from
Tuberculous disease of the Cervical Spine. The swelling on the left
side of the neck is due to a retro-pharyngeal abscess.]

An abscess may form between the vertebræ and the wall of the
pharynx--_retro-pharyngeal abscess_--the pus accumulating between the
diseased bones and the prevertebral layer of the cervical fascia. The
abscess may project towards the pharynx as a soft fluctuating
swelling, and may cause difficulty in swallowing and breathing, and
snoring during sleep; if it bursts internally it may cause
suffocation. The abscess may bulge towards one or both sides of the
neck, and come to the surface behind the posterior border of the
sterno-mastoid muscle (Fig. 214). In some cases it comes to the
surface in the sub-occipital region.

If the cord is pressed upon by inflammatory products, there is
muscular weakness, beginning in the arms and extending to the legs,
and sometimes followed by complete paralysis. In the early stages
there is retention of urine and constipation; later the bladder and
rectum are paralysed, and there is incontinence.

Sudden death may result when dislocation of the atlo-axoid joint takes
place.

Cervical caries has to be diagnosed from rheumatic torticollis, and
from the effects of injuries, such as a sprain or twist of the spine.
When a retro-pharyngeal abscess points behind the sterno-mastoid, it
is apt to be mistaken for a cold abscess originating in tuberculous
cervical glands. Retro-pharyngeal abscess due to other causes is
described with diseases of the pharynx.

_Treatment._--Extension is applied to the head, preferably by means of
an elastic band fixed to the top of the bed, and the head of the bed
is raised on blocks so that the weight of the body may furnish the
necessary counter-extension. Lateral movements of the head are
prevented by means of sand-bags. After the acute symptoms have
subsided, the spine should be fixed by some rigid apparatus, such as a
double Thomas' splint prolonged so as to support the occiput (Fig.
215).

[Illustration: FIG. 215.--Thomas' Double Splint for Tuberculous
disease of Spine.]

When it is considered advisable to open a retro-pharyngeal abscess,
this should be done from the side of the neck by an incision along the
posterior border of the sterno-mastoid, as first recommended by John
Chiene. The abscess is evacuated, and the cavity filled with iodoform
emulsion, and closed without drainage. An opening made through the
mouth is attended with the risks of pus being inhaled into the
air-passages and of pyogenic infection.

When the patient is allowed to get up, a poroplastic collar and jacket
of the Minerva type which supports the head and controls the movement
of the cervical and thoracic vertebræ must be worn until the cure is
complete.

#Cervico-thoracic Region.#--When the lower cervical and upper thoracic
vertebræ are affected, in addition to the fixed pain in the diseased
bones, the patient complains of pain radiating along the distribution
of the superficial cervical nerves and down the arms. There is often
marked angular deformity. If an abscess forms, it may come to the
surface in the lower part of the posterior triangle, or may spread
into the posterior mediastinum or into the axilla. Sometimes the pus
burrows behind the œsophagus and trachea, and it may find its way into
the pleural cavity. The cord is not often pressed upon; when it is,
the cervical sympathetic is implicated.

#Thoracic or Dorsal Region.#--When the disease is confined to the
thoracic region, stiffness of the back and boarding of the vertebral
muscles are prominent features. On being asked to pick up an object
from the floor, the patient reaches it by bending his knees and hips,
while he keeps his back rigid. He refuses to make any movement that
involves jolting of the spine, such, for example, as jumping from a
chair to the ground. Children often attempt to take the weight off the
diseased vertebræ by placing the palms of the hands on the edge of a
chair so that the weight is borne by the arms.

Angular deformity is often well marked, and may implicate several
vertebræ. In order to maintain the head erect, the spine above and
below the seat of disease becomes unduly arched forward--compensatory
lordosis. In advanced cases the ribs become approximated, and the
lower end of the sternum is projected forward. The antero-posterior
diameter of the thorax is thus increased, while its vertical diameter
is diminished. These changes, together with the telescoping of the
vertebral bodies, lead to the deformity characteristic of the
tuberculous hunch-back (Fig 216). The alterations in the shape of the
chest may lead to functional disturbances of the heart and lungs.

[Illustration: FIG. 216.--Hunch-back Deformity following Pott's
disease of Thoracic Vertebræ.

(Photograph lent by Sir George T. Beatson.)]

_Dorsal Abscess._--As already mentioned, the earliest stage of abscess
is well seen in skiagrams (Fig. 213), especially in children. When
there is an extension of the suppurative process, the pus may pass
directly backwards along the posterior branches of the intercostal
vessels and nerves, and come to the surface behind the transverse
processes, or it may travel forward between the pleura and the ribs,
and, passing along the course of the lateral cutaneous branches of the
intercostals, come to the surface opposite the middle of the rib. In
the latter case, the abscess is liable to be mistaken for one
associated with tuberculous disease of the rib, particularly as the
rib is usually found to be bare. In rare cases the pus opens into the
pleura, giving rise to empyema. When the disease is on the anterior
surface of the bodies of the lower thoracic vertebræ, the pus may
spread down through the pillars of the diaphragm and reach the sheath
of the psoas muscle.

_Treatment_ is on the usual lines.

#Thoracico-lumbar Region.#--The symptoms are similar to those of
disease in the thoracic region. Children while standing often assume a
characteristic attitude--the hips and knees are slightly flexed, and
the hands grasp the thighs just above the knees (Fig. 217). In this
way the weight is partly taken off the affected vertebræ and borne by
the arms. If the child is laid on its back and lifted by the heels,
the spine remains rigid. By this test a projection due to tuberculous
disease may be differentiated from one due to rickets, as in the
latter case the projection disappears.

[Illustration: FIG. 217.--Attitude in Pott's disease of
Thoracico-lumbar Region of Spine.]

The patient often complains of pain in the abdomen--which in children
may be mistaken for a simple "belly-ache"--and of pain shooting down
the buttocks and into the legs. If the cord is pressed upon at the
level of the lumbar enlargement the anal and vesical sphincters are
paralysed, and the reflexes are exaggerated.

_Psoas Abscess._--When an abscess forms, it usually occupies the
sheath of the psoas muscle, in which it spreads down towards the iliac
fossa, and into the thigh, passing beneath Poupart's ligament,
posterior and lateral to the femoral vessels. The communication
between the pelvis and the thigh is often very narrow, so that the
abscess cavity has to some extent the shape of an hour-glass. The pus
may reach the surface in the region of the saphenous opening, or may
spread farther down the thigh under cover of the deep fascia. In some
cases it is liable to be mistaken for a femoral hernia, as the
swelling becomes smaller when the patient lies down, and has an
impulse on coughing.

_Lumbar Abscess._--Sometimes the pus travels along the posterior
branches of the lumbar vessels and nerves to the lateral border of the
sacro-spinalis (erector spinæ) and comes to the surface in the space
between the edges of the latissimus dorsi and external oblique
muscles--the triangle of Petit.

In rare cases it passes through the sacro-sciatic foramen and forms a
swelling in the buttock (_sub-gluteal abscess_); or it may pass
through the obturator foramen and reach the adductor region of the
thigh or even the perineum.

#Lumbo-sacral Region.#--Pott's disease in the lumbo-sacral region
usually affects adults, and, on account of the breadth of the
vertebral bodies and the limited range of movement in this segment of
the spine, is seldom accompanied by marked symptoms or deformity. The
diagnosis, therefore, is often difficult, unless good skiagrams are
available. The disease may be associated with pain in the distribution
of the sciatic nerve, which is liable to be mistaken for sciatica.
Single or double _iliac abscess_ frequently forms without the patient
showing any characteristic signs of spinal disease. When the disease
begins in childhood it may induce a permanent deformity of the
pelvis, the conjugate diameter at the brim being increased, while the
transverse diameter at the outlet is diminished--kyphotic pelvis, and,
in females, this may lead to complications in parturition.

#Tuberculous Disease of the Sacro-iliac Joint.#--This condition may
occur as a primary affection, but is much more frequently secondary to
disease in the ilium, sacrum, or lower lumbar vertebræ, and is most
common in adolescents and young adults of the male sex. It is attended
with pain in the lumbar region, and sometimes in the buttock and along
the course of the sciatic nerve. The pain is aggravated by movements,
especially such as involve sudden and violent contraction of the
lumbar and abdominal muscles, for example, coughing, sneezing, or
straining during defecation. Tenderness is elicited on making pressure
over the joint, on pressing together the iliac bones, or on attempting
to abduct the limb while the pelvis is fixed. The muscles of the
buttock and thigh are wasted. As any attempt to bear weight on the
affected limb causes pain, the patient walks with a limp, and to save
the joint he assumes an attitude which is characteristic: he throws
his weight on the sound limb, leans forward, using a stick for
support, tilts the affected side of the pelvis downwards, and flexes
the hip and knee-joints of the diseased limb. The anterior superior
spine is unduly prominent on the affected side, and the limb appears
to be lengthened. Sooner or later, in most cases, an abscess forms,
and the pus may reach the surface over the posterior aspect of the
joint. When the pus forms in front of the joint, it may spread
laterally in the iliac fossa as an _iliac abscess_ or may gravitate
downwards in the hollow of the sacrum and emerge on the buttock
through the sacro-sciatic foramen--_sub-gluteal abscess_. Sometimes it
passes into the ischio-rectal fossa or into the perineum. The presence
of an abscess in the pelvis may sometimes be recognised on rectal
examination. The appearance of an abscess is sometimes the first thing
to draw attention to the condition.

As pain across the small of the back and along the course of the
sciatic nerve may be among the early symptoms of sacro-iliac disease,
the condition is liable to be mistaken for lumbago or for sciatica.
From hip disease it is recognisable by noting that the movements of
the hip-joint are not restricted. It is not always possible without
the aid of skiagrams to differentiate sacro-iliac disease from disease
of the lumbar spine, and the two conditions sometimes coexist.

The _prognosis_ is unfavourable, particularly in cases complicated by
extensive disease of the ilium with abscess formation and mixed
infection.

_Treatment._--In early cases the patient should use crutches and wear
a patten on the foot of the sound side; in more advanced cases he must
be confined to bed, and have absolute rest to the joint secured by
means of extension applied to both legs, or by other apparatus. In
children a double Thomas' splint or Stiles' abduction frame is a
convenient appliance. Counter-irritation by blisters or the actual
cautery may be had recourse to in dry cases in which pain is a
prominent feature. If operative treatment becomes necessary, as it
may, for removal of a sequestrum, access to the seat of disease is
obtained by removing the posterior portion of the iliac bone. Cold
abscess is treated on the usual lines.

#Syphilitic Disease of the Vertebræ.#--All the clinical features of
Pott's disease may be simulated by gummatous disease of the vertebræ.
This is usually met with in adults who have suffered from acquired
syphilis; it is most common in the upper cervical vertebræ, and begins
on the anterior surface of the bodies. The onset is more sudden than
that of tuberculous caries, and the progress more rapid. The bone is
early and extensively destroyed, but abscess formation is rare. Severe
nocturnal pains are complained of, and some degree of angular
deformity may develop. In almost all cases other evidence of tertiary
syphilis is present, and this, together with the history and the
effects of anti-syphilitic treatment, aids in diagnosis. The local
treatment is carried out on the same lines as for tuberculous disease.

#Malignant Disease of the Vertebræ.#--_Sarcoma_ is the most important
of the primary tumours met with in the vertebral column. It gives rise
to symptoms which are liable to be mistaken for those of Pott's
disease or of arthritis deformans. The pain, however, is more intense,
and the disease progresses more continuously, and is uninfluenced by
treatment. The changes in the vertebræ, as seen in skiagrams, are
helpful in diagnosis. The growth may encroach upon the vertebral canal
and cause pressure on the cord (p. 451). In the sacrum--the most
common site--the tumour implicates the sacral nerves, and causes
symptoms of intractable sciatica; and the real nature of the disease
is often only detected on making a rectal examination.

_Secondary cancer_ is a common disease, particularly in cases of
advanced scirrhus of the breast. It leads to extensive softening of
the bodies of the vertebræ, so that they yield under the weight of the
body, as in Pott's disease. Clinically it is associated with severe
pain in the region of the vertebræ affected, and along the course of
the nerves emerging in the neighbourhood. If paralysis occurs from
the cancerous bodies pressing upon the cord (_paraplegia dolorosa_),
it is of rapid development, often becoming complete in a few hours.
When the cervical cord is compressed all four limbs are paralysed, and
from interference with respiration, the condition is fatal within a
few days.

#Actinomycosis#, #Blastomycosis#, and #Hydatid Cysts# also occur in
the vertebræ, and are difficult to diagnose from tuberculous disease.

#Typhoid Spine.#--An acute infective condition of the vertebræ,
intervertebral discs, and spinal ligaments occasionally occurs during
convalescence from typhoid fever. The lumbar region is most frequently
affected, and the X-rays reveal inflammatory changes in the bones,
disappearance of the discs, and, in the later stages, deposits of new
bone leading to synostosis of adjacent vertebræ. The onset, which may
be gradual or sudden, is attended with intense pain, and tenderness
over the affected vertebræ. The temperature is raised, and other signs
of an acute infective process are present. In a few cases there are
symptoms of involvement of the membranes and cord. With prolonged rest
and immobilisation of the spine the inflammation usually subsides, but
sometimes it goes on to suppuration.

#Hysterical Spine.#--This term is applied to a functional affection of
the spine occasionally met with in neurotic females between the ages
of seventeen and thirty, and liable to be mistaken for Pott's disease.
The patient complains of pain in some part of the spine--usually the
cervico-thoracic or thoracico-lumbar region--and there is marked
hyperæsthesia on making even gentle pressure over the spinous
processes. As the patients are usually thin, the pressure of the
corset is apt to redden the skin over the more prominent vertebræ, and
give rise to an appearance which at first sight may be mistaken for a
projection. The general condition of the patient, the freedom of
movement of the vertebral column, and the entire absence of rigidity,
are sufficient to exclude tuberculosis. The condition is treated on
the same lines as other hysterical affections.

#Acute osteomyelitis# of the vertebræ is a rare affection, and is met
with in young subjects. It attacks the more mobile portions of the
spine--cervical and lumbar--and may begin either in the bodies or in
the arches. It is attended with extreme sensitiveness on movement,
severe localised pain in the region of the vertebræ attacked, and a
marked degree of fever. Pus usually forms rapidly, but, being deeply
placed, is not easily recognised unless it points towards the
surface. The infection is liable to spread to the meninges of the cord
and give rise to meningitis, particularly when the disease begins in
the arches. A milder form occurs, in which the main incidence is on
the periosteum; the symptoms are less severe, it does not tend to
suppurate, and is usually recovered from. The treatment consists in
applying extension to the spine and in opening any abscess that may be
detected. The suppurative form usually proves fatal, and, indeed, is
often only diagnosed on post-mortem examination.

#Arthritis Deformans.#--This disease usually begins between the ages
of thirty-five and forty, and attacks men who follow some laborious
occupation which involves exposure to cold and wet. It is met with,
however, in women who lead a sedentary life. There is sometimes a
recent history of gonorrhœa, rheumatism, or other toxic disease, and
occasionally the condition follows upon injury. The discs disappear,
osteophytic outgrowths develop at the margins of the bodies and in
connection with the transverse processes, and bridge across the space
between neighbouring vertebræ (Fig. 218). The articulations between
the ribs and the vertebræ show similar changes, and the ligaments of
the several joints tend to undergo ossification, so that the bones are
fused together.

[Illustration: FIG. 218.--Arthritis Deformans of Spine. The vertebræ
are fixed to one another by outgrowths of bone which bridge across the
intervertebral spaces, and there is a slight lateral deviation to the
left in the mid-dorsal region.

(Anatomical Museum, University of Edinburgh.)]

In the early stage the patient complains of pain and stiffness in the
back; later the spine becomes rigid, and gradually develops a
kyphotic curve, sometimes accompanied by lateral deviation. In some
cases, the curvature of the spine assumes an extreme type, the
shoulders are rounded, and the head depressed, the face approximating
the sternum, so that to see an object such as a picture on a wall, the
patient must turn his back to it. The chest is flattened and
restricted in its movements, with the result that respiration is
embarrassed and becomes almost entirely abdominal. The muscles of the
back, shoulders, and hips undergo atrophy, and may exhibit tremors,
and the deep reflexes become exaggerated. The nerves are liable to be
pressed upon as they pass through the intervertebral foramina, and
this gives rise to pain and other disturbances of sensation in their
area of distribution. These pains may simulate those associated with
renal or gastro-intestinal affections.

The disease may simulate tuberculous caries or malignant disease. The
changes in the bones are demonstrated by the use of the X-rays.

The treatment is carried out on general principles (Volume I., p.
530), but it is seldom possible to do more than arrest the progress of
the disease.

#Coccydynia# is the name applied to a condition in which the patient
experiences severe pain in the region of the coccyx on sitting or
walking, and during defecation. The pathology is uncertain. In some
cases there is a definite history of injury, such as a kick or blow,
causing fracture of the coccyx, or dislocation of the sacro-coccygeal
joint. These lesions have also been produced during labour. In other
cases the pain appears to be neuralgic in character, and is referable
to the fifth sacral and the coccygeal nerves, or to the terminal
branches of the sacral plexus distributed in this region. The
affection is almost entirely confined to females, and the patients are
usually of a neurotic type. On rectal examination the coccyx is
exceedingly tender, and it is sometimes found to be less movable than
normal, and unduly arched forward. When medicinal treatment fails to
give relief, the coccyx may be excised.

#Tumours of the Spinal Cord and Membranes.#--Tumours may develop in
the substance of the cord (_intra-medullary_), in the membranes
(_meningeal_), or in the tissues between the dura and the bone
(_extra-dural_); or the cord may be pressed upon by a tumour
originating in the vertebræ. It is seldom possible to diagnose the
nature of a tumour before operation, and it is often difficult to
determine in which of the above situations it has originated.

Tumours growing _in the substance of the cord_ are nearly as common
as extra-medullary growths, and as the growth is usually sarcoma,
glioma, tuberculoma, or gumma, and infiltrates the cord, it is seldom
capable of being removed by operation.

The great majority of _meningeal_ tumours are primary sarcomas, and in
about 25 per cent. of cases they are multiple. Hydatid cysts and
fibromas are also met with in this situation, and they too may be
multiple.

_Extra-dural_ growths are comparatively rare. The forms usually met
with are sarcoma and lipoma.

These extra-medullary tumours seldom infiltrate the cord; they simply
compress it, and should be subjected to operative treatment before
secondary changes are produced in the cord.

The _symptoms_ vary according as the tumour presses on the nerve
roots, on one half, or on both halves of the cord. Pressure on nerve
roots is a characteristic sign in extra-medullary growths. It gives
rise to pain, which, according to the level of the tumour, passes
round the trunk (girdle-pain), or shoots along the nerve-trunks of the
upper or lower limbs.

When the cord is pressed upon, intense neuralgic pain related to the
segment first involved is one of the earliest symptoms, particularly
in extra-medullary tumours. The pain is at first unilateral, but later
becomes bilateral--a point of importance in diagnosis. The painful
areas are anæsthetic, but the anæsthesia does not always reach to the
level of the lesion. There may be a zone of hyperæsthesia at the upper
limit of the anæsthesia, or in the area corresponding to the roots on
which the tumour is situated, but there is never diffuse hyperæsthesia
(V. Horsley). In intra-medullary tumours the pain is less severe, it
is rarely an initial symptom, and is seldom referable to individual
nerve roots.

The next symptom to appear is motor paresis, followed by complete
paralysis, and later by contracture of the paralysed muscles--_spastic
paraplegia_. In intra-medullary tumours the paraplegia is usually less
complete than in those that are extra-medullary. When only one lateral
half of the cord is pressed upon, the motor paralysis and loss of
ordinary sensation are on the same side as the tumour, and the loss of
the sense of pain and of the temperature sense is on the opposite
side. Retention of urine accompanies the onset of paralysis, and later
gives place to incontinence. The rectum becomes paralysed, and
cystitis and pressure sores develop.

Anti-syphilitic treatment should be employed in the first instance to
exclude the possibility of the lesion being of the nature of a gumma.
Radical operative treatment is contra-indicated in intra-medullary
and in metastatic growths, but decompressive measures may be employed
for the relief of pain. In meningeal and extra-dural tumours, however,
in view of the hopeless prognosis if the condition is allowed to take
its course, an attempt may be made to remove the tumour by operation.
It is to be borne in mind that the lesion may be two or three segments
higher than the complete anæsthesia would appear to indicate; the
vertebral canal, therefore, should be opened about four inches above
the level of the anæsthesia.

When the tumour is not removable, the patient's suffering may
sometimes be alleviated by resecting the posterior roots of the nerves
emerging in the vicinity of the lesion.

#Chronic Spinal Meningitis.#--Victor Horsley (1909) described by this
name a condition which gives rise to symptoms closely simulating those
of a tumour of the cord. He believes it to consist in a
pachymeningitis combined with a certain degree of sclero-gliosis of
the periphery of the cord. The theca is greatly distended over a
variable extent of the cord; the cerebro-spinal fluid is increased in
quantity and is under considerable tension; and the cord itself
presents a shrunken appearance. Sometimes there is thickening of the
arachno-pia and matting of the nerve roots. The condition appears to
begin in the lower part of the cord, and to spread up, usually as far
as the mid-thoracic region. There is frequently a history of syphilis,
sometimes of recent gonorrhœa, but in some cases no cause can be
assigned for the lesion.

_Clinical Features._--This affection is almost always met with in
adults, and the earliest symptoms are pain and weakness in the legs,
and sometimes a slight kyphotic projection of the spinous processes.
The loss of power, which is sometimes attended with spasticity,
usually manifests itself in one leg first, and later affects the
other; it is progressive, and ultimately ends in complete paraplegia.
The pain is not confined to the region supplied by any one nerve root,
but affects a diffuse area, and the patient complains also of a
sensation of tightness in the limbs. There is never absolute
anæsthesia, but there is relative anæsthesia for all forms of
sensation, which extends as a rule as far as the sixth or eighth
thoracic root.

There are no vaso-motor phenomena, and no tendency to the formation of
pressure sores. Sometimes the patient complains of pain in the spine,
but this is not aggravated by movement.

_Treatment._--The treatment recommended by Horsley consists in
performing laminectomy, opening the theca, and washing it out with 1
in 1000 mercurial lotion. After the wound has healed, mercurial
inunction over the spine is employed to hasten the absorption of
inflammatory products. The administration of anti-syphilitic drugs has
not proved beneficial.

#Acute Spinal Meningitis.#--The spinal membranes may become implicated
by direct spread in cases of acute intra-cranial lepto-meningitis, or
they may be infected from without--for example, in gun-shot injuries
or in cases of spina bifida.

When the infection spreads from the cranial cavity, the cerebral
symptoms dominate the clinical picture, but evidence of involvement of
the membranes of the cord may be present in the form of rigidity of
the cervical muscles with retraction of the neck; deep-seated pain in
the back, shooting round the body (girdle-pain) and down the limbs;
painful cramp-like spasms in the muscles of the back and limbs, with
increased reflex excitability, sometimes so marked as to simulate the
spasms of tetanus.

When the theca of the cord is directly infected the spinal symptoms
predominate at first, but as the condition progresses it involves the
cerebral membranes, and symptoms of acute general lepto-meningitis
ensue.

Once the condition has started little can be done to arrest its
progress, but the symptoms may be relieved by repeated lumbar
puncture.

#Spinal Myelitis.#--The term "myelitis" is applied to certain changes
which occur in the spinal cord as a result, for example, of hæmorrhage
into its substance (_hæmorrhagic myelitis_); or of pressure exerted on
it by fragments of bone, blood-clot, tuberculous material, or new
growths (_compression myelitis_).

In another group of cases myelitis is a result of the action of
organisms or their toxins. Syphilis is a common cause, but the
condition may follow on infections with ordinary pyogenic cocci,
pneumococci, the influenza bacillus or the bacillus coli.

In addition to the use of anti-syphilitic remedies, or of sera
directed to neutralise the toxins of the causative organism, attention
must be directed to the bladder, and steps taken to prevent cystitis
and the formation of bed-sores.


CONGENITAL DEFORMITIES OF THE SPINE

#Spina Bifida.#--Spina bifida is a congenital defect in certain of the
vertebral arches, which permits of a protrusion of the contents of the
vertebral canal. It is due to an arrest of development, whereby the
closure of the primary medullary groove and the ingrowth of the
mesoblast to form the spines and laminæ fail to take place. The cleft
may implicate only the spinous processes, but as a rule the laminæ
also are deficient. The defect usually extends over several vertebræ
(Fig. 219). While the protrusion varies much in size, there is no
constant ratio between the dimensions of the swelling and the extent
of the defect in the neural arches.

[Illustration: FIG. 219.--Meningo-myelocele of Thoracico-lumbar
Region.]

The condition is comparatively common, being met with in about one out
of every thousand births. It is most frequent in the lumbar and sacral
regions (Fig. 219), but occurs also in the cervical (Fig. 220) and
thoracic regions. It is not uncommon to find spina bifida associated
with other congenital deformities such as hydrocephalus, club-foot,
and extroversion of the bladder.

[Illustration: FIG. 220.--Meningo-myelocele of Cervical Spine.]

_Varieties._--Four varieties are usually described according to the
character of the protrusion. They are analogous, to a certain extent,
to the varieties of cephalocele (p. 387). (1) _Spinal meningocele_, in
which only the membranes, filled with cerebro-spinal fluid, are
protruded. (2) _Meningo-myelocele_, the form most commonly met with
clinically, in which the cord and some of the spinal nerves are
protruded, and spread out over the inner aspect of the sac (Figs. 219,
220). (3) _Syringo-myelocele_, in which there is a dilatation of the
central canal in the protruded part of the cord. In these three forms
the protrusion may be covered by healthy skin, or by a thin, smooth,
translucent membrane through which the contents are visible.
Frequently this thin covering sloughs or ulcerates, and permits the
cerebro-spinal fluid to drain away. (4) In the _myelocele_, this skin,
as well as the vertebral arches and membranes, is absent, and the cord
lies exposed on the surface. This form is comparatively common, but as
the infants are either dead born or die within a few days of birth, it
seldom comes under the notice of the surgeon.

_Clinical Features._--The presence of a swelling in the middle line of
the back, which has existed since birth, and which contains fluid and
increases in size and tenseness when the child cries, renders the
diagnosis of spina bifida easy. The defect in the bone may be seen in
skiagrams. The swelling is usually sessile, but may be pedunculated;
it is usually possible to palpate the edges of the gap in the bones.
It may be reduced in size by making gentle pressure over it, and in
young children this may cause a bulging of the fontanelles. This test,
however, must be employed with caution, as it is liable to induce
convulsions. A meningocele, as it contains no nerve elements, may be
translucent. In a meningo-myelocele the shadows of the cord and nerves
stretched out in the sac may be recognised. The presence of the cord
is sometimes indicated by a median furrow, and after withdrawal of
some of the fluid the cord can sometimes be palpated. It is, however,
often difficult to distinguish between a meningocele and
meningo-myelocele.

[Illustration: FIG. 221.--Meningo-myelocele in Thoracic Region.]

Sometimes there are no nervous disturbances, and this is especially
the case when the defect is in the lower lumbar and sacral regions
below the termination of the cord. In most cases, however, there are
paralytic symptoms referable to the lower extremities, the bladder,
and the rectum, and there may also be trophic disturbances in the
parts below. Paralytic symptoms may be absent during infancy, and
develop during childhood or adolescence.

_Prognosis._--Comparatively few children born with spina bifida
survive longer than four or five years. The great majority die within
a few weeks of birth, death being due to the escape of cerebro-spinal
fluid, or to spinal meningitis following on infection. The condition
in some cases remains stationary for years, but spontaneous
disappearance is rare.

_Treatment._--The more severe forms of spina bifida only call for
palliative treatment, which consists in protecting the protrusion
against infection and applying a sterilised dressing and a supporting
bandage. A meningocele may be tapped with a fine needle passed through
healthy skin, and the empty sac compressed by a pad of wool and an
elastic bandage.

Operative treatment is seldom to be recommended in a young child
unless it is otherwise viable and the swelling is increasing rapidly
and threatening to burst, and there is reason to believe that the
paralysis is due to pressure. The immediate results of operation are
usually satisfactory, but in a large proportion of cases the child
subsequently develops hydrocephalus, from which it ultimately
succumbs. The hope of improvement in the motor symptoms after
operation depends on the site of the spina bifida; above the twelfth
thoracic vertebra there is no prospect of improvement; below this
level, inasmuch as it is the tip of the conus or the cauda equina that
is involved, there may be regeneration of nerve fibres and return of
power in the lower extremities, and control of the sphincters may be
regained. Murphy has practised resection of cicatricial or atrophied
portions of the cauda, with end-to-end suture.

The term #spina bifida occulta# is applied to a condition in which
there is no protrusion of the contents of the vertebral canal,
although the vertebral arches are deficient. The skin over the gap is
often puckered and adherent, and is frequently covered with a growth
of coarse hair.

A mass of fat may project towards the surface, and when situated in
the lumbo-sacral region may suggest a caudal appendage or tail (Fig.
222).

[Illustration: FIG. 222.--Tail-like Appendage over Spina Bifida
Occulta in a boy æt. 5, and associated with incontinence of urine.
Operation was followed by temporary retention.]

The clinical importance of spina bifida occulta lies in the fact that
it is sometimes associated with congenital club-foot, and with nerve
symptoms, in the form of sensory, motor, and trophic disturbances
referable to the lower limbs, such as perforating ulcer, and to the
sphincters. These nerve symptoms usually result from the presence of a
tough cord composed of connective tissue, fat, and muscle, stretching
from the skin through the vertebral canal to the lower end of the
spinal cord. As this strand of tissue does not grow in proportion
with the body, in the course of years it drags the cord against the
lower border of the membrana reuniens, which closes in the vertebral
canal posteriorly. These symptoms may be relieved by the removal of
this strand of tissue from the gap in the vertebral arches, or by
incising the membrana reuniens.

#Congenital Sacro-coccygeal Tumours--Teratoma.#--Many varieties of
congenital tumours are met with in the region of the sacrum and
coccyx. The majority are developed in relation to the communication
which exists in the embryo between the neural canal and the alimentary
tract--the post-anal gut or neurenteric canal. Some are evidently of
bigerminal origin, and contain parts of organs, such as limbs, partly
or wholly formed, nerves, parts of eyes, mammary, renal, and other
tissues.

Among other tumours met with in this region may be mentioned: the
congenital _lipoma_--a small, rounded, fatty tumour which often
suggests a caudal appendage (Fig. 222); the _sacral hygroma_, which
forms a sessile cystic tumour growing over the back of the sacrum, and
is believed to be a meningocele which has become cut off _in utero_ by
the continued growth of the vertebral arch; dermoids, sarcoma, and
lymphangioma.

[Illustration: FIG. 223.--Congenital Sacro-coccygeal Tumour.

(Photograph lent by Sir George T. Beatson.)]

The _treatment_ consists in removing the tumour, as from its situation
it is exposed to injury, and this is liable to be followed by
infection. From the position of the wound, and the fact that many of
these tumours extend into the hollow of the sacrum and therefore
necessitate an extensive dissection, there is considerable risk from
infection, especially in young children. The risk is increased when
the tumour communicates with the vertebral canal.

#Congenital Sacro-coccygeal Sinuses and Fistulæ.#--The _post-anal
dimple_, a shallow depression frequently observed over the tip of the
coccyx, may be due to traction exerted on the skin at this spot by the
remains of the neurenteric canal, or by the caudal ligament of
Luschka. Sometimes the integument is retracted to such an extent that
one or more _sinuses_ are formed, lined with skin which is furnished
with hairs, sweat, and sebaceous glands. The bursting of a dermoid, or
its being incised in mistake for an abscess, may result in the
formation of such a sinus, which fails to heal and may persist for
years.

In some cases the depression communicates with the vertebral canal,
constituting a complete _sacro-coccygeal fistula_, which may be lined
with cylindrical or ciliated epithelium.

From the accumulation of secretions and subsequent infection, these
conditions may be associated with a persistent offensive discharge,
and they are liable to be mistaken for ano-rectal fistulæ. They are
best dealt with by complete excision, and as primary union cannot be
expected, the wound should be treated by the open method.




CHAPTER XVIII

DEVIATIONS OF THE VERTEBRAL COLUMN


LORDOSIS--KYPHOSIS--SCOLIOSIS

Three main deviations of the vertebral column are described:
_Lordosis_, in which it is unduly arched forwards; _Kyphosis_, in
which it is unduly arched backwards; and _Scoliosis_ or lateral
deviations, in which the spine deviates to one side of the middle
line.

#Lordosis# or _anterior curvature of the spine_ with the convexity
forwards, is chiefly met with in the lumbar region as an exaggeration
of the natural curvature. A minor degree of lordosis sometimes occurs
as a peculiarity in the conformation of the individual and may be
present in several members of the same family; also in street-hawkers
and others who carry weights suspended in front of them; in very obese
persons; in those who suffer from large abdominal tumours, such as
fibroids; and in pregnant women. In its more marked and typical forms
it is met with as a compensatory deviation when the pelvis is tilted
forwards in association with flexion of one or of both hip-joints.
Illustrations of this association are found in congenital dislocation
of the hip, particularly when this is bilateral, in tuberculous
disease of the hip when recovery has occurred with ankylosis in the
flexed position, and in Charcot's disease of the hip. The resuming of
the erect position with tilting of the pelvis from flexion at the hip
is necessarily attended by an exaggeration of the forward curvature of
the lumbar spine. Its relationship to the erect posture is readily
demonstrated by noting its partial or complete disappearance when the
patient is sitting and the tilting of the pelvis is thus eliminated.

Lordosis elsewhere than in the lumbar segment is met with as a
compensatory deviation to kyphotic or backward curvature of the spine:
in Fig. 211, for example, a kyphotic projection in the mid-thoracic
region has led to a lordosis in the cervico-thoracic segment above,
and in the thoracico-lumbar segment below, the forward curve being
again a necessary outcome of the resuming of the erect posture. The
absence of a compensatory lordosis in such a condition would warrant
the inference that the patient had been bed-ridden.

#Kyphosis# or _posterior curvature of the spine_ with the convexity
backwards, is met with at all periods of life, and results from a wide
range of conditions.

In infancy it is a common result of _general debility_. The child need
not appear to be badly nourished, it may even be fat and look well,
but there is a want of muscular vigour such as should enable it to
hold itself erect in the sitting posture. It is to be noted that a
considerable degree of kyphosis may exist without interference with
the normal outlook in the erect posture, and, therefore, the question
of compensatory curvature does not arise. In the adolescent a degree
of kyphosis in the cervico-thoracic region is common, and is spoken of
as "round shoulders"; it is largely a matter of habit that requires
correction by the governess or nurse. Among agricultural labourers and
gardeners after middle life, and in the aged, this type of curvature
is of common occurrence and is evidently associated with their
occupation. An exaggerated form of the same cervico-thoracic kyphosis
is met with in patients suffering from progressive muscular atrophy,
poliomyelitis, osteitis deformans of Paget, acromegaly, and many
allied conditions in which either the muscular or the mental vigour is
deficient, and the patient adopts the cervico-thoracic kyphosis as the
attitude of rest.

Another type of diffuse kyphosis without compensatory curvature is met
with in _arthritis deformans_, in which the kyphosis is associated
with the disappearance of the intervertebral discs and ankylosis of
the vertebral bodies by bridges of new bone in the position of the
anterior common ligament.

_Partial or localised kyphosis_, on the other hand, is the result of
organic changes in the bodies of the vertebræ of the segment of spine
affected. It is most often met with in Pott's disease in which the
extent of the curve depends on the number of bodies affected, and its
degree on the amount of destruction that the bodies have undergone.
With the resumption of the erect posture, and in order that the eyes
should look directly forwards, a compensatory lordosis is acquired
above and below the segment that is the seat of kyphosis (Fig. 211). A
similar but less marked type of kyphosis may follow upon compression
fracture of the spine--in the condition known as traumatic
spondylitis; and as a result of other lesions, such as osteomalacia,
or malignant disease, in which the bodies undergo softening and yield,
so that the spinous processes project posteriorly.


SCOLIOSIS

#Scoliosis# or _lateral curvature_ is by far the commonest and most
important deviation of the spine. The student will obtain a clearer
conception of the nature of this deformity if we consider in the first
place those types for which an obvious explanation is available.

_Static scoliosis_, for example, when one leg is shorter than the
other, the pelvis is tilted down on the short side, the
thoracico-lumbar spine deviates laterally to the normal side, and to
restore the equilibrium of the trunk the cervico-thoracic spine
deviates again in the opposite direction. The causes of one leg being
shorter than the other are numerous and varied; they include such
conditions as unilateral congenital dislocation of the hip, fractures
united with overriding of the fragments, diseases of the joints,
_e.g._, hip disease, or of the bones, especially such as interfere
with the function of ossifying junctions; and acquired deformities
such as unilateral flat-foot, knock-knee, or bow-leg. Clinically,
this type of scoliosis is identified by observing that when the
patient sits down the deviation of the spine disappears; it is
relieved or got rid of by raising the sole and the heel of the boot on
the short side, and, if required, by inserting an "elevator" inside
the boot.

When there is _shortening of the muscles on one side of the trunk_
there develops a lateral curvature of the spine with its convexity to
the normal side; a good example of this is afforded in cases of
infantile hemiplegia (Fig. 224) in which the deviation affects the
entire column: a localised form is seen in congenital wry-neck, in
which the convexity of the cervico-dorsal curve is on the side of the
normal sterno-mastoid with a compensatory deviation to the opposite
side in the spine below (Fig. 272). _Unilateral paralysis_ of
_muscles_ acting on the trunk may also cause a lateral deviation of
the spine, as is well seen in paralysis of the trapezius, which
results in a cervical scoliosis with the convexity to the
non-paralysed side.

[Illustration: FIG. 224.--Scoliosis following upon Poliomyelitis
affecting right arm and leg.

(Mr. D. M. Greig's case.)]

_Asymmetry of the thorax_, such as may follow on empyema with
defective expansion of the lung, causes a lateral deviation of the
dorsal spine with the convexity towards the normal side.

_Attitudes_ adopted to relieve pain, such as that caused by sciatica,
sacro-iliac or hip disease, in which the weight of the body is
transferred to the normal side, cause a scoliosis similar to that due
to irregularity in the length of the lower extremities, and is
similarly made to disappear when the patient sits upon a flat surface.

_Malformation_ or _disease of the vertebræ_ themselves is a well
recognised cause of scoliosis; the best known, as it may be also the
most severe and the most intractable, is that due to rickets, under
which heading it has already been described (Fig. 225). In a few cases
a rudimentary wedge-shaped vertebra has been revealed by the X-rays.

[Illustration: FIG. 225.--Rickety Scoliosis in a child æt. 2.]

In all of these forms or types of scoliosis the primary cause must be
searched for and when found is made the first object of treatment; the
treatment of the scoliosis as such is on the same lines as in the
postural variety that now falls to be described.

#Habitual or Postural Scoliosis.#--These names have been given to the
type of scoliosis that develops in young girls and for which there is
no mechanical explanation.

It is most frequently met with in rapidly growing girls of poor
physique who are overworked at school or lessons, or on commencing an
apprenticeship for which they are physically unfit. In some cases
there is nasal obstruction from adenoids, in others the development
and free play of the chest are interfered with by tight and
ill-fitting garments; in all of them the muscular system is weak and
the muscles of the trunk do not take their proper share in maintaining
the erect posture. The most important determining factor would appear
to be the habitual or repeated assumption of faulty attitudes, partly
from carelessness, largely from fatigue, in order to relieve the
feeling of tiredness in the back. So far as is known, the condition
does not occur in communities living under aboriginal conditions. In
some cases there is a hereditary tendency to scoliosis; we have seen
it, for example, in a father and his daughters.

The excessive use of one arm in the carrying of weights, the habit of
resting on one leg more than the other, or the assumption of a faulty
attitude in writing or in playing the piano or violin, doubtless,
determine the seat and direction of the curvature, and, when it has
once commenced, tend to aggravate and to perpetuate it.

It is probable that the greater frequency of the primary curvature
towards the right is associated with the more general use of the right
hand and arm, although primary curvatures towards the left are not
confined to left-handed persons.

_Morbid Anatomy._--The original deviation or "primary curve" is
usually in the thoracic region, and has its convexity directed towards
the right side. To re-establish the equilibrium of the column,
"secondary" or "compensatory" curves, with their convexities to the
left, develop in the regions above and below the primary curve. It has
been proved experimentally that lateral deviation of the spine is
inevitably accompanied by rotation of the vertebræ around a vertical
axis, in such a way that their bodies look towards the convexity of
the curve, while their spines, laminæ, and articular processes are
directed towards the concavity (Fig. 226).

[Illustration: FIG. 226.--Vertebræ from case of Scoliosis, showing
alteration in shape of bones.]

As the deformity increases, the individual vertebræ are distorted, the
bodies becoming wedge-shaped from side to side, the base of the wedge
looking towards the convexity of the curve, while the narrow end looks
towards the concavity (Fig. 228). As the spine, laminæ, and articular
processes also undergo alterations in shape, a line uniting the tips
of the spinous processes does not furnish an accurate index of the
degree of lateral deviation but minimises it considerably. The muscles
and ligaments are altered in length in accordance with the changes in
the shape and position of the bones.

In the thoracic region, the ribs necessarily accompany the transverse
processes, so that on the side of the convexity they form an undue
prominence behind--the "rib-hump" (Fig. 227), while on the side of the
concavity the chest is flattened and the ribs crowded together so that
the intercostal spaces are diminished or even obliterated. The
converse--flattening on the side of the concavity--is seen on the
front of the chest.

[Illustration: FIG. 227.--Adolescent Scoliosis in a girl æt. 23.]

The general shape of the thorax is altered: on the side of the
convexity it is longer and narrower than normal and its capacity
diminished, while on the side of the concavity it is shorter and
broader and its capacity is increased.

The viscera are distorted and displaced in accordance with the altered
shape of the thoracic and abdominal cavities. The twisting of the
spine causes the patient to lose in stature, and the limbs appear to
be disproportionately long. In advanced cases the pelvis becomes
obliquely contracted--a deformity known as the _scoliotic pelvis_.

[Illustration: FIG. 228.--Scoliosis with primary curve in Thoracic
Region.]

In spite of the marked deformity the spinal cord is never compressed.

_Clinical features._--The development of scoliosis is always slow and
insidious. As a rule, attention is first attracted to the deformity
about the age of puberty, but in most cases it has existed for a
considerable time before it is observed. The patient--usually a girl,
although it also occurs in boys--is easily fatigued, has difficulty in
keeping herself erect, and often complains of pain in the back and
shoulders and along the intercostal spaces on the side of the
convexity. To relieve the muscles of the back she is inclined to
lounge in easy and ungainly attitudes.

The most common form of scoliosis met with in adolescents is a
_primary thoracic curvature_ with its convexity to the right (Fig.
227), and with more or less marked compensatory curves towards the
left in the lumbar and cervical regions. The thoracic spines lie
towards the right of the middle line. On account of the prominence of
the ribs, the right scapula is projected backwards, and its inferior
angle is on a higher level and farther from the middle line than that
of the left scapula. The right shoulder seems higher than the left,
and is popularly said to be "growing out"--a point which is often
first observed by the dressmaker. The right side of the back is unduly
prominent, while the left side is flattened. A deep sulcus forms in
the left flank below the costal margin, and the space between the arm
and the chest wall--the "brachio-thoracic triangle"--on the left side
is much more marked than on the right; and the left iliac crest
usually projects upwards and backwards. As seen from the front, the
right side of the chest is flattened, while the left side is
abnormally prominent, the breasts are asymmetrical, and the right
nipple is on a higher level than the left.

[Illustration: FIG. 229.--Scoliosis showing rotation of bodies of
vertebræ, and widening of intercostal spaces on side of convexity.]

In aggravated cases, the patient may suffer from shortness of breath
on exertion, and the respiratory difficulty may react on the heart,
causing dilatation of the right side, palpitation, and precordial
pain.

Sometimes, and particularly in males, the primary curvature is in the
lumbar region, and the convexity is to the left. The deviation of the
lumbar vertebræ produces a prominence in the left flank which masks
the outline of the iliac crest on that side, while the right flank
shows a deep furrow and the right half of the pelvis is unduly
prominent. There is a slight compensatory curve to the right in the
thoracic region, and the right side of the chest projects backwards.
The brachio-thoracic triangle is much more marked on the right than on
the left side.

_Diagnosis of Adolescent Scoliosis._--In many cases the patient is
brought to the surgeon on account of pain and weakness in the back
before any distinct deviation has developed, and, unless a careful
examination is made, the real cause of the symptoms is liable to be
overlooked.

The patient should be stripped and examined in a good light in various
attitudes; for example, standing in an easy position, standing as
straight as she can, and sitting on a flat stool. She should also be
asked to read from a book and to write, in order to exhibit her usual
attitudes. In early cases, an inequality in the level of the angles of
the scapulæ is often the only physical sign to be detected. It should
also be observed whether the line of the spines is altered when the
patient hangs from a horizontal bar or trapeze. Any backward
projection of the ribs on one side is rendered more obvious if the
patient folds the arms across the chest and bends well forward, while
the surgeon looks along the back from behind.

Pott's disease may be excluded by the absence of rigidity. Any
mechanical cause of deviation of the spine, such, for example, as
inequality in the length of the limbs or contraction of the chest
after empyema, must be sought for. Scoliosis that depends upon
inequality in the length of the limbs or tilting of the pelvis,
disappears on sitting.

_Treatment._--The treatment of postural scoliosis implies a
comprehensive programme, including attention to the general health,
habits, and exercises out of doors and in the gymnasium, clothing,
etc., all requiring supervision over a period of months, or even of
years. The object of the treatment is to correct the deformity before
the position has become fixed by rotation of the vertebræ and
alteration in their shape. The child must not be allowed to assume
awkward attitudes while reading, writing, or playing the piano; she
must sit on a low chair, the seat of which slopes slightly downwards
and backwards, and the back rest of which reaches as high as the
shoulders, and is at an angle of 100°-110° with the seat. The feet
should rest on a sloping stool, and when the child is reading or
writing, a desk sloping at an angle of 45° should be used. In weakly
girls approaching the period of puberty, special care should be taken
to avoid compression of the trunk by tight corsets. Adenoids or other
sources of respiratory obstruction must be removed; and if the patient
is myopic she should be provided with suitable glasses. Standing
should be avoided, as there is a great tendency to throw the weight on
to one leg; but walking, running, and other exercises which bring both
sides of the body into action equally are permitted under supervision.
Horse-riding is a suitable form of exercise, but girls must ride
astride; cycling is not to be recommended.

In mild cases--that is, those in which the curvature is obliterated
when the patient is suspended--the prophylactic measures above
mentioned must be rigidly enforced, and gymnastic exercises should be
prescribed. The exercises should not be commenced, however, until,
after a period of rest in bed, all pain and feeling of tiredness in
the back have disappeared.

In cases in which the curvature is not affected by suspension, the
deformity is usually permanent, but by suitable exercises it may be
prevented from becoming worse, and the patient may be educated to
disguise it to a considerable extent. Training is also directed
towards _regaining the muscular sense_; with the eyes shut before a
mirror, the child should endeavour to assume the correct posture; on
opening the eyes, the faulty attitude is seen and corrected. Forcible
correction by means of successive plaster jackets, applied in _the
flexed position_, somewhat on the lines employed by Calot in Pott's
disease, has yielded results which may be described as encouraging.
Only in very advanced cases should the patient be allowed to wear a
supporting jacket; such appliances have no curative effect, and can
only be expected to relieve symptoms.

       *       *       *       *       *

_Exercises for Lateral Curvature._--The particular exercises given
must be carefully selected to meet the indications present in each
case, the movements prescribed being designed to strengthen the weak
muscles and ligaments, to increase the mobility of the spine as a
whole, and to correct the deviation that exists. The exercises should
be taken twice daily, preferably in the morning and afternoon, and
after each spell the patient should rest for an hour, lying flat on
the back. During the exercises the breathing should be carefully
regulated, and at the end of each movement one or two deep breaths
should be taken. Each movement should be carried out slowly, the
number of times it is repeated varying from four to twelve or more,
according to the nature of the exercise and the strength of the
patient. The exercises should be stopped if the patient feels
fatigued. Hot-air baths and massage are useful adjuvants to all forms
of exercise.

#Special Exercises for Thoracic Curvature with convexity to
right.#--1. _Stand_ with arms by side; palms directed forward;
shoulders braced back. This is referred to as the "_best standing
position_" or _original position_. 2. Slowly raise arms from sides
until level with shoulders, with palms directed forward; carry left
arm straight upward--"_the keynote position_." Then slowly lower left
arm to level of shoulder; lower both arms into original position. 3.
_Assume keynote position_: slowly bend body forwards at hips until
stooping position is reached, with legs kept quite straight, head bent
slightly backwards, and eyes directed forward. Gradually return to
keynote and original positions. 4. _Keynote position_: slowly bend
whole spine to right; resume keynote and original positions. 5.
_Keynote position_: turn body forward sideways. 6. _Keynote position_:
rise on to balls of toes. 7. _Keynote position_: rise on to balls of
toes; bend knees; back to original position in reverse order. 8.
_Patient suspended from bar or rings, the left end of the bar or left
ring being three inches higher than the right._ (_a_) Draw right knee
upwards and forwards against resistance. (_b_) Draw legs apart against
resistance. (_c_) Draw legs together against resistance. 9. _Patient
lying on back._ (_a_) Bend right knee- and hip-joints against
resistance. (_b_) Extend right knee and hip against resistance. (_c_)
Rotate right hip against resistance. 10. _Patient lying on face with
pillow under chest_; slowly raise arms to keynote position. While
limbs are firmly held by a nurse, raise the body backwards and to the
right. 11. _Same position_: make swimming movements. 12. _Patient
astride a narrow table or chair, without a back._ (_a_) Repeat
exercises 3, 4, 5, and 11. (_b_) Bend body forwards, backwards; and
rotate to right and left against slight resistance made by nurse
grasping patient's shoulders.

_Klapp's "four-footed" Exercises._--Rudolf Klapp has devised a series
of exercises designed to strengthen the muscles and ligaments of the
spine, and to increase the mobility of the column. To take the weight
of the body off the spine, and to render both ends of the column
mobile, these exercises are carried out in the "all-fours" attitude,
the patient crawling in imitation of a quadruped, that is, in such a
way that the hand and knee of one side are approximated, while those
of the other side are separated; in other words, the hand and knee of
one side should not move forward simultaneously (Fig. 230). With each
step the spine is curved laterally, the concavity of the curve being
towards the side on which the hand and knee are approximated. The
exercises, for a case of dorsal curvature with the convexity to the
right, for example, are graduated as follows: (1) The child crawls in
a straight line till he has acquired the "quadruped gait"; (2) with
each step forward the head is inclined towards the side on which the
hand and knee are approximated; (3) at each step the hand and knee
which are wide apart are brought over and cross the limbs on the other
side; (4) to open out the concave left side, he crawls in a circle
towards the right. The exercises are practised morning and afternoon
for from fifteen to sixty minutes at a time. If there is a marked
_double_ curve, it is best neutralised by imitating the "pacing"
action of a quadruped, _i.e._, the limbs of the same side moving
forward together. The hands, knees, and toes should be protected by
suitable gloves and leather pads. Hot-air baths and massage are useful
adjuvants to the exercises.

[Illustration: FIG. 230.--Diagram of attitudes in Klapp's four-footed
exercises for Scoliosis.]

Abbott has introduced a method of treatment applicable to cases in
which the deformity has become permanent. Under general anæsthesia,
the patient being slung in a bracket-frame with the spine flexed, the
curvature is over-corrected and a plaster-case is then applied to
maintain the attitude; the plaster-case is renewed at intervals of two
or three months.




CHAPTER XIX

THE FACE, ORBIT, AND LIPS


FACE--Congenital malformations: _Hare-lip and cleft palate_;
    _Macrostoma_; _Microstoma_; _Facial cleft_; _Mandibular
    cleft_--Injuries of soft parts: _Wounds_; _Burns_--Bacterial
    diseases: _Boils_; _Anthrax_; _Glanders, etc._; _Lupus_;
    _Syphilis_. Tumours: _Epithelioma_. ORBIT--Injuries: _Contusion_;
    _Wounds_; _Fractures_--Injuries of eyeball--Orbital
    cellulitis--Tumours. LIPS--_Cracks_; _Chronic induration_;
    _Tuberculous ulcers_; _Syphilitic lesions_--Tumours: _Nævi_;
    _Lymphangioma_; _Cysts_; _Epithelioma_.


THE FACE

CONGENITAL MALFORMATIONS.--The description of the various congenital
malformations of the face will be simplified by a brief consideration
of its development.

_Development._--About the middle of the first month of intra-uterine
life the prosencephalon bends acutely forward over the end of the
notochord and sends out from its base a series of processes, which
ultimately blend to form the face (Fig. 231). These processes surround
a stellate depression, the primitive buccal cavity or stomatodæum,
from which the mouth and nasal cavities are developed. The buccal
cavity is bounded above by the fronto-nasal process, which is divided
by a fissure--the nasal cleft or olfactory pit--into a lateral nasal
process, and a mesial nasal process, at the outer angle of which a
spheroidal elevation appears--the globular process.

[Illustration: FIG. 231.--Head of human embryo about 29 days old,
showing the division of the lower part of the mesial frontal process
into the two globular processes, the intervention of the nasal clefts
between the mesial and lateral nasal processes, and the approximation
of the maxillary and lateral nasal processes, which, however, are
separated by the nasal-orbital cleft. (After His.)]

From the mesial nasal and globular processes the septum of the nose,
the mesial segment of the premaxillary bone, and the middle portion of
the upper lip are developed; while the lateral nasal process forms the
roof of the nasal cavity, the ala nasi and adjacent portion of the
cheek, and the lateral segment of the os incisivum or premaxillary
bone. Each segment of the os incisivum carries one of the incisor
teeth, and each of the mesial segments may contain in addition an
accessory tooth. The nasal cleft ultimately becomes the anterior
nares.

The primitive buccal cavity is bounded below by the mandibular arch,
which contains Meckel's cartilage, and from which are developed the
mandible, the lower lip, and the floor of the mouth.

From the lateral and back part of the mandibular arch springs the
maxillary process, which grows upwards and blends with the lateral
nasal process across the naso-orbital cleft--the deeper portion of
which persists as the nasal duct. From the maxillary process are
developed the cheeks, certain of the facial bones, the lateral
portions of the upper lip, the soft and hard palate (with the
exception of the os incisivum). The development of the face is
completed about the end of the second month of intra-uterine life.


HARE-LIP AND CLEFT PALATE

Hare-lip is a congenital notch or fissure in the substance of the
upper lip, and cleft palate a congenital defect in the roof of the
mouth. Either of these conditions may exist alone, but they occur so
frequently in combination that it is convenient to consider them
together.

In hare-lip the cleft may be median or lateral, and it may or may not
be associated with a cleft in the palate. The resemblance to the
Y-shaped cleft in the upper lip of the hare, suggested by the name, is
in most cases only superficial.

#Median hare-lip# is extremely rare. It occurs in two forms: one in
which there is a simple cleft in the middle of the lip, the result of
non-union of the two globular processes; another in which there is a
wide gap due to entire absence of the parts developed from the mesial
nasal process--the central portion of the lip, the mesial segment of
the os incisivum, and the septum of the nose. The second form is
usually associated with cleft palate.

#Lateral hare-lip# is much more common. It is due to imperfect fusion
of the globular process with the labial plates of the maxillary
process. There may be a cleft only on one side of the lip, or the
condition may be bilateral. In some cases the cleft merely extends
into the soft parts of the lip--_simple hare-lip_ (Fig. 232) forming a
notch with rounded margins on which the red edge of the lip shows
almost to the apex. In other cases the cleft passes into the alveolus
of the jaw--_alveolar hare-lip_--partly or completely separating the
mesial and lateral segments of the premaxillary bone (Fig. 233). These
cases are usually combined with cleft palate (Fig. 236).

[Illustration: FIG. 232.--Simple Hare-lip.]

[Illustration: FIG. 233.--Unilateral Hare-lip with Cleft Alveolus.]

When the hare-lip is _bilateral_, the two clefts may be unequal, one
forming a simple notch in the lip, the other passing into the nostril.
In most cases, however, both clefts are complete, and the mesial
portion of the lip is entirely separated from the lateral portions.
The central portion or prolabium is usually smaller than normal, and
is closely adherent to the os incisivum. This bone may retain its
normal position in line with the alveolar processes of the maxilla
(Fig. 234), or it may be tilted forward so that the incisor teeth,
when present, project beyond the level of the prolabium (Fig. 235). In
aggravated cases, the os incisivum and prolabium are adherent to the
end of the nose. In these cases there is a Y-shaped cleft in the
palate.

[Illustration: FIG. 234.--Double Hare-lip in a girl æt. 17.]

[Illustration: FIG. 235.--Double Hare-lip with Projection of Os
Incisivum, in an infant before first dentition.]

#Cleft Palate.#--It has already been mentioned that the palate is
formed by the blending of the two palatal plates of the maxillary
processes with the four segments of the os incisivum, derived from the
nasal processes. The foramen incisivum (anterior palatine foramen)
marks the point at which these elements of the palate unite. The
process of fusion begins in front and spreads backwards, the two
halves of the uvula being the last part to unite.

As development may be arrested at any point, several varieties of
cleft palate are met with. The uvula, for example, may be bifid, or
the cleft may extend throughout the soft palate. In more severe cases,
it extends into the hard palate as far forward as the foramen
incisivum. In these varieties the whole cleft is mesial. In still more
aggravated cases, the cleft passes farther forward, deviating to one
or to both sides in the fissures between the mesial and lateral
segments of the os incisivum or between the lateral segments and the
maxillæ. These cases are combined with double hare-lip.

The cleft varies considerably in width. It may be so wide that the
imperfectly developed nasal septum is seen between its edges, and
gives to the cleft the appearance of being double, or the septum is
adherent to one edge of the palate--usually the right--and the cleft
appears to be to the left of the middle line. In most cases the roof
of the mouth is unduly arched, and is narrower than normal (Fig. 236).

[Illustration: FIG. 236.--Asymmetrical Cleft Palate extending through
alveolar process on left side.]

_Clinical Features._--_Single hare-lip_ is about twice as common on
the left as on the right side, and it occurs more frequently in boys
than in girls. In a considerable proportion of cases there is a
well-marked hereditary tendency to these deformities, and they
frequently occur in several members of a family.

The nose is characteristically broad and flattened, the ala being
bound down to the alveolar margin of the maxilla by fibrous tissue.
The margins of the cleft in the lip are also attached to the alveolus
by firm reflections of the mucous membrane. The orbicularis oris and
other muscles of expression about the mouth being defective, the
deformity is exaggerated when the child cries or laughs. In simple
hare-lip the child may have difficulty in sucking, but this can
usually be overcome by some mechanical contrivance to occlude the
cleft.

When the _hare-lip is double and combined with cleft palate_, the
child is unable to suck, and food introduced into the mouth tends to
regurgitate through the nose. The nutrition can only be maintained by
having recourse to spoon-feeding, and in feeding the child it is
necessary to throw the head well back and to introduce the food
directly into the back of the pharynx. Many of these infants are of
such low vitality, however, that in spite of the most careful feeding
they emaciate and die.

In those who survive, the voice has a peculiar nasal twang, as in
phonation the air is expelled through the nose instead of through the
mouth, and the articulation, especially of certain consonants, is very
indistinct. Taste and smell are deficient. The constant exposure of
the nasal and pharyngeal mucous membrane renders it liable to
catarrhal inflammation and granular pharyngitis.

_Treatment._--The only means of correcting these deformities is by
operation, and, speaking generally, it may be said that the earlier
the operation is performed the better, provided the general condition
of the child is equal to the strain. In simple hare-lip the best time
is between the sixth and the twelfth weeks. When cleft palate coexists
with hare-lip, the lip should be operated on first, as the closure of
the lip often exerts a beneficial influence on the cleft in the
palate, causing it to become narrower.

Considerable difference of opinion exists as to when the cleft in the
palate should be dealt with. Some surgeons, notably Arbuthnot Lane,
recommend that it should be done in early infancy, as soon as the
viability of the child is assured. We agree with R. W. Murray, James
Berry, and others in preferring to wait until the child is between two
and a half and three years old. It should not be delayed longer,
because, even if the cleft in the palate is repaired, the nasal
character of the voice persists, as the patient cannot overcome the
habit of expelling the air through the nose.

Before the operation is undertaken, the child must be got into the
best possible condition; and arrangements must be made for its
constant supervision by a competent nurse. Success depends largely on
the avoidance of infective complications, and on absence of tension
between the rawed surfaces that are brought into apposition. More than
one operation is sometimes required to effect complete closure of the
cleft.

_Voice Training._--The treatment of cleft palate does not cease with a
successful operation; the importance of voice training must be
explained to the parents. The child must be taught, in speaking, to
send the stream of air through the mouth, instead of through the nose.
If the soft palate is not sufficiently large and mobile to shut off
the mouth from the nasal cavity, little improvement in speaking can be
looked for.

In _adolescents_ and _adults_, if the cleft is wide and the soft
tissues of the palate are thin and atrophied, better physiological
results may be obtained by the use of an artificial obturator or
velum. With the aid of the dentist a plate of vulcanite or gold is
fitted to the teeth and kept in position by suction.

#Other Congenital Deformities of the Face.#--_Macrostoma_ is an
abnormal enlargement of the mouth in its transverse diameter, due to
imperfect fusion of the maxillary and mandibular processes.

_Microstoma_ is due to excessive fusion of the maxillary and
mandibular processes. In some cases the buccal orifice is so small as
only to admit a probe.

_Facial cleft_ is due to non-closure of the fissure between the nasal
and maxillary processes. It passes upwards through the lip and cheek
to the lateral angular process of the frontal bone.

_Mandibular cleft_ occurs in the middle line of the lower lip, and may
extend to, or even beyond, the chin; it is due to non-union of the two
lateral halves of the mandibular arch.

These various deformities are treated by plastic operations carried
out on the same principles as for hare-lip.

_Fistulæ of the Lower Lip._--Two small openings, about the size of a
pin's head, are occasionally met with on the free border of the lower
lip, near the middle line. On passing a probe, each is found to lead
into a narrow cul-de-sac, which runs for about an inch laterally and
backwards under the mucous membrane. Watery, saliva-like fluid exudes
through the openings. These fistulæ frequently occur in several
members of the same family, and are usually associated with hare-lip.
The treatment consists in dissecting them out.

#Injuries of the Soft Parts of the Face.#--Owing to its free blood
supply, the skin of the face has great vitality, and even when
severely lacerated it not only survives, but shows such resistance to
bacterial infection that primary union frequently takes place. In
plastic operations, also, even extensive flaps seldom become infected,
and they heal so rapidly that the sutures can be removed in two or
three days.

In _incised_ wounds the bleeding is usually free at first, but unless
one of the larger arteries, such as the external maxillary (facial) or
temporal, is injured, it soon ceases. Paralysis of the muscles of
expression may follow if the facial nerve is injured; and loss of
sensation may result from injury to the supra-orbital or infra-orbital
nerves. If the parotid gland is implicated, saliva may escape from the
wound, but it usually ceases in a few days; if the duct is involved, a
persistent salivary fistula may form.

_Punctured_ wounds may perforate the orbit, the cranial cavity, or the
maxillary sinus, and be followed by infective complications,
particularly if the point of the instrument breaks off and is left in
the wound.

_Contused and lacerated_ wounds result from explosions and injuries by
firearms, and foreign bodies, such as particles of stone or coal, or
grains of gunpowder and small shot, may lodge in the tissues. Every
effort should be made to remove such foreign bodies, as if left
embedded they cause unsightly pigmentation of the skin. Ligatures are
seldom necessary for the arrest of hæmorrhage unless the larger
branches are injured, as the bleeding from smaller twigs is arrested
by the sutures. The edges of the wound are approximated by means of
Michel's clips, or by a series of interrupted horse-hair stitches, and
for this purpose a fine Hagedorn needle is to be preferred, as it
leaves less mark than the ordinary bayonet-shaped needle. If the
mucous membrane of the mouth or of the eyelid is implicated, its edges
should be approximated by a separate row of catgut stitches.

_Cicatricial contraction_ after severe burns may lead to marked
deformities of the eyelids (ectropion), mouth, and nose. When the burn
has implicated the neck, the chin may be drawn towards the chest, and
the movements of the lower jaw and head seriously impeded.

#Bacterial Disease.#--_Boils_, _carbuncles_, and _anthrax pustules_
frequently occur on the face, and when situated near the middle line,
and particularly on the upper lip, are liable to give rise to general
infection and to intra-cranial complications which may prove fatal.
The primary infection of _glanders_ and of _actinomycosis_ may also
occur on the face.

The various forms of _tuberculous lupus_ are met with more frequently
on the face than in any other situation (Fig. 237). _Tuberculous
disease of the facial bones_, particularly of the lateral half of the
orbital margin at the junction of the zygomatic (malar) bone with the
maxilla, is not uncommon in children.

[Illustration: FIG. 237.--Illustrating the deformities caused by Lupus
Vulgaris, which dated from adolescence.

(Mr. D. M. Greig's case.)]

The primary lesion of _syphilis_, and the various forms of secondary
and tertiary syphilides, may simulate tuberculous lupus, cancer, and
other ulcerative conditions.

#Tumours.#--The simple tumours met with on the face include sebaceous
and dermoid cysts, nævus, plexiform neuroma and adenoma; the malignant
forms include the squamous epithelioma, and rodent, paraffin, and
melanotic cancers.

_Epithelioma_ occurs most frequently in men beyond the age of forty.
The affection usually begins at the margin of the lip, the edge of the
nostril, or the angle of the eye. There is generally a history of
prolonged or repeated irritation, or the condition may develop in
connection with a scar, a wart, a cutaneous horn, or an ulcerating
sebaceous cyst. It may begin as a hard nodule, or as a papillary
growth which breaks down on the surface, leaving a deep ulcer with a
characteristically indurated base--the _crateriform ulcer_. The
neighbouring lymph glands are infected early, but metastases to other
organs are not common. The treatment consists in excising the growth
and the associated lymph glands as early and as freely as possible.
When excision is impracticable, benefit may be derived from the use of
radium or of the X-rays.

The face is the commonest seat of _rodent cancer_ (Volume I., p. 395).


THE ORBIT

#Injuries.#--_Wounds of the eyelids_ are liable to be complicated by
damage to the lachrymal apparatus, leading to stenosis of the
canaliculus and persistent watering of the eye. If the wall of the
lachrymal sac or nasal duct is torn, the patient should be warned not
to blow his nose for some days lest air be forced into the tissues and
produce emphysema. In suturing wounds of the lids care must be taken
to secure accurate apposition at the free margins, and to avoid
constricting the canaliculi.

_Contusion_ of the eyelids and circum-orbital region--the ordinary
"black eye"--is associated with extravasation of blood into the loose
cellular tissue of these parts, and is followed within a few hours of
the injury by marked ecchymosis. The lids may swell to such an extent
that the eye is completely closed. In some cases the impinging object
lacerates the vessels of the conjunctiva and produces a
sub-conjunctival ecchymosis, which may be situated under the palpebral
conjunctiva of the lower lid, or close to the corneal margin on the
front of the globe. The blood effused under the conjunctiva remains
bright red as it is aerated from the atmospheric air. The
characteristic play of colours which attends the disappearance of
effused blood is observed within a week or ten days of the injury.

Firm pressure applied by means of a pad of cotton wadding and an
elastic bandage, if employed early, may limit the effusion of blood;
and massage is useful in hastening its absorption.

A black eye is to be distinguished from the effusion which sometimes
follows such injuries as fracture of the anterior fossa of the skull,
fracture of the orbital ridges, or a bruise of the frontal region of
the scalp, chiefly by the facts that in the former the discoloration
comes on within a very short time of the injury, the swelling appears
simultaneously in both lids, and the sub-conjunctival ecchymosis, when
present, is coeval with the ecchymosis of the lids. In fractures of
the orbital plate and bruises of the forehead, on the other hand, the
ecchymosis does not appear in the eyelids for several days, and that
under the conjunctiva is usually disposed on the globe as a triangular
patch towards the lateral canthus.

_Wounds_ of the orbit result from the introduction of pointed objects,
such as knitting pins, pencils, or fencing foils, or from chips of
stone or metal, or small shot. They are attended with considerable
extravasation of blood, which may be diffused throughout the cellular
tissue of the orbit, or may form a defined hæmatoma. In either case
the eyeball is protruded, and the cornea is exposed to irritation and
may become inflamed and ulcerated. The optic nerve may be lacerated,
and complete and permanent loss of vision result. Sometimes the ocular
muscles and nerves are damaged, and deviation of the eye or loss of
motion in one or other direction results. The globe itself may be
injured. Foreign bodies lodged in the orbit, so long as they are
aseptic, may give rise to little or no disturbance, and are liable to
be overlooked. The Röntgen rays are useful in determining the presence
and position of a foreign body.

Infective complications are liable to follow injuries by bullets or
fragments of shell, and they not only endanger the eyeball, but are
liable to be associated with suppurative conditions in the adjacent
air sinuses--frontal, maxillary, and ethmoidal--or in the cranial
cavity. In purifying wounds of the orbit, and in extracting foreign
bodies, great care is necessary to avoid injury of the eyeball or of
its muscles or nerves.

_Fracture of the margin_ of the orbit results from a direct blow, and
is followed by circum-orbital and sub-conjunctival ecchymosis, and
sometimes is associated with paralysis of the optic nerve, or of the
other ocular nerves. Implication of the frontal sinus may be followed
by emphysema of the orbit and lids, and if there is infection by
suppurative complications.

The _roof_ of the orbit is implicated in many fractures of the
anterior fossa of the skull produced by indirect violence. It is also
liable to be fractured by pointed instruments thrust through the
orbit, in which case intra-cranial complications are prone to ensue,
and these in a large proportion of cases prove fatal. When the medial
wall is fractured and the nasal fossa opened into, epistaxis and
emphysema of the orbit are constant symptoms. Sub-conjunctival
ecchymosis, and some degree of exophthalmos, are almost always
present. Treatment is directed towards the complications. When the
nasal fossæ or the air sinuses are opened into, the patient should be
warned against blowing his nose, as this is liable to induce or
increase emphysema of the orbit or lids.

#Injuries of the Eyeball.#--These injuries may be divided into two
groups--(1) those in which the globe is contused without its outer
coat being ruptured, and (2) those in which the outer coat is
ruptured.

In cases belonging to the first group, while the sclerotic coat and
cornea remain intact, the iris may be partly torn from its ciliary
origin, and the blood effused collects in the lower portion of the
anterior chamber; or the pupillary margin of the iris may be ruptured
at several points, causing apparent dilatation of the pupil. The lens
may be partly or completely dislocated, and in the latter case it may
pass forward into the anterior chamber or backward into the vitreous.
Among other injuries resulting from contusion of the eye may be
mentioned hæmorrhage into the vitreous, rupture of the choroid, and
detachment of the retina.

Injuries in which the outer coat of the eyeball is ruptured may be
further subdivided into two groups according to whether or not a
foreign body is lodged in the globe.

Rupture of the outer coat, especially when it results from a punctured
wound, adds greatly to the risk of the injury, by opening up a path
through which infective material may enter the globe, and this risk is
materially increased when a foreign body is retained in the cavity of
the eyeball.

When the globe is burst by a blow with a blunt object, the sclerotic
usually gives way, and as the rupture takes place from within outward,
there is less risk of infection than in punctured wounds. The lens may
be extruded through the wound, and the iris prolapsed. If the rupture
is large, the conjunctiva torn, and the globe collapsed from loss of
vitreous, the eye should be removed without delay. If sight is not
entirely lost and there is no marked collapse of the globe, an attempt
should be made to save the eye.

Wounds produced by stabs or punctures are liable to be followed by
infective complications ending in panophthalmitis. When this is
threatened, removal of the eye is indicated, not only because the
affected eye is destroyed beyond hope of recovery, but to avoid the
risk of "sympathetic ophthalmia" affecting the other eye.

#Orbital Cellulitis.#--Infection of the cellular tissue of the orbit
by pyogenic bacteria is specially liable to follow punctured wounds
and compound fractures, if a foreign body has lodged in the orbital
cavity. It may also result from the spread of a suppurative process
from the globe of the eye, the conjunctiva, or the nasal fossæ or
their accessory air sinuses. Both orbits may be affected
simultaneously.

_Clinical Features._--The disease is ushered in by rigors, high
temperature, and severe pain, which radiates all over the affected
side of the head. There is exophthalmos and fixation of the globe,
with redness, swelling and tenderness of the eyelids, and congestion
and ecchymosis of the conjunctiva. The pupil is usually dilated, the
cornea becomes opaque and may ulcerate, and there is photophobia and
sometimes diplopia. Suppuration usually ensues, and the pus burrows in
every direction, and may ultimately point through the eyelids or
conjunctiva. Sometimes the infection spreads to the meninges, and to
the ophthalmic vein, and the phlebitis may then extend to the
cavernous sinus. The eyeball may be infected and destructive
panophthalmitis result. The prognosis therefore is always grave.

The _treatment_ consists in making one or more incisions into the
cellular tissue for the purpose of removing the pus and establishing
drainage. A narrow bistoury is passed in parallel to the wall of the
orbit, care being taken to avoid injuring the globe. When possible,
the incision should be made through the reflection of the conjunctiva,
but in some cases efficient drainage can only be established
by incising through the lid. When the eye is destroyed by
panophthalmitis, the propriety of eviscerating or enucleating it will
have to be considered.

#Tumours of the Orbit.#--Tumours may originate in the orbit or may
invade it by spreading from adjacent cavities. Those which originate
in the orbit may be solid or cystic. Of the solid tumours the glioma
and the sarcoma are the most common, and when they originate in the
pigmented structures of the globe they present the characters of
melanotic growths. Primary carcinoma begins in the lachrymal gland.
Osteoma--usually the ivory variety--may originate in the wall of the
orbit, or may spread from the adjacent sinuses.

_Clinical Features._--In children, the tumour is usually a glioma, and
it is frequently bilateral. It generally occurs before the age of
four, is associated with increased intra-ocular tension, protrusion of
the eyeball, and dilatation of the pupil, and soon produces blindness.
The tumour fungates and bleeds, and rapidly invades adjacent
structures and spreads along the optic nerve to the brain. It is
highly malignant, and recurrence usually takes place, even when the
tumour is removed early.

In adults melanotic sarcoma is most common. It occurs between the ages
of forty and sixty, and is almost always unilateral; and while it
shows little tendency to invade the brain, the adjacent lymph glands
are early infected, and death usually results from dissemination.

In all varieties of intra-orbital tumour exophthalmos is a prominent
feature (Figs. 238, 239), and when the protrusion of the eyeball is
marked the lids become swollen, œdematous, and dusky. The eye is
seldom pushed directly forward except when the tumour is growing in
the optic nerve or its sheath. When the tumour is solid, the eye
cannot be pressed back into the orbit, but in cystic tumours it may to
some extent. The movements of the eyeball are restricted in a varying
degree, and ptosis often results from paralysis of the levator
palpebræ superioris. In almost all cases there is also more or less
visual disturbance. The cornea being unduly exposed is liable to
become inflamed, or even ulcerated. Pain is a variable symptom; when
present, it usually radiates along the branches of the first and
second divisions of the trigeminal nerve. Tenderness on pressure is
not always present. It is comparatively uncommon for a tumour of the
orbit to invade the globe directly.

[Illustration: FIG. 238.--Sarcoma of Orbit, causing exophthalmos and
downward displacement of the eye, and projecting in temporal region.]

[Illustration: FIG. 239.--Sarcoma of Eyelid in a child.

(Mr. D. M. Greig's case.)]

_Treatment._--When practicable, removal of the tumour is the only
method of treatment, and in malignant tumours it is often necessary to
sacrifice the eye to ensure complete removal. When the tumour has
invaded the orbit secondarily, its removal may be impossible, but it
may be necessary to remove the eye for the relief of pain.

The _orbital dermoid_ usually occurs at the lateral end of the
supra-orbital ridge (Fig. 240). A less common situation is the
anterior part of the orbit, near the nasal wall, and this variety,
from its position and from the fact that it is usually met with in
children, is liable to be confused with orbital meningocele or
encephalocele. Treatment consists in its removal by careful
dissection, and this can usually be done under local anæsthesia.

[Illustration: FIG. 240.--Dermoid Cyst at outer angle of orbital
margin.]

_Orbital aneurysms_ have already been described, Volume I., p. 317.


THE LIPS

_Herpes_ of the lips, due to a mild staphylococcal infection, is
common in delicate children and in the early stages of pneumonia. A
crop of vesicles forms and, after bursting, these leave dry scabs.

A more severe staphylococcal infection may give rise to a carbuncular
swelling with great œdema, and lead to infective phlebitis of the
facial vein and general septicæmia. Excision of the focus is
indicated.

The lip is sometimes the seat of the malignant pustule of anthrax.

Painful _cracks and fissures_ are frequently met with in the middle
line of the lip and at the angle of the mouth in young subjects. They
usually develop during frosty weather, and as they are constantly
being torn open by the movements of the mouth, they are difficult to
heal. If local applications fail, it may be necessary to cocainise the
fissure and scrape it with a sharp spoon.

_Chronic Induration of the Lips (Strumous Lip)._--A chronic œdematous
infiltration, probably of the nature of a lymphangitis, sometimes
affects the submucous tissue of the lips of delicate children. It is
most common on the upper lip, and may be associated with a fissure or
with chronic coryza. The lip is everted, and its mucous membrane
unduly prominent. The cervical glands are frequently enlarged.

The _treatment_ consists in removing the cause and in improving the
general condition. In cases of long standing it may be necessary to
remove from the inner aspect of the lip a horizontal strip of tissue
having the shape of a segment of an orange.

The term "_double lip_" is applied to a condition occasionally met
with in young men, in which there is a hypertrophy of the labial
glands in the mucous membrane of the upper lip. It is of slow growth,
and forms an elongated swelling on each side of the frenum, covering
the teeth, and projecting the lip. It is shotty to the feel, and the
only complaint is of disfigurement. The treatment consists in excising
the redundant fold of mucous membrane, including the enlarged mucous
glands.

_Tuberculous disease_ may occur in the form of lupus or of ulcers. The
_ulcers_ generally occur in patients suffering from advanced pulmonary
or laryngeal phthisis. They are usually superficial, may be single or
multiple, and are exceedingly painful.

_Syphilitic Lesions._--The upper lip is the most frequent seat of
extra-genital chancre. The _chancre of the lip_ begins on the mucous
surface as a small crack or blister, which becomes the seat of a
rounded, indurated swelling, about a quarter of an inch in diameter.
The surface is smooth, of a greyish colour, and exudes a small
quantity of sero-purulent fluid. The lip is swollen and everted, and
there is a considerable area of induration around. The submental and
submaxillary lymph glands on one or on both sides soon become
enlarged, and may reach the size of a pigeon's egg. At first they are
firm, but they may subsequently soften and become painful. In some
cases the sore is much less characteristic, resembling an ordinary
crack or fissure, and its true nature is only revealed when the
secondary manifestations of syphilis appear.

_Mucous patches_ and _superficial ulcers_ are frequently met with on
the mucous surface of the lips and at the angles of the mouth during
the secondary stage of syphilis. In the inherited form of the disease
deep cracks and fissures form, and often leave characteristic scars
which radiate from the angles of the mouth.

Gummatous lesions occur on the lips, and are liable to be mistaken for
epithelioma.

_Tumours._--_Nævi_ are not uncommon on the lips. When confined to the
mucous surface they may be dissected out, but when they invade the
skin they are best treated by electrolysis.

_Lymphangioma._--The term _macrocheilia_ is applied to a congenital
hypertrophy of the lip (Fig. 241), which is probably of the nature of
a lymphangioma (Middeldorpf). One or both lips may be affected. The
lip is protruded, the mucous membrane everted, and, when the lower lip
is implicated, it becomes pendulous and is liable to ulcerate. The
substance of the lip is uniformly firm and rigid, so that it moves in
one piece, and sucking, mastication, and phonation are interfered
with.

[Illustration: FIG. 241.--Macrocheilia.

(From a photograph lent by Sir H. J. Stiles.)]

The _treatment_ consists in removing a wedge-shaped portion of the
swelling on the same lines as for "strumous lip," or in employing
electrolysis.

_Mucous cysts_ occur as small rounded tumours, projecting from the
inner surface of the lip. They are of a bluish colour, and contain a
glairy fluid. They are treated by removal of the cyst wall, together
with the overlying portion of mucous membrane.

#Epithelioma of the lip# is of the squamous-celled variety, and is met
with either as a fungating wart-like projection, or as an indurated
ulcer. It almost exclusively occurs on the lower lip of men over forty
years of age. The growth begins about midway between the middle line
and the angle of the mouth, either as a horny epidermal thickening, or
as a warty excrescence, which bleeds readily and soon ulcerates. The
affection is said to be especially common in those who smoke short
clay pipes, and it is a suggestive fact that, while epithelioma of the
lip is rare in women, the majority of those who do suffer are
smokers.

The ulceration spreads along the lip, chiefly towards the angle of the
mouth, and downwards towards the chin, and the substance of the lip
becomes swollen and indurated (Figs. 242, 243). The edges are
characteristically raised and hard, and the raw surface is extremely
painful, especially when irritated by hot food or fluids. The growth
is liable to spread to the mucous membrane and gum, and to invade the
mandible. The disease spreads early to the submental and submaxillary
glands, which are best felt with one finger inside the mouth, under
the tongue, and another outside, behind the mandible. The infected
glands tend to become fixed to the bone, and while at first extremely
hard, so much so that they simulate a bony tumour of the jaw, they
later soften, liquefy, and fungate (Fig. 244). Metastasis to internal
organs is rare. Unless removed by operation, the disease usually
proves fatal in from three to three and a half years.

[Illustration: FIG. 242.--Squamous Epithelioma of Lower Lip in a man
æt. 55.

(Mr. D. M. Greig's case.)]

[Illustration: FIG. 243.--Advanced Epithelioma of Lower Lip.]

[Illustration: FIG. 244.--Recurrent Epithelioma in Glands of Neck
adherent to mandible.]

The _treatment_ consists in early and free removal of the affected
portion of lip and of all the lymphatic connections in the
submaxillary region and neck. Recurrence in the scar is rare; it is
nearly always located in the glands.

The operation of cleaning out the glands below the mandible on both
sides in men who are advanced in years is not free from risk to life,
especially from respiratory complications which may or may not be
traceable to the anæsthetic.

In inoperable cases benefit may follow the use of the X-rays, or of
radium.

_Epithelioma of the upper lip_ is less common. It occurs with equal
frequency in the two sexes, progresses more slowly, and is, on the
whole, less malignant. It sometimes appears to be due to contact
infection from the lower lip. It is treated on the same lines as
cancer of the lower lip.




CHAPTER XX

THE MOUTH, FAUCES, AND PHARYNX


Stomatitis--Roof of mouth: _Abscess_; _Gumma_; _Tuberculous disease_;
    _Tumours_--Elongation of uvula--Epithelioma of floor of
    mouth--Tonsillitis: _Varieties_--Hypertrophy of
    tonsils--Calculus--Syphilis and
    Tuberculosis--Tumours--Retro-pharyngeal abscess.


THE MOUTH

#Stomatitis.#--The term stomatitis is applied to any inflammation of
the buccal mucous membrane. The _catarrhal_ form is often associated
with the presence of carious teeth or an infected wound; the mucous
membrane is hyperæmic and swollen, and exudes an excessive amount of
viscid mucous secretion, and the epithelium desquamates in patches,
leaving small superficial erosions or ulcers, which are very
sensitive. The _aphthous_ form, met with in unhealthy, underfed
children, is characterised by the occurrence of patches of fibrinous
exudate into the superficial layers of the mucous membrane; the
epithelium is shed, leaving a series of whitish spots surrounded by a
red hyperæmic zone, which may become confluent and form small ulcers.
The condition known as _thrush_, which closely resembles aphthous
stomatitis, is met with in infants during the period of teething, and
is due to the _oïdium albicans_, a fungus met with in sour milk. The
spots, which are most numerous on the lips, tongue, and throat, have
the appearance of curdled milk.

The _treatment_ of these forms consists in improving the general
condition of the patient, and in employing a mouth-wash, such as
peroxide of hydrogen, Condy's fluid, chlorate of potash, or
boro-glyceride. The superficial ulcers may be touched with silver
nitrate or with a 1 per cent. solution of chromic acid.

_Ulcerative stomatitis_ is frequently met with in debilitated subjects
with decayed teeth, and is specially liable to occur during the course
of acute febrile diseases in which sordes accumulate about the teeth
and gums. It also occurs in syphilitic subjects while under treatment
by mercury--_mercurial stomatitis_. Some patients show a special
susceptibility to mercury, and one of the first signs of intolerance
of the drug is some degree of stomatitis, which may ensue after a
comparatively small quantity has been administered. It begins in the
gums, which become swollen and spongy, growing on to the teeth and
into the interstices. The gums assume a bluish-red colour and bleed
readily, and the teeth may become loose and fall out. The tongue may
share in the swelling--mercurial glossitis. There is also profuse
salivation, and the breath has a characteristically offensive odour.
In severe cases the alveolar margin of the jaw undergoes necrosis. A
similar condition occurs in lead and in phosphorus poisoning, and in
patients suffering from scurvy.

The _treatment_ consists in removing the cause, and in employing
antiseptic and astringent mouth-washes. The internal administration of
chlorate of potash is also indicated, as this drug is excreted in the
saliva. Loose teeth should not be removed as they become fixed again
when the stomatitis subsides.

_Gangrenous stomatitis_, or cancrum oris (Fig. 245), has already been
described (Volume I., p. 102).

[Illustration: FIG. 245.--Cancrum Oris.

(Mr. D. M. Greig's case.)]

#Roof of the Mouth.#--_Suppuration_ in the muco-periosteum of the
palate is usually secondary to suppuration at the root of a carious
tooth. It may also arise in excoriations caused by an ill-fitting
tooth-plate, or from the impaction of a foreign body, such as a fish
or game bone, in the mucous membrane. The inflammation begins close to
the alveolus, and may spread back along the palate. The
muco-periosteum becomes swollen, red, and exceedingly tender, and, as
pus forms, is raised from the bone, forming a prominent, firm,
elongated swelling, which on bursting or being incised gives exit to
foul-smelling pus.

The _syphilitic gumma_, which begins as a rounded indolent swelling,
is usually situated in the middle line near the posterior edge of the
hard palate. The swelling gradually softens and ulcerates, and a
sequestrum may separate and leave a perforation in the palate (Fig.
246). The treatment consists in employing the usual remedies for
tertiary syphilis. If the perforation persists and causes trouble by
allowing food to pass into the nose, or by giving a nasal tone to the
voice, it may be closed by an operation on the same principle as that
performed for cleft palate, or an obturator may be fitted to occlude
the opening.

[Illustration: FIG. 246.--Perforation of Palate, the result of
Syphilis, and Gumma of Right Frontal Bone.

(From Dr. Byrom Bramwell's _Atlas of Clinical Medicine_.)]

_Tuberculous_ disease is chiefly met with in the form of lupus which
has spread from the nose or lips, and it may lead to widespread
destruction of the soft tissues, or even to perforation of the bony
palate.

Mucous cysts, dermoids, adenomas, lipomas, and fibromas are
occasionally met with. _Papillomatous thickening_ of the mucous
membrane sometimes occurs in association with leucoplakia. It resists
anti-syphilitic treatment, but yields to scraping with the sharp
spoon. _Endotheliomas_, or _mixed tumours_, similar to those met with
in the parotid gland, also occur in young subjects, and grow in the
submucous tissue of the soft palate, usually to one side of the middle
line. In their early stages they are of slow growth, and give rise to
no inconvenience save from their size, are easily removed, and show no
tendency to recur. Later, they grow more rapidly, tend to infiltrate
their surroundings and to assume malignant characters, so that
complete removal becomes difficult or impossible.

_Epithelioma_ may originate in the hard palate as a result of local
irritation, or may spread from adjacent parts. When it is confined to
the palate it is treated by removal of the palatal and alveolar
portions of the maxilla.

#Elongation of the uvula# is usually due to a chronic inflammatory
engorgement combined with glandular hypertrophy of the mucous
membrane. It often occurs in children, and is associated with a
constant hacking cough, which is usually worst when the patient is
lying down. By tickling the back of the tongue and pharynx it may
induce vomiting after meals. The treatment consists in snipping off
the redundant portion with scissors.

#Epithelioma of the floor of the mouth# frequently originates in the
mucous membrane between the frenum of the tongue and the inner aspect
of the gum. It develops insidiously, grows slowly, and gradually
spreads to the mandible and to the substance of the tongue, tacking it
down so that it cannot be protruded. The glands are early involved,
and their enlargement not infrequently first draws attention to the
condition. It is to be regarded as a particularly unfavourable site,
as local recurrence is frequent. For the complete removal of the
disease it is necessary to excise the tissues in the floor of the
mouth, and a variable portion of the tongue and mandible, and to clear
out the glands and fat from the submaxillary and submental regions.


THE TONSILS AND PHARYNX

#Infective Conditions.#--The majority of the infective conditions
included under the popular term "sore throat" originate in the
tonsils, and are due to the action of bacteria which under normal
conditions are present in the crypts of the tonsils and of the mucous
membrane of the naso-pharynx. The most important of these organisms
are streptococci, various forms of staphylococci and of
pneumo-bacteria, and diphtheritic and pseudo-diphtheritic bacilli. So
long as the health is good these organisms are harmless, but when
there is any lowering of the vitality they become virulent and give
rise to various forms of infection.

_Catarrhal tonsillitis_--usually attributed by the laity to "catching
cold"--is characterised by hyperæmia and congestion of the tonsils and
mucous membrane of the pharynx, soft palate, and uvula. It is often
met with in those who are much exposed to air contaminated with
organisms--for example, patients who have been long in hospital, or
the resident staff of hospitals (_septic_ or _hospital throat_), and
particularly in persons of a "rheumatic" tendency. There is slight
pain on swallowing, and a tickling sensation passes along the
Eustachian tube to the ear; the throat feels dry, and the patient has
a constant desire to clear it, and there is usually a rise of
temperature to 101°-102° F. As a rule the symptoms pass off in three
or four days, but the condition may spread along the Eustachian tube
to the ear, and interfere with hearing, or it may set up chronic
suppuration of the middle ear.

A similar condition of the pharynx is frequently one of the initial
symptoms in acute febrile diseases, such as scarlet fever, measles,
influenza, or acute rheumatism.

The _treatment_ of the throat affection consists in employing
antiseptic and soothing gargles, inhalations of chloride of ammonium,
or a spray of peroxide of hydrogen, menthol, or eucalyptol. Lozenges
or pastilles containing chloride of ammonium, chlorate of potash, and
cubebs may be employed. In rheumatic cases, salicin, aspirin, and
salicylate of soda are indicated.

In _follicular tonsillitis_, the infection first implicates the
lymphoid follicles. The crypts are distended with yellowish-white
plugs, composed of inflammatory exudate, leucocytes, and desquamated
epithelium, and these may project from the openings, giving the tonsil
a spotted appearance. Sometimes the exudate accumulates on the surface
of the tonsils and pharynx, forming a thin, greyish-white film, which
is liable to be mistaken for the false membrane of diphtheria. It can,
however, usually be wiped off, and when examined microscopically does
not contain the typical Löffler's bacillus.

The tonsils are enlarged, and project so that they obstruct the
isthmus of the fauces, sometimes even meeting in the middle line.
There is pain on swallowing, and the respiration is impeded and noisy
during sleep. There is usually some degree of fever, and the glands
behind the angle of the jaw are enlarged and tender and may suppurate
and set up cellulitis. The acute symptoms usually subside in four or
five days, but if the deeper crypts are filled with plugs of exudate
the condition may prove obstinate. The patient is liable to periodic
attacks, particularly if the tonsils are chronically enlarged.

The _treatment_ is carried out on the same lines as for the catarrhal
form. In recurrent cases the tonsils should be removed.

#Acute Suppurative Tonsillitis and Peri-tonsillitis--Quinsy.#--This is
an acute suppurative inflammation of the tonsils and peritonsillar
tissue, due to infection with pyogenic bacteria. It affects the whole
substance of the tonsils, and the cellular tissue of the pillars of
the fauces, the soft palate, and the pharynx.

_Clinical Features._--The onset is usually sudden, and the affection
is ushered in by a rigor, high fever, and a feeling of malaise. There
is persistent thirst and dryness of the throat, and the patient has
the sensation of a foreign body being in the pharynx, with a constant
desire to swallow. Swallowing is extremely painful, the pain shooting
up to the ears, and the patient has difficulty in taking nourishment.
The saliva accumulates in the mouth; the voice is thick and nasal; and
the respiration impeded and noisy. If the patient can open the mouth
sufficiently to afford a view of the back of the throat (which,
however, is seldom the case), the inflamed parts are seen to be of a
dull reddish-violet colour. One tonsil is often more swollen than the
other, and the corresponding anterior pillar of the fauces more
prominent. The uvula is swollen and œdematous, and is deviated towards
the side on which there is least swelling. Suppuration occurs in from
three to seven days; in adults it is usually in the peritonsillar
tissue of the anterior pillar of the fauces, and extends into the soft
palate. In children the pus sometimes forms in the substance of the
tonsil. If left to burst, the abscess discharges itself into the
mouth, and the patient experiences instant relief. The pus is always
offensive, and if the abscess bursts during sleep, it may enter the
air-passages and cause septic pneumonia. The lymph glands in the neck
are usually enlarged and tender, and sometimes they suppurate and give
rise to a diffuse cellulitis. General infection of the blood may
follow, leading to metastatic invasion of different tissues and
organs, particularly one or other of the large joints.

_Treatment._--In the early stages soothing antiseptic gargles are
indicated. Later, when the patient is unable to gargle, the inhalation
of steam impregnated with the vapour of carbolic acid or friar's
balsam, and the application of hot fomentations or a large linseed
poultice to the neck may afford relief. When an abscess is formed, it
should be opened by means of a fine-pointed pair of sinus forceps,
thrust through the soft palate at a point opposite the base of the
uvula, and in the line of the anterior pillar of the fauces. As those
who suffer from quinsy are liable to have attacks coming on
periodically, if the tonsils remain permanently enlarged they should
be removed between attacks.

#Hypertrophy of the tonsils# is most commonly met with in children
between five and ten years of age, and is often associated with
adenoid vegetations in the naso-pharynx and chronic thickening of the
pharyngeal mucous membrane.

The whole tonsil is enlarged, the mucous membrane thickened, and the
connective tissue more or less sclerosed. The crypts appear on the
surface as deep clefts or fissures, and the lymph follicles are
enlarged and prominent. Secretion accumulates in the crypts, and a
calculus may form from the deposit of lime salts. Sometimes food
particles lodge in the crypts, and they may collect and form
accumulations of considerable size, requiring the use of a scoop to
dislodge them.

_Clinical Features._--The hypertrophy is bilateral, but not always
symmetrical. Sometimes the tonsils project to such an extent as almost
to meet in the middle line; sometimes they scarcely pass beyond the
level of the pillars of the fauces. They are usually sessile, but
sometimes the base is so narrow as almost to form a pedicle. During
childhood they are usually soft and spongy, but when they persist into
adolescence or adult life they become firm and indurated. This
sclerotic change is due to the repeated attacks of catarrhal or
suppurative tonsillitis to which the patient is subject. The lymph
glands behind the angle of the jaw are frequently enlarged. Swallowing
is sometimes interfered with, and the patient is liable to attacks of
nausea and vomiting. Respiration is always more or less impeded; the
patient breathes through the open mouth, and snores loudly during
sleep; and the hindrance to respiration interferes with the
development of the chest. In some cases alarming suffocative attacks
occasionally supervene during sleep, but the difficulty in breathing
disappears as soon as the child is wakened. The voice is
characteristically thick and nasal, especially when adenoids are
present, and in many cases the patient has a vacant and stupid
expression. Hearing is often impaired from obstruction of the
Eustachian tube.

_Treatment._--In early and mild cases, the tonsils should be painted
with glycerine of tannic acid, or some other astringent, and an
antiseptic mouth-wash, or spray of hydrogen peroxide, should be used
several times a day. When the condition is interfering with the
general health or with the development of the chest, or when there is
deafness or disturbance of sleep, the tonsils should be removed.

#Calculi# composed of phosphate or carbonate of lime are sometimes
formed in the crypts of enlarged tonsils; as a rule they are about the
size of a pea, but they may be much larger. They cause a sharp
stabbing pain on swallowing, and sometimes a persistent hacking cough.
They are easily shelled out through a small incision into the tonsil.

#Syphilis.#--The fauces and tonsils are occasionally the seat of a
hard chancre, and the condition may simulate malignant disease. The
submaxillary glands, however, become enlarged sooner and increase more
rapidly than in cancer, and they are tender. The secondary
manifestations of the disease usually appear before the chancre has
healed.

Early in secondary syphilis, mucous patches and superficial ulcers are
frequently met with. Later, severe phagedænic ulceration sometimes
occurs, especially in alcoholic subjects, and may rapidly eat through
the soft palate, leading to marked deformity from contraction when
cicatrisation takes place.

In the tertiary stage, a diffuse gummatous infiltration occurs, and is
liable to be followed by ulceration, which spreads to the pharyngeal
wall and soft palate, and, by causing cicatricial contraction and
adhesions, may lead to narrowing or even complete occlusion of the
communication between the pharynx and the naso-pharynx.

#Tuberculous# lesions of the fauces and tonsils are almost invariably
secondary to tubercle of the larynx or lungs, or to lupus of the face
or naso-pharynx. They are attended with more pain than syphilitic
lesions; are less prone to spread to the palate and cause perforation;
but, when cicatrisation takes place, they are equally liable to
produce contraction and deformity.

#Tumours.#--_Innocent tumours_--fibroma, lipoma, myoma--are
comparatively rare. When sessile they cause inconvenience only by
their bulk; when pedunculated they may hang down into the pharynx and
interfere with swallowing and breathing. They may be shelled out, or
ligated at the base and cut off, according to circumstances.

_Malignant Disease._--The _tonsil_ is frequently the primary seat of
_lympho-sarcoma_, a very malignant form of round-celled sarcoma. The
tumour is at first confined to the tonsil, which differs in appearance
from simple hypertrophy only in being paler and more nodular. The
growth rapidly infiltrates the peritonsillar connective tissue and
adjacent palatal mucous membrane, which becomes pale and œdematous,
and the condition at this stage may simulate a suppurative
tonsillitis. As it increases, the tumour encroaches upon the cavity of
the pharynx, causing interference with swallowing and breathing; the
mucous membrane soon gives way, and widespread ulceration and
sloughing of the tumour substance occurs, sometimes leading to serious
and even fatal hæmorrhage. The patient emaciates rapidly. The adjacent
lymph glands are early infected.

Removal by operation is seldom practicable, but the introduction of a
tube containing radium for several days has in some cases proved
beneficial.

_Carcinoma_ is more common than sarcoma. It may take the form of
_squamous epithelioma_ or of _medullary cancer_, and may originate in
the tonsil, in the groove between the tonsil and the tongue, or in the
soft palate. By the time the patient seeks advice it has usually
implicated the fauces, soft palate, and pharyngeal wall as well as the
tonsil.

Males suffer more frequently than females. The disease may exist for a
considerable time before giving rise to marked symptoms, and attention
may first be drawn to it by pain and difficulty in swallowing, or by
pain shooting towards the ear. In some cases enlargement of the glands
behind the angle of the jaw is the first thing to attract the
patient's attention. The other symptoms are very like those of cancer
of the tongue--pain during eating or drinking, salivation and fœtid
breath. Sometimes fluids regurgitate through the nose, and the voice
may become nasal and indistinct. As the patient is usually unable to
open the mouth widely, it is seldom possible to learn much by
inspection, but a digital examination may reveal an irregular, hard,
and ulcerated growth. The swelling is sometimes palpable from the
outside, filling up the hollow behind the angle of the jaw, and in
this situation also the enlarged lymph glands may be felt. These are
often enlarged out of all proportion to the size of the primary
growth. The disease tends to spread locally, causing increasing
difficulty in swallowing and breathing. The patient gradually loses
strength, and may die from exhaustion induced by pain and insomnia,
from hæmorrhage, or from septic pneumonia.

In early cases an attempt may be made to remove the disease by
operation. In our experience radium has proved less efficacious in
cancer than in sarcoma.

In advanced cases, it is only possible to relieve the patient's
suffering by palliative measures. Antiseptic mouth-washes are used to
diminish the fœtor of the breath and the risk of pneumonia, and heroin
or morphin to relieve pain. The use of the nasal tube, or even a
gastrostomy, may be necessary to enable the patient to take sufficient
food, and tracheotomy may be called for to relieve dyspnœa.

#Retro-pharyngeal Abscess.#--The _chronic_ retro-pharyngeal abscess
associated with tuberculous disease of the cervical vertebræ, in which
the pus accumulates behind the prevertebral fascia, has already been
described (p. 441).

The _acute_ abscess occurs in the space between the prevertebral
fascia and the wall of the pharynx. The infection usually begins in
one of the lymph glands that occupy this space, and rapidly ends in
suppuration, which spreads to the surrounding cellular tissue. It is
most common in children during the first and second years, and the
patient may be convalescent after one of the eruptive fevers attended
with inflammation of the bucco-pharyngeal mucous membrane--such as
scarlet fever, measles, or chicken-pox--or may suffer from nasal
excoriations or coryza. In some cases the irritation of dentition is
the only discoverable cause.

In infants, the condition is usually very acute, and is attended with
fever, rigors, vomiting, and often with convulsions. The head is held
rigid, and usually twisted to one side, and there is pain on
attempting to move it. The child has great pain on swallowing, there
is regurgitation of food, and the saliva dribbles from the mouth.
There is marked dyspnœa and a short, dry cough. The back of the throat
is red and swollen, and a localised projection, which is soft and
fluctuating, and is usually asymmetrical, may be recognised by digital
examination. Sometimes the voice is lost, and the patient has severe
attacks of choking--symptoms which have led to the disease being
mistaken for membranous laryngitis. In some cases a soft swelling is
palpable on one or on both sides of the neck. Unless the abscess is
promptly opened the condition usually proves fatal. The mouth is
opened by means of a gag, the head allowed to hang over the end of the
table, and the abscess incised, with a guarded bistoury, through the
wall of the pharynx. The dangers associated with opening the abscess
from the mouth appear to have been exaggerated.

A _less acute_ form of retro-pharyngeal abscess sometimes develops in
the course of chronic middle ear disease, the inflammatory process
spreading along the Eustachian tube, in the wall of which an abscess
forms and burrows into the retro-pharyngeal space.




CHAPTER XXI

THE JAWS, INCLUDING THE TEETH AND GUMS


TEETH: Dental caries--Impacted wisdom tooth. GUMS: Gingivitis;
    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 the
enamel of a tooth--usually in the region of its neck--and gradually
extends through the dentine till the pulp cavity is reached.

Infection of the exposed pulp cavity may set up an acute purulent
_pulpitis_. This is associated with severe pain, which is not confined
to the diseased tooth, but may spread to adjacent teeth, and sometimes
to all the branches of the trigeminal nerve on the same side of the
face.

The infection may spread from the tooth to the alveolo-dental
periosteum, and set up a _periodontitis_. In the affected tooth there
is at first a feeling of uneasiness, which is relieved by the patient
biting against it. Later there is severe lancinating or throbbing
pain. The affected tooth usually projects beyond its neighbours, and
is excessively tender when the opposing tooth comes in contact with it
in mastication. The gum becomes red and swollen, and the cheek is
œdematous.

Periodontitis is usually followed by the formation of an _alveolar
abscess_. The pus, which forms at the root of the tooth, in most cases
works its way through the bone and into the gum, constituting a
"gum-boil." The pus may then burst through the gum, or may spread
underneath the external periosteum of the jaw and lead to necrosis.

In some cases the cheek becomes adherent to the gum and to the jaw
before the abscess bursts, and the pus escapes through the skin,
leaving a sinus which leads down to the defaulting tooth, and which is
slow to heal, usually because there is a small sequestrum at the
bottom of it. The opening of the sinus is most commonly situated at
the under margin of the mandible a little in front of the masseter
muscle. An alveolar abscess deeply seated in the maxilla may open into
the maxillary antrum and set up suppuration in that cavity. To avoid a
scar on the face, the abscess should be opened from the mouth. A
periodontal abscess of one of the upper central incisors spreads
backwards between the muco-periosteum and the bony palate, causing an
elongated swelling in the roof of the mouth.

In all cases the extraction of the carious tooth is necessary before
the abscess will cease discharging and the sinus heal. If a sequestrum
is present it must be removed, and the bone scraped with a sharp
spoon. Among the other effects of dental caries may be mentioned
localised necrosis of the alveolar margin, cellulitis of the neck, and
enlargement of the cervical lymph glands.

A _cyst_ is frequently found attached to the root of a decayed tooth.
It is lined with epithelium, and is probably derived from a belated
portion of the enamel organ which has been stimulated to active growth
by infective processes in the pulp cavity. It is seldom larger than a
pea, and contains a pultaceous mass like inspissated pus. It gives
rise to no symptoms, and is only recognised after extraction of the
root.

_Odontomas_ have already been described (Volume I., p. 192).

A localised swelling of the mandible, associated with pain referred to
the ear and neck, and in some cases with spasmodic contraction of the
muscles of mastication, may be due to _impaction of the wisdom tooth_
(lower third molar). If the tooth is merely embedded in the gum,
incision may allow of its eruption; if the X-rays show that it is
wedged under the second molar it must be extracted, and this may prove
a difficult dental operation.

#Affections of the Gums.#--Inflammation of the
gums--_gingivitis_--usually occurs in association with a general
stomatitis. The gums are swollen and spongy, and may show superficial
ulceration, associated with bleeding and extreme fœtor of the breath.
The teeth become loose, project from the alveoli, and sometimes fall
out. These symptoms are prominent in cases of scurvy, and of chronic
mercurial poisoning. In chronic lead-poisoning a characteristic blue
line is seen on the gums near the dental margin. The _treatment_
consists in removing the cause, improving the hygienic and dietetic
conditions of the patient, and administering lime-juice, iodide of
potash, quinine, or cod-liver oil, according to the cause. Antiseptic
mouth-washes and dentifrices are also indicated. Chlorate of potash,
being excreted in the saliva, is particularly useful.

_Pyorrhœa alveolaris_ is a chronic form of gingivitis, met with after
middle life, which begins in relation to the necks of the teeth and
the alveolo-dental periosteum. It is due to bacterial infection, and
is associated with an accumulation of tartar between the gums and the
teeth. A muco-purulent discharge escapes from within the free edge of
the gum and alveolus. The alveolar borders and the gum subsequently
undergo atrophy, so that the roots are exposed, and the teeth are
liable to become loose and eventually to fall out. The condition may
only affect a few teeth, or it may spread to them all, in which case
the patient may in the course of some years become edentulous.
Gastro-intestinal disturbances, chronic joint affections of the nature
of arthritis deformans, a form of pernicious anæmia, and other general
conditions have been attributed to the absorption of toxic products.
The _treatment_ consists in removing the tartar from the teeth,
applying strong antiseptics to the groove between the teeth and the
gums, and employing mouth-washes and dentifrices. Massage of the gums
night and morning, and rubbing in a paste of chlorate of potash and
menthol, is often of great value. Good results have followed the use
of vaccines and improvement of the general health.

_Hypertrophy of the gums_ is occasionally met with in children and
young adults who are mentally defective, and the teeth appear early
and are abnormally large. The gum almost buries the teeth, and large
polypoid masses form which tend to fungate. The treatment consists in
removing not only the hypertrophied gums, but also the affected
alveolus (Heath).

A localised hypertrophy--_polypus of the gum_--sometimes results from
the irritation of a carious tooth, or from the pressure of an
artificial denture, and may simulate an epulis (p. 513). The swelling
is usually pedunculated, and if cut away close to the alveolar margin
does not tend to recur.

_Epithelioma_ sometimes originates in the gum in relation to a carious
tooth or to an artificial tooth-plate. The growth tends to invade the
bone and to spread to the cheek or buccal mucous membrane, or to the
maxillary antrum, and its malignant nature is suggested by its
persisting after the removal of the irritation. The only treatment is
early and complete removal of the growth and the adjacent segment of
bone.

Other tumours of the gums, such as angioma and papilloma, are rare.


THE JAWS

#Pyogenic Infections.#--The jaws may be infected in fractures
communicating with the mouth or as a result of the unskilful
extraction of teeth, but the majority of pyogenic infections originate
in relation to carious teeth, beginning as a periodontitis which is
followed by diffuse periostitis that may lead to necrosis of
considerable portions of bone. In workers exposed to the fumes of
yellow phosphorus, the bone may be so devitalised that it readily
becomes infected with pyogenic organisms and undergoes a process of
cario-necrosis--the _phosphorus necrosis_ of the older writers.

[Illustration: FIG. 247.--Cario-necrosis of Mandible.]

_Acute osteomyelitis_ occasionally attacks the mandible, less
frequently the maxilla. Pus rapidly forms under the periosteum, and a
considerable area of bone may undergo necrosis.

In _cancrum oris_, also, the bones are frequently attacked and may
undergo necrosis.

The _treatment_ is to let out the pus, and, whenever possible, this
should be done from the mouth to avoid a cicatrix on the face. When
the angle or the ascending ramus of the mandible or the facial portion
of the maxilla is involved, it is not possible to avoid making an
external opening. Drainage is secured, and the mouth kept sweet by the
frequent use of antiseptic washes. When the condition is due to a
carious stump or to an unerupted tooth, this should be extracted at
the same time as the abscess is opened.

The separation of a sequestrum is usually slow, taking from two to
four months according to the acuteness of the infection and the extent
of the necrosis. In the mandible the sequestrum becomes surrounded by
a sheath of new periosteal bone, so that, even if the greater part of
the jaw undergoes necrosis, the arch is reproduced, and after removal
of the sequestrum little or no deformity results. The sequestrum can
usually be removed after dividing the mucous membrane and gouging away
a portion of the outer aspect of the new sheath. The cavity is packed
with iodoform or bismuth gauze. When the ascending ramus is involved,
precautions must be taken to prevent fixation of the jaw taking place
during the healing process. In the maxilla no new case is formed, and
deformity results from sinking in of the cheek, unless this is
prevented by wearing a plate made by the dentist.

#Tuberculous disease# is comparatively rare. It is occasionally met
with on the orbital margin of the maxilla and in the region of the
zygomatic (malar) bone. In the mandible it usually occurs near the
angle. Stockman isolated the tubercle bacillus from a series of cases
of "phosphorus necrosis" investigated by him. The sinuses that form
when a cold abscess bursts on the surface are peculiarly intractable
and only heal after the diseased bone has been removed, leaving a
characteristically depressed scar, which is adherent to the bone.

#Syphilitic# affections are also rare. A localised gumma may develop
in the neighbourhood of the angle of the mandible, or the whole of the
body of that bone may be the seat of a diffuse gummatous infiltration
(Fig. 248). In either case the clinical importance of the condition
lies in the fact that it is liable to be mistaken for a new growth,
such as an osteo-sarcoma, or for actinomycosis.

[Illustration: FIG. 248.--Diffuse Syphilitic Disease of Mandible.]

#Actinomycosis.#--This condition is met with in the jaws more
frequently than in any other part, and the mandible is attacked
oftener than the maxilla. The actinomyces gain access to the bone
through a carious tooth or through the gum.

At the outset the patient complains of pain and tenderness referred to
one or more carious teeth. Within a few weeks a swelling forms--in the
mandible near the angle as a rule, and in the maxilla in some part of
the cheek. The swelling, which varies in consistence, implicates the
bone and cannot be moved apart from it. The skin over it becomes red,
suppuration occurs, and sinuses form and give exit to a sero-purulent
fluid in which the characteristic yellow "sulphur grains" may be
detected. The surrounding soft tissues are infiltrated, and the part
becomes riddled with sinuses, which lead down to bare bone. The
disease usually runs a chronic course, lasting for one or two years,
and, unless pyogenic infection is superadded, is not attended with
fever.

In the absence of the characteristic yellow granules, actinomycosis
may readily be mistaken for tuberculous or syphilitic disease, or for
sarcoma.

The _treatment_ consists in removing the diseased tissue with the
knife or sharp spoon, and in the administration of large doses of
potassium iodide. The insertion of tubes of radium has a beneficial
effect.

#Tumours of the Alveolar Process.--Epulis.#--The tumours that grow
from the alveolar processes of the jaws appear at first sight to
spring from the gums, hence the term _epulis_, generally applied to
them. They really originate in the periosteum of the alveolus or in
the periodontal membrane, and are essentially of the nature of
fibro-sarcoma. In some, the fibrous element predominates, but the
frequency with which they recur after removal, unless the segment of
bone from which they spring is also excised, indicates their malignant
tendency. In most cases the tumour is of the myeloid type--myeloma; in
others new bone is formed in its substance--osteo-sarcoma.

An epulis usually begins in the gap between two teeth, and grows
slowly, either towards the cavity of the mouth, or more frequently
towards the lip or cheek, where it appears as a bright red, smooth,
firm, rounded swelling, which is adherent to the jaw, and may be
sessile or pedunculated (Fig. 249). It causes little pain, but is
liable to interfere with mastication. As it increases in size it
spreads over the alveoli of several teeth, becomes softer, and assumes
a dark violet colour, and if subjected to pressure or irritation may
ulcerate and bleed.

[Illustration: FIG. 249.--Epulis of Mandible.

(Anatomical Museum, University of Edinburgh.)]

The true alveolar tumour is to be diagnosed from a mass of redundant
granulations such as may form in relation to a carious tooth, from a
polypus or an epithelioma of the gum, a tumour of the body of the jaw,
or an angioma.

The _treatment_ consists in removing the tumour together with a
wedge-shaped or quadrilateral portion of the alveolar process from
which it grows. A dental plate should be fitted to fill up the gap in
the alveolus. After such free removal these tumours show little
tendency to recur and metastases are rare.

#Malignant Tumours of the Maxilla.#--All varieties of _sarcoma_ and
_carcinoma_ are met with; of the former, the round and spindle-celled
are the most common. Carcinoma occurs chiefly in two forms, less
commonly a columnar epithelioma arising from glandular epithelium,
much more commonly a squamous epithelioma either originating within
the antrum and causing its expansion, or spreading to the maxilla from
the mucous membrane of the nose or mouth. Clinically it is practically
impossible to differentiate sarcoma from carcinoma; in the later
stages the infection of the glands below the mandible is more marked
in carcinoma. An important point to determine is whether the growth
arises within the maxilla or has spread to it from adjacent parts,
such as the base of the skull, the nose, or the palate. In this the
X-rays are helpful. Their malignancy is evidenced by the rapidity of
their growth, the manner in which they infiltrate adjacent parts, and
the frequency with which they recur after removal. They occur at all
ages, and have been met with even in children.

The _clinical features_ vary according to whether the tumour
originates on the anterior aspect of the bone, in the maxillary
antrum, or on the posterior aspect.

When the tumour originates in the periosteum covering the front of the
bone, it forms a swelling under the cheek, usually in the vicinity of
the zygomatic (malar) bone, and grows towards the mouth as well as
towards the surface. The cheek is gradually invaded, and in some cases
the growth extends into the maxillary sinus.

The typical malignant tumour of the upper jaw originates in the lining
membrane of the antrum; it first fills the cavity and then bulges its
walls in every direction, so that, on pressure being made over the
swelling, the osseous shell of the sinus dimples and crackles under
the finger. The sinus is dark on trans-illumination. The tumour may
obstruct the nostril on the same side, and, by pressing on the tear
duct, may cause the tears to flow over the cheek. It may be seen
through the anterior nares, and may be attended with a sanious
discharge from the nose. The eyeball is liable to be displaced
upward, and if the ethmoid cells are invaded, it is also pushed
outward; the palate may be depressed and the cheek projected (Figs.
250, 251).

[Illustration: FIG. 250.--Sarcoma of the Maxilla.]

[Illustration: FIG. 251.--Malignant Disease of Left Maxilla, which
displaced the eyeball and caused double vision.]

When the tumour grows from the periosteum of the posterior aspect of
the bone, and extends into the spheno-maxillary or pterygo-maxillary
fossa, the eyeball is usually protruded by the invasion of the orbit
from behind, and a swelling appears in the temporal region. If the
sinus is invaded, the tumour spreads in the various directions already
indicated. Not infrequently a tumour, which appears to have its seat
in the maxilla, is really a downward prolongation of a growth
originating in the base of the skull, a point on which the X-rays may
yield valuable information.

In all cases the tumour tends to infiltrate the surrounding tissues
indiscriminately. There is severe pain referred to the distribution
of the maxillary division of the trigeminal nerve. Hæmorrhage is
liable to occur when exposed portions of the tumour ulcerate--for
example in the nasal fossæ. Sarcoma is to be distinguished from the
solid and cystic forms of odontoma, which also may distend the bone,
bulging the hard palate and projecting on the face.

_Treatment of Malignant Disease._--Without the help of radiation the
results of operative treatment of malignant disease of the maxilla are
far from encouraging. Probably the best line to follow is to embed
several tubes of radium in different parts of the tumour for several
days, and when the resulting shrinkage of the growth appears to have
attained its limits, the maxilla should be excised. If on microscopic
examination it is found to be a carcinoma, the glands on the same side
of the neck should be removed at a second operation on lines similar
to those in Butlin's operation in cancer of the tongue. The aid of the
dentist is required to fit a denture which will at least restore the
hard palate and alveolar margin. The operation of excising the
upper jaw is not a dangerous one, especially if the risk of
broncho-pneumonia is minimised by the intra-tracheal administration of
ether. The final illness in cases of malignant disease of the upper
jaw left to nature, or when it has recurred after operation, is a
terrible one; the growth displaces and destroys the globe, blocks the
nose and fungating on the face, causes hideous disfigurement.

#Simple tumours# are rare. _Fibroma_ may originate in the periosteum
or in the lining membrane of the maxillary sinus. It usually tends to
assume the characters of sarcoma. _Chondroma_ usually begins either on
the nasal surface of the bone or in the maxillary sinus. _Osteoma_
occurs in two forms: the exostosis, which may be composed of
cancellated or of compact tissue, and the diffuse osteoma or
leontiasis ossea (Volume I., p. 485). All intermediate forms are met
with, and when confined to the maxilla, the resulting disfigurement
may be improved or remedied by operation; the cheek is raised or
reflected and the bone shaved away with a strong knife or osteotome.

#Tumours of the Mandible.#--The same varieties are met with as in the
maxilla. The non-malignant forms--osteoma, chondroma, and fibroma--are
rare.

A _dentigerous cyst_ appears as a smooth, rounded, and painless
swelling, usually in the region of the molar teeth. The bone gradually
becomes expanded and crackles on pressure. The cyst is filled with a
glairy mucoid fluid, and may contain one or more unerupted teeth (Fig.
252). The X-ray appearances are characteristic. The treatment consists
in removing the anterior wall of the cyst, scraping the interior, and
packing the cavity with iodoform or bismuth gauze.

[Illustration: FIG. 252.--Dentigerous Cyst of Mandible containing
rudimentary tooth.

(From Sir Patrick Heron Watson's collection.)]

The myeloid tumour or _myeloma_ is comparatively common. It develops
in the interior of the bone and expands the affected segment (Fig.
253). It grows slowly, is more or less encapsulated, and therefore
does not infiltrate the surrounding tissues. Sometimes it so weakens
the bone that pathological fracture occurs. There is no glandular
involvement, and the tumour shows little evidence of malignancy.

[Illustration: FIG. 253.--Osseous Shell of Myeloma of Mandible.

(From Professor Annandale's collection.)]

The _periosteal sarcoma_ is the most malignant form. It grows rapidly,
and infiltrates the surrounding tissues. The submaxillary salivary
glands and the cervical lymph glands are usually implicated, and the
disease tends to spread by metastasis to distant parts.

_Epithelioma_ is the commonest new growth affecting the mandible; it
usually involves the central portion of the bone, being a direct
spread from the lower lip, tongue, or floor of the mouth. When it
originates in the pillars of the fauces it implicates the ascending
ramus. In all cases the infection of the cervical lymph glands is a
serious factor both in prognosis and treatment.

_Treatment._--_Partial removal_ of the mandible may be undertaken for
myeloma, and in cases of sarcoma and epithelioma in which the tumour
is limited to a small area of the bone--for example, to the alveolar
process, the angle, the horizontal ramus, or the symphysis; in other
cases, the whole bone must be removed.


INJURIES OF THE JAWS

#Fracture of the Maxilla.#--Fractures of the maxilla are nearly always
due to direct violence, such as a blow on the face, a stab, or a
gun-shot wound. They are often rendered compound by opening into the
mouth, into the maxillary sinus, or on to the skin of the cheek. The
alveolar process, in whole or in part, may be separated from the body
of the bone by a severe blow, such as the kick of a horse, and when
the whole alveolus is detached, it may carry with it the hard palate.
Limited portions of the alveolus are frequently broken in the
extraction of teeth. The main trouble after severe alveolar fractures
is that the upper teeth do not accurately oppose the lower ones, and
mastication is thereby interfered with.

When the frontal (nasal) portion of the maxilla is broken, the
lachrymal sac and nasal duct may be damaged and the flow of the tears
obstructed. In such cases emphysema is also liable to develop.
Fractures of the facial portion are frequently complicated by
hæmorrhage from the infra-orbital vessels, and anæsthesia of the area
supplied by the infra-orbital nerve. Suppuration may occur in the
maxillary sinus. In some cases the maxilla is driven in as a whole,
and in others the fracture radiates to the base of the skull and
cerebral symptoms develop.

The _treatment_ consists in reducing any deformity that may be
present, ensuring efficient drainage, and keeping the mouth as aseptic
as possible. Union takes place rapidly, and owing to the vascularity
of the parts necrosis is rare, even when suppuration ensues. When the
alveolar portion is comminuted, the fragments may be kept in position
by fixing the mandible against the maxilla by means of a four-tailed
bandage (Fig. 255), or by adjusting a moulded lead or gutta-percha
splint to the alveolus and palate.

The _zygomatic (malar) bone_ is sometimes fractured by direct
violence, along with the adjacent portion of the maxilla. It may be
possible to manipulate the displaced fragments into position with the
fingers introduced between the cheek and the gum; if this fails, a
small incision should be made in the mucous membrane anterior to the
masseter, and the bone levered into position with an elevator.

The _zygomatic arch_ is occasionally fractured by a direct blow. As
the depressed fragments are liable to interfere with the movement of
the mandible, they should be elevated either by manipulation or
through an incision.

#Fractures of the Mandible.#--The most common situation for fracture
of the mandible is through the _body_ of the bone in the vicinity of
the canine tooth (Fig. 254). The depth of the socket of this tooth,
and the comparative narrowness of the jaw at this level, render it the
weakest part of the arch. The fracture is usually due to direct
violence, such as a blow with the fist, the kick of a horse, or a fall
from a height. It is sometimes bilateral, the bone giving way at the
canine fossa on one side and just in front of the masseter on the
other; or both fractures may be at the canine fossæ. The fracture is
usually oblique from above downwards and outwards, and is nearly
always rendered compound by tearing of the mucous membrane of the
mouth.

[Illustration: FIG. 254.--Multiple Fracture of Mandible.

(From Sir Patrick Heron Watson's collection.)]

When only one side is broken, the smaller fragment is usually
displaced outwards and forwards by the masseter and temporal muscles,
so that it overlaps the larger fragment. In bilateral fractures the
central loose segment is driven downwards and backwards towards the
hyoid bone by the force causing the fracture, and is held in this
position by the muscles attached to the chin, while both lateral
fragments are tilted outwards and forwards by the masseters and
temporals. The amount of displacement is best recognised by observing
the degree of irregularity in the line of the teeth. Abnormal mobility
and crepitus are readily elicited, and there is severe pain,
particularly if the inferior dental nerve is stretched or crushed. The
patient's attitude is characteristic; he supports the broken jaw with
his hands, and keeps it as steady as possible when he attempts to
speak or swallow. Saliva dribbles from the open mouth, and the speech
is indistinct.

In adults, the bone may be broken at the _symphysis_ as a result of
lateral compression of the jaw--for example, pressing together of the
angles. The general characters of the fracture are the same as those
of fracture of the body, but the displacement is inconsiderable.

Fractures of the _angle_ and through the _ramus_ are less common, and
are not attended with deformity, as the fragments are retained in
position by the masseter and internal pterygoid muscles. Fracture of
the _coronoid process_ is rare.

The _condyle_ is usually fractured just below the insertion of the
external pterygoid muscle (Fig. 254) by a fall on the chin or by a
severe blow on the side of the face. When the fracture is unilateral,
the broken condyle is tilted inwards and forwards by the external
pterygoid, and can be palpated from the mouth, while the rest of the
jaw is displaced _towards_ the affected side, and not away from it, as
happens in unilateral dislocation. When the fracture is bilateral, the
mandible falls backwards, so that the lower teeth lie behind those of
the maxilla.

In a few cases the condyle has been driven through the floor of the
glenoid cavity, causing fracture of the base of the skull. The
diagnosis may be established by means of the X-rays.

_Complications._--As the majority of these fractures are compound,
suppuration is comparatively common during the process of repair, but
if means are taken to keep the mouth clean it can usually be kept in
check, and seldom leads to necrosis. The teeth adjacent to the
fracture are liable to be loosened or displaced. If merely loosened
they should be left in place, as they usually become firmly fixed in
the course of a few days. Care must be taken that a displaced tooth
does not pass between the fragments, as this has been the cause of
difficulty in reducing a fracture and of its failure to unite.
Irregular union, by destroying the alignment of the teeth, leads to
interference with mastication. The bone usually unites in from four to
six weeks. Want of union is a rare event.

_Treatment._--In the majority of cases of unilateral fracture after
reduction, the fragments can be kept in apposition by closing the
mouth and keeping the lower jaw fixed against the upper by means of a
four-tailed bandage (Fig. 255). Care must be taken that the posterior
tails of the bandage do not pull the mandible backward. Additional
security may be given by a light poroplastic or gutta-percha splint
fitted to the chin, the vertical portion passing well up the ramus of
the jaw. After a few days the apparatus is removed, the patient is
encouraged to move the jaw, and massage is employed. The mouth must be
regularly cleansed by an antiseptic mouth-wash, or by a spray of
hydrogen peroxide.

[Illustration: FIG. 255.--Four-tailed Bandage applied for Fracture of
Mandible.]

In certain fractures implicating the body of the jaw, and particularly
when bilateral, the co-operation of the dentist is necessary to obtain
the best results. After the fragments have been coapted, a plaster
impression is taken of the jaw and teeth, and from this a silver frame
is cast which surrounds but does not envelop the teeth. This frame is
then applied to the fractured jaw, and restrains movement of the
fragments without interfering with the action of the jaw (W. Guy).
The use of an intra-oral frame obviates the necessity of wiring the
fragments.

Even in badly united fractures the original contour of the bone is
eventually restored by the movements of the tongue moulding it into
shape.


AFFECTIONS OF THE TEMPORO-MANDIBULAR ARTICULATION

#Dislocation of the Mandible.#--Dislocation of the lower jaw may be
unilateral or bilateral. The bilateral form is the more common, and is
met with most frequently in middle life, and in females. The liability
to dislocation is greatest when the mouth is widely open--for example,
in yawning, laughing, or vomiting--as under these conditions the
condyle, accompanied by the meniscus, passes forwards out of the
glenoid cavity and rests on the summit of the articular eminence. If,
while the bone is in this position, the external pterygoid muscle is
thrown into contraction, it pulls the condyle forward over the
eminence into the hollow beneath the root of the zygoma, and the
contraction of the masseter and temporal muscles retains it there.
Muscular contraction is therefore an important factor in its
production.

Dislocation may be produced also by a downward blow on the chin, by
the unskilful introduction of a mouth gag, particularly while the
patient is anæsthetised, or even in the attempt to take a big
bite--say, of an apple. The dislocation that results from such causes
is usually unilateral.

In some persons the ligaments of the joint are unnaturally lax, and
dislocation is liable to occur repeatedly from comparatively slight
causes--_recurrent dislocation_.

_Clinical Features._--The appearance of a patient suffering from
_bilateral_ dislocation is characteristic. The mouth is open, the jaw
fixed, and the chin protruded so that the lower teeth project beyond
the upper. The patient has difficulty in swallowing, and the saliva
dribbles from the mouth. As the lips cannot be approximated, the
speech is indistinct and guttural. Just in front of the auditory
meatus a deep hollow can be felt, and in front of this the condyle
forms an undue projection. The coronoid process is displaced below and
behind the zygomatic (malar) bone, and may be felt through the mouth.
The contracted temporal muscle forms a prominence above the zygoma.

In _unilateral_ dislocation the deformity is the same in character,
but is less marked, and in mild cases its cause is liable to be
overlooked. In most cases the chin deviates towards the sound side.

_Treatment._--In recent cases, reduction is usually easily effected.
The patient should be seated on a low chair or stool, an assistant
supporting the head from behind. The surgeon, standing in front,
places his thumbs, well protected by a roll of lint, far back on the
molar teeth, and with his other fingers grasps the body of the jaw.
Pressure is now made downwards and backwards to free the condyles from
the articular eminence, and to overcome the tension of the temporal
and masseter muscles, and as this is effected the tip of the chin is
carried upward, while the whole jaw is pushed directly backward. The
condyle slips into position, sometimes with a distinct snap. When
difficulty is experienced in levering the condyle from its abnormal
position, a cork may be placed between the molar teeth on each side to
act as a fulcrum. After reduction the jaw is fixed by means of a
four-tailed bandage for a few days. The patient is warned to avoid for
some weeks opening the mouth widely.

_Old-standing Dislocation._--It sometimes happens that, from having
been overlooked or neglected, the dislocation remains unreduced. In
such cases the movement of the jaw is in time partly restored, and the
patient acquires sufficient control of the lips to be able to
articulate intelligibly and to prevent dribbling of saliva. The power
of masticating the food, however, remains impaired. The hollow behind
the condyle and the projection of the chin persist. Reduction by
manipulation is seldom possible after the dislocation has existed for
more than three months, but it has been effected as long as ten months
after the accident. Several attempts at reduction should be made at
intervals of two or three days, and if these fail recourse may be had
to operation. As the masseter and internal pterygoid muscles have
assumed a vertical position and become shortened, they form an
obstacle to reduction, and to overcome their action it is necessary to
separate them from their insertion to the ascending ramus of the bone
through an incision carried round the angle. If the adhesions about
the dislocated condyle are then separated, reduction can be effected
(Samter). In some cases it is necessary to excise the condyle to
restore movement.

_Internal Derangements of the Temporo-mandibular Joint._--The
intra-articular cartilage is liable to be displaced by excessive
traction exerted on it by the external pterygoid muscle during some
sudden movement of the joint, particularly in closing the mouth.
There is acute pain in the region of the joint, the teeth on the
affected side cannot be brought into apposition, so that mastication
is interfered with, and the patient is conscious of something locking
inside the joint. The joint is tender to the touch, but there is no
external swelling. Replacement is effected by keeping up firm pressure
at the back of the condyle with the mouth open, and slowly closing the
jaw. If recurrence takes place repeatedly, the disc may be sutured to
the periosteum (Annandale), or excised (Hogarth Pringle).

#Arthritis# of the temporo-mandibular joint occurs in two forms,
non-suppurative and suppurative.

The _non-suppurative_ form is usually due to gonorrhœal infection, and
as a rule is bilateral. The patient complains of neuralgic pains
shooting towards the ears and temples, and of pain in the joint on
movement. The jaw is therefore kept fixed, usually with the mouth
slightly open and the chin protruded. Mastication is impossible, and
the speech is indistinct. There is effusion into the joint, and a
swelling may be detected in front of the ear. The inflammation may
subside and movement restored, or fibrous ankylosis may ensue.

The _suppurative_ form may be due either to direct spread of infection
from adjacent parts, as, for example, in middle ear disease,
suppurative parotitis, or pyogenic affections of the mandible, or it
may be part of a general pyæmic infection, as sometimes occurs after
exanthematous fevers and in gonorrhœa. The clinical features are
similar to those of the non-suppurative form, but the signs referable
to the joint are often masked by those of the primary lesion. When the
pus originates in the joint, it may point either towards the skin or
into the external auditory meatus through the petro-tympanic
(Glaserian) fissure. The joint is usually completely disorganised and
ankylosis results.

#Tuberculous arthritis# is rare, and is usually secondary to disease
of the mandible, the temporal bone, or the middle ear. It leads to
destruction of the joint and ankylosis. It is treated by incision and
scraping, or by excision of the condyle.

#Arthritis deformans# is a comparatively common affection, and is
generally bilateral. In the earlier stages the condyle is usually
hypertrophied and distorted, and the glenoid cavity is correspondingly
broadened and flattened, and in time may be filled up by new bone.
Osteophytic outgrowths form around the joint and lead to fixation or
locking. The enlarged condyle may be felt in front of the ear, and
there is pain and cracking on movement; the pain is worst at night and
in wet weather. The jaw is usually depressed and the chin protruded.
The disease runs a chronic course, with occasional acute
exacerbations. Excision of the condyle may be advisable when
non-operative measures have failed to give relief. In the later
stages, the condyle, together with the meniscus, may be worn away and
completely disappear.

#Closure or Fixation of the Mandible.#--_Temporary fixation_ is due to
spasmodic contraction of the muscles of mastication, particularly the
masseter. This may be symptomatic of some inflammatory condition in
the vicinity, such as a pyogenic affection of the lower jaw--for
example, that associated with a carious root or an unerupted wisdom
tooth, or with parotitis or tonsillitis. In such cases the spasm
passes off on the removal of the cause. It is occasionally a
manifestation of hysteria. The administration of a general anæsthetic
and the introduction of a wedge or separator is usually necessary to
confirm the diagnosis and, it may be, to permit of operative measures,
such as the extraction of a wisdom tooth.

Muscular fixation may be due to rheumatic or syphilitic myositis, and
this is sometimes followed by fibroid degeneration of the muscles,
rendering the fixation permanent.

_Permanent fixation_ may be due to a variety of causes. Fibroid
degeneration of muscles following myositis has already been mentioned.
Much more frequently it results from cicatricial contraction of the
soft parts of the face or mouth following such conditions as cancrum
oris, ulceration, or burns. Fixation following upon prolonged
immobilisation after fracture or dislocation, or any of the forms of
arthritis or suppurative or tuberculous disease of the adjacent
portions of the mandible, is also met with. The ankylosis may be
fibrous or osseous, and may be intra- or extra-articular.

The _clinical features_ vary with the degree of separation of the
jaws. There is always some deformity, and more or less interference
with mastication and speech. The patient usually feeds himself by
pushing small portions of bread or meat with the fingers through some
gap between the badly opposed and badly formed and preserved teeth. As
the patient is unable to keep the mouth clean, particles of food lodge
and decompose there, causing irritation of the mucous membrane, caries
of the teeth, and fœtor of the saliva and breath. When osseous
ankylosis occurs in childhood, it leads to _arrest of development of
the mandible_, which is small and markedly receding, so that the teeth
do not oppose those of the maxilla (Fig. 256).

[Illustration: FIG. 256.--Defective development of Mandible from
fixation of jaw due to tuberculous osteomyelitis in infancy.]

_Treatment._--When the cause of the fixation is in the joint itself,
the best treatment is to resect one or both condyles.

When the fixation is due to cicatricial contraction of the soft parts,
mobility is best restored by forming an artificial joint well in front
of the cicatricial tissue, as suggested by Esmarch.




CHAPTER XXII

THE TONGUE


Surgical Anatomy--Wounds--Dental ulcer--Inflammatory affections:
    _Acute parenchymatous glossitis and hemi-glossitis_; _Mercurial
    glossitis_; _Chronic superficial glossitis_; _Leucoplakia_;
    _Smoker's patch_--_Tuberculous disease_; _Syphilitic affections_;
    _Sclerosing glossitis_; _Gummas_; _Ulcers and fissures_--Tumours:
    _Carcinoma_; _Sarcoma_; _Innocent tumours_;
    _Cysts_--Thyreo-glossal tumours and cysts--Malformations:
    _Absence_; _bifid tongue_; _Tongue-tie_; _Excessive length of
    frenum_; _Macroglossia_; _Atrophy_--Nervous affections.

#Surgical Anatomy.#--The tongue is composed of interlaced, striped
muscle fibres, partly consisting of the terminations of the extrinsic
muscles, and partly of the intrinsic muscles. A median fibrous septum
divides it into two lateral halves so completely that but little
communication takes place between the blood vessels and lymphatics of
the two sides. It is covered by stratified squamous epithelium. For
practical purposes it is described as consisting of an _anterior_ or
_oral_ part, and a _posterior_ or _pharyngeal_ part.

The _oral part_, which includes the anterior two-thirds of the organ,
is mobile, and the epithelium on its dorsal aspect is modified so as
to form several varieties of papillæ. A slight median depression is
recognisable on the dorsum as far back as the vallate (circumvallate)
papillæ, which mark the boundary between the oral and pharyngeal
parts. A double fold of mucous membrane--the _frenum_--connects the
under aspect of the tip with the floor of the mouth and the mandible.
On each side of the frenum, under the mucous membrane of the tip, are
mucous glands--_apical glands_--in which cysts sometimes form. On the
lateral border of the tongue, just in front of the anterior palatine
arch, are several vertical folds of mucous membrane--the _folia
linguæ_, or _foliate papillæ_.

The _pharyngeal_ part, or base of the tongue, forms the anterior wall
of the pharynx, and is attached to the hyoid bone. Its mucous membrane
is devoid of papillæ, but contains numerous lymphoid follicles--the
_lingual tonsil_. The _foramen cæcum_ lies just behind the apex of the
vallate papillæ in the middle line.

The chief artery, the _lingual_, a branch of the external carotid,
passes forward beneath the hyoglossus muscle, and is continued to the
apex as the ranine, lying nearer the under than the upper aspect of
the tongue. The pharyngeal part is supplied by the dorsalis linguæ
branch. The blood is returned to the internal jugular by the ranine
vein, which can be seen under the mucous membrane on the inferior
aspect near the frenum, and by the venæ comites of the lingual artery
and its branches.

The _hypoglossal_ is the motor nerve of the tongue. The _lingual_
branch of the mandibular (inferior maxillary) supplies the anterior
two-thirds with common sensation. It is accompanied by the _chorda
tympani_ branch of the facial, which probably carries the taste
fibres. The _glosso-pharyngeal_ supplies the posterior third of the
tongue with both common and gustatory sensation.

The _lymph vessels_ of the anterior two-thirds of the tongue drain
into the submental and submaxillary glands, and these in turn into the
deep cervical group which accompany the internal jugular vein. The
vessels of the base converge into several large trunks which pass out
behind the tonsils and drain directly into the deep cervical glands.
One of these, which lies in the angle between the internal jugular and
common facial veins, is frequently infected in cancer of the tongue.

#Wounds# are commonly produced by the teeth, as, for instance, when a
child falls on the chin with the tongue protruded, or when an
epileptic bites his tongue during a fit. Less frequently a foreign
body, such as a pipe-stem, a bullet, or a displaced tooth, is driven
into the tongue. The immediate risk is hæmorrhage, particularly when
the posterior part of the tongue is implicated and the wound
penetrates deeply. Of the later complications, infections and
secondary hæmorrhage are the most serious, and they are most liable to
occur when a foreign body is embedded in the tongue.

_Treatment._--In superficial wounds near the tip the oozing is
efficiently arrested by sutures, but in deeper wounds a ligature must
be applied to the bleeding vessel. Secondary hæmorrhage is much more
difficult to arrest on account of the friable state of the tissues,
and it may be necessary to ligate the lingual or even the external
carotid in the neck.

To prevent infective complications any foreign body must be removed
and an antiseptic mouth-wash regularly employed.

Cases have been recorded in which such a foreign body as a bullet, a
needle, or a piece of a pipe-stem, has remained embedded in the
substance of the tongue for a long period, and caused a firm, indolent
swelling liable to be mistaken for a new growth.

#Dental Ulcer.#--The continuous friction of a jagged tooth, or of an
ill-fitting dental plate, is liable to cause swelling and excoriation
of the side of the tongue. A painful superficial ulcer forms, and if
the irritation continues and infection occurs, the surrounding parts
become indurated, the ulcer assumes a crater-like appearance, not
unlike that of a commencing epithelioma. If such an ulcer does not
promptly heal on the removal of the irritant, a portion of the margin
should be removed and submitted to microscopic examination to make
sure that it is not cancerous.

#Inflammatory Affections.#--_Acute Parenchymatous Glossitis_ is
usually due to the action of streptococci. Although it affects mainly
the mucous membrane and submucous tissue, it causes a diffuse
œdematous swelling of the whole organ, and this may extend to the
ary-epiglottic folds and give rise to œdema of the glottis. As a rule
it does not go on to suppuration.

The onset is sudden, and is marked by pain and stiffness of the
tongue, particularly when the patient attempts to masticate or to
speak. The tongue rapidly swells, and in the course of twenty-four or
forty-eight hours may fill the mouth and protrude beyond the teeth.
There is profuse salivation, and in addition to difficulty in
swallowing and speaking there may be considerable interference with
respiration. The salivary and lymph glands in the submaxillary space
are enlarged and tender. The symptoms begin to subside in three or
four days, unless suppuration occurs.

The _treatment_ consists in administering a sharp purge and employing
a mouth-wash; leeches may be applied to the submaxillary region with
benefit. When the swelling is excessive, it may be necessary to make
longitudinal incisions into the substance of the tongue, and dyspnœa
may call for laryngotomy. If an abscess forms it must be opened.

A similar condition has been met with in patients who have contracted
the "_foot and mouth disease_" of cattle. Vesicles form on the mucous
membrane, and after bursting, ulcerate, and a mixed infection with
streptococci occurs, leading to diffuse œdema. Portions of the tongue
may become gangrenous, and the infection may spread to the tissues of
the neck and set up one form of angina Ludovici. The condition is
usually fatal.

_Acute Hemi-glossitis._--An acute transitory swelling, confined to one
half of the tongue, in the distribution of the lingual nerve, is
occasionally met with. It is attended with great pain and high
temperature, and is believed to be analogous to herpes zoster
(Güterbock).

_Mercurial Glossitis_ may accompany mercurial stomatitis (p. 496).

_Chronic Superficial Glossitis._--Several forms of chronic superficial
glossitis are met with. The most important, as it is frequently
followed by the development of epithelioma, is that known as
_leucoplakia_ or _leucokeratosis_.

The tongue is studded over with white patches, which result from
overgrowth and cornification of the surface epithelium, whereby it
becomes thickened and raised above the surface, and at the same time
there is small-celled infiltration of the submucous tissue. The
patches are irregularly lozenge-shaped, and when crowded together they
present the appearance of a mosaic (Fig. 257). Similar patches are
often present on the mucous membrane lining the cheek.

[Illustration: FIG. 257.--Leucoplakia of the Tongue.]

The disease is met with almost invariably in men between the ages of
forty and fifty. Syphilis appears to be a predisposing factor, and any
form of irritation--for example, the chewing or smoking of tobacco,
the drinking of raw spirits, friction by a rough tooth or
tooth-plate--plays an important part in inducing or in aggravating the
condition.

The milder forms give rise to no discomfort, but when the condition is
advanced the patient complains of dryness and hardness of the tongue,
with impairment of the sense of taste and persistent thirst. When
cracks, fissures, or warts develop, there is pain on chewing or
speaking, or on taking hot or irritating food. The glands below the
jaw may be enlarged.

The disease is most intractable and persistent, and even after
disappearing for a time is liable to recur. After a variable number
of years epithelioma is prone to develop, usually in one or other of
the fissures which accompany the condition.

The _treatment_ consists in removing all sources of irritation,
particularly smoking, and in employing mouth-washes. Butlin recommends
antiseptic ointments applied before going to bed. In some cases
painting the patches with chromic acid (10 grains to the ounce) or
lactic acid (20 per cent.) is useful in removing the excess of
epithelium, but stronger caustics are to be avoided. Constitutional
treatment is of little use even when the patient has suffered from
syphilis. The best results have been attained by the use of radium.

The "_smoker's patch_" consists of a small oval area on the front of
the tongue from which the papillæ have disappeared. It is slightly
raised, smooth and red, and may be covered with a yellowish-brown or
yellowish-white crust. It causes no discomfort unless the crust is
removed, when a raw, sensitive surface is exposed. The condition is
liable to spread over the tongue if the patient persists in smoking.
It may eventually assume the characters of leucoplakia. The
_treatment_ consists in stopping the use of tobacco, and painting the
patches with chromic acid, tannic acid, or alum, and employing a
chlorate of potash mouth-wash.

#Tuberculous Disease.#--The tongue is rarely the primary seat of
tuberculosis. The majority of cases occur in adult males, who suffer
from advanced pulmonary or laryngeal phthisis, the tongue being
infected by bacilli from the sputum or through the blood stream. In
other cases the infection is due to direct spread of lupus from the
face or nose.

The condition may begin as a firm, painless lump, seldom larger than a
hazel-nut, on one side of the tongue, or near its tip. At first the
swelling is covered by epithelium; in time caseation takes place, the
epithelium gives way, and an open sore is formed.

The _tuberculous ulcer_ is the form most frequently met with. The
surface of the ulcer is uneven, pale and flabby, and is covered with a
yellowish-grey discharge, with here and there feeble granulations
showing through. The edges are shreddy, sinuous in outline, and there
is little or no induration. The surrounding parts are slightly
swollen, and may be studded with small tuberculous foci. The ulcer may
be quite superficial, or it may extend into the muscular substance,
and the tip of the tongue may be completely eaten away so that it
looks as if it had been cut off with a knife. As the disease advances
there is severe pain and usually profuse salivation. The submaxillary
glands may be, but are not always, enlarged. The ulcer may heal, but
tends to break down again.

Unless there is advanced pulmonary disease or other contraindication
to operation, the ulcer should be excised under local anæsthesia. Care
must be taken to avoid reinfecting the raw surface. When excision is
impracticable, it is only possible to palliate the symptoms by dusting
with orthoform, or applying local anæsthetics, and by attending to the
hygiene of the mouth and removing all sources of irritation.

#Syphilitic Affections.#--A _primary lesion_ on the tongue is
accompanied by marked enlargement and tenderness of the submaxillary
lymph glands on one or on both sides. It is most common in men,
infection usually taking place through the medium of tobacco pipes, or
implements such as the blow-pipes of glass-blowers.

During the _secondary stage_--particularly in the later
periods--mucous patches and ulcers are common, and they may assume a
condylomatous or warty appearance.

The _tertiary_ manifestations in the tongue are sclerosing glossitis,
gummas, and gummatous ulcers.

_Sclerosing glossitis_ is the term applied by Fournier to a condition
in which there is an abundant new formation of granulation tissue in
the substance of the tongue, leading to the appearance of tuberous
masses on the dorsum. These tend to be oval in outline, are elevated
above the normal mucous membrane, and present a dull red mammilated or
lobulated surface, comparable to the surface of a cirrhotic liver.
They are firm, elastic, and insensitive.

A _gumma_ is usually situated on the dorsum and more often towards the
centre than at the edges. As it seldom implicates the floor of the
mouth or the base of the tongue, the tongue can usually be protruded
freely. It forms an indolent swelling, which tends to break down
slowly and to ulcerate. So long as it remains unbroken it does not
cause pain, and there is no enlargement of the adjacent lymph glands.
Two forms are met with--the superficial, and the deep or
parenchymatous.

A _superficial_ gumma appears as a small hard nodule under the mucous
membrane, varying in size from a pin's head to a pea. The mucous
membrane over it is redder than normal, and in the early stages
retains its papillæ but later becomes smooth. It tends to break down
early, forming a superficial ulcer. Superficial gummas are often
multiple.

The _deep_ or parenchymatous form varies in size from a hazel-nut to a
walnut, and feels like a hard body in the substance of the tongue.
The mucous membrane over the swelling is of normal colour, but is
usually devoid of papillæ. The gumma may remain for months unchanged,
or may approach the surface, soften, and break down, leaving a deep,
ragged ulcer.

_Syphilitic ulcers and fissures_ are nearly always due to the
softening and breaking down of gummas. The ulcers have seldom the
typically rounded or serpiginous outline of gummatous ulcers on other
parts of the body. The base is ragged and unhealthy, and on it a
yellowish-grey slough resembling wash-leather may be seen. The edges
are steep, ragged, and often undermined, and the surrounding parts
thickened and indurated. The neighbouring glands are not usually
enlarged. The ulcer is extremely painful when irritated by food, hot
fluids, or spirits. If untreated, the sore may remain indolent and for
months show no sign either of spreading or healing, but at any time it
may become the seat of cancer.

Syphilitic fissures are met with as long, narrow, deep clefts, or as
stellate or sinous cracks in the substance of the tongue. After the
healing of these ulcers and fissures permanent furrows and depressed
scars remain.

_Treatment._--The tertiary manifestations of syphilis in the tongue
are treated on the same lines as other tertiary lesions. Locally, the
use of mouth-washes, such as chlorate of potash or black wash diluted
with lime-water, the insufflation of powdered iodoform and borax with
a small quantity of morphin, or the application of mercurial ointment
is useful. The sore must be thoroughly cleansed before these remedies
are applied.


NEW GROWTHS

#Carcinoma# is by far the most common form of new growth met with in
the tongue, and it is almost invariably a squamous epithelioma.

Epithelioma generally occurs between the ages of forty and sixty, and
attacks males oftener than females, in the proportion of about six to
one. Its development is favoured by any long-continued irritation,
such as the rubbing of the tongue against a carious tooth, an
ill-fitting tooth-plate, or the rough end of a short clay pipe,
particularly when such irritation leads to the formation of an ulcer.
Chronic superficial glossitis associated with leucoplakia, and
syphilitic fissures, ulcers, or scars, also act as predisposing
factors. The repeated application of strong caustics to chronic
inflammatory conditions is, according to Butlin, a determining cause
of cancer. The degree of malignancy appears to vary in different
cases, and is probably lowest when the disease originates in a patch
of leucoplakia or other pre-cancerous lesion.

The disease is usually situated in the anterior half of the tongue,
and more commonly on the edge than on the dorsum. It may begin as an
excoriation, ulcer, or fissure, or as a warty growth, particularly in
association with a patch of leucoplakia. In all cases ulceration
begins early, and the base of the ulcer and the surrounding parts
become indurated. The lymph glands are, as a rule, early infected.

_Clinical Features._--The clinical appearances vary widely. Sometimes
the surface presents a warty growth; sometimes it is excavated,
forming a deep ulcer with raised nodular edges; in other cases the
ulcer is smooth, and its edges even and rounded. Extreme hardness of
the edges and base of the ulcer is always a characteristic feature.
The tongue tends to become fixed, especially when the disease spreads
to the floor of the mouth, so that it cannot be protruded, and the
restriction of its movement produces a characteristic interference
with articulation, certain words being slurred, and when the fixation
is extreme it may interfere with mastication and swallowing. The
patient complains of a constant gnawing pain in the tongue, and of
severe pain shooting along the branches of the trigeminal nerve, and
especially towards the ear. In the advanced stages there is salivation
and fœtor of the breath.

When the disease is situated on the edge of the tongue it tends to
spread to the floor of the mouth and the muco-periosteum of the
mandible. If situated far back on the dorsum, it spreads on to the
epiglottis, the pillars of the fauces, and the tonsil.

The neighbouring lymph glands--particularly those under the jaw and
along the line of the carotid vessels--soon become infected and are
palpable. The submaxillary and sublingual salivary glands are also
liable to be affected. The enlarged cervical glands later undergo
softening, or suppurate and burst on the skin surface, forming
fungating ulcers. Metastasis to the liver, lungs, and other viscera is
exceptional. If the disease is allowed to run its course, the patient
usually dies in from twelve to eighteen months from repeated small
hæmorrhages, toxin absorption, or septic broncho-pneumonia.

_Differential Diagnosis._--Cancer of the tongue has to be diagnosed
from syphilitic and tuberculous affections, from papilloma, and from
simple ulcer and fissure. It is to be borne in mind that any of these
conditions may take on malignant characters and develop into
epithelioma. The microscopic examination of a portion of the growth
removed under local anæsthesia from the base of the ulcer at some
distance from its epithelial core is often the only certain means of
establishing the diagnosis, and should be had recourse to as early as
possible. When there is still doubt as to the nature of the growth, it
should be treated as if it were cancerous.

An unbroken gumma is liable to be confused only with the uncommon form
of epithelioma which begins as a nodule under the mucous membrane.
Gumma, however, are often multiple, and the tongue shows old scars or
other evidence of syphilis.

Gummatous ulcers are usually situated on the dorsum, are frequently
multiple, and have sloughy, undermined edges; the surrounding parts,
although indurated, are not so densely hard as in cancer; there is not
necessarily any involvement of lymph glands. The cancerous ulcer is
usually single and situated on the margin of the tongue; its edges are
hard, raised, and nodular; and the glands are usually enlarged and
hard. Little reliance is to be placed on the therapeutic effects of
anti-syphilitic drugs in the differential diagnosis, as they are often
inconclusive, and their use results in loss of time.

Tuberculous ulcers usually occur in association with other and
unmistakable evidences of tuberculosis. A papilloma, when sessile, may
simulate cancer; these tumours show a marked tendency to become
malignant. Simple ulcers and fissures are usually recognised by the
history of the condition, the absence of induration and of glandular
involvement, and by the fact that they heal quickly on removal of the
cause.

_Treatment._--The only treatment that offers any hope of cure is free
removal of the disease, and experience has proved that unless this is
done early the prospect of the cure being a radical one is remote. Not
only must the segment of the tongue on which the growth is situated be
widely excised, but all the lymphatic connections must also be removed
whether the glands are palpably enlarged or not.

The chief risk after operation is pneumonia resulting from the
inhaling of blood and products of infection: hence the importance of
rendering the mouth as dry and as sweet as possible before operation,
special attention being paid to the teeth, and precautions being taken
at the operation to prevent the passage of blood down the trachea. The
patient is usually able to be out of bed on the second or third day,
and is well in a fortnight or three weeks. The operation, even when
followed by recurrence, usually prolongs life by six or eight months,
and renders the patient more comfortable by removing the foul ulcer
from the mouth. The speech, although impaired by the removal of
one-half or even more of the tongue, is distinct enough for ordinary
purposes. When recurrence takes place it is usually in the glands, and
may be attended with great suffering.

_Treatment of Inoperable Cases._--The mouth must be kept as sweet as
possible. The pain may be relieved to some extent by cocain or
orthoform, but as a rule the free administration of morphin is called
for. Pain shooting up to the ear may be relieved by resection of the
lingual nerve, or the injection of alcohol into its substance. If
hæmorrhage takes place from the ulcerated surface and cannot be
controlled by adrenalin, or other local styptics, it may be necessary
to ligate the lingual, or even the external carotid artery.
Interference with respiration may necessitate tracheotomy. When the
patient has difficulty in taking food, recourse should be had to the
use of the stomach-tube or to gastrostomy. The use of radium or of the
X-rays appears to have a restraining influence on the disease in the
glands, but has not proved curative.

#Sarcoma# of the tongue is rare, and is sometimes met with in
children. The round-cell type is the most common; it grows rapidly,
and tends to ulcerate and fungate, pain becoming severe when the
growth has broken down. The diagnosis is always difficult, and is
seldom made until a portion of the growth has been removed and
examined microscopically. The more slowly growing forms, if removed
before ulceration has taken place, show little tendency to recur, but
those which grow rapidly and break down, not only recur locally, but
are liable to give rise to metastases. The treatment is the same as
for cancer; the use of radium is more likely to be beneficial than in
epithelioma.

#Innocent Tumour and Cysts.#--_Lipoma_, _fibroma_, and various forms
of _angioma_ (Fig. 258) are occasionally met with. They are all of
slow growth, and give rise to inconvenience chiefly by their bulk, and
should be removed.

[Illustration: FIG. 258.--Papillomatous Angioma of left side of tongue
in a woman aged 26.]

_Papilloma_ may occur on any part of the tongue, and at any age. It
may be single or multiple, pedunculated or sessile, and is liable to
become malignant, especially when associated with leucoplakia. It
should be freely removed by excising a wedge-shaped portion of the
tongue.

_Dermoid_ cyst is met with beneath the tongue, lying in the middle
line, between the genio-glossi (genio-hyoglossi), and on the upper
surface of the mylo-hyoid muscles. It may be noticed soon after
birth, or may only attract attention during adult life. The cyst
usually projects under the chin, forming a soft swelling of putty-like
consistence, which varies in size from a pigeon's to a turkey's egg
(Fig. 259). When it bulges towards the mouth it is liable to be
mistaken for a retention cyst of one of the salivary glands. It is
distinguished by its medial position, its yellow colour, and its
opacity, the retention cyst being to one side of the middle line,
purplish in colour, translucent and fluctuating. The cyst should be
dissected out, either from the mouth or from under the chin, according
to circumstances.

[Illustration: FIG. 259.--Dermoid Cyst in middle line of neck.

(Mr. J. W. Struthers' case.)]

A _sebaceous cyst_ may reach such dimensions as to simulate a dermoid
or thyreo-glossal cyst.

_Hydatid and cysticercus cysts_ have also been met with in the tongue.

#Thyreo-glossal Tumours and Cysts.#--Tumours may develop in the
embryonic tract which passes from the isthmus of the thyreoid gland
to the foramen cæcum at the base of the tongue--the thyreo-glossal
tract of His. They have the same structure as the thyreoid gland, and
occupy the dorsum of the tongue, extending from the foramen cæcum
backwards towards the epiglottis, in some cases attaining considerable
size. They are of a bluish-brown or dark red colour, and are liable to
repeated attacks of hæmorrhage. These tumours sometimes become cystic,
the cysts being lined with ciliated epithelium and containing colloid
material. Bleeding may take place into a cyst, causing it to become
suddenly enlarged, or the cyst may burst and the blood escape into the
mouth. These variations in size and repeated attacks of bleeding help
to distinguish thyreo-glossal cysts from other swellings of the
tongue. Treatment is only called for when the swelling causes
interference with speech or swallowing; it consists in removing the
tumour by dissection.

When the lower end of the tract becomes cystic it forms a swelling in
the neck (p. 583).

#Malformations.#--Complete or partial _absence_ of the tongue is
exceedingly rare.

Occasionally the fore part of the tongue is _bifid_. The function of
the organ is not interfered with, and the operation of paring and
suturing the two halves is only called for on account of the
disfigurement.

_Congenital tongue-tie_ is a condition in which the tip of the tongue
is bound down to the floor of the mouth by an abnormally short and
narrow frenum, or by folds of mucous membrane on each side of the
frenum, so that the tongue cannot be protruded. Although this
deformity is rare, it is common for parents to blame an imaginary
tongue-tie when a child is slow in learning to speak, or when he
speaks indistinctly or stammers, and the doctor is frequently
requested to divide the frenum under such circumstances. In the vast
majority of cases nothing is found to be wrong with the frenum. In the
rare cases of true tongue-tie the edges of the shortened bands should
be snipped with scissors close behind the incisor teeth, and then torn
with the finger-nail.

_Excessive length_ of the frenum is occasionally met with, and in
children may allow of the tongue falling back into the throat and
causing sudden suffocative attacks, one of which may prove fatal. In
some cases the patient is able voluntarily to fold the tongue back
behind the soft palate.

_Macroglossia_ is the term applied to a variety of conditions in which
the tongue becomes unduly large, so that it tends to be protruded from
the mouth, and to become scored by the teeth. The typical
form--lymphangiomatous macroglossia--is due to a dilatation of the
lymph spaces of the tongue. It is often congenital, and may affect the
whole or only a part of the tongue. The enlargement may be progressive
from the first, or may remain stationary for years, and then begin to
develop somewhat suddenly, sometimes after an injury or as a result of
some infective condition. The treatment consists in removing a
wedge-shaped portion of the tongue.

In certain cases of macroglossia in children, the lesion has been
found to be a fibromatosis of the nerves of the tongue, analogous to
the plexiform neuroma.

_Atrophy_ of the tongue is rare as a congenital condition.
Hemi-atrophy occurs in various diseases of the central nervous system,
as well as after injuries and diseases implicating the hypoglossal
nerve.

#Nervous Affections of the Tongue.#--_Neuralgia_ confined to the
distribution of the lingual nerve is comparatively rare. It usually
yields to medical treatment, but in inveterate cases it is sometimes
necessary to resect the nerve.

It is more common to meet with a condition in which the patient
complains of severe burning or aching pain in the region of the
foliate papilla, which is situated on the edge of the tongue just in
front of the anterior pillar of the fauces. The patient is usually a
middle-aged, neurotic woman, and often with a gouty or rheumatic
tendency. The pain, for which it is seldom possible to discover any
cause, is usually worst at night, and may last for months, or even
years. The practical importance of the condition is that, as the
foliate papilla is prominent and red, it is liable to be mistaken on
superficial examination for a commencing epithelioma. An inspection of
the opposite side of the tongue, however, will reveal an exactly
similar condition, which is not painful. The first and most important
step in treatment is to assure the patient that the condition is not
cancerous. Caustics and other irritating applications are to be
avoided.

_Spasm_ of the tongue sometimes occurs after injuries of the head
implicating either the centre or the trunk of the hypoglossal nerve.
It may also appear as a reflex condition in infective affections of
the teeth and gums, or as a manifestation of some general disease of
the central nervous system.

_Paralysis_ of the tongue--unilateral or bilateral--may be due to
injury or disease of the nerve centres of the hypoglossal nerve, more
frequently to injury of or pressure on the nerve-trunk. The nerve may
be bruised or divided in operations for the removal of tuberculous
glands or other tumours in the neck. When the tongue is protruded it
deviates towards the paralysed side, being pushed over by the active
muscles of the opposite side (Fig. 260), and speech and mastication
may be interfered with. The paralysed half of the tongue subsequently
undergoes atrophy, but the functional disability largely disappears.

[Illustration: FIG. 260.--Temporary Unilateral Paralysis of Tongue,
from bruising of hypoglossal nerve during operation for tuberculous
cervical glands.]




CHAPTER XXIII

THE SALIVARY GLANDS


Surgical Anatomy--Injuries--Salivary fistulæ--Salivary
    calculi--Infective conditions: _Parotitis_; _Inflammation of
    submaxillary gland_; _Angina Ludovici_; _Inflammation of
    sublingual gland_; _Tuberculous disease_--Tumours: _Ranula_;
    _Mixed tumours of parotid_; _Sarcoma_; _Carcinoma_; _Tumours of
    submaxillary and sublingual glands_.

#Surgical Anatomy.#--_The parotid gland_ lies on the side of the face
below and in front of the ear, and extends deeply behind the mandible
reaching almost to the side wall of the pharynx. Its deeper part lies
in close relation with the internal carotid artery, the internal
jugular vein, and the vagus, glosso-pharyngeal, accessory, and
hypoglossal nerves. The external carotid artery passes through the
substance of the parotid, and bifurcates opposite the neck of the
condyle into the temporal and internal maxillary arteries. It is
accompanied by the venous trunk formed by the junction of the temporal
and internal maxillary veins. The facial nerve and its branches
traverse the lower third of the gland from behind forwards. The facial
portion of the gland lies on the surface of the masseter muscle, and
the _parotid duct (Stenson's duct)_ emerges from its anterior border.
After crossing the masseter, the duct pierces the buccinator muscle
and the mucous membrane obliquely, and opens into the mouth opposite
the second upper molar tooth. Its course is indicated by a line
passing from the upper part of the lobule of the ear to a point midway
between the ala of the nose and the margin of the upper lip--that
is, at a higher level than the facial nerve. Several lymph
glands--pre-auricular--lie inside the capsule of the parotid just in
front of the ear.

The _submaxillary gland_ lies under the integument and fascia in the
triangle formed by the lower jaw and the two bellies of the digastric
muscle. Its anterior part is crossed by the facial vessels, and
several lymph glands lie inside its capsule. The _submaxillary duct
(Wharton's duct)_ opens into the mouth by the side of the frenum of
the tongue.

The _sublingual gland_ lies in the floor of the mouth just beneath the
mucous membrane. It has numerous ducts, some of which open directly
into the mouth, others into the submaxillary duct.

#Injuries.#--The _parotid_ is frequently injured by accidental wounds
and in the course of operations. If the blood vessels traversing the
gland are divided, such wounds are liable to bleed freely, and if the
facial and auriculo-temporal nerves are damaged, motor and sensory
paralysis of the parts supplied by them ensues. Wounds of the parotid
heal rapidly and without complications so long as infection is
prevented, but if suppuration takes place they are liable to be
followed by the escape of saliva, which may go on for weeks; in some
cases a salivary fistula is thus established.

_The parotid duct_ may be divided and a salivary fistula result. If
the external wound heals rapidly, a salivary cyst may develop in the
substance of the cheek, forming a swelling, which fills up at meals,
and may be emptied by external pressure, the saliva escaping into the
mouth.

In a wound implicating the whole thickness of the cheek the skin
should be accurately sutured, care being taken that the stitches do
not include the duct, but in order that the saliva may readily reach
the mouth, the mucous membrane should not be stitched.

#Salivary Fistulæ.#--A salivary fistula may occur in relation to the
glandular substance of the parotid or in relation to the duct. Fistula
in connection with the glandular substance--_parotid fistula_--seldom
results from a wound, made, for example, in the removal of a tumour or
in an operation on the ramus of the jaw, so long as it is aseptic; but
as a sequel of suppuration in the gland, and particularly of an
abscess developing around a concretion, it is not uncommon. The
fistulous opening is usually small, and may occur at any point over
the gland. The fistula may be dry between meals, or the saliva may
escape in small transparent drops, but the quantity is always greatly
increased when food is taken. A parotid fistula, although it may
continue to discharge for weeks, or even for months, usually closes
spontaneously.

In persistent cases, the edges of the fistula may be pared and brought
together with sutures, or the actual cautery may be applied to induce
cicatricial contraction.

_Fistula of the parotid duct_ is more serious. It is usually due to a
wound, less frequently to abscess or impacted calculus. From the
minute opening, which is most frequently situated over the buccinator
muscle, there is an almost continuous flow of clear limpid saliva,
which is greatly increased in quantity while the patient is eating.
These fistulæ show little tendency to close spontaneously. Attempts to
close the opening by the external application of collodion, by
cauterising the edges, or even by paring the edges and introducing
sutures, usually fail. It is necessary to establish an opening into
the mouth, either by opening up the original duct or by making an
internal fistula in place of the external one.

#Salivary Calculi.#--Salivary calculi are most commonly met with _in
the submaxillary gland or its duct_. They consist of phosphate and
carbonate of lime with a small proportion of organic matter, and
result from the chemical action of bacteria on the saliva. In rare
cases a foreign body, such as a piece of straw, a fruit-seed, or a
fish-bone, forms the nucleus of the concretion. They vary in size from
a pea to a walnut, and are hard, of a whitish or grey colour, and
rough on the surface. Those that form in the gland itself are usually
irregular, while those met with in the duct are rounded or
spindle-shaped (Fig. 261).

[Illustration: FIG. 261.--Series of Salivary Calculi.]

A calculus in the duct gives rise to sharp lancinating pain, which is
aggravated when the patient takes food. The duct is seldom completely
obstructed, but the flow of saliva is usually so much impeded that the
gland becomes greatly swollen during meals. The swelling gradually
subsides between meals, or can be made to disappear by external
pressure. The calculus can usually be felt by means of a probe passed
along the duct, or by puncturing the swelling with a needle; or, with
one finger inside the mouth and another under the jaw, a hard lump can
be detected under the mucous membrane of the floor of the mouth. It
may be revealed by the X-rays. When the obstruction is complete, a
retention cyst forms in which suppuration is liable to occur, causing
marked aggravation of the symptoms. In some cases the wall of the duct
and the surrounding tissues become thickened and indurated, forming a
swelling which is liable to be mistaken for a malignant growth. The
treatment consists in making an incision through the mucous membrane
over the calculus and extracting it with a scoop or forceps.

INFECTIVE CONDITIONS.--#Parotitis.#--Inflammation of the parotid gland
may be non-suppurative or suppurative.

Of the _non-suppurative_ varieties the most common is the epidemic
form known as _mumps_. This is an acute infective condition, which
usually attacks young children, and implicates both glands, either
simultaneously or consecutively. It runs a definite course, which
lasts for from one to two weeks, and almost invariably ends in
resolution. The parotid gland is swollen and tender, there is pain on
attempting to open the mouth, difficulty in swallowing, and dribbling
of saliva. The surgical interest of this disease lies in the fact that
it is frequently complicated by pain and swelling of the testis, œdema
of the scrotum, and occasionally by a urethral discharge, and atrophy
of the testis has been observed after such an attack. In females there
is sometimes pain in the ovary, tenderness and swelling of the mamma,
and a vaginal discharge.

[Illustration: FIG. 262.--Acute Suppurative Parotitis.]

The parotid on one or both sides may suddenly become swollen and
tender in patients who are taking large doses of mercury, in gouty
subjects, or in patients suffering from infective conditions of the
genito-urinary organs, such as orchitis, ovaritis, urethritis, or
cystitis. The condition is usually transient and leads to no
complications.

_Recurrent enlargement_ of the parotid and submaxillary glands, as
well as of the lachrymal glands, is occasionally met with in adults,
and was first described by Mikulicz. It may be associated with
salivary lithiasis, xerostomia, or organic narrowing of the ducts, but
in the majority of cases no such cause can be discovered (D. M.
Greig). When the parotid is affected the condition tends to be
bilateral and there is some constitutional disturbance. The
submaxillary form is usually unilateral and the symptoms are entirely
local. The affected gland rapidly becomes swollen, painful and tender
to the touch, and the swelling increases markedly while the patient is
eating. Each attack lasts for a few hours to one or two weeks, and
then subsides spontaneously. The intervals between attacks vary from a
few weeks to a year or more. In the course of a few years there is
considerable deformity, and sometimes deficiency in the glandular
secretion, but the disease is not attended by other inconvenience.
Benefit has followed the administration of arsenic and iodides, and
the use of radium and X-rays.

The treatment of these non-suppurative forms of parotitis consists in
relieving the symptoms.

_Suppurative parotitis_ may be due to direct spread of infection from
the mouth along the parotid duct, or to extension of suppurative
processes from the temporo-mandibular joint, the jaw, or a lymph
gland. It is liable to occur also in the course of any disease in
which there is an infection of the blood with pyogenic bacteria, and
has been met with in diphtheria, typhoid fever, scarlet fever,
measles, and other eruptive fevers.

The _post-operative_ form of parotitis is most frequently met with
after laparotomy for such conditions as suppurative appendicitis,
perforated gastric ulcer, ovarian cyst, and pyosalpinx.

These secondary forms are probably due to infection from the mouth
under conditions in which the secretion of saliva is arrested or its
escape from the gland interfered with.

The early symptoms are apt to be overshadowed by those of the general
disease from which the patient suffers. At first the gland is swollen,
hard, and tender, and the seat of constant, dull, boring pain; later
there is redness, œdema, and fluctuation. The movements of the jaw
are restricted and painful, the patient is unable to open the mouth,
and has difficulty in swallowing. The inflammation reaches its height
on the third or fourth day, and usually ends in suppuration. The pus
is scattered in numerous foci throughout the gland, and sometimes
large sloughs form. The dense capsule of the gland prevents the pus
reaching the surface and causes it to burrow among the tissues of the
neck, giving rise to dyspnœa and dysphagia. It may find its way
downwards towards the mediastinum, inwards towards the pharynx--where
it constitutes one form of retro-pharyngeal abscess--or upwards
towards the base of the skull. Not infrequently it burrows into the
temporo-mandibular joint, or escapes by bursting into the external
auditory meatus. Serious hæmorrhage may result from erosion of the
vessels traversing the gland or of the internal jugular vein, or
venous thrombosis may ensue. Persistent paralysis may follow
destruction of the facial nerve; and salivary fistulæ may form. Death
may take place from toxæmia even before pus forms.

_Treatment._--During the first two or three days hyperæmia is induced
by means of poultices, hot fomentations, or Klapp's suction bells, and
the mouth is frequently washed out with an antiseptic. As soon as
there is reason to believe that pus has formed an incision is made
behind the angle of the jaw, parallel to the branches of the facial
nerve, the abscess opened by Hilton's method, a finger passed into the
gland, and all septa broken down and drainage secured.

Acute infection of the #submaxillary gland# is met with under the same
conditions as that of the parotid. Both glands are occasionally
attacked at the same time.

The acute phlegmonous peri-adenitis of the submaxillary gland, known
as _angina Ludovici_, is referred to at p. 597.

The _treatment_ consists in making incisions through the deep fascia
in order to relieve the tension, or to let out pus if it has formed.

Acute suppurative inflammation of the #sublingual gland# may occur
under the same conditions as in the parotid, and is associated with
the formation of an exceedingly painful and tender swelling under the
tongue. The tongue is gradually pushed against the roof of the mouth,
so that swallowing is difficult and respiration may be seriously
impeded. There is marked constitutional disturbance. An incision into
the swelling is immediately followed by relief of the symptoms.

#Tuberculous disease# of the salivary glands is rare. It usually
begins in the lymph glands within the capsule of the parotid or
submaxillary, and spreads thence to the salivary gland tissue.

TUMOURS.--#Cystic Tumours--Ranula.#--The term ranula is applied to any
cystic tumour formed in connection with the glands in the floor of the
mouth. Formerly these tumours were believed to be retention cysts due
to blocking of the salivary ducts. They are now known to be the result
of a cystic degeneration of one or other of the secreting glands in
the floor of the mouth. They contain a thick glairy fluid, which
differs from saliva in containing a considerable quantity of mucin and
albumin, while it is free from any amylolytic ferment or
sulpho-cyanide of potassium. Numerous degenerated epithelial cells are
found in the fluid.

The _sublingual ranula_ is the most common variety. It appears as a
painless, smooth, tense, globular swelling of a bluish colour. It
usually lies on one side of the frenum, and over it the mucous
membrane moves freely. As it increases in size it gradually pushes the
tongue towards the roof of the mouth, and so causes interference with
speech, mastication, and swallowing. It is to be differentiated from a
retention cyst of the submaxillary gland by the fact that a probe can
usually be passed down the submaxillary duct alongside of the
swelling, and from sublingual dermoid (p. 539).

The _treatment_ consists in making an incision through the mucous
membrane over the swelling, dissecting away the whole of the cyst wall
if possible, and, if any portion cannot be removed, swabbing it with a
solution of chloride of zinc (40 grains to the ounce), after which the
cavity is stuffed with bismuth gauze and allowed to close by
granulation. It is sometimes found more satisfactory to dissect out
the cyst through an incision below the jaw, and in the event of
recurrence this should be undertaken.

Cystic tumours, similar to the sublingual ranula, form in the other
glands in the floor of the mouth--for example, the incisive gland,
which lies just behind the symphysis menti, as well as in the apical
gland on the under aspect of the tip of the tongue. The latter is
distinguished by the fact that it moves with the tongue. In rare cases
children are born with a cystic swelling in the floor of the
mouth--the so-called _congenital ranula_. It is usually due to an
imperfect development of the duct of the submaxillary or sublingual
gland.

#Solid Tumours--Mixed Tumours of the Parotid.#--The most important of
the solid tumours met with in the salivary glands is the so-called
"mixed tumour of the parotid." This was formerly believed to be an
endothelioma derived from a proliferation of the endothelial cells
lining the lymph spaces and blood vessels of the gland. A more
probable view is that it develops from rests derived from the first
branchial arch an not from the parotid. The matrix of the tumour is
made up of cartilaginous, myxomatous, sarcomatous, or angiomatous
tissue, the proportion of these different elements varying in
individual specimens, and it may include some portions that are
adenomatous. A gelatinous substance forms in the intercellular spaces
of the tumour, and may accumulate in sufficient quantity to give rise
to cysts of various sizes. There is reason to believe that the tumours
of the parotid previously described as adenoma, chondroma, angioma,
myxoma, and many of the cases of sarcoma, were really mixed tumours in
which one or other of these tissues predominated.

The tumour usually develops in the vicinity of the parotid, and
presses on the salivary tissue, thinning it out and causing it to
undergo atrophy.

_Clinical Features._--The mixed tumour is usually first observed
between the ages of twenty and thirty. It is of slow growth and
painless, and forms a rounded, nodular swelling, the consistence of
which varies with its structure. The skin over the swelling is normal
in appearance and is not attached to the tumour (Figs. 263, 264). Only
in rare cases does paralysis result from pressure on the facial nerve.

[Illustration: FIG. 263.--Mixed Tumour of Parotid.]

[Illustration: FIG. 264.--Mixed Tumour of the Parotid of over twenty
years' duration.]

Although usually benign, these tumours may, after lasting for years,
take on malignant characters, growing rapidly, implicating adjacent
lymph glands, and showing a marked tendency to recur after removal.

The _treatment_ consists in shelling out the tumour, care being taken
to avoid injuring the facial nerve or the parotid duct by making the
incision and the subsequent cuts in the dissection run parallel to
them. If the tumour is removed early and completely, recurrence is the
exception.

#Sarcoma and carcinoma# are rare. They are very malignant, grow
rapidly, infiltrate surrounding parts, including the skin, and infect
the adjacent lymph glands. There is severe neuralgic pain, and
paralysis from involvement of the facial nerve is an early symptom.

The _treatment_ consists in excising the whole of the parotid gland
with the tumour, no attempt being made to conserve the facial nerve or
other structures traversing it. Recourse should be had to the use of
radium both before and after operation, otherwise recurrence is all
but inevitable.

The _submaxillary and sublingual glands_ may be the seat of the same
varieties of tumour as the parotid. These glands are particularly
liable to become invaded along with the adjacent lymph glands in
epithelioma of the tongue and floor of the mouth.




CHAPTER XXIV

THE EAR[5]


Surgical Anatomy--CARDINAL SYMPTOMS OF EAR DISEASE: _Impairment of
    hearing_; _Tinnitus aurium_; _Earache_; _Giddiness_;
    _Discharge_--Hearing tests--Inspection of ear--Inflation of middle
    ear. AFFECTIONS OF EXTERNAL EAR: _Deformities_; _Hæmatoma auris_;
    _Epithelioma and Rodent cancer_; _Impaction of wax_; _Eczema_;
    _Boils_; _Foreign bodies_. AFFECTIONS OF TYMPANIC MEMBRANE AND
    MIDDLE EAR: _Rupture of membrane_; _Acute inflammation of middle
    ear_; _Chronic suppuration_; _Suppuration in the mastoid antrum
    and cells_.

[5] We desire here to acknowledge our indebtedness to Dr. Logan Turner
for again revising this chapter.

#Surgical Anatomy.#--The anatomical subdivision of the ear into three
parts--the external, middle, and internal ear--forms a satisfactory
basis for the study of ear lesions. The outer ear consists of the
auricle and external auditory meatus, the latter being made up of an
outer cartilaginous portion half an inch in length, and a deeper
osseous portion three-quarters of an inch long. The canal forms a
curved tube, which can be straightened to a considerable extent for
purposes of examination by pulling the auricle upwards and backwards.
It is closed internally by the tympanic membrane, which separates it
from the tympanic cavity or middle ear. The middle ear includes the
tympanum proper, which is crossed by the chain of ossicles--malleus,
incus, and stapes--the Eustachian tube, which communicates with the
naso-pharynx, and the tympanic antrum and mastoid cells. As these
cavities lie in close relation to the middle and posterior cranial
fossæ, infective conditions in the tympanum and mastoid cells are
liable to spread to the interior of the skull. The internal ear or
labyrinth lies in the petrous part of the temporal bone, its outer
boundary being the inner wall of the middle ear.

Physiologically the different parts of the auditory mechanism may be
divided into (1) the _sound-conducting apparatus_, which includes the
outer and middle ears; and (2) the _sound-perceiving apparatus_--the
internal ear and central nerve tracts. Impairment of hearing may be
due to causes existing in one or other or both of these subdivisions.
The condition of the sound-conducting apparatus can be investigated by
direct inspection through the speculum, and by inflation of the
Eustachian tube and tympanum, while that of the sound-perceiving
apparatus is ascertained partly by testing the hearing, and partly by
excluding affections of the outer and middle ear. When the
sound-conducting apparatus is at fault, the resulting deafness is
spoken of as "obstructive"; when the sound-perceiving apparatus is
affected, the term "nerve deafness" is used. The semicircular canals,
which are peripheral organs concerned in the maintenance of
equilibration, form part of the inner ear apparatus.

CARDINAL SYMPTOMS OF EAR DISEASE.--The most important symptom of ear
disease is _impairment of hearing_, which varies in degree, and may be
due to lesions either in the sound-conducting or in the
sound-perceiving apparatus. The sudden onset of deafness may be due to
impaction of wax in the external meatus or to hæmorrhage or effusion
into the labyrinth. A gradual onset is more common. In children there
is a great tendency for acute inflammatory conditions of the middle
ear to arise in connection with the exanthemata and in association
with adenoids. In adult life chronic catarrhal processes are more
common causes of gradually increasing deafness, while in advanced age
there is a tendency to acoustic nerve impairment. Certain anomalous
conditions of hearing are occasionally met with, such as the
"paracusis of Willis"--a condition in which the patient hears better
in a noise; "diplacusis," or double hearing; and "hyperæsthesia
acustica," or painful impressions of sound.

_Tinnitus aurium_, or subjective noises in the ear, may constitute a
very annoying and persistent symptom. These sounds vary in their
character, and may be described by the patient as ringing, hissing, or
singing, or may be compared to the sound of running water or of a
train. They are usually compared to some sound which, from his
occupation or otherwise, the patient is accustomed to hear. They may
be purely aural in origin, being due, for example, to increased
pressure on the acoustic nerve endings from causes in the labyrinth
itself or in the middle or external ear; or they may be due to certain
reflex causes, such as naso-pharyngeal catarrh or gastric irritation.
Vascular changes such as occur in anæmia, Bright's disease, and heart
disease may also be concerned in their production.

_Pain_, or _earache_, varies in degree from a mere sense of discomfort
to acute agony. The pain associated with a boil in the external meatus
is usually aggravated by movements of the jaw, by pulling the auricle,
and by pressure upon the tragus. The pain of acute middle-ear
inflammation is deep-seated, intermittent in character, and worse at
night, and is aggravated by blowing the nose, coughing, and
sneezing--acts which increase middle-ear tension by forcing air along
the Eustachian tube. Mastoid pain and tenderness are indicative of
inflammation in the antrum or cells, and when these symptoms supervene
in the course of a chronic middle-ear suppuration, they should always
be regarded as of grave import. Severe neuralgia of the ear may
simulate the pain of acute mastoiditis, and it must not be forgotten
that earache may be traced to a diseased tooth. A careful examination,
not only of the ear, but also of the throat and teeth, should
therefore be made in all cases of earache.

_Vertigo_, or _giddiness_, may be produced by causes which alter the
tension of the labyrinthine fluid, such, for example, as the pressure
of wax upon the tympanic membrane, or exudation into the middle ear or
into the labyrinth. Giddiness occurring in the course of chronic
middle-ear suppuration may be significant of labyrinthine or of
intra-cranial mischief, but is not necessarily so. Giddiness preceded
by nausea suggests a gastric origin; if followed by nausea it points
to an aural origin. In cases of suspected aural vertigo, the patient's
"static sense" should be carefully tested. He should be asked (1) to
stand with both feet together with the eyes closed, (2) to stand on
one or other foot with eyes closed, (3) to walk in a straight line,
(4) to hop backwards and forwards off both feet. His incapacity for
performing such movements should be noted. As nystagmus may be
associated with disturbance of equilibrium due to ear disease, the
movements of the eyeballs must be carefully tested.

Labyrinthine _nystagmus_ is of a rhythmic character, and consists of a
slow and a rapid movement. Physiological nystagmus can be induced by
stimulating the movement of the endolymph in the semicircular canals,
by syringing the ear with hot and cold water (caloric test), by
rotating the individual (rotation test), and by the galvanic current.
Any departure from the normal reactions which these tests may produce,
should raise the suspicion of a pathological condition of the
semicircular canals.

_Discharge from the ear_, or _otorrhœa_, is occasionally due to an
eczematous condition of the skin lining the external meatus. It is
then usually of a thin, watery character, and contains epithelial
flakes and débris. An aural discharge is, however, most commonly of
middle-ear origin. It may be muco-purulent and stringy, or purulent
and of thicker consistence. A peculiar, offensive odour is
characteristic of chronic middle-ear suppuration. The surgeon should
smell the speculum in suspicious cases. He should never accept the
patient's statement as regards the absence of discharge, but should
satisfy himself by inspection and by the introduction of a cotton-wool
wick.

#The Hearing Tests.#--In testing the hearing, a definite routine
method should be adopted, the watch, whisper, voice, and tuning-fork
tests being systematically employed. Although the patient only
complains of one ear, both must be examined. Each ear should be tested
separately, and the patient should be so placed that he cannot see the
lips of the examiner. While one ear is being tested, the other should
be closed with the finger, and each test should be commenced outside
the probable normal range of hearing. All the results should be
written down at once, and the date of the test recorded, as this is
essential for following the progress of the case.

_Tuning-fork Tests._--To differentiate between deafness due to a
lesion in the sound-conducting apparatus and that due to labyrinthine
causes, it is necessary to enter into a little more detail. The tone
produced by a vibrating tuning-fork is conducted to the nerve
terminations in the labyrinth both through the air column in the
external meatus (air-conduction), and through the cranial bones
(bone-conduction). When, in a deaf ear, the vibrations of a
tuning-fork placed in contact with the mastoid process are heard
better than when the fork is held opposite the meatus, the lesion is
in the sound-conducting apparatus. When, on the other hand, the
vibrations are heard better by air-conduction, the lesion is in the
sound-perceiving apparatus. In addition to these facts, we find also
that in obstructive deafness low tones tend to be lost first, while in
nerve deafness the higher notes are the first to go. This may be
investigated by tuning-forks of different pitch or with the aid of a
Galton's whistle. Again, in middle-ear deafness, hearing may be better
in a noisy place, and be improved by inflation of the tympanum; while
in labyrinthine deafness, hearing may be better in a quiet room, and
be rendered worse by inflation.

#Inspection of the Ear.#--This should be carried out by the aid of
reflected light, the ear to be examined being turned away from the
window, lamp, or other source of light that may be employed. A small
ear reflector, either held in the hand or attached to a forehead band,
and a set of aural specula are required. Before introducing the
speculum, the outer ear and adjacent parts should be examined, and the
presence of redness, swelling, sinuses or cicatrices over the mastoid,
displacement of the auricle, or any inflammatory condition of the
outer ear observed. To inspect the tympanic membrane, a medium-sized
speculum held between the thumb and index finger is insinuated into
the cartilaginous meatus, the auricle being at the same time pulled
upwards and backwards by the middle and ring fingers, so as to
straighten the canal. The tympanic membrane is then sought for and its
appearance noted.

The _normal membrane_ is concave as a whole on its meatal aspect; it
occupies a doubly oblique plane, being so placed that its superior and
posterior parts are nearer the eye of the examiner than the anterior
and inferior parts. While varying to some extent in colour, polish,
and transparency, it presents a bluish-grey appearance. The handle of
the malleus traverses the membrane as a whitish-yellow ridge, which
appears to pass from its upper and anterior parts downwards and
backwards to a point a little below the centre. At the lower end of
the handle of the malleus a bright triangular cone of light passes
downwards and forwards to the periphery of the membrane. At the upper
end of the handle is a white knob-like projection, the short process
of the malleus. Passing forwards and backwards from this are the
anterior and posterior folds. The portion of the membrane situated
above the short process is known as the membrana flaccida or
Shrapnell's membrane. Behind the malleus the long process of the incus
may be visible through the membrane. The mobility of the membrana
tympani should be tested by inflating the tympanum or by means of
Siegle's pneumatic speculum.

Various departures from the normal may be observed. _Atrophy_ of the
membrane is characterised by extreme transparency of the whole disc.
Circumscribed atrophic patches appear as dark transparent areas, which
show considerable mobility and bulge prominently on inflation. A
_cicatrix_ in the membrane is evidence of a healed perforation, and is
also transparent, but differs from an atrophic patch in being more
sharply defined from the surrounding membrane. A _thickened membrane_
presents an opaque white appearance. _Calcareous_ or _chalky patches_
are markedly white, and when probed are hard to the touch; they are
often evidence of past suppuration. An _indrawn_ or retracted
membrane, resulting from Eustachian obstruction, is characterised by
increased concavity, undue prominence of the lateral short process of
the malleus and of the anterior and posterior folds, and by the handle
of the malleus assuming a more horizontal position. An _inflamed_
membrane, showing congestion of the vessels about the malleus or a
general diffuse redness, is evidence of middle-ear inflammation. A
yellow appearance of the lower part of the membrane, limited above by
a dark line stretching across the drum-head, is indicative of
sero-purulent exudation into the tympanum. The membrane may be bulged
outwards into the meatus by the fluid, and thus lie nearer the
observer's eye than normally. A _perforation_ is usually single, and
varies in size from a small pinhead to complete destruction of the
membrane. The labyrinthine (inner) wall of the tympanum may be visible
through the perforation, and is recognised by being on a deeper plane
than the membrane, and by its hard bony consistence when touched with
the probe. The diagnosis of a perforation associated with middle-ear
discharge may be further assisted by inspection during inflation, when
bubbles of air and secretion are visible. When the perforation is
invisible, its existence may be inferred if a small pulsating spot of
light can be recognised through the speculum. _Granulations_ in the
tympanum appear as red fleshy masses of different sizes. When large
they constitute _aural polypi_, which are recognised by their
proximity to the outer end of the meatus, their soft consistence and
mobility, and the fact that the probe may be passed round them.
Granulations and polypi usually indicate the presence of middle-ear
suppuration.

#Inflation of the Middle Ear.#--Before proceeding to inflate the
middle ear, the examiner should inspect the nose, naso-pharynx, and
pharynx. This should be made a routine part of the examination in all
cases of ear disease. As inflation is not only an aid in diagnosis,
but is also of great assistance in prognosis, it is necessary that the
hearing should be tested and noted before the ear is inflated. There
are three methods of inflating the tympanum: Valsalva's method,
Politzer's method, and by means of the Eustachian catheter.

In _Valsalva's inflation_ the patient himself forces air into his
Eustachian tubes, by holding his nose, closing his mouth, and forcibly
expiring. This method of inflation has only a limited application and
is of little therapeutic value.

_Politzer's Method._--For this a Politzer's air-bag and an
auscultating tube, one end of which is inserted into the patient's ear
and the other into the ear of the examiner, are required. The nasal
end of the bag should be protected with a piece of rubber tubing or be
provided with a nozzle. The patient retains a small quantity of water
in his mouth until directed to swallow. The nozzle of the bag is
inserted into one nostril, and the other is occluded by the fingers of
the surgeon. The signal to swallow is then given, and, simultaneously
with the movement of the larynx during this act, the bag is sharply
and forcibly compressed. Holt's modification of this method consists
in directing the patient to puff out his cheeks while the lips are
kept firmly closed.

_Inflation through the Eustachian Catheter._--For this method, in
addition to the Politzer's bag and the auscultating tube, a silver or
vulcanite Eustachian catheter is required. The silver instrument has
the advantage that it can be sterilised by boiling. The patient is
seated facing the light, while the surgeon stands in front of him,
and, having placed the auscultating tube in position, with his left
thumb he tilts up the tip of the patient's nose. The beak of the
catheter is now inserted into the inferior meatus, point downwards,
and carried horizontally backwards along the floor of the nose until
the convexity of the curve touches the posterior wall of the
naso-pharynx. When the posterior pharyngeal wall is felt, the point of
the instrument is rotated inwards through a quarter of a circle; the
position of the point is indicated by the metal ring upon the outer
end of the catheter. The finger and thumb of the left hand should now
grasp the stem of the catheter just beyond the tip of the nose so as
to steady it. It is now gently withdrawn until the concavity of the
beak is brought against the posterior edge of the septum nasi. With
the right hand the point of the instrument is then rotated downwards
and outwards through a little more than half a circle, so that the
point slips into the Eustachian orifice and the metal ring looks
outwards and upwards towards the external canthus of the eye of the
same side. While the instrument is maintained in this position by the
left hand, the nozzle of the Politzer's bag is inserted into the
funnel-shaped outer extremity of the catheter, and inflation is gently
carried out with the least possible jerking. Before withdrawing the
catheter its point must be disengaged from the Eustachian opening by
turning it slightly downwards. Difficulties in introducing the
catheter may arise from the presence of spines and ridges upon, and
deviations of, the septum, and it may be necessary to pass the
instrument under the guidance of the mirror and speculum.

More accurate information is gained from the use of the catheter than
from Politzer's inflation, and it is the safer method to employ when a
cicatrix or atrophied patch exists in the tympanic membrane, as by the
latter method rupture of these areas might occur. Further, the
catheter has the advantage of only inflating one ear, and thus
preventing any undue strain being put upon the other. In children the
catheter can seldom be employed, on account of the difficulty in
passing it.

Considerable information may be derived from inflation. If the
Eustachian tube is patent, a full clear sound is heard close to the
examiner's ear through the auscultating tube. If the Eustachian tube
is obstructed, the sound is fainter and more distant. If there is
fluid in the tympanum, a fine moist sound may be detected, which must
not be confounded with the coarser and more distant gurgling sound
associated with moisture at the pharyngeal opening of the tube. If a
small dry perforation exists in the tympanic membrane, the air may be
heard whistling through it, while if the perforation is large, a
sensation which is almost painful may be produced in the examiner's
ear. If there is fluid associated with the perforation, these sounds
may be accompanied by a bubbling noise. The effect of inflation upon
the hearing must be carefully tested and recorded.


AFFECTIONS OF THE EXTERNAL EAR

#Deformities.#--The auricle, together with the external auditory
meatus, may be _congenitally absent_ on one or on both sides. The
condition is not amenable to surgical treatment. _Double auricles_ are
occasionally met with; more frequently rudimentary _auricular
appendages_ about the size of a pea, consisting of skin, subcutaneous
connective tissue and nodules of cartilage occur in front of the
tragus, on the lobule or in the neck. These appendages should be
snipped off with scissors. These congenital deformities are due to
errors in development of the mandibular arch, and are frequently
associated with macrostoma, facial clefts, and other malformations of
the face.

_Outstanding ears_ may be treated by excising a triangular or
elliptical portion of skin and cartilage from the posterior surface of
the pinna and uniting the cut edges with sutures. Abnormally _large
ears_ may be diminished in size by the removal of a V-shaped portion
from the upper part of the auricle.

The term #hæmatoma auris# is applied to a sub-perichondrial effusion
of blood, which may occur either as the result of injury to the
auricle, for example in football players, or as a result of trophic
changes in the cartilage and perichondrium. The latter form is not
uncommon among the insane. A more or less tense fluctuating swelling
forms on the anterior surface of the auricle, presenting in some cases
a distinctly bluish coloration. Inflammation may ensue, and in some
cases suppuration and even necrosis of cartilage may follow.

The _treatment_ in a recent case consists in applying cold or elastic
compression with cotton-wool and a bandage, or in withdrawing the
effused blood by means of a hollow needle. In the event of suppuration
supervening, incision and drainage must be carried out.

#Epithelioma# may attack the auricle and extend along the external
auditory meatus. It begins as a small abrasion which refuses to heal,
and is attended with a constant fœtid discharge and intense pain. The
disease may spread to the middle ear and invade the temporal bone, and
facial paralysis then ensues. The adjacent lymph glands are early
infected. The treatment consists in removing the growth freely, and
excising the associated lymph glands at an early stage of the disease.
In inoperable cases radium or the X-rays may be employed.

#Rodent cancer# also may attack the outer ear.

#Impaction of Wax or Cerumen.#--Hyper-secretion may result from
unknown causes, or it may accompany or be induced by the discharge
from a chronic middle-ear suppuration. The association of these two
conditions should be borne in mind. An accumulation of wax may be
caused by the too zealous attempts of the patient to keep the ear
clean, the wax being forced into the narrow deeper part of the meatus.

The chief _symptom_ of impacted wax is deafness, which is often of
sudden onset. Impaction of wax causes deafness only when the lumen of
the auditory canal becomes completely occluded by the plug. Tinnitus
aurium and vertigo are sometimes present, and may be troublesome if
the wax rests upon the tympanic membrane. Pain is occasionally
complained of, and is usually due to the pressure of the plug upon an
inflamed area of skin. Certain reflex symptoms, such as coughing and
sneezing, have been met with.

It is only by an objective examination of the ear that the diagnosis
can be made. The plug varies in colour and consistence, and may be
yellow, brown, or black in appearance. Sometimes from the admixture of
a quantity of epithelium it is almost white in colour.

_Treatment._--The ear should be syringed with a warm antiseptic or
sterilised solution. The lotion is at a suitable temperature if the
finger can be comfortably held in it. The ear should be turned to the
light, a towel placed over the patient's dress, and a kidney basin
held under the auricle and close to the cheek. A syringe provided with
metal rings for the fingers and armed with a fine ear nozzle should be
held with the point inserted just within the aperture of the external
meatus and in contact with the roof of the canal. Care must be taken
that all the air is first removed from the syringe. To straighten the
canal, the pinna should be pulled upwards and backwards by the left
hand. It may be necessary to exert some considerable degree of force
before the plug becomes dislodged, but this must be done with caution.
The ear should then be dried out with cotton-wool, and a small plug
of wool inserted for a few hours. If pain is complained of, or if the
wax is hard and cannot be readily removed, the syringing should be
stopped, and means taken to soften it by the instillation of a few
drops of a solution of bicarbonate of soda (10 grains to the ounce of
water or glycerine), or of peroxide of hydrogen, several times daily.

#Eczema of the external meatus# is often associated with eczema of the
auricle and of the surrounding parts. Not infrequently there also
exists a chronic middle-ear suppuration, which may be the cause of the
eczema. Intense itchiness is the most characteristic symptom, and a
watery discharge may also be complained of. Deafness and tinnitus are
dependent upon the accumulation of epithelium and débris. After the
ear is syringed the skin may present a dry, scaly appearance, while
sometimes fissures and an indurated condition of the outer end of the
meatus may be noted. Rarely is the outer surface of the tympanic
membrane itself involved.

_Treatment_ consists in keeping the ear clean by syringing and careful
drying. Probably the best local application is nitrate of silver (10
grains to the ounce of spiritus ætheris nitrosi). This is applied by
means of a grooved probe dressed with a small piece of cotton-wool.
Care should be taken that none of the fluid is allowed to escape upon
the cheek, otherwise staining of the skin occurs. A plug of
cotton-wool is inserted, and the solution is re-applied at the end of
a week. Sometimes the condition is very intractable.

Occasionally the vegetable parasite _aspergillus_ is present in the
external meatus, and produces a condition that is liable to be
mistaken for eczema. Strong antiseptic lotions are required to kill
the fungus.

#Furunculosis# or #Boils#.--Boils in the ear may arise singly or in
crops, and may be associated with eczema of the meatus or with chronic
suppuration of the middle ear. Pain is the chief symptom complained
of, and it may be very acute. Deafness ensues when the meatus becomes
completely blocked by the swelling. The boil occurs in the
cartilaginous meatus, and it is to be borne in mind that the skin may
present a normal appearance even when suppuration has occurred.
Palpation of the affected area with the probe causes intense pain.
Sometimes œdema over the mastoid with displacement forwards of the
pinna supervenes, and simulates acute inflammation of the mastoid.

_Treatment._--If seen in the earliest stages, an attempt may be made
to relieve the pain by the application of a 20 per cent. menthol and
parolein solution, or by the use of carbolic acid and cocain, 5 grains
of each to a dram of glycerine. When suppuration has occurred, the
best treatment is by early incision, transfixing the base of the
swelling with a narrow knife and cutting into the meatus. If the
tendency to boils persists, a staphylococcal vaccine will be found of
value.

#Foreign Bodies.#--It is unnecessary to enumerate all the varieties of
foreign bodies that may be met with in the ear. They may be
conveniently classified into the animate--for example maggots, larvæ,
and insects; and the inanimate--for example beads, buttons, and peas.
Pain, deafness, tinnitus, and giddiness may be produced, and such
reflex symptoms as coughing and vomiting have resulted.

The main practical point consists in identifying the body by
inspection. The mere history of its introduction should not be taken
as proof of its presence. In children it is advisable to give a
general anæsthetic so that a thorough examination may be made with the
aid of good illumination. If previous attempts to remove the body have
caused œdema of the meatal walls, and if the symptoms are not urgent,
no further attempt should be made until the swelling has been allayed
by syringing with warm boracic lotion, and by applying one or more
leeches to the tragus. An attempt should always be made in the first
instance to remove the body by syringing. It is rare to find this
method fail. Should it do so, a small hook should be used, sharp or
blunt according to the consistence of the body. Maggots, larvæ, and
insects should first be killed by instillations of alcohol and then
syringed out.


AFFECTIONS OF THE TYMPANIC MEMBRANE AND MIDDLE EAR

#Traumatic Rupture of the Tympanic Membrane.#--Perforating wounds may
result from direct violence caused by the patient--for example, in
attempts to remove wax or foreign bodies, or by clumsiness on the part
of the surgeon. It is also a comparatively common complication of
fracture of the middle fossa of the base of the skull. More commonly,
perhaps, the membrane is ruptured from indirect violence due to great
condensation of the air in the external auditory meatus, following
blows upon the ear, heavy artillery reports, or diving from a height.
The injury is followed by pain in the ear, often by considerable
deafness and tinnitus, and bleeding is frequently observed. If early
examination of the ear is made, coagulated blood may be found in the
meatus or upon the membrane, or ecchymosis may be visible on the
latter. A rupture in the membrane following indirect violence is
usually lozenge-shaped. During inflation by Valsalva's method the air
may be heard to whistle through the perforation. In all such injuries
the hearing should be carefully tested, and the possibility of an
injury to the labyrinth investigated by means of the tuning-fork test.
Prognosis as regards hearing should be guarded at first. As a rule the
rupture heals rapidly, and no treatment is necessary save the
introduction of a piece of cotton-wool into the meatus. Syringing
should be avoided unless suppuration has already occurred, in which
case treatment for this condition must be adopted. As these injuries
frequently have a medico-legal bearing, careful notes should be made.

#Acute Infection of the Middle Ear.#--This usually arises in
connection with infective conditions of the throat and naso-pharynx.
It varies considerably in its severity, and may run a mild or a severe
course. It is characterised by pain in the ear, deafness, and a
certain degree of fever. In children the symptoms may simulate those
of meningitis. When the tympanic membrane is examined in the mild
forms of the affection or in the early stages of the more severe type,
the vessels about the handle of the malleus and periphery of the
membrane are injected, and possibly a number of injected vessels may
be seen coursing across the surface of the membrane. In the later
stages the whole membrane presents a red surface, the anatomical
landmarks being indistinguishable, the membrane bulges outwards into
the meatus, and, if an abscess is pointing, a yellowish area may be
visible upon it. The sudden cessation of pain and the appearance of a
discharge from the meatus indicate perforation of the membrana
tympani.

The _treatment_ of acute otitis media varies with the severity of the
attack. The patient should be confined to the house or to bed, alcohol
and tobacco should be forbidden, and the bowels must be freely opened.
Pain may be allayed by repeated instillations of cocain and carbolic
acid (5 grains of each to a dram of glycerine). A few drops of
laudanum, hot boracic instillations, or the application of a dry hot
sponge, may prove soothing. Two or three leeches may be applied over
the mastoid, but should the pain persist or should rupture of the
membrane appear imminent, paracentesis must be carried out. After
spontaneous perforation or puncture, the meatus must be kept clean. It
is probably safer not to inflate through the Eustachian tube in the
acute stage. Attention must be paid to any affection of the nose or
throat that may be present.

#Chronic Suppuration in the Middle Ear.#--Acute suppuration may pass
into the chronic variety, which is characterised by a perforation of
the tympanic membrane, a persistent purulent or muco-purulent
discharge from the middle ear, and a certain amount of deafness.

_Various complications_ may arise in the course of chronic middle-ear
disease, and so long as a person is the subject of a chronic otorrhœa,
he is liable to one or more of these. The complications may be
extra-cranial or intra-cranial. Those affecting the middle ear itself
include granulations, polypi, cholesteatoma, caries and necrosis of
the temporal bone, destruction and loss of one or more of the
ossicles, facial paralysis, hæmorrhage from the carotid artery or
jugular vein, and malignant disease. As mastoid complications may be
mentioned: suppurative mastoiditis, leading to destruction of the
bone, mastoid fistula, and sub-periosteal mastoid abscess. The
intra-cranial complications that may arise are: extra-dural abscess,
sub-dural abscess, meningitis, cerebral and cerebellar abscess, and
lateral sinus phlebitis with general septicæmia and pyæmia.

The _treatment_ of chronic middle-ear suppuration consists in keeping
the parts clean by syringing with antiseptic lotions. The installation
of hydrogen peroxide, followed by syringing with boiled water or
boracic lotion, and inflation through the Eustachian tube once, twice,
or thrice daily, according to the requirements of the case, constitute
a routine method. Packing the meatus with antiseptic gauze after
washing out may be practised.

#Suppuration in the Tympanic Antrum and Mastoid Cells#, or _Acute
Suppurative Mastoiditis_.--Acute suppuration may occur in the mastoid
cells in the course of an attack of acute otitis media, or as a result
of interference with drainage in chronic suppuration of the antrum and
middle ear. As the outer wall of the mastoid is liable to be
perforated by cario-necrosis, the pus may find its way externally and
form an abscess over the mastoid process behind the ear. In some cases
the pus escapes into the external auditory meatus by perforating its
posterior wall; in others a sinus forms on the inner side of the apex
of the mastoid, and the pus burrows in the digastric fossa under the
sterno-mastoid--_Bezold's mastoiditis_. If the posterior wall or roof
of the antrum is destroyed, intra-cranial complications are liable to
ensue.

The _clinical features_ are pain behind the ear, tenderness on
pressure or percussion over the mastoid, redness and œdematous
swelling of the skin, and, when pus forms under the periosteum, the
œdema may be so great as to displace the auricle downwards and
forwards (Fig. 265). The deeper part of the posterior osseous wall of
the meatus may be swollen so that it conceals the upper and back part
of the membrane.

[Illustration: FIG. 265.--Acute Mastoid Disease, showing œdema and
projection of auricle.]

_Treatment._--When arising in connection with acute otitis, the
application of several leeches behind the ear, free incision of the
membrane, and syringing with hot boracic lotion may be sufficient. As
a rule, however, it is necessary to expose the interior of the antrum
by opening through the mastoid cells--_Schwartze's operation_. When
mastoid suppuration is associated with chronic middle-ear disease,
it is usually necessary to perform the complete radical
operation--_Stacke-Schwartze operation_. The operations are described
in _Operative Surgery_, p. 98.




CHAPTER XXV

THE NOSE AND NASO-PHARYNX[6]


Fracture of nasal bones--Deformities of nose: _Saddle nose_; _Partial
    and complete destruction of nose_; _Restoration of nose_;
    _Rhinophyma_--Intra-nasal affections--Examination of the nasal
    cavities: _Anterior rhinoscopy_; _Posterior rhinoscopy_; _Digital
    examination_. CARDINAL SYMPTOMS OF NASAL AFFECTIONS: Nasal
    obstruction: _Erectile swelling of inferior turbinals_; _Nasal
    polypi_; _Malignant tumours_; _Deviations, spines, and ridges of
    septum_; _Hæmatoma of septum_--Nasal discharge: _Foreign bodies_;
    _Rhinoliths_; _Ozæna_; _Epistaxis_; _Suppuration in accessory
    sinuses_--Anomalies of smell and taste: _Anosmia_;
    _Parosmia_--Reflex symptoms of nasal origin--Post-nasal
    obstruction: _Adenoids_--Tumours of naso-pharynx.

[6] Revised by Dr. Logan Turner.

#Fracture of the Nasal Bones and Displacement of the
Cartilages.#--These injuries are always the result of direct violence,
such as a blow or a fall against a projecting object, and in spite of
the fact that the fracture is usually compound through tearing of the
mucous membrane, infective complications are rare. The fracture
usually runs transversely across both nasal bones near their lower
edge, but sometimes it is comminuted and involves also the frontal
processes of the maxillæ. In nearly all cases the cartilage of the
septum is bent or displaced so that it bulges into one or other
nostril, and not infrequently a hæmatoma forms in the septum (p. 573).
Sometimes the perpendicular plate of the ethmoid is implicated, and
the fracture in this way comes to involve the base of the skull. The
nasal ducts may be injured, obstructing the flow of the tears, and a
lachrymal abscess and fistula may eventually form.

The _clinical features_ are pain, bleeding from the nose,
discoloration, and swelling. Crepitus can usually be elicited on
pressing over the nasal bones. The deformity sometimes consists in a
lateral deviation of the nose, but more frequently in flattening of
the bridge--_traumatic saddle nose_. Within a few hours of the injury
the swelling is often so great as to obscure the nature of the
deformity and to render the diagnosis difficult. Subcutaneous
emphysema is not a common symptom; when it occurs, it is usually due
to the patient forcing air into the connective tissue while blowing
his nose. The lateral cartilages may be separated from the nasal bones
and give rise to clinical appearances which simulate those of
fracture. Sometimes the septum is displaced laterally without the bone
being broken, and this causes symptoms of nasal obstruction.

_Treatment._--As the bones unite rapidly, it is of great importance
that any displacement should be reduced without delay, and to
facilitate this a general anæsthetic should be administered, or the
nasal cavity sprayed with cocain. The bones can usually be levered
into position with the aid of a pair of dressing forceps passed into
the nostrils, the blades being protected with rubber tubing. After the
fragments have been replaced and moulded into position, it is seldom
necessary to employ any retaining apparatus, but the patient must be
warned against blowing or otherwise handling the nose. When the septum
is damaged and the bridge of the nose tends to fall in, rubber tubes
may be placed in the nostrils to give support, or, if this is not
sufficient, a soft lead or gutta-percha splint should be moulded over
the nose, and the splint and the fragments transfixed with one or more
hare-lip pins. These may be removed on the fourth or fifth day. Rigid
appliances introduced into the nostrils are to be avoided if possible,
as they are uncomfortable and interfere with proper cleansing and
drainage of the nose. The inside of the nose should be smeared with
vaseline to prevent crusting of blood, and the nasal cavities should
be frequently irrigated.

#Deformities of the Nose.#--The most common deformity is that known as
the _sunken-bridge_ or _saddle nose_ (Volume I., p. 174). It is most
frequently a result of inherited syphilis, the nasal bones being
imperfectly developed, and the cartilages sinking in so that the tip
of the nose is turned up and the nostrils look directly forward. The
bridge of the nose may sink in also as a result of necrosis of the
nasal bones, particularly in tertiary syphilis, and less frequently
from tuberculous disease. A similar, but as a rule less marked
deformity may result from fracture of the nasal bones or from
displacement of the cartilages.

When the condition is due to mal-union of a fracture, the contour of
the nose may be restored by operation. A narrow knife is passed in at
the nostril and the skin freely separated from the bone; the bone is
then broken into several pieces with necrosis forceps, and the
fragments moulded into shape. A rubber drainage tube introduced into
each nostril maintains the contour of the nose till union has taken
place.

When it results from disease, it is much less amenable to treatment.
The present-day tendency is to discard the use of subcutaneous
paraffin injection and to employ grafts of cartilage or bone. An
artificial bridge has been made by turning down from the forehead a
flap, including the periosteum and a shaving of the outer table of the
skull, or by implanting portions of bone or plates of gold, aluminium,
or celluloid.

Portions of the alæ nasi may be lost from injury, or from lupus,
syphilis, or rodent cancer. After the destructive process has been
arrested, the gap may be filled in by a flap taken from the cheek or
adjacent part of the nose. When the tip of the nose is lost, it may be
replaced by Syme's operation, which consists in raising flaps from the
cheeks and bringing them together in the middle line.

The whole of the nose, including the cartilages and bones, may be
destroyed by syphilitic ulceration or by lupus. In parts of India the
nose is sometimes cut off maliciously or as a punishment for certain
crimes.

In reconstructing the nose it is necessary to provide skin, a
supporting structure in the form of cartilage or bone, and an
epithelial lining. In the "Indian operation" a racket-shaped flap,
including skin and periosteum, is turned down from the forehead and
fixed in position, the edges of the flap being inturned to provide a
lining for the passage. An implant of free cartilage may be necessary
to support the skin flaps and to prevent subsequent contraction.
Flaps of skin may be formed by Gillies' tube-pedicle method from the
cheek, the forehead, or the neck, and utilised to form the covering of
the nose. When the deformity cannot be corrected by operation, the
appearance may be greatly improved by wearing an artificial nose held
in position by spectacles.

The term #Rhinophyma# has been applied by Hebra to a condition in
which the skin of the tip and alæ of the nose becomes thick and
coarse, and presents large, irregular, tuberous masses on which the
orifices of the sebaceous follicles are unduly evident--_potato_ or
_hammer nose_ (Fig. 266). The capillaries of the skin are dilated and
tortuous, and the nose assumes a bluish-red colour, and its surface is
soft and greasy. The condition is met with in elderly men, and the
masses appear to be chiefly composed of sebaceous adenomas. The term
_lipoma nasi_, formerly employed, is therefore misleading.

[Illustration: FIG. 266.--Rhinophyma or Lipoma Nasi in man æt. 65.]

The treatment consists in paring away the protuberant masses until the
normal size and contour of the nose are restored, care being taken not
to encroach on the cartilages or on the orifices of the nostrils.
There is comparatively little bleeding, and the raw surface rapidly
becomes covered with epidermis.

#Examination of the Nasal Cavities.#--For the examination of the
interior of the nose the following appliances are necessary: A
reflector, such as is used in laryngoscopy, attached to a forehead
band or spectacle frame; one of the various forms of nasal speculum; a
long, pliable probe; a tongue depressor; and a small-sized mirror. As
additional aids, a 10 per cent. solution of cocain, a grooved probe as
a cotton-wool holder, and a palate retractor should be in readiness.
Good illumination is important, and may be obtained from an electric
light, or from a Welsbach or Argand burner. The light should be placed
close to, and on a level with, the patient's left ear. Both the
anterior and posterior nares should be examined.

_Anterior Rhinoscopy._--Before the introduction of the speculum the
tip of the nose should be tilted up and the interior of the vestibule
and the anterior part of the septum examined. In this way the
existence of eczema or small furuncules, the presence of dilated or
bleeding vessels upon, or a perforation of, the anterior part of the
septum may be noted, and the general appearances observed. After
inserting the speculum into the vestibule and dilating it, the
following parts should be sought for and examined:--Close to the
floor, and attached to the outer wall of the nasal cavity, is the
anterior end of the inferior concha or turbinated body (Fig. 267),
which overhangs the inferior meatus. It presents a pink appearance,
and its size varies in different persons. At a higher level and on a
posterior plane is the anterior end of the middle concha or turbinated
body, which is of a paler colour than the inferior, and is only
visible when the head is tilted backwards. Between it and the inferior
turbinated body is the middle meatus, with which communicate the
openings of the maxillary sinus, the frontal sinus, and the anterior
ethmoidal cells. A considerable area of the anterior part of the nasal
septum is also visible by anterior rhinoscopy, and between it and the
middle turbinal is a narrow chink--the olfactory sulcus.

[Illustration: FIG. 267.--The outer wall of Left Nasal Chamber, after
removal of the middle turbinated body. (After Logan Turner.)]

_Posterior Rhinoscopy._--Examination of the posterior nares and
naso-pharynx is frequently attended with difficulty. The patient is
directed to breathe through the nose, the tongue is depressed with a
spatula, and a small-sized laryngeal mirror, comfortably warmed and
with its reflecting surface turned upwards, is introduced behind the
soft palate. When a good examination of the naso-pharynx is obtained,
the following parts may be seen reflected in the mirror: the posterior
surface of the uvula and soft palate, and above them, in the mesial
plane, the posterior free edge of the septum nasi; on each side of the
septum the apertures of the posterior nares, in which may be seen the
upper part of the posterior end of the inferior turbinal, the middle
meatus, the posterior end of the middle turbinal, the superior meatus,
and occasionally a portion of the superior turbinal. On the lateral
wall of the naso-pharynx the Eustachian opening and cushion can be
seen, while by tilting the mirror backwards the vault of the
naso-pharynx can be inspected.

_Digital examination_ of the naso-pharynx may be required, especially
in children. The examiner passes his left arm and hand round the back
of the child's head, and with one of his fingers presses the cheek
inwards, between the jaws. His right forefinger is carried along the
dorsum of the tongue, passed up behind the soft palate and a rapid
examination made of the post-nasal space.

CARDINAL SYMPTOMS OF NASAL AFFECTIONS.--The chief symptoms of nasal
disease are: nasal obstruction, nasal discharge, anomalies of smell
and taste, and certain reflex phenomena.

#Nasal Obstruction.#--This may be partial or complete, intermittent or
constant, and may be the cause of such symptoms as alteration in the
tone of the voice, catarrh of the respiratory passages, snoring,
cough, headache, inability to concentrate the attention, alteration in
the physiognomy, or deformity of the chest. The half-open mouth,
drooping jaw, lengthened appearance of the face, narrow nostrils, and
vacant expression are characteristic signs of nasal obstruction.

Nasal obstruction may be due to _intra-nasal_ or to _post-nasal_
(naso-pharyngeal) causes. Amongst the former may be noted as the more
common, erectile swelling and hypertrophy of the mucous membrane
covering the inferior turbinated bones, and nasal polypi growing from
the middle turbinal and middle meatal region. Causes originating in
the septum include deviations, spines, and ridges, and septal hæmatoma
and abscess. Obstruction may also be due to the presence of a foreign
body in the nasal cavity, to a rhinolith, and to imperfect development
of the nasal chambers. Further, tumours, both simple and malignant,
and such conditions as tubercle, lupus, syphilis, and glanders may
interfere more or less with nasal respiration. The most common cause
of post-nasal obstruction is the presence of adenoids; more rarely
fibro-mucous polypi, fibrous tumours, malignant disease, and
cicatricial contractions and adhesions resulting from syphilis are met
with.

_Erectile swelling_ of the inferior turbinated bodies is due to
engorgement of the venous spaces contained in the mucous membrane.
Obstruction from this cause is usually intermittent in character, and
may be unilateral or bilateral. It is influenced by posture, being
worse when the patient is in the horizontal position, and also by
changes in atmospheric conditions and temperature. It is characterised
objectively by a swelling of the mucous membrane, which is pink or red
in appearance and of a soft consistence, pitting when touched with the
probe, and shrinking on the application of a 5 per cent. solution of
cocain. Its soft consistence and the fact that it becomes smaller when
painted with cocain differentiate it from true hypertrophy of the
mucous membrane. Its situation and immobility, its pink colour, and
the shrinkage under cocain, distinguish it from the mucous polypus of
the nose. The turgescence may involve the whole extent of the mucosa
of the inferior turbinated bodies, including their posterior ends.
After anæsthetising with cocain, the electric cautery, or fused
chromic acid applied on a probe, may be employed for the relief of the
condition. If a true hypertrophy exists, it is better to remove it
with a nasal snare.

_Nasal polypi_ spring from the mucous membrane covering the middle
turbinated bone and from the adjacent parts of the middle meatus, but
rarely from the septum. They consist of œdematous masses of mucous
membrane, and are as a rule multiple. They are usually pedunculated,
and as they increase in size they become pendulous in the nasal
cavity. They are smooth, rounded in outline, of a translucent
bluish-grey colour, soft in consistence, and freely movable. These
characters, and the fact that the probe can be passed round the
greater part of the polypus, serve to differentiate this affection
from the erectile swelling. It must not be forgotten that nasal polypi
may be associated with suppuration in one or more of the accessory
sinuses. They are frequently present also in malignant disease, and in
these cases they bleed readily. They are best removed by means of the
cold snare, with the aid of the speculum and a good light. Several
sittings are usually necessary.

_Carcinoma_ and _sarcoma_ sometimes grow from the muco-periosteum in
the region of the ethmoid. They tend to invade adjacent parts, giving
rise to hæmorrhage and symptoms of nasal obstruction, and as they
increase in size they may cause considerable deformity of the face. If
diagnosed early, an attempt should be made to remove the growth.

_Deviations, spines, and ridges of the septum_ may produce partial or
complete occlusion of the anterior nares. In deviation of the septum,
the obstructed nostril is more or less occluded by a smooth rounded
swelling of cartilaginous or bony hardness, which is covered with
normal mucous membrane, while the opposite nostril shows a
corresponding concavity or hollowing of the septum. Sometimes the
convex side is thickened in the form of a ridge. A simple spine of the
septum is usually situated anteriorly, and presents an acuminate
appearance, often pressing against the inferior turbinated body; it is
hard to the touch. Ridges and spines may be cut or sawn off, or
removed with the chisel. Many methods of dealing with a deviated
septum have been suggested, such as forcible fracture or excision of a
portion of the cartilage. A submucous resection of the deflected
portion is to be preferred.

_Hæmatoma of the septum_ is usually traumatic in origin. As the result
of a blow, an extravasation of blood takes place beneath the
perichondrium on each side of the septum, and a bilateral, symmetrical
swelling, smooth in outline and covered with mucous membrane, is
visible immediately within the anterior nares. The blood is usually
absorbed and should not be interfered with. If suppuration occurs,
however, the swelling becomes soft, fluctuation can be detected, and
the patient's discomfort increases. The abscess must then be incised
and the cavity drained. It is sometimes found that a portion of the
cartilage undergoes necrosis, leading to perforation of the septum.

#Nasal discharge# may be mucous, muco-purulent, or purulent in
character. When it is of a clear, watery nature, it is usually
associated with erectile swelling of the inferior turbinated bodies. A
purulent discharge may be complained of from one or both nostrils. If
unilateral, it should suggest, in the case of children, the presence
of a foreign body; in adults, the possibility of suppuration in one or
more of the accessory sinuses. In infants, a purulent discharge from
both nostrils may be due to gonorrhœal infection or to inherited
syphilis. Nasal discharge may be constant or intermittent. It is
sometimes influenced by changes in posture; for example, it may be
chiefly complained of at the back of the nose and in the throat when
the patient occupies the horizontal position, or it may flow from the
nostril when he bends his head forward or to one side. The discharge
may be intra-nasal in origin, or due altogether to naso-pharyngeal
catarrh. It varies somewhat in colour and consistence, and may be
associated with such intra-nasal conditions as purulent rhinitis
following scarlet fever and other exanthemata or ulceration
accompanying malignant disease, syphilis, or tuberculosis. Sometimes
it contains shreds of false membrane, for example in nasal diphtheria;
or white cheesy masses as in coryza cascosa. The formation of crusts
is significant of fœtid atrophic rhinitis (ozæna) and syphilis, and in
these conditions the discharge is associated with a most objectionable
and distinctive fœtor. Pus from the maxillary sinus is often fœtid,
and the odour is noticed by the patient; while the odour of ozæna is
not recognised by the patient, although very obvious to others.

#Foreign bodies# of various descriptions have been met with in the
nasal cavities, particularly of children. They set up suppuration and
give rise to a unilateral discharge, which is often offensive in
character. The surgeon must not be satisfied with the history given by
the parents, but, with the aid of good illumination, and, in young
children, under general anæsthesia, the nose should be carefully
inspected and probed. If there is much swelling, the introduction of a
5 per cent. solution of cocain will facilitate the examination by
diminishing the congestion of the mucous membrane. No attempt should
be made to remove a foreign body from the nose by syringing. If fluid
is injected into the obstructed nostril, it is liable to force the
body farther back, while, if injected into the free nostril, it is apt
to accumulate in the naso-pharnyx and to pass into the Eustachian
tubes. A fine hook should be passed behind the body and traction made
upon it, or sinus forceps or a snare may be employed. Care must be
taken that the body is not pushed still deeper into the cavity. Fungi
and parasites should first be killed with injections of chloroform
water, or by making the patient inhale chloroform vapour.

#Rhinoliths.#--Concretions having a plug of inspissated mucus or a
small foreign body as a nucleus sometimes form in the nose. They are
composed of phosphate and carbonate of lime, and have a covering of
thickened nasal secretion. They are rough on the surface, dark in
colour, and usually lie in the inferior meatus. They give rise to the
same symptoms as a foreign body, and are treated in the same way. The
stone, which is usually single, may be so large and so hard that it is
necessary to crush it before it can be removed.

#Ozæna#, or #fœtid atrophic rhinitis#, is characterised by atrophy of
the nasal mucous membrane, and sometimes even of the turbinated bones,
and is accompanied by a muco-purulent discharge and the formation of
crusts having a characteristic offensive odour, which is not
recognised by the patient. It is usually bilateral, and the nasal
chambers, owing to the atrophy, are very roomy. It may be
differentiated from a tertiary syphilitic condition by the absence of
ulceration and necrosis of bone, by the odour, and by the fact that it
is not influenced by anti-syphilitic treatment.

Various methods of treatment are in vogue, but thorough cleanliness is
the most essential factor, and this is best secured by regular
syringing. Plugging of the nostrils with cotton-wool for half an hour
before washing out the nose greatly facilitates the detachment of the
crusts. A pint of lukewarm solution containing a teaspoonful of
bicarbonate of soda or of common salt, is then used with a Higginson's
syringe, the patient leaning over a basin and breathing in and out
quickly through the open mouth. The patient should then forcibly blow
down each nostril in turn, the other being occluded with the finger,
so that the infective material may thus be blown out without risk of
it entering the Eustachian tubes, as may happen when the handkerchief
is used in the ordinary way. Antiseptic sprays, such as peroxide of
hydrogen, and ointments may be applied to the mucous membrane after
cleansing.

#Epistaxis.#--Bleeding from the nose may be due either to local or to
general causes. Among the former may be cited injuries such as result
from the introduction of foreign bodies, blows on the face, and
fractures of the anterior fossa of the skull, and the ulceration of
syphilitic, tuberculous, or malignant disease. Amongst the general
conditions in which nasal hæmorrhage may occur are typhoid fever,
anæmia, and purpura cardiac and renal disease, cirrhosis of the liver,
and whooping-cough. Prolonged oozing of blood may be an evidence of
hæmophilia. Nasal hæmorrhage usually takes place from one or more
dilated capillaries situated at the anterior inferior part of the
septum close to the vestibule, and in such cases the bleeding point is
readily detected. Occasionally bleeding occurs from one of the
anterior ethmoidal veins, and under these circumstances the blood
flows downwards between the middle turbinal and the septum. Before
steps are taken to arrest the bleeding, the interior of the nose
should, if possible, be inspected and the bleeding point sought for.
As a preliminary to the use of local applications, the nose should be
washed out with boracic lotion or salt solution to remove all clots
from the cavity. In many cases this is all that is necessary to stop
the bleeding. If the bleeding is not very copious, it may be stopped
by grasping the alæ nasi between the finger and thumb, or by spraying
the nasal cavity with adrenalin. If the blood is evidently flowing
from the olfactory sulcus, a strip of gauze soaked in adrenalin,
turpentine, or other styptic should be packed between the septum and
middle turbinated body. If recurrent hæmorrhage takes place from the
anterior and lower part of the septum, the application of the electric
cautery at a dull red heat, or of the chromic acid bead fused on a
probe, is the best method of treatment. Plugging of the posterior
nares is rarely necessary, as, in the majority of cases, an anterior
plug suffices. In bleeders, the administration of sheep serum by the
mouth has proved efficacious.

#Suppuration in the Accessory Nasal Sinuses.#--As already stated, the
presence of pus in the nose should always direct attention to its
possible origin in one or more of the accessory sinuses, especially if
the discharge is unilateral. The condition is usually a chronic one,
and may be present for months, or even years, without the patient
suffering much inconvenience save from the presence of the discharge.

If on examination by anterior rhinoscopy, pus is seen in the middle
meatus, suspicion should be aroused of its origin in the maxillary
sinus, frontal sinus, or anterior ethmoidal cells, as all these
cavities communicate with that channel. If, on the other hand, the pus
is detected in the olfactory sulcus, attention must be directed to
the posterior ethmoidal cells and sphenoidal sinus (Fig. 267). Further
evidence of its source in the last-named cavities may be gained by
finding pus in the superior meatus above the middle turbinal on
examination by posterior rhinoscopy.

As the anterior group of sinuses is most frequently affected, and of
these most commonly the _maxillary sinus_, attention should first be
turned to this cavity. Pain, tenderness on pressing over the canine
fossa or on tapping the teeth of the upper jaw, and swelling of the
cheek are rarely met with save in acute inflammation. The complaint of
a bad odour or taste, the reappearance of pus in the middle meatus
after mopping it away and directing the patient to bend his head well
forwards, and opacity on trans-illumination of the suspected cavity,
are signs which strongly suggest an affection of the maxillary sinus.
The withdrawal of pus by a puncture through the thin outer wall of the
inferior meatus of the nose with a fine trocar and cannula will
establish the diagnosis.

The _treatment_ consists in opening and draining the sinus. If the
infection is due to a carious tooth, this should be extracted, the
socket opened up and drainage established through it in recent cases.
If the teeth are sound, and the case is of long duration, the sinus is
opened through the canine fossa and its walls curetted. To avoid the
risk of reinfecting the cavity from the mouth, an opening may be made
into the nose by removing a portion of the nasal wall of the sinus and
part of the inferior turbinated bone, after which the incision in the
buccal mucous membrane is closed with sutures.

Suppuration in the _frontal sinus_ is attended with frontal headache,
vertigo, especially on stooping, and tenderness on pressure,
particularly over the internal orbital angle, or on percussion over
the frontal region. Pus escapes into the middle meatus of the nose,
and if wiped away will reappear if the head is kept erect for a few
minutes. After removal of the anterior end of the middle turbinated
bone, it may be possible to catheterise the sinus and wash out pus
from its interior. The diseased sinus may present a darker shadow than
the healthy one on trans-illumination, or in an X-ray photograph.

The _treatment_ consists in exposing the anterior wall of the sinus,
chiselling away sufficient bone to admit of free removal of all
infected tissue, and establishing efficient drainage through the
infundibulum (Fig. 267) into the nose.

The _anterior ethmoidal cells_ (Fig. 267) are frequently affected in
conjunction with the frontal, and sometimes with the maxillary sinus.
The presence of polypi and granulations, with pus oozing out from
between them, and increasing after withdrawal of the probe, and the
detection of carious bone are significant of ethmoidal suppuration.

The _treatment_ consists in extending the operation for the frontal or
maxillary sinus so as to ensure drainage of the ethmoidal cells.

_Suppuration in the sphenoidal sinus_ (Fig. 267) is characterised in
many cases by the presence of eye symptoms. Pus in the olfactory
sulcus, on the upper surface of the middle turbinal posteriorly, and
on the vault of the naso-pharynx, is suggestive of sphenoidal
suppuration. The removal of the middle turbinated bone permits of
inspection of the ostium sphenoidale by anterior rhinoscopy, and pus
may be seen escaping from the orifice. A probe is then passed into the
ostium, and the anterior wall of the sinus is removed with a curette
or rongeur forceps.

The _posterior ethmoidal cells_ (Fig. 267) are frequently affected
along with the sphenoidal sinus. The nasal appearances just noted are
present, and if the sphenoidal sinus can be washed out and its ostium
temporarily plugged, and pus rapidly reappears, its origin from these
cells is probable. The operation for draining the sphenoidal sinus is
extended by removing the inner wall of the posterior ethmoidal cells.

#Anomalies of Smell and Taste.#--_Anosmia_ or loss of smell and
impairment or loss of the sense of recognising flavours may follow
fracture of the anterior fossa attended with injury of the olfactory
nerves, and is a common sequel of influenza. Any lesion that prevents
the passage of the odoriferous particles to the olfactory region of
the nose interferes with the sense of smell. In ozæna also the sense
of smell is lost. _Parosmia_, or the sensation of a bad odour, may be
of functional origin; it sometimes occurs after influenza. It may also
be associated with maxillary suppuration.

#Reflex Symptoms of Nasal Origin.#--It is only necessary here to draw
attention to the relation that exists between affections of the nose
and asthma. When present in asthmatic subjects, nasal polypi, erectile
swelling of the inferior turbinated bodies, spines of the septum in
contact with the inferior turbinal, or areas on the mucous membrane
which, when probed, produce coughing, call for treatment with the
object of modifying the asthma.

#Post-nasal Obstruction--Adenoid Vegetations.#--The most common cause
of post-nasal obstruction is hypertrophy of the normal lymphoid
tissue which constitutes the naso-pharyngeal or Luschka's tonsil.
_Adenoids_ form a soft, velvety mass, which projects from the vault of
the naso-pharynx and extends down its posterior and lateral walls, in
some cases filling up the fossæ of Rosenmüller behind the Eustachian
cushions. They do not grow from the margins of the posterior nares.
Adenoids are frequently associated with hypertrophy of the faucial
tonsils, and the patient often suffers from granular pharyngitis and
chronic nasal catarrh.

These growths are sometimes met with in infants, but are most common
between the ages of five and fifteen, after which they tend to undergo
atrophy. They may, however, persist into adult life.

_Clinical Features._--The most prominent symptom in most cases is
interference with nasal respiration, so that the patient is compelled
to breathe through the mouth. The facies of adenoids is
characteristic: the mouth is kept partly open, the face appears
lengthened, the nose is flattened by the falling in of the alæ nasi,
the inner angles of the eyes are drawn down, and the eyelids droop,
while the whole facial expression is dull and stupid. As the
respiratory difficulty is increased during sleep, the patient snores
loudly, and his sleep is frequently broken by sudden night terrors.
Owing to the disturbed sleep, to imperfect oxygenation of the blood,
and to frequent attacks of nasal and bronchial catarrh, the child's
nutrition is interfered with, and he becomes languid and backward at
his lessons.

When the adenoids encroach upon the Eustachian cushions, the patient
suffers from deafness, frequent attacks of earache, and sometimes from
suppurative otitis media with a discharge from the ear.

Among the rarer conditions attributed to adenoids are asthma,
inspiratory laryngeal stridor, persistent cough, chorea, and nocturnal
enuresis.

A _diagnosis_ should never be made from the symptoms alone; an attempt
must be made to examine the naso-pharynx by posterior rhinoscopy and
by digital examination. The interior of the nose must always be
examined and any further cause of obstruction excluded.

_Treatment._--Thorough removal is the only satisfactory line of
treatment, and this should be done under general anæsthesia. The
following instruments are necessary: two Gottstein's adenoid curettes,
one provided with a cradle and hooks, the other without, a Hartmann's
lateral ring knife, and one pair of adenoid forceps--Kuhn's or
Lœwenberg's--a tongue depressor, a gag, and one or two throat sponges
on holders. The patient having been anæsthetised, his head should be
drawn over the end of the table. An assistant standing on the left
side inserts the gag and maintains it in position. The operator, being
on the patient's right, depresses the tongue and insinuates the
curette provided with the hooks behind the soft palate, carrying it to
the roof of the naso-pharynx between the growth and the posterior free
edge of the nasal septum. Firm pressure is then made against the vault
of the naso-pharynx, and the curette is carried backwards and
downwards in the mesial plane and withdrawn with the main mass of the
adenoids caught in the hooks. The unguarded curette is then introduced
and several strokes are made with it, the instrument being carried on
either side of the mesial plane. With Hartmann's lateral ring knife
the posterior naso-pharyngeal wall and fossæ of Rosenmüller are
curetted. The curette should not be used on the lateral pharyngeal
wall in case the Eustachian orifices and cushions are damaged.
Bleeding soon ceases when the head is again elevated, and the patient
should be at once laid well over upon his side so that the blood may
escape from the mouth.

No local after-treatment is required, and spraying or syringing may
prove harmful. The patient should remain in the house for five or six
days. If nasal obstruction has been the outstanding symptom,
respiratory exercises through the nose should be carried out for some
considerable time; on the other hand, if Eustachian obstruction and
deafness have been the main features of the case, a course of Politzer
inflation should be conducted after the wound has healed.

#Tumours of the Naso-Pharynx.#--Tumours are occasionally met
with growing from the muco-periosteum of the basi-sphenoid
and basi-occipital, and projecting from the vault of the
naso-pharynx--_naso-pharyngeal tumour_ or retro-pharyngeal polypus.
This usually occurs between the ages of fifteen and twenty, and while
it may originally be a fibroma, it tends to assume the characters of a
fibro-sarcoma and to exhibit malignant tendencies. At first the tumour
is firm, rounded, and of slow growth, but later it becomes softer,
more vascular, and grows more rapidly, spreading forwards towards the
nasal cavity and downwards towards the pharynx.

_Clinical Features._--In its growth the tumour blocks the nostrils,
and so interferes with nasal respiration and causes the patient to
snore loudly, especially during sleep. It may also bulge the soft
palate towards the mouth and interfere with deglutition. In some cases
the face becomes flattened and expanded and the eyes are pushed
outwards, giving rise to the deformity known as _frog-face_. Deafness
may result from obstruction of the Eustachian tube. The patient
suffers from intense frontal headache, and there is a persistent and
offensive mucous discharge from the nose. Profuse recurrent bleeding
from the nose is a common symptom, and the patient becomes profoundly
anæmic. The tumour can usually be seen on examination with the nasal
speculum or by posterior rhinoscopy, and its size and limits may be
recognised by digital examination.

Unless removed by operation these tumours prove fatal from hæmorrhage,
interference with respiration, or by perforating the base of the skull
and giving rise to intra-cranial complications.

_Treatment._--These growths are seldom recognised before they have
attained considerable dimensions, and owing to the fact that they are
permeated by numerous large, thin-walled venous sinuses, their removal
is attended with formidable hæmorrhage. Attempts to remove them by the
galvanic snare are seldom satisfactory, because the base of the tumour
is left behind and recurrence is liable to take place. The operative
treatment is described in _Operative Surgery_, p. 153.




CHAPTER XXVI

THE NECK


Surgical Anatomy--Malformations: _Cervical auricles_; _Thyreo-glossal
    cysts and fistulæ_; _Lateral fistula_--Cervical ribs--Wry-neck:
    _Varieties_; _Cicatricial contraction_--Injuries:
    _Contusions_--_Fractures of hyoid, larynx, etc._:
    _Cut-throat_--Infective conditions: _Diffuse cellulitis_;
    _Actinomycosis_; _Boils and Carbuncles_--Tumours: _Cystic_:
    _Branchial cysts_; _Cystic lymphangioma_; _Blood cysts_; _Bursal
    cysts_--_Solid_: _Lipoma_; _Fibroma_; _Osteoma_; _Sarcoma_;
    _Carcinoma_--The thymus gland--The carotid gland.

#Surgical Anatomy.#--In the middle line the following structures may
be recognised on palpation: (1) the _hyoid bone_, lying below and
behind the body of the lower jaw, on a level with the fourth cervical
vertebra; (2) the _hyo-thyreoid membrane_, behind which lies the base
of the epiglottis and the upper opening of the larynx; (3) the
_thyreoid cartilage_, to the angle of which the vocal cords are
attached about its middle; (4) the _crico-thyreoid_ membrane, across
which run transversely the crico-thyreoid branches of the superior
thyreoid arteries; (5) the _cricoid cartilage_, one of the most
important landmarks in the neck. It lies opposite the disc between the
fifth and sixth cervical vertebræ, and at this level the common
carotid artery may be compressed against the _carotid tubercle_ on the
transverse process of the sixth cervical vertebra. The cricoid also
marks the junction of the larynx with the trachea, and of the pharynx
with the œsophagus; at this point there is a constriction in the food
passage, and foreign bodies are frequently impacted here. At the level
of the cricoid cartilage the omo-hyoid crosses the carotid artery--a
point of importance in connection with ligation of that vessel. The
middle cervical ganglion of the sympathetic lies opposite the level of
the cricoid. (6) Seven or eight rings of the _trachea_ lie above the
level of the sternum, but they cannot be palpated individually. The
_isthmus_ of the thyreoid gland covers the second, third, and fourth
tracheal rings. As the trachea passes down the neck, it gradually
recedes from the surface, till at the level of the sternum it lies
about an inch and a half from the skin. The _thyreoidea ima_
artery--an inconstant branch of the anonyma (innominate) or of the
aorta--runs in front of the trachea as far up as the thyreoid isthmus.
The inferior thyreoid plexus of veins also lies in front of the
trachea. In the superficial fascia, cross branches between the
anterior jugular veins cross the middle line.

In children under two years of age the _thymus gland_ may extend for
some distance into the neck in front of the trachea and carotid
vessels, under cover of the depressors of the hyoid bone.

_Cervical Fascia._--This fascia completely envelops the neck, and from
its deep aspect two strong processes--the prevertebral and pretracheal
layers--pass transversely across the neck, dividing it into three main
compartments. The posterior or _vertebral compartment_ contains the
muscles of the back of the neck, the vertebral column and its
contents, and the prevertebral muscles. This compartment is limited
above by the base of the skull, and below is continued into the
posterior mediastinum. The middle or _visceral compartment_ contains
the pharynx and œsophagus, the larynx and trachea with the thyreoid
gland, and the carotid sheath and its contents. These different
structures derive their special fascial coverings from the processes
that bound this compartment. The middle compartment extends to the
base of the skull and passes into the anterior mediastinum as far as
the pericardium. The connective tissue space around the subclavian
vessels is continued into the axilla. The anterior or _muscular
compartment_ contains the sterno-mastoid muscle and the depressor
muscles of the hyoid bone. It extends upwards as far as the hyoid bone
and base of the mandible, and downwards as far as the sternum and
clavicle. The arrangement and limits of the different layers of the
cervical fascia explain the course taken by inflammatory products and
by new growths in the neck.

#Malformations of the Neck.#--Various congenital deformities result
from interference with the developmental processes which take place in
and around the fore-gut. These malformations are associated chiefly
with imperfect development of the visceral or branchial arches and
clefts, or of the hypoblastic diverticula from which the thyreoid and
thymus glands are formed.

The term _cervical auricles_ is applied to small outgrowths, composed
of skin, connective tissue, and yellow elastic cartilage, found
usually along the anterior border of the sterno-mastoid. These
appendages are usually unilateral, and are derived from the second
visceral arch. Sometimes they are situated near the orifice of a
lateral fistula. When, on account of their size, or their situation on
an exposed part of the neck, they give rise to disfigurement, they
should be removed.

_Thyreo-glossal Cysts and Fistulæ._--The thyreo-glossal _cyst_ is
developed in relation to the thyreo-glossal tract of His, which in
early embryonic life extends from the foramen cæcum at the base of the
tongue to the isthmus of the thyreoid. Those that form in the upper
part of the tract, in relation to the base of the tongue, have already
been described (p. 538). Those arising from the lower part form a
swelling in the middle line of the neck, usually above, but sometimes
below the hyoid bone. They have to be diagnosed from other forms of
cyst occurring in the middle line of the neck--sebaceous and dermoid
cysts--and when giving rise to disfigurement they should be excised.

Such a cyst may rupture on the surface, usually as a result of
superadded infection, and give rise to a _thyreo-glossal_ or _median
fistula of the neck_. As a rule the external opening of the fistula is
above the hyoid bone, only the upper part of the duct having remained
pervious. When the whole length of the duct has persisted, the fistula
extends from the skin to the foramen cæcum, passing usually in front
of, but sometimes through the substance of, the hyoid bone.
Occasionally the fistula only extends as high as the hyoid.

[Illustration: FIG. 268.--Congenital Branchial Cyst in a woman æt. 33.

(Microscopically the cyst was lined with squamous epithelium and the
wall contained rudimentary salivary-gland tissue.)]

The part of the tract near the tongue is lined by squamous
epithelium; the lower part by columnar epithelium, which, below the
level of the hyoid, is usually ciliated. Lymphoid tissue and mucous
glands are found in its wall.

The _treatment_ consists in excising the duct and the connections, and
it is usually necessary to resect the central portion of the hyoid
bone to ensure complete removal.

The _lateral fistula of the neck_--formerly described as a branchial
fistula--according to Weglowski, usually takes origin from the remains
of the hypoblastic diverticulum, which arises from the pharyngeal part
of the third visceral cleft and extends downwards to form the thymus
gland. The internal opening is situated in the lateral wall of the
pharynx in the region of the posterior palatine arch close to the
tonsil, and the fistula passes out above the hypoglossal nerve, and
runs downwards and laterally between the carotids and along the medial
border of the sterno-mastoid muscle. When the fistula is complete, the
external opening is situated a short distance above the
sterno-clavicular joint. As the lower part of the thymus canal most
often persists, an incomplete external fistula is the form most
frequently met with. It is lined with ciliated columnar epithelium.

The fistula may be present at birth, or may result from the rupture of
a cystic swelling, which has become infected. Clear viscous fluid
exudes from it, and, when the fistula is complete and the lumen
sufficiently wide, particles of food may escape. As the track is
tortuous, it is seldom possible to pass a probe along it, but its
extent and course may be recognised by injecting an emulsion of
bismuth and taking an X-ray photograph.

The _treatment_ consists in excising the fistula in its whole length,
but, owing to its long and tortuous course, and its relations to
important structures, the operation is a tedious and difficult one.
Less radical measures, such as scraping with the sharp spoon,
cauterising, or packing, are seldom successful.

#Cervical Ribs.#--Supernumerary ribs are not infrequently met with in
connection with the seventh cervical vertebra, and in the majority of
cases the condition is bilateral. The extra rib may be thin and
pointed, and project straight out from the transverse process
terminating in a free end, in which case, as it passes above the
subclavian artery and the brachial plexus, it gives rise to no
trouble. In other cases it arches downwards and forwards, and is
attached by dense fibrous tissue to the first thoracic rib about the
level of the scalene tubercle, or to the sternum by cartilage like an
ordinary rib. When it encroaches upon the posterior triangle the
scalene muscles are attached to it, and the subclavian artery and the
lower trunk and medial cord of the brachial plexus pass over it in a
groove behind the scalenus anterior. The pleura may reach as high as
the medial border of the rib.

_Clinical Features._--The condition, which is more common in women
than in men, is seldom recognised before the age of twenty, and is
often discovered accidentally, for example after some emaciating
illness, or by a tight collar causing pain. The diagnosis is
established by the X-rays.

[Illustration: FIG. 269.--Bilateral Cervical Ribs; the left one is the
better developed.]

When symptoms arise, they may be referable either to pressure on the
artery or on the nerve roots. When the subclavian artery is displaced
upwards it may be recognisable as a prominent pulsatile swelling, and
as the part of the vessel distal to the rib is sometimes dilated and
yields a systolic bruit, it may simulate an aneurysm (Sir William
Turner). The pulse beyond is weakened while the arm hangs by the side,
but may be restored by raising the hand above the head. Gangrene of
the tips of the fingers has been observed in rare instances, but it is
probably nervous rather than vascular in origin.

Symptoms referable to pressure on the nerve roots usually affect the
right arm, and may be either neuralgic or paralytic in character (Wm.
Thorburn). In the neuralgic group there is tingling pain, a feeling of
numbness, and sensations of cold in the limb, most marked along the
ulnar border of the forearm; the arm is weak, and susceptible to cold.
This condition may be mistaken for brachial neuritis; it is relieved,
however, by holding the arm above the head, for example, during sleep.

In the paralytic group, the pressure symptoms are referred to the
first dorsal, or first dorsal and eighth cervical roots. The paralysis
is most marked in the muscles of the thumb, and becomes less towards
the ulnar side; the affected muscles atrophy, especially those forming
the thenar eminence, and the finer movements of the thumb and fingers
are impaired.

When pressure symptoms are present, the extra rib should be removed
through an incision which exposes the posterior triangle sufficiently
to admit of the bone and its periosteum being excised, without damage
being inflicted on the brachial plexus, the subclavian artery, or the
pleura.

Similar clinical features to those of cervical rib may be caused by a
prominent transverse process of the first thoracic vertebra and
similarly got rid of by its removal.

_Branchial cysts and branchial tumours_ are described with tumours of
the neck (p. 598).

WRY-NECK OR TORTICOLLIS.--The term wry-neck or torticollis is applied
to a condition in which the head assumes an abnormal attitude, which
is usually one of combined lateral flexion and rotation.

The most important form is due to faulty action of the cervical
muscles, and three varieties of muscular wry-neck are recognised--(1)
the acute or transient; (2) the chronic or permanent; and (3) the
spasmodic.

#Acute# or #transient wry-neck#--so-called "rheumatic
torticollis"--comes on suddenly, usually after the patient has been
exposed to a draught of cold air or to damp. The condition is
popularly known as "stiff neck," and is probably associated with
fibrositis of the affected muscles. The sterno-mastoid, and often the
trapezius, are contracted, and pull the head to one side, twisting
the face slightly towards the opposite side (Fig. 270). There is
tenderness on pressing over the affected muscles, and sometimes over
the vertebral spines, and in the lines of the cervical nerves, and
severe pain on attempting to move the head. Usually in the course of a
few days the condition passes off as suddenly as it came on, but in
some cases a certain amount of wasting of the affected muscles ensues.

[Illustration: FIG. 270.--Transient Wry-neck, which came on suddenly
after sitting in a draught, and passed off completely in a few days.]

In the _diagnosis_ of this form of wry-neck it is necessary to exclude
such conditions as cellulitis, inflammation of the cervical glands,
and disease of the cervical spine, in which the head may assume an
abnormal attitude, the position being that which gives the patient
greatest comfort.

The _treatment_ consists in ensuring free action of the bowels and
kidneys, in inducing hyperæmia by means of heat, and applying gentle
massage. Salicylates and similar drugs are useful in relieving the
pain.

#Permanent# or #true wry-neck# is due to an organic shortening of the
sterno-mastoid muscle. The trapezius, the splenius, the scaleni, and
the levator scapulæ muscle may also undergo shortening, along with
their investing sheaths derived from the cervical fascia.

The sternal head of the sterno-mastoid is always markedly shortened,
and stands out as a tight cord; sometimes the clavicular head is also
prominent.

There is evidence that in the majority of cases the deformity results
from some interference with the development of the muscles during
intra-uterine life. This is probably the effect of undue pressure on
the fœtus diminishing the arterial supply to the central part of the
muscle, with the result that the muscle fibres undergo degeneration
with subsequent sclerosis and contraction. It may result also from
cicatricial contraction of the muscle following rupture of its fibres
during delivery. In such cases there is a history that the birth was a
difficult one, the presentation having been abnormal; and that a
swelling was observed in the sterno-mastoid shortly after birth. This
swelling--_a hæmatoma of the sterno-mastoid_--is at first soft, later
becomes smaller, and eventually disappears. In course of time,
sometimes months, sometimes years after the disappearance of the
swelling, shortening of the muscle takes place, and the deformity is
established.

_Clinical Features._--Although the condition is usually described as
"congenital," it is the common experience in practice that the child
has reached the age of from seven to ten years before advice is
sought. The appearance of the patient is characteristic (Fig. 271).
The shortening of the sterno-mastoid pulls the head towards the
affected side, usually the right, so that the ear is approximated to
the shoulder. At the same time the head is rotated towards the
opposite side and slightly tilted backwards, with the result that the
chin is directed towards the opposite side, and is somewhat raised.
The shortened sterno-mastoid stands out prominently, and, on any
attempt to straighten the head, can be felt as a firm, fibrous band.
The skin of the affected side of the neck may be thrown into
transverse folds. The patient is unable to correct the deformity, but
it is usually possible to diminish it by manipulation.

[Illustration: FIG. 271.--Congenital Wry-neck in a boy æt. 14.]

If the condition is not corrected, all the structures on the affected
side of the neck undergo organic shortening, with the result that the
deformity becomes accentuated. In advanced cases a lateral curvature,
with the convexity towards the normal side, occurs in the cervical
region, the vertebræ becoming wedge-shaped from side to side, and a
compensatory curve may develop in the thoracic region (Fig. 272).

[Illustration: FIG. 272.--Congenital Wry-neck seen from behind to show
scoliosis.]

There is also asymmetry of the head and face, the affected side being
the smaller. The eye on this side lies on a lower level, and is more
oblique than its neighbour, the cheek is flattened, and the mouth
asymmetrical. Instead of the eyebrows and the lips forming parallel
lines, their axes converge towards the side of the contracted muscles
and fasciæ.

_Treatment._--While it may be possible when the condition is
recognised during infancy to counteract the tendency to contraction
and deformity by manipulations, massage, and exercises alone, it is
usually necessary to divide the shortened structures as a preliminary
to orthopædic measures.

Subcutaneous tenotomy--at one time the favourite method of
treatment--has been entirely replaced by the _open operation_, which
admits of all the structures at fault, including the cervical fascia,
being thoroughly divided, without risk of injuring other structures in
the neck. The result of division of the shortened tissues is
seen at once in a marked increase in the interval between the
sterno-clavicular joint and the mastoid process. As in other
deformities, the operation is only a preliminary, although an
essential one, to the treatment by massage, movement, and exercises
which must be persevered with for months, and it may be for years.
When the torticollis attitude has been corrected in childhood, the
asymmetry of the skull disappears.

#Spasmodic wry-neck# is the term applied to a condition in which
clonic contractions of certain muscles produce jerkings of the head.
The muscles most frequently at fault are the sterno-mastoid and
trapezius of one side, and the posterior rotators of the opposite
side. By these muscles the head is pulled into the wry-neck position,
and is at the same time retracted, and there is more or less constant
nodding or jerking of the head.

The condition is usually met with in adults of a neurotic disposition
who are in a depressed state of health, and is due to some lesion, as
yet undiscovered, in the nerve mechanism of the affected muscles--most
probably in their cortical centres. It would appear that in some cases
the spasmodic jerkings are originated by certain movements habitually
made by the patient in the course of his work. In others, as a result
of astigmatism and other errors of refraction, the patient has
acquired the habit of repeatedly tilting his head to enable him to see
clearly, and these movements have become continuous and
uncontrollable.

The affection tends to become progressively worse until the patient is
incapacitated for work or enjoyment. Sleep even may be interfered
with.

_Treatment._--In well-marked cases the use of drugs, electricity, or
restraining apparatus is never curative, but these measures combined
with massage have been temporarily beneficial in milder cases.

Of the operative procedures, resection of portions of the accessory
nerve on one side, and of the posterior primary divisions of the first
five cervical nerves on the opposite side, seems to offer the best
prospect of recovery. Simple division of these nerves or resection of
the accessory alone has not proved permanently curative. Open division
of the offending muscles without interfering with the nerves has given
good results, and is a much simpler operation (Kocher).

Spasmodic wry-neck must be distinguished from the #hysterical#
variety, which after lasting for weeks, or even months, may pass off
completely, but, like other hysterical affections, is liable to recur.

Deviations of the neck simulating torticollis may occur in cervical
caries, and in unilateral dislocation of the spine.

The #cicatricial contraction# of the integument of the neck that
results from extensive burns, abscesses, or ulcers, may cause
unsightly deformity and fixation of the head in an abnormal attitude,
and call for surgical treatment. The contraction which follows the
disappearance of a gumma of the sterno-mastoid may also produce a
deformity resembling wry-neck.


INJURIES

#Contusion# of the neck may result from a blow or crush, as, for
example, the passage of a wheel over the neck, or from throttling,
strangling, or hanging. In medico-legal cases the distribution of the
discoloration should be carefully noted. When due to throttling, the
marks of the fingers may be recognisable, and nail-prints may be
present. In cases of strangling, the mark of the cord passes straight
round the neck, while in suicidal hanging it is more or less oblique
and is higher behind than in front. When due to a direct blow, for
example by a fist, the discoloration is limited, while it is usually
diffused over the neck when due to the passage of a wheel over the
part.

The clinical importance of these injuries depends on the complications
that may ensue; for example, extravasation of blood under the
cervical fascia may press upon the air-passage and œsophagus to such
an extent as to cause interference with breathing and swallowing; the
larynx or the trachea may be so grossly damaged that death results
immediately from suffocation, or later from gradually increasing œdema
causing obstruction of the glottis. If the mucous membrane of the
air-passage or the apex of the lung and its investing pleura is torn,
emphysema of the connective tissue may develop and spread widely over
the body. In contusions of the lower part of the neck the cords of the
brachial plexus may be injured.

#Fractures of the Hyoid, Larynx, and Trachea.#--The _hyoid bone_, on
account of its mobility and the protection it receives from the body
of the mandible, is seldom fractured, except in old people in whom the
great cornu has become ossified to the body of the bone. It is usually
broken either by a direct blow, or by transverse pressure as in
garrotting. The fracture is almost always at the junction of the great
cornu with the body, and there is marked displacement of the
fragments, which may injure the pharyngeal mucous membrane.

The _thyreoid and cricoid cartilages_ are also liable to be fractured
in run-over accidents, particularly in old people after calcification
or ossification has taken place.

The _trachea_ may be lacerated, or even completely torn from the
larynx, by the same forms of injury as produce fracture of the
laryngeal cartilages.

The _clinical features_ common to all these injuries are swelling and
discoloration; and if the mucous membrane is torn, air may escape into
the tissues and produce emphysema. There is always more or less
difficulty in breathing, which may amount to actual suffocation, and
this may come on immediately, or in the course of a few hours from
œdema of the glottis. Blood may pass into the lungs and be coughed up.
Swallowing is usually difficult and painful, especially in fracture of
the hyoid bone. There is also pain on speaking, the voice is husky and
indistinct, and spasmodic coughing is common. When blood has entered
the air-passages there is considerable risk of septic pneumonia.

_Treatment._--As the immediate risk to life is from suffocation, it is
usually necessary to perform tracheotomy at once. In fracture of the
hyoid the fragments may be replaced by manipulation through the mouth,
after which the head and neck are immobilised by a poroplastic collar.

#Wounds--Cut-throat.#--The most important variety of wound of the neck
met with in civil practice is that known as "cut-throat"--an injury
usually inflicted with suicidal, less frequently with homicidal
intent.

Suicidal wounds are usually directed from left to right (if the
patient is right-handed), and they run more or less obliquely from
below upwards across the neck; the wound being deepest towards its
left end, that is where the weapon enters, and gradually tailing off
towards the right. In most cases the would-be suicide throws his head
so far back at the moment of inflicting the wound, that the main
vessels are carried backward under cover of the tense sterno-mastoid
muscles, and so escape injury. The knife may even reach the vertebral
column without damaging the contents of the carotid sheath.

Homicidal wounds are usually more directly transverse, and are of
equal depth throughout. The main vessels are generally divided, the
œsophagus and trachea opened into, and in some cases the vertebral
canal is opened and the cord and its membranes injured.

_Clinical Features._--The clinical features vary with the level of the
wound and with its depth. In all cases the contraction of the platysma
causes the wound to gape widely, and its edges tend to be turned in.

In a large proportion of suicidal attempts the patient only succeeds
in inflicting one or more comparatively superficial wounds across the
front of the neck. In many cases the hæmorrhage from these is
trifling, but if the external jugular and other large superficial
veins are divided, it may be fairly profuse, although it is seldom
immediately fatal, unless the blood is sucked in to the wounded
air-passage.

Occasionally, but rarely, the wound is made _above the hyoid bone_,
and opens directly into the mouth. There may then be sharp hæmorrhage
from the base of the tongue or from the lingual and external maxillary
(facial) arteries or their branches in the submaxillary region, and
asphyxia may result from the base of the tongue and the epiglottis
falling back and obstructing the larynx.

The _hyo-thyreoid membrane_ is frequently divided, and the pharynx
thus opened. As the depressor muscles of the hyoid are divided, there
is interference with deglutition and phonation, but respiration is not
affected. In such cases the upper portion of the epiglottis is often
cut off, and the base of the tongue, the tonsil or the soft palate may
be injured. The lingual, external maxillary and superior thyreoid
arteries, and the hypoglossal nerve are also liable to be divided at
this level, but the main vessels of the neck usually escape. There is
pain and difficulty in swallowing, and food and saliva tend to escape
through the wound. Particles of food may pass into the air-passages
and cause violent fits of coughing.

In more severe cases the knife enters the _larynx_ or the _trachea_.
Sometimes the thyreoid cartilage is divided--as a rule only
partly--and the vocal cords are injured; in other cases the trachea is
opened, or it may be completely cut across. The bleeding is serious,
as the superior thyreoid arteries are usually damaged. If the common
carotid and the internal jugular vein also are wounded, the hæmorrhage
usually proves fatal. The fatal issue may be contributed to by blood
entering the air-passages and causing asphyxia, or by air being sucked
into the open veins and causing air embolism. The laryngeal branches
of the vagus may be divided and paralysis of the larynx ensue.

In all cases there is more or less dyspnœa and persistent coughing.
The voice is husky, and the patient can only express himself in a
hoarse whisper. There is difficulty in swallowing, and the food may
enter the trachea. When the external wound is small, there may be a
considerable degree of emphysema of the cellular tissue.

The _prognosis_ depends largely on the general condition of the
patient. The majority of those who attempt to take their own lives are
in a low state of health from alcoholic excess, mental worry,
privation or other causes, and many succumb even when the wound in the
neck is comparatively slight. Shock, loss of blood, asphyxia from
blood entering the air-passages, and œdema of the glottis are the most
frequent causes of death soon after the injury. Cellulitis,
inhalation, pneumonia, and delirium tremens are later complications
that may prove fatal.

_Treatment._--The first indication is to arrest hæmorrhage, and this
may be done by applying digital compression over the bleeding points.
The bleeding vessels are then sought for and ligated, the wound being
enlarged if necessary.

If the food and air-passages are intact, any muscles that have been
divided should be sutured.

When the epiglottis is cut across in wounds opening into the pharynx,
it should be united, preferably with fine silk sutures, as catgut is
absorbed before healing has time to take place. The wall of the
pharynx and the muscles should then be sutured layer by layer.

When the air-passage is opened, it is usually advisable to introduce a
tracheotomy tube (Fig. 273), and pack gauze round it to avoid the
risk of 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 low
tracheotomy and gastrostomy.

(Mr. J. M. Graham's case.)]

In all cases the superficial part of the wound should be drained, and
in applying the bandage the head should be flexed on the chest to take
all tension off the stitches. The patient must be kept under constant
supervision lest he should interfere with the dressings, or make a
further attempt on his life. In some cases it is necessary to feed him
through a tube passed into the stomach either through the mouth or
through the nose; when this is not feasible, nourishment must be given
by the rectum, or by a gastrostomy tube (Fig. 273).

_Wounds of the thoracic duct_ have been described with affections of
the lymphatics (Volume I., p. 324), and _wounds of the brachial
plexus_ with injuries of individual nerves (Volume I., p. 360).


INFECTIVE CONDITIONS

#Cellulitis# may occur in any of the cellular planes in the neck, the
most important form being that which occurs under the cervical fascia,
for example in the course of acute infective diseases, such as scarlet
fever, measles, or pyæmia. The pus tends to spread widely throughout
the neck, infiltrating the connective-tissue spaces around the blood
vessels, the air-passages, and the œsophagus. The density and tension
of the cervical fascia cause the pus to burrow downwards towards the
mediastinal spaces of the thorax, where it may give rise to such
complications as empyema, infective pericarditis, or gangrene of the
lung. The pus may also reach the axilla by spread of the infection
along the subclavian vessels.

An acute phlegmonous peri-adenitis sometimes occurs in the loose
cellular tissue around the submaxillary gland, and spreads with great
rapidity through the cellular planes of the neck. The condition--which
goes by the name of _angina Ludovici_--is usually met with in adults,
and appears to originate in some infective focus in the mouth.

_Clinical Features._--In all forms the process spreads rapidly, and
the neck becomes swollen, brawny, and of a dusky red colour. The head
is flexed towards the affected side, and there is pain on movement and
on palpating the swelling. Pus forms early, but, as it is under great
tension, fluctuation can seldom be detected. Respiration may be
interfered with by pressure on the air-passages, or by the onset of
œdema of the glottis, and tracheotomy may be urgently called for.
Swallowing may also be affected by pressure on the pharynx and
œsophagus. Pressure on the important nerves traversing the neck may
give rise to irritative or paralytic symptoms. The main vessels may
become thrombosed or eroded--particularly when the cellulitis is
associated with scarlet fever--and in the latter case copious
hæmorrhage may follow incision of the abscess.

There is always marked constitutional disturbance, as evidenced by
rigors, high temperature, a small, rapid pulse, and delirium; and
death may result within a few days from toxæmia.

_Treatment._--In the earliest stages hot fomentations or ichthyol and
glycerine should be applied, but if the process does not begin to
abate within twenty-four hours, and if the swelling becomes brawny in
character, one or more incisions should be made through the deep
fascia where the signs of inflammation are most intense, and the
deeper planes of the neck opened up by dissection. Drainage is secured
by tubes or strips of rubber tissue. If profuse hæmorrhage occurs it
may be necessary to ligate the main artery lower in the neck.

#Actinomycosis# manifests itself in the neck as a diffuse, painless
swelling, which slowly infiltrates the superficial structures,
becoming brawny at some places, and at others breaking down and
forming sinuses from which the ray fungus escapes in the discharge.

#Boils and carbuncles# frequently occur on the back of the neck, where
the skin is thick and coarse and is rubbed by the collar.

The affections of the _cervical lymph glands_ have already been
described (Volume I., p. 330).


TUMOURS

#Cystic Tumours.#--A great variety of cystic tumours is met with in
the neck.

#Branchial cysts# are formed by the distension of an isolated and
unobliterated portion of one of the branchial clefts. They usually
form in connection with the third cleft, and are met with in the
region of the great cornu of the hyoid bone, to which the wall of the
cyst is almost always attached. Less frequently they take origin in
the second cleft, and lie below the mastoid process, in which case the
cyst is adherent either to the mastoid or to the styloid process. In
some cases these cysts project towards the floor of the mouth. When
near the skin they are of the nature of _dermoid cysts_, being lined
with squamous epithelium and filled with sebaceous material. When
deeply placed, they are lined by cylindrical or ciliated epithelium
and contain a glairy mucoid fluid.

Although of congenital origin, these cysts do not usually attract
attention till about the age of puberty, when they are noticed as
small, soft, fluctuating tumours over which the skin moves freely.
They grow slowly, but may attain great dimensions. The only treatment
that yields satisfactory results is complete excision.

The _cystic lymphangioma_, _hygroma_, or _hydrocele of the neck_ (Fig.
274), has been described with affections of lymphatics (Volume I., p.
327); and _thyreo-glossal cysts in the neck_ at p. 583.

[Illustration: FIG. 274.--Hygroma of Neck.

(Photograph lent by Mr. J. W. Dowden.)]

_Blood Cysts._--These may originate in a diverticulum of a vein that
has become isolated, or in a cavernous angioma; or they may be due to
hæmorrhage taking place into a branchial or thyreo-glossal cyst. The
diagnosis is often only possible by exploratory puncture; and the
treatment consists in complete excision.

_Cystic Bursæ._--Cystic degeneration may occur in the supra-hyoid and
thyreo-hyoid bursæ, and give rise to a rounded swelling which moves
with the thyreoid on swallowing, and is only troublesome from the
disfigurement it causes. It is treated by excision.

#Solid Tumours#, apart from the common enlargements of lymph glands,
and the various forms of goitre, are not often met with in the neck.

The _circumscribed lipoma_ usually occurs over the nape of the neck or
in the supra-clavicular region. It may attain considerable size, and
from its weight become pedunculated and hang down over the back or
shoulder.

_Diffuse lipomatosis_ usually begins over the nape and spreads more or
less symmetrically till it completely surrounds the neck. As the
new-formed fat is not encapsulated, extirpation of the mass is
difficult and is seldom called for.

[Illustration: FIG. 275.--Lympho-sarcoma of Neck.

(Mr. D. M. Greig's case.)]

_Fibroma_ originating in the ligamentum nuchæ, or the periosteum of
the vertebral processes, is of slow growth, but it may attain
considerable size, and on account of its deep attachments the
operation for its removal may be difficult.

_Mixed tumours_ like that described as occurring in the vicinity of
the parotid, and taking origin from branchial rests, are sometimes met
with in the upper part of the anterior triangle.

_Osseous_ and _cartilaginous tumours_ occasionally grow in connection
with the transverse processes of the lower cervical vertebræ.

_Sarcoma_ and _fibro-sarcoma_ of the slowly growing type may develop
from any of the fascial structures in the neck, or from the connective
tissue surrounding the blood vessels. In those taking origin beneath
the sterno-mastoid, there is difficulty in removing them completely on
account of their deep attachments, and when they are found to
infiltrate the surrounding tissues the attempt should be abandoned.
This rule may be relaxed in view of the aid that may be afforded by
the insertion of a tube of radium, which is capable of rendering inert
such portions of the growth as are not capable of being removed.
Sacrifice of the common carotid artery is attended with the risk of
hemiplegia and cerebral softening, especially in persons over fifty;
resection of a portion of the vagus is less dangerous to life than
stimulation by irritation of its fibres; resection of the internal
jugular vein and of the cervical sympathetic cord are factors which
add to the shock of the operation but do not carry with them any
special risk.

_Carcinoma._--The commonest form of primary cancer is the _branchial
carcinoma_, a squamous epithelioma which originates in connection with
the second visceral cleft (Fig. 276). It appears as a rule under the
sterno-mastoid at the level of the hyoid bone, and extends towards the
submaxillary region, infiltrating the muscles and the sheath of the
vessels.

[Illustration: FIG. 276.--Branchial Carcinoma--subsequently removed by
operation.]

It is more common in men than in women, and there is often a history
of a small swelling having been present for many years, or even since
birth. About middle life more active growth begins, the swelling
becomes more fixed and is painful, and once it begins to grow, it
increases rapidly and within a month or two may reach the size of a
child's head. In spite of its size, however, it seldom causes
interference with breathing or swallowing, and it has comparatively
little effect on the general health. Clinically, the induration and
fixation of the tumour suggest its epitheliomatous character, but the
absence of a primary growth in the mouth or pharynx excludes its being
a metastasis in the lymph glands.

Unless completely removed at an early stage, recurrence inevitably
takes place.

Primary carcinoma may also occur in a supernumerary thyreoid, and in
the para-thyreoid glands.

We have met with a case of _paraffin epithelioma_ on the neck, and a
similar type of epithelioma may be met with in a lupus or a burn of
long standing.

#The Thymus Gland.#--The thymus gland begins to diminish in size
towards the end of the second year, and by the time puberty is reached
it has entirely disappeared. In some cases, however, the process of
involution fails to take place, and the gland may even undergo
hyperplasia and exert pressure on the trachea, the great blood
vessels, or the left vagus nerve and its recurrent branch. The
enlargement of the thymus may be part of a general lymphatic
hyperplasia--known as the _status lymphaticus_.

The pressure effects may be entirely referable to the trachea--_thymus
stenosis of the trachea_--giving rise to progressive dyspnœa
accompanied by stridor, with paroxysmal exacerbations during which the
child becomes asphyxiated. It is only expiration that is interfered
with, as with each inspiratory effort the gland is sucked in towards
the mediastinum and so frees the air-passages, while with expiration
it rises again, and, becoming jammed in the upper opening of the
thorax, exerts pressure on the trachea, and during expiration a soft
swelling is sometimes recognisable in the episternal notch. The
paroxysms occur at irregular intervals, and any one of them may prove
fatal. In some cases the symptoms seem to be associated with pressure
on the blood vessels and nerves rather than on the air-passages, and
in these there is distension of the veins and a tendency to syncopal
attacks.

The only way to afford relief is to expose the gland and withdraw it
from behind the sternum by making traction on its capsule. If the
breathing is not thereby improved, the capsule should be opened and
the gland shelled out.

The term _thymic asthma_ has been applied to another form of disturbed
respiration due to a large thymus, which comes on suddenly in infants
otherwise apparently healthy. Without warning, the child seems to
choke, has great difficulty in breathing, with inspiratory stridor and
indrawing of the epigastrium; he rapidly becomes cyanosed, and in the
majority of cases dies in a few minutes--_thymus death_. No
satisfactory explanation of the sudden onset of the symptoms is
forthcoming, but it appears to be associated with something which
suddenly narrows the mediastinal space, such as backward bending of
the head, or venous engorgement of the thymus gland. Cases are
recorded in which an attack has come on during the administration of a
general anæsthetic; in some instances the patient has suffered from
the generalised status lymphaticus.

#Tumours of the Carotid Gland or Glomus Carotica# (_Potato-like tumour
of the neck_).--The carotid gland under normal conditions is about the
size of a grain of corn, and lies to the posterior aspect of the
bifurcation of the carotid. It is sometimes the seat of
_endothelioma_. The tumour has a definite capsule, is moderately firm
and elastic, increases in size slowly and gradually for a time, and
then may grow more rapidly. Its relation to the vessels is
characteristic: as it grows it envelops the common carotid and its
branches, and becomes adherent to the internal jugular vein; and it
may come to implicate the nerves in the neck, particularly the vagus
and its recurrent branch, and the cervical sympathetic.

It gives rise to few symptoms, and in the majority of cases the
surgeon is consulted on account of the disfigurement resulting from
the presence of the swelling in the neck. This swelling is ovoid,
smooth or slightly lobulated; it lies at the level of the bifurcation
of the carotid, and tends to grow upwards rather than downwards; it is
movable from side to side, but not up and down; it lies under the
sterno-mastoid, and the skin is not implicated. There is transmitted
pulsation in the tumour, but no expansion.

The diagnosis has to be made from lymphoma, adenoma, tuberculous
glands, sarcoma, and carcinoma.

In a large proportion of the cases operated upon it has been necessary
to ligate the carotids and to excise portions of the internal jugular
vein, and as severe cerebral symptoms are liable to ensue the
mortality has hitherto been high. Operation is therefore only to be
recommended when the growth is rapid, or the symptoms have become
urgent.




CHAPTER XXVII

THE THYREOID GLAND


Surgical Anatomy--Physiological hyperæmia--Acute
    thyreoiditis--GOITRE--Varieties: _Parenchymatous_; _Adenomatous_;
    _Cystic_; _Malignant_; _Toxic_.

#Surgical Anatomy.#--The _thyreoid gland_ consists of two lateral
lobes connected by an isthmus. The lateral lobes lie in contact with
the side of the larynx up to the middle of the thyreoid cartilage, and
with the sides of the first five or six rings of the trachea. The
isthmus lies in front of the second, third and fourth rings of the
trachea, and from it a process of gland tissue--the _pyramidal
lobe_--passes up in the middle line towards the hyoid bone.

The gland lies under cover of the superficial muscles of the neck, and
is surrounded by a process of the cervical fascia--the external
thyreoid capsule of Kocher--which connects it with the larynx,
trachea, and œsophagus, so that it moves with these structures on
swallowing. In this capsule are numerous veins; and in the groove
between the œsophagus and trachea the recurrent (laryngeal) nerve
runs. Enclosing the gland substance is the capsule proper, which sends
in processes to form its fibrous stroma. The arteries of supply--the
superior and inferior thyreoids--are very large for the size of the
gland, and enter it at its four corners. The thyreoidea ima, when
present, goes to the isthmus. Isolated nodules of thyreoid
tissue--_accessory thyreoids_--are sometimes met with in different
parts of the neck; they are liable to the same diseases as the main
gland.

The secretion of the gland is absorbed into the general circulation
through the veins; it consists of a complex colloid substance which
contains an iodine-albumin--iodothyrin--and plays an important part in
maintaining the normal metabolism of the body, particularly of the
central nervous and cutaneous tissues in adults, and of the bones in
children. Disturbance of the function of the thyreoid gland plays a
part in producing the symptoms characteristic of myxœdema, cretinism,
and goitre.

The _para-thyreoid glands_--usually two on each side--lie in the
external capsule along the posterior edge of the lobes of the
thyreoid. They are flattened, elliptical bodies, averaging a quarter
of an inch in length and an eighth of an inch in width, of a light
brown colour, smooth and glistening on the surface, and of a soft,
flabby consistence (W. G. MacCallum). When tetany follows operations
for goitre it is due to the removal of these glands.

#Physiological Hyperæmia.#--The thyreoid varies greatly in size even
within normal limits, and may become engorged and swollen from
physiological causes, particularly in the female. Before the onset of
menstruation at puberty, for example, the thyreoid frequently becomes
engorged, and the enlargement may recur with each period for months or
even years. During pregnancy also the gland may become swollen.

#Acute Thyreoiditis# may occur in a healthy thyreoid or in one that is
the seat of goitre, and may end within a few days in resolution, or go
on to suppuration. It is due to infection with pyogenic bacteria,
which usually gain access to the gland by the blood stream, as, for
example, in typhoid fever, pyæmia, influenza, and other acute
infective diseases. Direct infection sometimes occurs from an abscess,
a cellulitis, or an infected wound in the neck; it has also occurred
from a foreign body impacted in the œsophagus ulcerating through and
perforating the gland.

One lobe is usually more involved than the other, but the condition
may be diffused. When pus forms it may infiltrate the stroma of the
gland, or may be collected into several small foci.

_Clinical Features._--The usual signs of inflammation are present;
there is severe headache of a congestive nature, and sometimes
vertigo. The swelling takes the shape of the thyreoid, and although
the skin may not be red, the subcutaneous veins are dilated. In severe
cases there is pain and difficulty in swallowing and dyspnœa.

When suppuration ensues, all the symptoms are aggravated, and repeated
rigors occur. The pus may burst into the cellular tissue of the neck,
or into the air-passage or the œsophagus.

_Treatment._--In the non-suppurative stage the ordinary treatment of
acute inflammatory conditions is employed; if pus forms, the abscess
should be opened and drained.

#Tuberculous and syphilitic affections# of the thyreoid are very rare.


PARENCHYMATOUS GOITRE OR BRONCHOCELE

The term goitre is applied clinically to any non-inflammatory
enlargement of the thyreoid gland.

_Etiology._--Parenchymatous goitre, sometimes called also simple, or
non-toxic goitre, is endemic in certain hilly districts in
England--particularly Derbyshire and Gloucestershire--and in various
parts of Scotland. It is exceedingly common in certain valleys in
Switzerland. It is met with less frequently in men than in women, and
it occurs chiefly during the child-bearing period of life. The toxic
agent that causes goitre has been traced to certain mountain springs
in goitrous districts; it has been observed that a patient with goitre
may, through fæcal contamination apparently, infect the water supply,
and that conscripts in order to avoid military service have drunk from
goitrous springs with success. Children born in a goitrous district
are liable to be cretins, while if goitrous parents move to a healthy
district, the children are born healthy. If the water supply of a
goitrous valley be changed to a healthy spring, goitre and cretinism
disappear. Thorough boiling of the water rids it of its toxic
properties.

[Illustration: FIG. 277.--Parenchymatous Goitre in a girl æt. 15.

(Mr. D. M. Greig's case.)]

_Morbid Anatomy._--Both the secreting and the fibrous elements share
in the hyperplasia, and the gland as a whole becomes enlarged and
forms a horseshoe-shaped swelling of moderate size in the neck. This
swelling is soft and smooth on the surface, and is seldom quite
symmetrical. In some cases the hypertrophy involves chiefly the
isthmus. In others an outlying accessory lobule of thyreoid tissue
constitutes the bulk of the swelling, and this may extend a
considerable distance from the position of the normal thyreoid,
reaching even behind the sternum into the thorax--_infra-thoracic_ or
_retro-sternal goitre_.

[Illustration: FIG. 278.--Larynx and Trachea surrounded by Goitre.]

[Illustration: FIG. 279.--Section of Goitre shown in Fig. 278, to
illustrate compression of Trachea.]

When the secreting elements increase out of proportion to the stroma,
numerous rounded or irregular spaces filled with a thick yellow
colloid material are formed in the substance of the goitre--_colloid
goitre_. The majority of these spaces are not larger than a pea, but
one or more may enlarge and form cysts of considerable size--_cystic
goitre_. These varieties, especially the cystic form, attain greater
dimensions than any other form of goitre.

When the fibrous stroma is greatly in excess--_fibrous goitre_--the
swelling is smaller, firmer, and shows a greater tendency to contract
and compress the trachea. If the sclerosis is extreme and the
secretory tissue undergoes atrophy, myxœdema may result.

In some cases the hyperplasia affects chiefly the blood vessels of
the thyreoid--_vascular goitre_. The capillaries, veins, and arteries
are increased in size and number; the swelling pulsates and increases
in size when the patient makes any muscular effort. Hæmorrhagic cysts
may also develop in the substance of these goitres.

       *       *       *       *       *

_Effects on the Trachea._--The trachea may be _displaced laterally_
when the enlargement of the gland affects one lobe more than the
other; or it may be _compressed and narrowed_ from side to side--the
_scabbard trachea_--when both lobes are about equally affected and the
enlargement extends posteriorly so as almost to surround the
air-passage (Figs. 278, 279). The third effect is that of _softening
of the cartilaginous rings_ of the trachea so that the air-tube,
instead of having a considerable degree of elastic resiliency, is soft
and flaccid and readily yields to pressure. Under these conditions an
alteration in the attitude of the patient, from the erect or sitting
to the recumbent position, would appear to be sufficient to permit of
a compression of the trachea.

Further changes in the trachea consist in catarrh and engorgement of
the blood vessels of its mucous membrane, attended with an abundant
secretion of mucus, which, if it accumulates behind a narrowed segment
of the trachea, may still further encroach on the lumen.

_Pressure on other Structures._--The _recurrent nerve_ may be pressed
upon intermittently causing spasms and choking, or continuously
causing abductor paralysis and hoarseness.

The gullet is rarely compressed; if marked difficulty in swallowing
develops, some additional factor should be suspected, notably
carcinoma at the junction of the pharynx with the œsophagus. The
carotid arteries are displaced laterally beneath the sterno-mastoids
without detriment; the superficial veins--anterior and external
jugular--are greatly distended in those cases in which the goitre
grows downwards behind the sternum.

_Clinical Features._--The symptoms vary widely in different cases, and
their severity is not proportionate to the size of the goitre. The
disfigurement produced by the swelling is often the only cause of
complaint. In some cases the symptoms are due to the pressure of the
enlarged thyreoid on surrounding structures. In others toxic effects,
in the form of cardiac, nervous, muscular, and general metabolic
disturbances, predominate, and are due to absorption of excessive or
abnormal thyreoid secretion. This thyreoid toxæmia varies in degree;
in the milder cases it merely amounts to a nervousness or
excitability that may unfit the patient for occupation; it reaches
its maximum in the condition of hyperthyreoidism characteristic of
exophthalmic goitre or Graves' disease (p. 614).

The skin over the goitre is freely movable, and the tumour itself can
be moved transversely, carrying the larynx and trachea with it, but it
cannot be moved vertically. It moves up and down with the larynx on
swallowing--a point of great diagnostic value. Of the mechanical
symptoms dyspnœa is the most constant. It may only amount to shortness
of breath on exertion, or the patient may suffer from sudden and
severe dyspnœic attacks, especially when lying on the back during
sleep, and such an attack may prove fatal. This may be due to the
weight of the tumour pressing on the trachea, which has been softened
and distorted by the goitre, or to temporary congestion and
engorgement of the mucous membrane of the air-passages. In these cases
there is marked stridor both on inspiration and expiration, but no
aphonia. In rare cases the goitre presses upon the recurrent nerve,
causing spasmodic dyspnœa, hoarseness, and aphonia from impaired
movement of the vocal cords, and these symptoms, especially if
accompanied by pain, raise the suspicion of malignancy. Disturbance of
the heart's action may cause palpitation and sudden attacks of
syncope; and pressure on the blood vessels may give rise to a feeling
of fullness in the head, and giddiness.

The occurrence of hæmorrhage into the substance of the goitre or into
a cyst, produces a sudden aggravation of the symptoms.

In _intra-thoracic_ or _retro-sternal goitre_ the tumour displaces and
compresses the trachea and causes dyspnœa, and there are occasional
paroxysmal attacks of breathlessness, which may be mistaken for
asthma, particularly as the patient is usually the subject also of
bronchitis and emphysema. In some cases the patient can, by a violent
expiratory effort, such as coughing, project the goitre upwards into
the neck. When the goitre is fixed in the thorax, the clinical
features are those of a mediastinal tumour with lateral displacement
of the trachea, and engorgement of the veins of the neck.

_Treatment._--The patient should change his residence to a
non-goitrous district. The evidence regarding the benefit derived from
the internal administration of thyreoid extract, or of preparations of
phosphorus or of iodine, is conflicting.

Operative treatment is indicated when there are symptoms referable to
pressure on the air-passage, and in goitres which are steadily
increasing in size. Kocher considers it advisable to operate if the
patient becomes breathless on making pressure on the goitre from side
to side. The suspicion of a goitre becoming malignant is also a reason
for removing it by operation.

The operation--_thyreoidectomy_--consists in excising that portion of
the thyreoid which is causing pressure symptoms, and this usually
involves removal of one-half of the gland. The chief danger in
operations for goitre is cardiac insufficiency, as evidenced by
disturbed rhythm of the heart-beats, lowering of the blood pressure,
or dilatation of the cavities of the heart (Kocher).

It is sometimes advisable to perform the operation under local
anæsthesia. A general anæsthetic is, however, preferred in this
country. The injection of 1/6th grain of morphin and 1/120th grain of
atropin half an hour before the operation, and the administration of
ether by the open method, or by intra-tracheal insufflation, is safe
and satisfactory.

There is reason to believe that the absorption of thyreoid secretion
squeezed from the divided surfaces gives rise to a condition known as
_acute thyreodism_ during the first few hours after operation; its
symptoms are elevation of temperature, increase in the pulse-rate
(150-200), rapid respiration with dyspnœa, flushing of the face,
muscular twitchings, and mental excitement. The gentle handling of the
tumour and the employment of a drainage tube for the first forty-eight
hours diminishes this risk.

_Tetany_, as evidenced by the occurrence of cramp-like contractions of
the thumb and fingers, may supervene within a few days of the
operation if one or more of the para-thyreoids have been inadvertently
removed. It may be controlled by large doses of calcium lactate. On no
account may the whole of the thyreoid gland be removed, as this is
followed by the development of symptoms closely resembling those of
myxœdema--_operative myxœdema_ or _cachexia strumipriva_.

_Treatment of Sudden Dyspnœa._--When dyspnœa suddenly supervenes and
threatens life, it is sometimes possible to relieve the pressure on
the trachea by open division of the skin, superficial fascia, platysma
and deep fascia in the middle line of the neck, so as to relax the
tension on the goitre. If this is insufficient, the isthmus may be
divided. Should relief not follow, tracheotomy must be performed, and
a long tube or a large-sized gum-elastic catheter with a terminal
aperture be passed along the trachea beyond the seat of obstruction.

#Adenoma of the Thyreoid.#--In this condition the swelling of the
thyreoid is due to the growth within its substance of one or more
adenomas of variable size and surrounded by a capsule. The rest of
the gland may be normal, or may show some degree of hyperplasia. Some
are solid, others undergo cystic degeneration, the glandular tissue
being replaced by a quantity of clear or yellowish fluid, sometimes
mixed with blood. The cysts thus formed may be unilocular or
multilocular, and intra-cystic papillary vegetations frequently grow
from their walls. The walls of the cysts may be thin, soft, and
flaccid, or thick and firm, or they may even be calcified.

The thyreoid is enlarged, but instead of the uniform enlargement which
characterises the parenchymatous goitre, it tends to be uneven, with
hillocky projections corresponding to the individual cysts (Fig. 280),
and in these fluctuation may be detected. It is to be noted that
there are no toxic symptoms in cystic adenoma.

[Illustration: FIG. 280.--Multiple Adenomata of Thyreoid in a woman
æt. 50.

(Mr. D. M. Greig's case.)]

[Illustration: FIG. 281.--Cyst of Left Lobe of Thyreoid.

(Mr. D. M. Greig's case.)]

The treatment is necessarily operative; cystic tumours may be tapped
and injected with iodine, but the more satisfactory procedure, both
with the solid and cystic forms, is to incise freely the overlying
thyreoid tissue and enucleate the tumour.

#Malignant Disease of the Thyreoid.#--This, whether in the form of
_carcinoma_ or _sarcoma_, usually develops in a gland that has been
the seat of goitre for several years, although it may begin in a
previously healthy gland.

_Clinical Features._--Both sexes, above the age of fifty, are affected
in about equal proportion. The characteristic features are that the
tumour undergoes a progressive increase in size, that it becomes fixed
to its surroundings, that its surface tends to be uneven and nodular,
and its consistence densely hard. The voice often becomes hoarse from
abductor paralysis due to infiltration by the growth, usually of the
left recurrent nerve. The effects upon the trachea are more decided
and more progressive than in parenchymatous goitre; it displaces and
compresses the trachea and frequently overlaps it, so as to bury the
air-passage completely. If the tumour tissue has actually penetrated
the trachea, the expectoration is tinged with blood. Dysphagia is
rarely a prominent symptom. The lymph glands become enlarged after the
tumour bursts through the capsule; and metastases to the lungs and
bones, particularly the skull, sternum, and mandible, are common. When
the goitre extends behind the sternum--the _malignant form of
retro-sternal goitre_--the pressure symptoms are due to the
encroachment upon the limited accommodation of the upper opening of
the thorax; the trachea especially suffers, and the pressure on the
veins causes distension of the anterior and external jugulars and
their tributaries. The patient is unable to lie down; there are
violent paroxysms of coughing, and an abundant frothy expectoration.
Death may take place suddenly from asphyxia, from heart failure, or
from displacement of a thrombus from one of the veins in the neck.

_Treatment._--It is only in the earliest stages that a malignant
goitre can be successfully removed. In the later stages complete
extirpation is not to be attempted, as it usually involves the removal
of a portion of the trachea or œsophagus, and the operation is
attended with grave risk to life.

Operative interference is often called for, however, for the relief of
respiratory embarrassment. _Tracheotomy_ may prove a difficult and
dangerous procedure, owing to the trachea being buried under the
goitre and displaced or narrowed by it, so that it is not easy to
reach it or to introduce an efficient tube beyond the point of
obstruction. A more certain method consists in exposing the goitre by
an incision as for thyreoidectomy, rapidly removing sufficient of the
growth to expose the trachea and admit of a tube being introduced. If
there is a retro-sternal prolongation compressing the trachea within
the thorax, a long flexible tube may have to be passed beyond the site
of the compression before the dyspnœa is relieved. The benefit is
immediate and decided; the accumulated secretion is coughed up, and
after a few deep breaths the patient is able to lie down, and usually
falls asleep. The stridor disappears. Unfortunately the relief is
only temporary, and the patient soon succumbs to a broncho-pneumonia,
or to secondary hæmorrhage from the trachea.

#Toxic Goitre#--#Exophthalmic Goitre#--#Graves'# or #Basedow's
Disease#.--These terms are applied to a variety of goitre
in which the symptoms due to absorption of thyreoid
secretion--_thyreotoxicosis_--predominate. The name "exophthalmic
goitre" is misleading, as in some cases the enlargement of the
thyreoid, and in others the eye symptoms, are scarcely appreciable,
while the general symptoms are well marked. The term toxic goitre or
_hyperthyreoidism_, suggested by C. H. Mayo, is preferable, as the
manifestations of the disease depend upon excessive or abnormal action
of the thyreoid tissue.

[Illustration: FIG. 282.--Exophthalmic Goitre.]

The condition is chiefly met with in young adult women, and may
develop suddenly after a shock to the nervous system. The intoxication
affects the higher cerebral functions and causes nervousness,
irritability, and tremor; the cardiac and vaso-motor centres, causing
tachycardia and pallor of the skin; the sympathetic fibres to the eye,
causing protrusion of the eyeballs, staring of the eyes without
winking, narrowing of the palpebral fissure, dilatation of the pupil,
and lagging behind of the upper lid, and sometimes also of the lower
lid--von Graefe's symptom. There may be diarrhœa and vomiting, loss of
weight, and in the worst cases there is delirium at night. In course
of time there develops cardiac insufficiency with fibroid degeneration
of the myocardium. Coagulation of the blood is retarded, and there is
a marked diminution in the number of leucocytes, especially the
neutrophils, and an increase in the lymphocytes (Kocher).

In the early stages the thyreoid is enlarged and pulsatile, and bruits
may be heard over it; later, these vascular symptoms disappear, and
only a firm, diffuse, uniform swelling implicating all parts of the
gland remains.

_Prognosis._--The tenure of life is uncertain as the patient offers
little resistance to intercurrent affections such as influenza and
pneumonia. If the average course of the disease is represented by a
curve, the greatest height is reached during the second half of the
first year and then descends. For the next two to four years it
fluctuates with occasional exacerbations of symptoms due to fright or
worry.

_Treatment._--Medical measures, along with the external application of
radium, the strict observance of rest in bed with the exclusion of all
forms of excitement and worry, the administration of bromides, heroin
or other sedatives, and of digitalis or other cardiac tonics, are to
be prescribed in the first instance, and in any case, as a desirable
preparation for operation.

_Operative measures_ consist in the _ligation_ of the vessels and
nerves at one or other pole of the gland--usually the superior on one
side--followed by, if necessary, a partial _thyreoidectomy_.

Crile of Cleveland has organised his clinic in the direction of
arranging that the operation shall be performed without the patient
knowing that it is to take place--what he calls "stealing the
goitre"--the thorough preparation of the patient for the operation,
the minimising the risk from the anæsthetic by the combination of
novocain locally and of nitrous oxide and oxygen; and of diminishing
the risk of absorption of thyreoid secretion by packing the (open)
wound with gauze wrung out of a solution of flavin.

Operations on the cervical sympathetic cord have been abandoned.

The presence of toxic goitre may influence the question of operation
in the treatment of other surgical conditions, and may determine the
selection of one or other form of anæsthesia.




CHAPTER XXVIII

THE 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 the
cricoid cartilage to about the level of the lower end of the sternum.
The distance from the upper incisor teeth to the commencement of the
œsophagus is about 5 or 6 inches, and the œsophagus measures from 9 to
10 inches. The whole distance, therefore, from the teeth to the
stomach is from 14 to 16 inches.

The cervical portion of the œsophagus, extending from the cricoid
cartilage to the upper edge of the sternum, measures about 2 inches.
It lies behind and to the left of the trachea, and in the groove
between them on each side runs the recurrent nerve. The thoracic
portion is about 7 inches long, and traverses the posterior
mediastinum lying slightly to the left of the middle line. It is
crossed by the left bronchus, and below this level has the pericardium
immediately in front of it. The left pleura is closely related to the
anterior surface of the œsophagus throughout, while the right pleura
passes behind it in its lower part. This accounts for the frequency
with which growths in the œsophagus invade the pleura. The œsophagus
passes through the diaphragm about an inch above the cardiac opening
of the stomach.

There are three points at which the œsophagus shows narrowing of the
lumen: (1) at the lower border of the cricoid--the "mouth of the
œsophagus"; (2) where it is crossed by the left bronchus; and (3)
where it passes through the diaphragm. It is at these points that
foreign bodies tend to become impacted. The mucous membrane of the
œsophagus is insensitive to tactile and painful stimuli, but is
sensitive to heat and cold and to exaggerated peristaltic
contractions.

#Methods of Examination.#--It is sometimes possible to detect an
impacted foreign body, a distended diverticulum, or a new growth in
the cervical portion of the œsophagus by _palpation_.

_Auscultation_ while the patient is drinking sometimes aids in the
diagnosis of stricture; the stethoscope is placed at various points
along the left side of the dorsal spine, and abnormal sounds may be
heard as the fluid impinges against the stricture or trickles through
it.

_Introduction of Bougies._--Œsophageal bougies or probangs are used
for diagnostic purposes in cases of suspected stricture, and to aid in
the detection of foreign bodies. Various forms are employed, of which
the most generally useful are the round-pointed gum-elastic or
silk-web bougie, and the olive-headed metal bougie, consisting of a
flexible whalebone stem, to which one of a graduated series of
aluminium or steel bulbs is screwed. For some purposes, such as
pushing onward an impacted bolus of food, the sponge probang--which
consists of a small round sponge fixed on a whalebone stem--is to be
preferred.

Before passing bougies, it is necessary to make certain that the
symptoms are not due to the pressure of an aneurysm on the œsophagus,
as cases have been recorded in which a thin-walled aneurysm has been
perforated by a bougie. The existence of ulceration or of an abscess
pressing on the gullet also contra-indicates the use of bougies.

For the passage of a bougie the patient should be seated on a chair
with the head thrown back and supported from behind by an assistant,
and he is directed to take full deep breaths rapidly. The bougie,
lubricated with butter or glycerine, and held like a pen, is guided
with the left forefinger. As soon as the instrument engages in the
opening of the œsophagus, the chin is brought down towards the chest,
and if the patient is now directed to swallow, the instrument may be
carried down the œsophagus, or can be passed on by gentle pressure.
Great gentleness must be exercised, and no attempt should be made to
force the instrument past any obstruction. The instrument may catch
against the hyoid bone, and this may be mistaken for an obstruction.

It is to be borne in mind that in some cases the passage of a bougie
may be attended with a considerable degree of shock, and cases are on
record in which this has proved fatal without any gross lesion being
found after death.

_Intubation_, or the passage of a cannula through a stricture, is
referred to later.

_Œsophagoscopy._--The _œsophagoscope_--a form of speculum which
enables the œsophagus to be illuminated by an electric lamp--is
employed for the detection and removal of foreign bodies, for the
examination of ulcers, diverticula, and strictures of the tube, and
with its aid it is possible to remove a portion of a growth for
microscopic examination. The mouth, pharynx, and entrance to the
œsophagus having been cleansed and cocainised, the patient is placed
in the recumbent or sitting posture, and the tube introduced. For
prolonged examinations a general anæsthetic is preferred.

The mouth of the œsophagus is closed by the sphincter-like action of
the lower fibres of the inferior constrictor muscle, and the cervical
part of the tube appears as a transverse slit, due to the backward
pressure of the trachea. The thoracic portion is more open and may
contain air, so that it is possible to see down to the lower end, the
closed cardiac orifice appearing as an oblique cleft surrounded by a
rosette-like cushion of mucous membrane. The pulsation of the aorta
can be seen just above the prominence formed by the left bronchus.

_Radiography._--Opaque foreign bodies can be detected by the screen or
in a radiogram; and the position of a stricture by making the patient
swallow capsules containing bismuth and examining with the screen. To
determine the position and size of a diverticulum, a radiogram is
taken after the patient has swallowed some food, such as porridge
mixed with bismuth.

#Wounds# of the œsophagus inflicted from without, for example stabs,
cut-throat or gun-shot injuries, are rare, and are almost invariably
accompanied by lesions of other important structures in the neck,
which may rapidly prove fatal. It is more common to meet with wounds
inflicted from within, for example by the swallowing of rough and
irregularly shaped foreign bodies, or by unskilful attempts to remove
such bodies or to pass bougies along the œsophagus. The severity of
the lesion varies from a scratch of the mucous membrane to a
perforation of the tube. The less severe injuries are attended with
pain on swallowing and a sensation as if something had lodged in the
œsophagus. In more severe cases there is bleeding, followed by attacks
of coughing and expectoration of blood-stained mucus. When the
œsophagus is perforated, diffuse cellulitis of the neck or of the
posterior mediastinum may ensue. In the treatment of these injuries
the chief point is to give the œsophagus rest by feeding the patient
entirely by the rectum or through an opening made in the
stomach--gastrostomy.

#Rupture# of the œsophagus has occurred during violent vomiting, and
during lavage. The tear is longitudinal and is usually near the
cardiac orifice. It is probably due to increased pressure within the
gullet. The accident has usually been met with in alcoholics, and has
proved fatal by setting up left-sided empyema or cellulitis.

#Swallowing of Corrosive Substances.#--The œsophagus is damaged by the
swallowing of strong chemicals, such as sulphuric acid, nitric acid,
carbolic acid, or caustic potash. These substances produce their worst
effects at the two ends of the œsophagus, but in some cases the whole
length of the tube suffers. The mucous membrane alone may be
destroyed, or the muscular and even the fibrous coats may also be
implicated. The damaged tissue undergoes necrosis, and when the
sloughs separate, raw surfaces are left, and are very slow to heal.

If not rapidly fatal from shock and œdema of the glottis, these
injuries are usually attended with intense pain, severe thirst, and
vomiting, the vomit containing shreds of mucous membrane and blood.
Complications, such as cellulitis, perforation of the œsophagus, or
peri-œsophageal abscess, may follow. Later, cicatricial contraction
takes place at the injured portions, producing the most intractable
form of fibrous stricture.

The _treatment_ consists in administering solutions of carbonate of
potash, of soda, or of magnesia when an acid has been swallowed, or
vinegar diluted with water in the case of an alkali. When carbolic
acid has been swallowed, a large quantity of olive oil should be
administered. The stomach should be washed out with water, the tube
being passed with the greatest gentleness to avoid perforating the
softened œsophageal wall. Subsequently the patient should be fed by
the rectum, but, in the majority of cases, gastrostomy is called for
to enable the patient to take nourishment and put the gullet at rest.

As soon as the œsophagus has healed, say in three or four weeks,
bougies should be passed every three or four days to prevent
cicatricial contraction. As the calibre of the tube is restored, the
instruments may be passed less frequently, but for some years--it may
be for the rest of the patient's life--a full-sized bougie should be
passed at least once a month.

#Impaction of Foreign Bodies in the Pharynx and Œsophagus.#--It is an
interesting fact that foreign bodies, even as large as a dinner fork,
when intentionally swallowed, can pass through the pharynx and
œsophagus and enter the stomach without apparent difficulty. When the
body is accidentally swallowed impaction is more liable to take place,
probably on account of the spasm induced by fright and by
inco-ordinated attempts to eject it. For obvious reasons the accident
is most liable to occur in children, in epileptics, and in those who
are under the influence of alcohol. It happens also during anæsthesia
for the extraction of teeth or if the patient vomits solid substances.
The clinical aspects vary according as the object is impacted in the
pharynx or in the œsophagus.

_In the Pharynx._--If a large bolus of unmasticated food becomes
impacted in the pharynx, it blocks the openings of both the œsophagus
and the larynx, and the patient may, without manifesting the usual
signs of suffocation, suddenly fall back dead, and if he happens to be
alone at the time of the accident, the cause of death is liable to be
overlooked unless the pharynx is examined at the post-mortem
examination. Most surgical museums contain specimens illustrating the
impaction of a bolus of meat in the pharynx; this fatal accident has
occurred especially in men in a condition of alcoholic intoxication.

An object of irregular shape, for example a large denture, also, is
most likely to lodge in the pharynx, obstructing the openings of both
the œsophagus and the larynx, and causing suffocation. The face
immediately becomes blue and engorged, the patient is speechless, and
violent efforts are made to eject the object by retching and coughing.
It may be seen from the mouth and touched with the finger.

In the case of small sharp bodies, such as fish, game, and mutton
bones, there is not the same urgency, and a methodical search for the
foreign body is carried out. Even after the foreign body has been got
rid of, the patient may have the sensation that it is still present.
This may be due to a scratch of the mucous membrane, or to spasm, in
which case the swallowing of a few drops of cocain solution will cause
the sensation to disappear.

_Treatment._--In the presence of impending suffocation, the mouth must
be forced open by an extemporised gag, the finger passed into the back
of the throat, and the body hooked out. If this is impossible, and if
suitable forceps are not at hand, it may be necessary at once to
perform laryngotomy, followed by artificial respiration, because,
although the patient may appear lifeless, the heart continues to beat
after breathing has ceased. The foreign body should then be removed
with forceps. Sub-hyoid pharyngotomy, which consists in opening the
pharynx by a mesial vertical incision carried through the hyo-thyreoid
membrane, may be called for, as in the case of a denture, the hooks of
which have penetrated the wall of the pharynx.

_In the Œsophagus._--Smaller bodies, such as coins, bones, or pins,
usually enter the œsophagus, and the great majority become impacted
above the level of the manubrium sterni. Those that pass farther down
are liable to stick where the tube is narrowed at the crossing of the
bronchus, or at the opening through the diaphragm. In children, coins
predominate and are nearly always arrested at the level of the upper
end of the sternum; in adults, dentures are the commonest foreign
bodies, and may be impacted anywhere.

At the moment of impaction there is pain, which assumes the character
of cramp due to spasm of the muscular coat, and which is increased on
attempting to swallow, and violent retching and coughing are set up;
in many cases, as when bodies are impacted in the pharynx, respiratory
distress is again the predominant feature. If the passage is
completely obstructed, food and saliva--sometimes blood-stained--are
regurgitated with retching soon after being swallowed. When the
obstruction is incomplete, fluids may pass into the stomach while
solids are regurgitated.

If the mucous membrane is injured, there is severe stabbing pain and
choking attacks, both due to spasm, sometimes even after the body has
passed on, and the pain is not always referred to the seat of the
injury.

The _diagnosis_ is made by the history, and by the use of the
fluorescent screen, or X-ray photographs (Figs. 283, 284). The
œsophagoscope is also of great value, both for diagnostic purposes and
as an aid in the removal of the impacted body. Bougies are to be
employed with great care, as there is a danger of pushing the foreign
body farther down, or of wedging it more firmly in the œsophagus, and
the information obtained is often misleading.

[Illustration: FIG. 283.--Radiogram of Safety-pin impacted in the
Gullet and perforating the Larynx.

(Professor Annandale's case. Radiogram by Dr. Dawson Turner.)]

[Illustration: FIG. 284.--Denture impacted in Œsophagus.

(Professor F. M. Caird's case.)]

It should be borne in mind that drunkards may suffer from a form of
spasm of the œsophagus, which simulates the impaction of a foreign
body; hospital records also show that the patient may only have dreamt
that he has swallowed a foreign body, usually a denture. These
possibilities should be always excluded before further procedures are
undertaken.

_Treatment._--There being no urgency, a careful examination is carried
out, not only to confirm the impaction of a foreign body, but its site
and its relation to the wall of the gullet. In skilled hands, the
safest and most certain means of removing impacted foreign bodies is
with the aid of the 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 likely
to pass safely along the alimentary canal, if it cannot be extracted
with forceps, may be pushed on into the stomach by the aid of a
bulbous-headed or sponge probang. This must be done gently, especially
if the body has been impacted for any time, as the inflammatory
softening of the œsophageal wall may predispose to rupture.

Small, sharp, or irregular objects, such as fish bones, tacks, or
pins, may be dislodged by the "umbrella probang"--an instrument which,
after being passed beyond the foreign body, is expanded into the form
of a circular brush which, on withdrawal, carries the foreign body out
among its bristles.

Coins usually lodge edgewise in the œsophagus, and are best removed by
means of an instrument known as a "coin-catcher", which is passed
beyond the coin, and on being withdrawn catches it in a hinged flange.
In emergencies a loop of stout silver wire bent so as to form a hook
makes an excellent substitute for a coin-catcher.

In difficult cases the removal of solid objects is facilitated by
carrying out the manipulations in the dark room with the aid of the
X-rays and the fluorescent screen.

Irregular bodies with projecting edges or hooks, such as tooth-plates,
tend to catch in the mucous membrane, and attempts to withdraw them by
forceps or other instruments are liable to cause laceration of the
wall. When situated in the cervical part of the œsophagus, these
should be removed by the operation of _œsophagostomy_ (_Operative
Surgery_, p. 195).

If the foreign body is lodged near the lower end of the gullet, it may
be necessary to perform _gastrostomy_ (_Operative Surgery_, p. 291),
making an opening in the anterior wall of the stomach large enough to
admit suitable forceps, or, if necessary, the whole hand, in order
that the body may be extracted by this route; experience shows that an
impacted body is more easily extracted from below, that is, from the
stomach, than from above.

When the surgeon fails to remove the body by either of these routes,
_gastrostomy_ must be performed both to feed the patient and to place
the gullet at rest. Smooth bodies may lie latent for long periods, but
those with points or hooks damage the mucous membrane, cause
ulceration and perforation with the risk of erosion of vessels and
secondary hæmorrhage or of cellulitis of the neck or mediastinum and
empyema.

Other complications include septic broncho-pneumonia from damage to
the air-passage, and suppurative thyreoiditis.

#Infective conditions# due to pyogenic infection (_œsophagitis_ and
_peri-œsophagitis_) are rare.

A _chronic form of œsophagitis_ is occasionally met with in alcoholic
subjects, giving rise to symptoms that simulate those of impacted
foreign body, or of stricture.

In _tuberculous_ lesions the symptoms are pain, dysphagia, and
regurgitation of food mixed with blood, and the condition is liable to
be mistaken for gastric ulcer or for cancer of the œsophagus.

_Syphilitic affections_ of the œsophagus are rare.

#Varix# at the lower end of the œsophagus may give rise to
hæmatemesis, and be mistaken for gastric ulcer. Bleeding from the
dilated veins may follow the use of bougies or of the œsophagoscope.


CONDITIONS CAUSING DIFFICULTY IN SWALLOWING

Difficulty in swallowing may arise from a wide variety of causes which
it is convenient to consider together.

#Impaction of Foreign Bodies# has already been discussed, and
attention has been drawn to the importance of the history given by the
patient and to the various sources of fallacy or deception--in
children it may be artful reticence or misrepresentation, in adults,
the possibility of nightmare and of dreams.

#Compression of the Gullet from without.#--Any one of the numerous
structures in relation to the gullet may, when enlarged as a result of
disease, give rise to narrowing of its lumen, for example a
lymph-sarcoma at the root of the lung, or any enlargement of the
thyreoid or of the mediastinal lymph glands. The possibility of
aneurysm must always be kept in mind because of the risk attending the
passage of instruments for diagnostic purposes.

#Spasm of the Muscular Coat.#--As in other tubular structures
containing circular muscular fibres, sudden contraction or spasm may
occur in the œsophagus and cause narrowing of the lumen, attended with
difficulty in swallowing. This spasmodic dysphagia includes such
widely varying conditions as the "globus hystericus" of neurasthenic
women, the spasm of chronic alcoholics, and the affection known as
_cardiospasm_ or "hiatal œsophagismus."

In contrast with other affections causing difficulty in swallowing,
spasmodic dysphagia usually has a sudden and unexplained onset, the
progress of symptoms is irregular and erratic, while the remission of
symptoms common to all affections of the œsophagus, and the influence
of mental impressions, such as excitement, hurry in the presence of
strangers, are exaggerated.

In testing the calibre of the gullet it is found that on one occasion
a full-sized bougie may pass easily and be completely arrested at
another.

Apart from the treatment of the neurosis underlying the dysphagia,
reliance is placed upon dilatation of the portion of gullet affected.

#Cardiospasm# is the name given to "a recurrent interference with
deglutition by spasmodic contraction of the lower end of the
œsophagus." As there is no muscular or nervous mechanism at the
cardiac 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 the
initial stage, the first attack occurs suddenly and unexpectedly; a
choking sensation is felt at some point in the gullet, usually at its
lower end. Attacks of choking with difficulty in swallowing occur
chiefly at meals, but they have also been known to occur apart from
the taking of food. In this stage the peristalsis of the gullet is
sufficient to force the food through the cardia.

In the second stage, the peristalsis of the gullet above being no
longer able to overcome the contraction, there is regurgitation of
food, which at first is returned to the mouth immediately after being
swallowed, but, as the gullet becomes dilated, is retained for longer
periods.

In the third stage, the gullet becomes more and more dilated, and the
food collects in it and is regurgitated at irregular intervals. The
patient complains of a sensation of weight and discomfort in the lower
part of the chest, and sometimes of regurgitation of food into the
nasal passages during sleep.

Cardiospasm should be suspected as the cause of difficulty in
swallowing if a rubber tube cannot be passed into the stomach while a
solid one can. When it is impossible to pass a solid instrument in the
ordinary way it can always be passed on a silk thread as a guide. The
patient is directed to swallow 6 yards of silk thread, half in the
afternoon and the remainder on the following morning. The first
portion forms a snarl in the gullet or stomach which passes out into
the intestine during the night; the proximal end is fixed to the cheek
by a strip of plaster. The olive heads of the bougies are drilled for
threading from the tip to one side of the base.

The _treatment_ consists in dilating the contracted segments by a
bougie. The results are immediate and are most striking, the patients
being almost invariably able to take any kind of food at the following
meal, and the gain in weight and strength is rapid. In a small
proportion of cases, dilatation fails to give relief, and recourse has
been had to anastomosing the lower end of the dilated and pouched
œsophagus with the stomach.

#Paralysis of the Gullet.#--As the passage of the food along the
gullet is entirely dependent upon muscular peristalsis, when the
muscular coat is paralysed, as it may be after diphtheria, for
example, the patient is unable to swallow and the food materials are
regurgitated, with consequent loss of flesh and strength. The
difficulty may be tided over for a time by feeding through a rubber
tube, but it is to be remembered that, in children, struggling in
resisting the passage of the tube may seriously strain a heart that is
already threatened by the toxins of diphtheria.

#Diverticula or Pouches of the Gullet.#--A diverticulum consists in
the protrusion of the mucous and submucous coats through a defect or
weak part in the muscular tunic; it is therefore of the nature of a
hernia and not a localised dilatation of the tube as a whole.
Anatomically, there is such a weak spot in the posterior wall opposite
the cricoid cartilage, known as the _pharyngeal dimple_, between the
circular and oblique fibres of the crico-pharyngeus muscle. As the
pouch increases in size by pressure from within, it usually extends
downwards and to the left. This pouch is described as a _pressure or
pulsion diverticulum_ because the hernial protrusion is ascribed to
increased pressure within the pharynx, not only the normal increase
caused by the act of swallowing, but an abnormal pressure from the too
rapid swallowing or bolting of imperfectly masticated food materials.

[Illustration: FIG. 285.--Radiogram, after swallowing an opaque meal,
in a man suffering from malignant stricture of lower end of Gullet.]

The _clinical features_ are not so characteristic of difficulty in
swallowing as might be expected. The patient, usually a man over forty
years of age, complains of dryness in the throat and of a sensation as
of a foreign body; later there is regurgitation of saliva and of food
with occasional choking. In about one-third of the cases, there is a
fullness, or a palpable tumour in the neck, about three times more
often on the left than on the right side, which may increase in size
after a meal, and pressure on which may cause a gurgling sound and, it
may be, regurgitation of food.

It is suggestive of a pouch, if the patient regurgitates food
materials which can be identified as having been swallowed several
days before, currants perhaps being those most easily recognised and
remembered.

Diverticula are also met with at a lower level, springing from the
gullet at or below the upper opening of the thorax; the distension of
the pouch with food materials presses upon the gullet with more
serious effect, even to the extent of complete obstruction and
consequent rapid emaciation. In men over fifty, the resemblance to
carcinoma may be very close.

In this, as in all cases of difficulty in swallowing, chief stress
should be laid on the X-ray appearances after the administration of an
opaque meal; a pouch shows as a uniform, spherical shadow of from one
to two inches in circumference.

_Treatment_ is influenced by the manner in which the patient may have
learned to overcome the difficulty of getting food into his
stomach--Lord Jeffrey, who was the possessor of the pharyngeal pouch
shown in Fig. 286, was in the habit of emptying it, after a meal, by
means of a long silver spoon. Some patients learn to feed themselves
through a soft rubber tube.

[Illustration: FIG. 286.--Diverticulum of the Œsophagus at its
junction with the Pharynx.

(Anatomical Museum, University of Edinburgh.)]

If an _operation_ is decided upon, and for this it is essential that
the pouch should be accessible from the neck, the general condition is
improved by feeding through a stomach tube and by rectal and
subcutaneous salines. The operation consists in exposing and isolating
the pouch by a dissection on the left side of the neck, and either
excising it as if it were a tumour or cyst, or if the risk of
infection of the deeper planes of cellular tissue is regarded with
apprehension, the pouch may be _infolded_ into the lumen of the
gullet, or the excision be carried out in two _stages_. At the first
stage, the pouch is isolated and rotated on its pedicle, in which
condition it is fixed by sutures; after an interval of from ten to
fourteen days it is excised.

Should the diverticulum be inaccessible from the neck, and the
difficulty of swallowing be attended with progressive emaciation,
_gastrostomy_ may be required to avert death by starvation.

_Traction diverticula_ are due to the contraction of scar tissue
outside the gullet, as for example that resulting from tuberculous
glands in the posterior mediastinum; they are rarely attended with
symptoms, and are rather of pathological than surgical interest.

#Innocent Stricture or Cicatricial Stenosis of the Gullet.#--The
innocent or fibrous stricture follows upon the swallowing of corrosive
substances, usually by inadvertence, sometimes with suicidal intent.
Having recovered from the initial effects of the corrosive agent, the
patient suffers from gradually increasing difficulty in swallowing,
first with solids and later with fluids. There is the usual variation
or intermittence of symptoms that attend upon all conditions causing
difficulty of swallowing, the exacerbations being due to superadded
spasm of the muscular coat and congestion of all the coats. As the
gullet dilates above the stricture, there is an increasing
accumulation of what has been swallowed, and this the patient
regurgitates at intervals; this is usually described as "vomiting,"
but the material ejected shows no signs of gastric digestion. There is
pain referred to the epigastrium or between the shoulder-blades, the
patient suffers from hunger and thirst, and may present an extreme
degree of emaciation.

The _diagnosis_ is suggested by the history, and is confirmed by the
œsophagoscope or by the X-rays after an opaque meal. The use of
bougies has taken a secondary place since the introduction of these
methods of examination, but, when other means are not available, the
passage of bougies having a whalebone shaft and a series of metal
heads shaped like an olive, may give useful information regarding the
site, number, and size of the strictures that require to be dealt
with.

_Treatment._--If the patient is in a critical state from starvation,
gastrostomy must be performed to enable him to be fed; otherwise he is
prepared for treatment of the stricture by rest in bed, sedatives, and
suitable liquid or some solid foods to improve his general condition
and eliminate the muscular spasm and congestion already referred to.
If the passage of bougies with the object of dilating the stricture is
difficult or impossible, it may be made easier or possible by getting
a silk thread through the stricture. The patient swallows several
yards of a reliable silk thread a day or two before the proposed
dilatation is carried out; the thread is expected to pass through the
stricture of the stomach, and to enter for some distance into the
small intestine; the metal head of the bougie, which is canalised in
its long axis, is "threaded" on the silk, and the latter acting as a
guide, the bougie is passed safely and confidently through the
stricture. Larger olive-shaped heads are passed at intervals until the
normal calibre of the gullet is exceeded, after which it is usually
easy to pass an ordinary full-sized instrument at intervals of a month
or so.

In the event of failure, recourse must be had to gastrostomy, and
through the stomach it may be possible to dilate the stricture by the
"retrograde" route. In aggravated cases, the gastrostomy opening must
be retained in order to prevent death from starvation.

#Malignant Stricture--Carcinoma of the Gullet.#--This is met with in
two forms which present widely different pathological and clinical
features.

Cancer of the _cervical_ portion affects the gullet at its junction
with the pharynx, and for some unexplained reason is much more common
in women, and at the comparatively early age of between thirty and
fifty. Cancer of the _thoracic_ portion affects the extreme lower end
of the gullet, and is met with almost exclusively in men over fifty.

#Cancer of the Cervical Portion.#--Difficulty of swallowing may arise
suddenly; more often it is slow and progressive over a period of
months and, in some cases, even of years. Pain on swallowing is not a
constant or prominent feature; it may be referred to the site of the
lesion or to one or both ears. In a considerable number of cases, the
complaints of the patient are referred to the larynx; coughing, with
abundant mucous expectoration disturbing the night's rest, hoarseness,
or even loss of voice, which symptoms are due either to direct
invasion of the larynx or to implication of one or other recurrent
nerve; for the same cause, difficulty of breathing may supervene,
sometimes of such a nature as to render tracheotomy imperative. A
gurgling noise on swallowing, and regurgitation of food are
occasionally observed.

Palpation of the neck, and particularly of the larynx and trachea,
should be carried out in all cases presenting the symptoms described;
and as bearing on the question of operation, enlargement of the
cervical lymph glands and of the thyreoid should be looked for; cancer
of the thyreoid is sometimes secondary to disease at the
pharyngo-œsophageal junction.

Direct and indirect laryngoscopic examination is then made; if the
laryngeal mirror fails to reveal anything abnormal, suspension
laryngoscopy, which gives a more extensive view of that part of the
pharynx lying behind the larynx, may be employed, or the œsophagoscope
may be preferred. A portion of the growth may be removed for
microscopical examination.

The use of the œsophageal bougie as a diagnostic agent must be
deprecated; it gives no satisfactory explanation of the cause of the
obstruction, and its employment when malignant ulceration is present,
is not free from serious risk to the patient (Logan Turner).

_Treatment._--The surgeon is dependent on the help of the
laryngologist not only for the diagnosis of the disease at the
earliest stage possible, but also for information as to its extent,
especially with regard to involvement of the larynx.

_Œsophagectomy_, or resection of the cancerous segment of the gullet,
in suitable cases, even if it does not yield a permanent cure, not
only prolongs life but relieves the patient of her most distressing
symptoms. It is rarely possible to secure an end-to-end anastomosis,
but the feeding by means of a tube introduced into the open end of the
gullet is more satisfactory and the laryngeal symptoms are more
efficiently relieved, than by either of the purely palliative
operations. In the majority of cases, however, only the palliative
measures of _œsophagostomy_ or _gastrostomy_ can be adopted.
Œsophagostomy presents the advantage, that by exposing the cervical
portion of the gullet, the operator is enabled to investigate the
extent of the disease and to revise his opinion on the feasability of
its removal if necessary. In advanced cases, when the disease has
spread widely in the neck and involved, it may be, the thyreoid and
the larynx, it may only be possible to relieve the urgent distress of
the patient by gastrostomy. _Tracheotomy_ may also become necessary
because of the spread of the cancer to the interior of the larynx.

#Cancer of the Lower End of the Gullet.#--The remarkable preference of
this location of œsophageal cancer for the male sex has already been
referred to; it affects the same type of male patients as are subject
to squamous epithelioma in other parts of the body. So far as we have
observed, its association with chronic irritation of the mucous
membrane in which it takes origin, or with any pre-cancerous
condition, has not been demonstrated.

The _clinical features_ resemble those of cicatricial stricture; the
difficulty of swallowing is usually of gradual onset, it concerns
solids in the first instance, then semi-solids like porridge or bread
and milk, and finally fluids. As in other forms of œsophageal
obstruction, the difficulty of swallowing varies quite remarkably from
time to time, presumably from variations in the degree of congestion
of the mucous membrane and of spasm of the muscular coat, but also
from mere nervousness, the patient having greater difficulty when in a
hurry, as in a railway refreshment room, or embarrassed by the
presence of strangers.

As the lumen of the gullet becomes narrower, the food materials
accumulate above the obstruction, and the consequent dilatation of the
gullet above the stricture accounts for the large amount that may be
regurgitated and for the patient describing it as vomiting. Along with
food materials there is abundant saliva, and, if the cancer has
ulcerated, of pus and blood. Contrary to what might be expected, there
is little or no complaint of hunger, in spite of the progressive
starvation and emaciation which inevitably supervene.

Death takes place within a year or so of the onset of symptoms,
usually from starvation, but the fatal issue may be precipitated by
ulceration and perforation of the gullet into a large blood vessel or
into the left pleural sac; in the latter event, there follows a basal
_empyema_ which may contain gas and food materials.

_Diagnosis._--In the majority of cases the history is so
characteristic that there is little doubt regarding the diagnosis; the
most reliable corroboration, with least risk and distress to the
patient, is obtained by radiographic examination after an opaque meal;
the appearance of the dilated gullet is that of an elongated sausage,
parallel with the vertebral column, and terminating abruptly at the
site of stricture (Fig. 285). A filiform, tortuous shadow of the
bismuth may be continued downwards and show up the lumen of the
stricture. The use of the œsophagoscope and of bougies is to be
deprecated as not free from risk.

_Treatment._--The lower end of the gullet is one of the most
inaccessible portions of the body, and although it has been removed by
operation the prospects of success are so small that it is not at
present regarded as justifiable.

Among _palliative measures_, may be mentioned _intubation_ of the
stricture with a view to increasing the amount of food that can be
swallowed; a funnel-shaped tube like that of Symonds or of Hill is
introduced into the lumen of the stricture by means of a bougie or
with the help of the œsophagoscope. The tube is anchored to a denture,
or by means of a silk thread to the cheek by sticking-plaster. Our
experience of intubation is that it merely serves to tide the patient
over a critical period of starvation, so that he may regain some
strength for any other procedure that may be indicated.

The value of making a fistula in the stomach--_gastrostomy_--in order
to feed the patient, is a question about which widely different
opinions are held both by patients and by surgeons. Many patients
allege that they would prefer to die rather than prolong a precarious
existence by being fed through a tube; some surgeons look upon the
operation with disfavour because they doubt whether it even prolongs
life, and it is often followed by a pneumonia which rapidly proves
fatal. Variation in the results of gastrostomy observed by different
surgeons is partly due to differences in the stage of the disease at
which the operation is performed, and probably to a greater extent to
the confusion between cases of slowly growing squamous epithelioma of
the lower end of the gullet and cases of glandular carcinoma of the
cardiac end of the stomach, these being grouped together under the
clinical heading of "malignant stricture of the lower end of the
gullet." In our experience cases of epithelioma of the gullet (in the
strict sense of the term) benefit greatly if subjected to gastrostomy
as soon as the condition is recognised. In a case operated upon by
Thomas Annandale the patient survived the operation for three years
and some months.

_Radiation._--The introduction of a tube of radium into the stricture
and its retention there, the silk thread attached to the tube being
secured to the cheek by a strip of plaster, is described by Hill and
Finzi as the most valuable palliative measure that has so far been
employed in cancer of the gullet; the capacity of swallowing may be
regained to a considerable extent. The employment of radium is
rendered easier and more efficient if it is preceded by gastrostomy.

_The Roux-operation._--This consists in making a new gullet to replace
that which is obstructed; the abdomen is opened and a loop of jejunum
is isolated; its lower end is anastomosed--end to side--to the
stomach; the intestine is brought upwards through a tunnel made for it
between the skin and the sternum, and the upper end is brought out and
fixed to the skin, in the supra-sternal notch. It has scarcely passed
beyond the experimental stage.




CHAPTER XXIX

THE LARYNX, TRACHEA, AND BRONCHI[7]


Examination of the larynx--CARDINAL SYMPTOMS OF LARYNGEAL AFFECTIONS:
    (1) Interference with the voice: _Hoarseness_; _Aphonia_--(2)
    Dysphagia--(3) Interference with respiration: _Diphtheritic
    laryngitis_; _Acute 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 a
laryngeal reflector with forehead attachment, one or two sizes of
laryngeal mirror, a tongue cloth, and the means of obtaining good
illumination. The source of light should be by preference placed
opposite to and on the same horizontal plane as the patient's left
ear. The forehead reflector is placed over the observer's right eye so
that he may look through the central aperture, while at the same time
he throws a good circle of light into the patient's mouth. The patient
should be seated with the head thrown slightly back; the tongue is
protruded and covered with the cloth, and held lightly but firmly
between the finger and thumb of the left hand. A full-sized mirror,
warmed so as to prevent the condensation of the breath upon it, is
inserted with the reflecting surface turned downwards, and pressed
gently against the soft palate so as to push that structure upwards.
The handle of the instrument is carried towards the left angle of the
mouth, and by slightly altering the plane of the reflecting surface of
the mirror the different parts of the larynx are in turn brought into
view. The movements of the vocal cords should be observed during both
respiration and phonation, and for the latter purpose the patient
should be directed to phonate the vowel sound "eh."

In the upper part of the mirror the epiglottis usually comes first
into view: it is of a pinkish yellow colour, and presents a thin,
sharply defined free margin. In front of the epiglottis are the median
and lateral glosso-epiglottic folds passing forwards to the base of
the tongue, and enclosing the two valleculæ. Extending backwards and
downwards from the lateral margins of the epiglottis are the two
ary-epiglottic folds which reach the arytenoid cartilages posteriorly.
Between the two layers of mucous membrane of which the ary-epiglottic
folds are composed are the cartilages of Wrisberg and Santorini. In
the interval between the two arytenoid cartilages is the
inter-arytenoid fold of mucous membrane, which forms the upper margin
of the posterior wall of the larynx. The upper aperture of the larynx
is bounded by the epiglottis in front, the ary-epiglottic folds
laterally, and the inter-arytenoid fold behind. In the interior of the
larynx the vocal folds (true vocal cords) form the most prominent
features, being conspicuous as two flat white bands, which form the
boundary of the rima glottidis or glottic chink. Above each true cord,
and parallel with it, the ventricular fold or false cord is evident as
a pink fold of mucous membrane. Between the ventricular fold and the
vocal fold on each side is a linear interval, which indicates the
entrance to the ventricle of the larynx.

_Direct Laryngoscopy._--The larynx may also be examined by the direct
method by means of Jackson's or Killian's spatulæ. After cocainisation
of the base of the tongue, the soft palate, and the posterior surface
of the epiglottis, the patient is seated upon a low stool and his head
supported by an assistant. The light is obtained from a small lamp in
the handle of the instrument or reflected from a forehead mirror. The
spatula is warmed and introduced under the guidance of the eye, its
end being passed over the epiglottis, and pressure exerted so as to
draw the latter structure forward. In children a general anæsthetic is
required, and the examination is made with the head hanging over the
end of the table. Killian's "suspension laryngoscopy" affords the best
method of examining the larynx in young children.

_Tracheoscopy and Bronchoscopy._--Direct examination of the trachea
and larger bronchi may be carried out in a similar way, by passing
through the mouth and larynx metal tubes, after the method devised by
Killian. This procedure is described as direct upper tracheoscopy and
bronchoscopy. The examination may also be made through a tracheotomy
wound--direct lower tracheoscopy. These procedures have proved of
great service in the recognition of foreign bodies in the lower
air-passages, and in their extraction; in the diagnosis of stenosis of
the trachea, and of aneurysm pressing on the trachea.


CARDINAL SYMPTOMS OF LARYNGEAL AFFECTIONS

The cardinal symptoms of laryngeal affections are interference with
the voice and with respiration, and pain on swallowing. Laryngeal
cough of a croupy or barking character may be present, and is usually
associated with a lesion of the posterior wall or inter-arytenoid
fold. Hæmoptysis is seldom of laryngeal origin, and unless the
bleeding spot is visible in the mirror, the source of the bleeding is
much more likely to be in the bronchi or lungs.

#Interference with the Voice.#--_Hoarseness_ results from some
affection of the vocal cords: it may be simple laryngitis, some
specific cause such as tuberculosis or syphilis, or some condition
which prevents the proper approximation of the cords, as in tumours
and certain forms of paralysis. Huskiness of voice occurring in a
middle-aged person, lasting for a considerable period, and unattended
by any other local or constitutional symptom, should always arouse
suspicion of malignant disease, and calls for an examination of the
larynx. Should this reveal a congested condition of one vocal cord,
associated with some infiltration, and should the mobility of the cord
be impaired, suspicion of the malignant character of the affection is
still further increased. The hoarseness in these cases is sometimes
greater than the local appearances would seem to account for.

_Aphonia_, or loss of voice, sudden in origin, and sometimes
transient, occurs more often in women, and is usually functional or
hysterical in nature. Although the patient is unable to speak, she is
quite able to cough. In these cases there is a bilateral paralysis of
the adductor muscles, so that the cords do not approximate on
attempted phonation; or the internal tensors may be paretic, leaving
an elliptical space between the cords on attempted phonation. If the
arytenoideus muscle alone is paralysed, a triangular interval is left
between the cords posteriorly. There is no inflammation or other
evidence of local disease.

The _treatment_ of functional aphonia should be general and local;
tonics such as strychnin, iron, and arsenic should be administered;
the intra-laryngeal application of electricity usually effects a
sudden cure. In obstinate cases the use of the shower-bath and cold
douching, the administration of chloroform, and even hypnotism may be
tried.

An examination of the lungs should be made in all cases of adductor
paralysis, as this functional condition may be met with in early
pulmonary tuberculosis.

#Dysphagia.#--Pain on swallowing, due to causes originating in the
larynx, is usually associated with ulceration of the mucous membrane
covering the epiglottis, ary-epiglottic folds, or arytenoid
cartilages, that is, in connection with those parts with which the
food is brought into direct contact.

The most frequent causes of such ulceration are tuberculosis,
syphilis, and malignant disease. The differential diagnosis is often
difficult from local inspection alone. The Wasserman test, the
previous history, the state of the lungs and sputum, and the results
of anti-syphilitic treatment may clear it up.

The _treatment_ of dysphagia, apart from that of the disease
associated with it, resolves itself into the use of local sedative
applications, such as a weak cocain or eucain spray before meals,
insufflations of acetate of morphin and boracic acid, and the use of a
menthol spray. One of the best anæsthetic applications is orthoform
powder, introduced by means of the ordinary laryngeal insufflator. Its
action is more prolonged than that of any of the others, often
lasting for from twenty-four to forty-eight hours.

Injection of the superior laryngeal nerve with a 60 per cent. solution
of alcohol has been found satisfactory where other means have failed.

#Interference with Respiration.#--It is only necessary here to refer
to such causes of interference with respiration as may call for
surgical treatment.

The chief forms of _laryngitis_ to be considered in connection with
the production of dyspnœa, are membranous or diphtheritic laryngitis
and 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 inflammatory
or non-inflammatory in origin. The former is the more common, and may
arise in connection with disease of the larynx, such as tuberculosis
or syphilis, or it may be secondary to acute infective conditions at
the base of the tongue, or in the fauces or pharynx; more rarely it
results from infective conditions of the cellular tissue or glands of
the neck. The non-inflammatory form may be a local dropsy in renal or
cardiac disease, may be induced by pressure on the large cervical
veins, and in some cases it appears to follow the administration of
potassium iodide in the treatment of laryngeal affections.

The œdema consists of an exudation into the loose submucous areolar
tissue, which may be of a simple serous character or may
become sero-purulent. The situations mainly involved are the
glosso-epiglottic fossæ between the base of the tongue and the
epiglottis, the ary-epiglottic folds (Fig. 287), and the false cords.
If the infective process commences in front of the epiglottis this
structure becomes swollen and rigid, and often livid in
colour--points which are readily discerned on examination with the
mirror, or even without its aid in some cases. The patient complains
of great pain on swallowing, and has the sensation of a foreign body
in the throat. Should the 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 rapidly
become cyanosed, the inspirations assume a noisy, stridulous
character, and great distress and imminent suffocation supervene. If
laryngoscopic examination is possible, the ary-epiglottic folds may be
found greatly swollen and the upper aperture of the larynx partly
occluded. Digital examination may reveal the swollen condition of the
parts. The urine should be examined for albumin and tube casts.

[Illustration: FIG. 287.--Larynx from case of sudden death, due to
œdema of ary-epiglottic folds, _a_, _a_.

(From drawing lent by Dr. Logan Turner.)]

_Treatment._--In the milder forms, the sucking of ice, the inhalation
of medicated steam, or spraying with a solution of adrenalin, and the
application of poultices to the neck, may suffice to relieve the
condition. Scarification of the epiglottis and ary-epiglottic folds
with a knife, followed by free bleeding, may give complete relief.
Diaphoretic and purgative treatment should not be neglected. If
suffocation is imminent, tracheotomy or intubation is called for.

In performing #tracheotomy#, a roller pillow is placed beneath the
neck to put the parts on the stretch, and an incision is carried from
the lower margin of the cricoid cartilage downwards for about 2
inches. The sterno-hyoids and sterno-thyreoids are separated; the
cross branch between the anterior jugular veins, and any other veins
met with, secured with forceps before being divided; and the trachea
exposed by dividing transversely the layer of deep fascia which passes
from the cricoid to the isthmus of the thyreoid. If the isthmus cannot
be pulled downwards sufficiently, it may be divided in the middle
line. All active bleeding having been arrested, the larynx is steadied
by inserting a sharp hook into the lower edge of the cricoid
cartilage, and the trachea is opened by thrusting a short,
broad-bladed knife through the exposed rings. The back of the knife
should be directed downwards, and the opening in the trachea enlarged
upwards sufficiently to admit the tracheotomy tube. In children it is
sometimes found necessary to divide the cricoid for this purpose
(_laryngo-tracheotomy_). The slit in the trachea is then opened up
with a tracheal dilator, and the outer tube inserted and fixed in
position with tapes. The inner tube is not fixed, so that it may be
coughed out if it becomes blocked, and that it may be frequently
removed and cleaned by the nurse. The tube should be discarded as
soon as the patient is able to breathe by the natural channel.

_Intubation of the Larynx._--This procedure is employed as a
substitute for tracheotomy, especially in children suffering from
membranous and œdematous forms of laryngitis. As experience is
required to carry out the manipulations successfully, and as its use
is attended with certain risks which necessitate that the surgeon
should be constantly within call, the operation is more adapted to
hospital than to private practice. O'Dwyer's apparatus is that most
generally employed. The operation consists in introducing through the
glottis, by means of a specially constructed guide, a small metal or
vulcanite tube furnished with a shoulder which rests against the false
vocal cords. The part of the tube which passes beyond the true vocal
cords is bulged to prevent it being coughed out.

In an emergency a gum-elastic catheter with a terminal aperture may be
passed, as recommended by Macewen and Annandale.

#Bilateral Abductor Paralysis.#--Both recurrent nerves may be
interfered with by such conditions as enlargement of the thyreoid,
tumour of the œsophagus, or intra-thoracic tumour, or by injury in the
course of operations for goitre. A gradually increasing inspiratory
dyspnœa is developed, which at first is only noticed on exertion, when
the desire for air is increased; later it becomes permanent, and even
during sleep the stridor may be marked. Suffocation may become
imminent. When the larynx is examined with the mirror, the vocal cords
are seen to lie near each other, and on inspiration their
approximation is still greater.

The _treatment_ is directed to removing the cause of pressure on the
nerves. In the majority of cases tracheotomy is called for and the
tube must be worn permanently.

#Syphilitic Affections of the Larynx.#--_Secondary syphilitic_
manifestations in the form of congestion of the mucous membrane,
mucous patches, or condylomata, are occasionally met with, and give
rise to a huskiness of the voice. These conditions usually disappear
rapidly under anti-syphilitic treatment.

In _tertiary syphilis_, whether inherited or acquired, the most common
lesion is a diffuse gummatous infiltration, which tends to go on to
ulceration and to lead to widespread destruction of tissue. It usually
attacks the epiglottis, the arytenoids, and the ary-epiglottic folds,
but may spread and implicate all the structures of the larynx.
Syphilitic ulcers are usually single, deep, and crateriform; the base
is covered with a dirty white secretion, and the surrounding mucosa
presents an angry red appearance. When the perichondrium becomes
invaded, necrosis of cartilage is liable to occur.

Hoarseness, dyspnœa, and, when the epiglottis is involved, dysphagia,
are the most prominent symptoms.

Cicatricial contraction leading to stenosis may ensue, and cause
persistent dyspnœa.

The usual _treatment_ for tertiary syphilis is employed, but on
account of the tendency of potassium iodide to increase the œdema of
the larynx, this drug must at first be used with caution. Intubation
or tracheotomy may be called for on account of sudden urgent dyspnœa
or of increasing stenosis. The stenosis is afterwards treated by
gradual dilatation with bougies, which, if a tracheotomy has been
performed, may conveniently be passed from below upwards. An annular
stricture causing occlusion may be excised, and the ends of the
trachea sutured.

#Tuberculosis.#--The larynx is seldom the primary seat of tubercle. In
the majority of cases the patient suffers from pulmonary phthisis, and
the laryngeal mucous membrane is infected from the sputum. The disease
may take the form of isolated nodules in the vicinity of the arytenoid
cartilages, of superficial ulceration of the vocal cords and adjacent
parts, or of a diffuse tuberculous infiltration of all the structures
bounding the upper aperture of the larynx. The mucous membrane becomes
œdematous and semi-translucent. The nodules coalesce and break down,
leading to the formation of multiple superficial ulcers. The parts
adjacent to the ulcers are pale in colour. Perichondritis may occur
and be followed by necrosis of cartilage and the formation of
abscesses in the submucous tissue of the larynx or in the cellular
tissue of the neck.

The voice becomes hoarse or may be lost, there is persistent and
intractable cough, and in some cases dyspnœa supervenes. When the
epiglottis is involved there is pain and difficulty in swallowing.

In the presence of advanced pulmonary phthisis the treatment is
chiefly palliative, but if the disease in the lungs is amenable to
treatment, and the laryngeal lesion limited, the electric cautery may
be used. Tracheotomy may be called for on account of urgent dyspnœa.

#Tumours.#--The commonest form of simple tumour met with in the larynx
is the _papilloma_. It may occur at any age, and is comparatively
common in children. It most frequently springs from the vocal cords
and adjacent parts, forming a soft, pedunculated, cauliflower-like
mass of a pink or red colour, which may form a fringe hanging from
the edge of the cord (Fig. 288), or may spread until it nearly fills
the larynx. In children, the growths are frequently multiple and show
a marked tendency to recur after removal. They sometimes disappear
spontaneously about puberty.

[Illustration: FIG. 288.--Papilloma of Larynx.

(From drawing lent by Dr. Logan Turner.)]

The most prominent symptoms are hoarseness, aphonia, and dyspnœa,
which in children may be paroxysmal.

The _treatment_ consists in removing the growth by means of laryngeal
forceps or the snare, under cocain and adrenalin anæsthesia. For the
removal of multiple papillomata, the removal of the growths through
Killian's tubes or by suspension laryngoscopy has now taken the place
of the external operation in children. In a certain number of cases it
has been found that the tumour disappears after the larynx has been
put at rest by the operation of tracheotomy.

#Cancer.#--_Epithelioma_ of the larynx is almost always primary, and
usually occurs in males between the ages of forty and seventy. It is
important to distinguish between those cases in which the growth first
appears in the interior of the larynx--on the vocal cords, the
ventricular bands, or in the sub-glottic cavity (_intrinsic
cancer_)--and those in which it attacks the epiglottis, the
ary-epiglottic folds, or the posterior surface of the cricoid
cartilage (_extrinsic cancer_).

_Clinical Features._--In the great majority of cases of _intrinsic_
cancer the first and for many months the only symptom is huskiness of
the voice, which may go on to complete aphonia before any other
symptoms manifest themselves. When the larynx is examined in an early
stage, the presence of a small warty growth on the posterior part of
one vocal cord, or a papillary fringe extended along the free edge of
the cord, should raise the suspicion of malignancy, especially if the
affected cord is congested and moves less freely than its fellow.
Early diagnosis is essential in intrinsic cancer, and the absence of
enlargement of lymph glands, or of fœtor and cachexia, must in no way
influence the surgeon against making a diagnosis of malignancy. The
impaired mobility of the affected cord is an important point in
determining the malignant nature of the growth.

Intrinsic cancer may spread over the upper boundaries of the larynx
and become _extrinsic_, or the disease may be extrinsic from the
outset.

In cases of _extrinsic_ cancer the early symptoms are much more
marked, pain and difficulty in swallowing, and the secretion of
frothy, blood-stained mucus being among the earliest manifestations.
The cervical glands are infected early, sometimes even before there
are any symptoms of laryngeal disease. Difficulty of breathing is also
an early symptom on account of the growth obstructing the entrance of
air. Tracheotomy may therefore be called for. In other respects the
course and terminations are similar to those of intrinsic cancer.

When the growth spreads into the tissues of the neck the patient's
sufferings are greatly increased. The œsophagus may be invaded with
resulting dysphagia; the nerve-trunks may be pressed upon, causing
intense neuralgic pains; the lymph glands become infected and break
down, and the growth fungates through the skin. The general health
deteriorates and death results, usually from septic pneumonia set up
by the passage of food particles into the air-passages, from
absorption of toxins, or from hæmorrhage. The duration of this form of
the disease varies from one to three years.

The _treatment_ consists in removing the growth. In early and limited
forms of intrinsic cancer laryngo-fissure (thyreotomy) gives good
results; in more advanced cases the entire larynx must be
removed--_complete laryngectomy_--and at the same time, or after an
interval, the associated lymph glands are removed from the anterior
triangle of the neck on both sides.

In cases in which excision is impracticable, the sufferings of the
patient may be alleviated by performing low tracheotomy, and by
feeding with the stomach tube or by nutrient enemata. In some cases
the difficulty of feeding the patient may make it necessary to perform
gastrostomy.

#Sarcoma# of the larynx gives rise to the same symptoms as cancer, and
can seldom be diagnosed from it before operation.

#Foreign Bodies in the Air-Passages.#--Foreign bodies impacted _in the
pharynx_ usually consist of unmasticated pieces of meat or large
tooth-plates, and they occlude both the food and the air-passages,
frequently causing sudden death. They are considered with affections
of the pharynx.

The bodies most frequently impacted _in the larynx_ are small
tooth-plates in the case of adults, and buttons, beads, sweets, coins,
and portions of toys in children. These are drawn from the mouth into
the air-passage during a sudden inspiratory effort, for example while
laughing or sneezing. If the glottis is completely blocked, rapidly
fatal asphyxia ensues. If the obstruction is incomplete, the patient
experiences severe pain, difficulty of breathing, and a terrifying
sensation of being choked. The irritation of the foreign body causes
spasmodic coughing and retching, and may induce spasm of the glottis,
with threatening suffocation.

Small round bodies may lodge in the upper aperture or in one of the
ventricles, and give rise to hoarseness and repeated attacks of
dyspnœa and spasmodic cough. Wherever the body is situated, the
symptoms may suddenly become urgent from its displacement into the
glottis, or from the onset of œdema. The position of the body may
often be ascertained by the use of the X-rays.

_Treatment._--If the symptoms are urgent, laryngotomy, which consists
in opening the larynx below the glottis by dividing the crico-thyreoid
membrane, or tracheotomy must be performed at once, and an attempt
made to remove the foreign body thereafter. In less severe cases in
adults, the throat should be sprayed with cocain, and the larynx
examined with the mirror; in children, the direct method must be
employed. In both instances an attempt should be made to extract the
body by the direct method. As these manipulations are liable to induce
sudden spasm of the glottis, the means of performing tracheotomy must
be at hand. If it is found impossible to remove the body through the
mouth, laryngotomy or tracheotomy should be performed, and the body
extracted through the wound, or pushed up into the pharynx and removed
by this route. In the case of small bodies, a strand of gauze pushed
up from the tracheotomy wound, through the larynx and out of the
mouth, catches the foreign body and carries it out (Walker Downie).

The foreign bodies that are most likely to become impacted _in the
trachea_ are tooth-plates with projecting hooks, and small coins. The
position of the foreign body may be ascertained by the use of
Killian's tracheoscope, or by means of the X-rays. If the body remains
movable in the trachea, it is apt to be displaced when the patient
moves or coughs, and it may be driven up and become impacted in the
glottis, setting up violent attacks of coughing and spasmodic dyspnœa.

Tracheotomy should be performed at once, and the edges of the tracheal
wound held widely open with retractors, the patient being inverted, or
coughing induced by tickling the mucous membrane with a feather. The
foreign body is usually expelled, but it may be inhaled into one of
the bronchi. One of Killian's tracheal tubes may be introduced
through the tracheotomy wound and the body extracted by means of
suitable forceps.

_Foreign Bodies in the Bronchi._--Rounded objects, which pass through
the larynx, usually drop into one or other of the bronchi, usually the
right, which is the more vertical and slightly the larger. The body
may act as a ball-valve, permitting the escape of air with expiration,
but preventing its entrance on inspiration, with the result that the
portion of lung supplied by the bronchus becomes collapsed. The
physical signs of collapse of a portion or of the whole lung may be
recognised on examination of the chest. In some cases the body is
dislodged and driven up into the larynx, causing severe dyspnœic
attacks and spasms of coughing. The irritation caused by the foreign
body in the bronchus may set up bronchitis or pneumonia, and abscess
of the lung may supervene. This has frequently followed the entrance
of an extracted tooth into the air-passage, and it may be a
considerable time before pulmonary symptoms arise. Sometimes the tooth
is ultimately coughed up and the symptoms disappear. In some cases the
physical signs closely simulate those of pulmonary phthisis.

The _treatment_ consists in removing the body by the aid of Killian's
or Jackson's tube passed through the mouth. If this is not successful,
low tracheotomy is performed and the tube is passed through the
tracheotomy opening.




INDEX


  Abducens nerve, 400

  Abductor paralysis, 404, 639
    splint, 221

  Abscess. _See_ Individual Organs and Regions

  Accessory nasal sinuses. _See_ Individual Sinuses
    nerve, 404

  Acetabulum, fracture of, 125
    tuberculous disease of, 210
    wandering, 210, 227

  Achillo-bursitis, 294

  Acoustic nerve, 579

  Acromion process, fracture of, 69

  Actinomycosis. _See_ Individual Organs and Regions

  Adenoids, 578

  Alveolar abscess, 507
    process, fracture of, 519
    tumours of, 513

  Ambulant splint for ankle, 189
    treatment of hip disease, 222

  Amputation in compound fracture, 26

  Anatomy. _See_ Surgical Anatomy

  Angina Ludovici, 548, 597

  Ankle, deformities of, 273
    diseases of, 238, 240
    dislocations of, 194
    fractures in region of, 186, 187
    injuries in region of, 185
    surgical anatomy of, 185
    tuberculous disease of, 238

  Ankylosis of joints. _See_ Individual Joints

  Anosmia, 399, 578

  Anterior poliomyelitis, 242

  Aphasia, 335

  Aphonia, 636

  Arm, upper, injuries of, 44

  Arthritis. _See also_ Individual Joints

  Arthritis, septic, 34

  Arthrodesis, 246

  Astragalus. _See_ Talus

  Athetosis, 247

  Atlo-axoid disease, 440
    joint, fracture-dislocation of, 430

  Auditory nerve, 403

  Aural polypi, 558
    vertigo, 555

  Auricular appendages, 560

  Avulsion of scalp, 322


  Balkan frame splint, 150

  Basedow's disease, 614

  Bell's paralysis, 401

  Bennett's fracture, 116

  Bezold's mastoiditis, 566

  Bier's constricting bandage, 12, 26

  Black eye, 370, 484

  Blepharospasm, 403

  Bones, atrophy of, 2
    contusion of, 1
    fracture of, 1
    gun-shot injuries of, 27
    injuries of, 1
    repair of, 8
    wounds of, 1

  Bow-knee, 271
    -leg, 271

  Box splint, 182

  Brachial plexus, lesions of, 597

  Brachio-thoracic triangle, 470

  Bradford frame, 438

  Brain, abscess of, 360, 374, 376, 378, 382
      localisation of, 380
    adhesions, 358
    cerebral irritation, 342, 346
    compression of, 347
      differential diagnosis of, 350
    concussion of, 341, 344
    contusion of, 342
    cyst of, hæmorrhagic, 344
    decompression operations on, 396
    diseases of, 373
      pyogenic, 373
    foreign bodies in, 350
    functions of, 331
    hæmorrhage into, 352
    hernia of, 397
    injuries of, 341
      mechanism of, 343
      repair of, 344
    irritation of, 342, 346
    laceration of, 342
    lesions of, 341
    localisation of centres in, 336
    membranes of, 328
      diseases of, 372
    motor area of, 330
    sclerosis of, 358
    sensory mechanism of, 332
    softening of, 342
    surgical anatomy of, 328
    syphilitic gumma, 395
    traumatic 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