COLUMBIA LIBRARIES OFFSFTE HEALTH SCIENCES STANDARD HX00055255 'Surgery. VoUI. KTnnK Flirs. Columbia (Hnitttisitj> v^^ mt!)f(irttp0fi^rtt5gdrk College of ^fjj>£(iciansi anb ^urgeong Hibrarp -' TO, AND LECTUREE OX AXATOilT AT, THE LONDON HOSPITAL HUXTEKIAN PBOFESSOE AT THE ROYAL COLLEGE OF SURGEONS OF ENGLAND. Foluiuf IIH. THE ORGANS OF LOCOMOTION AND OF SPECIAL SENSE —THE RESPIRATORY PASSAGES — THE HEAD — THE SPINE. 7 ILLUSTRATED WITH 124 ENGRAVINGS. FHILAIjLLFHIA . LEA BROTHERS & CO 1892. 2. \i LIST OF AUTHOES. WILLIAM ANDERSON, ESQ., F.R.C.S. ; Assistant .SurgeoD to, and Lecturer on Anatomy at, St. Thomas's Hospital. Animal Poisons. W. MITCHELL BANKS, ESQ., F.U.CS. : Professor of Anatomy, Uniyersity Col- lege, Liverpool ; Surfr<0!i to the Liverpool Royal luflnuary. Diseases of the Breast. H. TRENTHAM BUTLIN, ESQ., F.R.C.S. ; Assistant Surgeon to St. Bartholo- mew's Hospital. Tumours. JAMES CANTLTE. ESQ., M.A., M.B., F.R.C.S. ; Assistant Surgeon to Charing Cross Hospital. GuiL-fihot Wounds. Injuries and Diseases of the Testis, Scrotum, and Penis. JOHN CHIENE, Esq., MD., P.R.C.S.B., F.R.S.E.; Professor of Sursrery, Univer- sity of Eilinburgh ; Surgeon to the Royal Infirmary, Edinburgh. The Process of Repair. Wounds. ANTHONY H. CORLEY, ESQ., M.D., F.R.C.S.T. ; Lecturer on Surgery, Car- michael College, Dublin ; Examiner in Surgery, Royal University, Ireland ; Surgeon to the Richmond Hospital. Injuries of the Head. HARRISON CRIPPS, ESQ., F.R.C.S.; Assistant Surgeon to St. Bartholomew's Hospital. Diseases of the Rect \im. JOHN CROFT, Esq., F.R.C.S. ; Surgeon to. and Lecturer on Clinical Surgery at, St, Thomas's Hospital ; Examiner in Surgery, Royal College of Surgeons of England. Injuries and Diseases of the (Esophagus. JOHN DUNCAN, Esq.. M.D., LL.D., F.R.C.S.E., F.R.S.E. ; Lecturer on Surgery, Edinburgh School of Medicine ; Surgeon to the Royal Infirmary, Edinburgh. Gangrene. Erusipelas. FREDERIC S. EVE, Esq., F.R.C.S. ; Assistant i=!urgeon to the London Hospital ; Pathological Curator, Royal College of Suriroons, England. Burns and Scalds. Scrofula and Tuberculosis. Rid'cts. Hectic or Suppurative Fever. Traumatic Fever. Traumatic Delirium. GEORGE P. FIELD, ESQ., M.R.C.S. ; Aural Surgeon to St. Mary's HospitaL Diseases of the Ear. A. PEARCE GOULD, ESQ., M.S. Lond., F.R.C.S. ; Assistant Surgeon to the Mid- dlesex Hospital ; Suri-'eon to the Royal Hospital for Diseases of the Clust. Injuries of Blood-Vc^sels. yluewrisin. The Surgery of the- Chest, Diseases of Blood-Vessels. . J. GREIG SMITH, ESQ., M.A., M.B., F.R.S.E. ; Surgeon to the Bristol Royal In- firmary. Diseases of the Bones. R. MARCUS GUNX, Esq., M.A., M.B., F.R.C.S. ; Assistant Surgeon to the Royal London Oiilitbalraic Hospital, Moorflelds. Ki'sedses of the Eye. VICTOR HORSLEY, Esq.. B.S. Lond., P.R.S.. F.R.C.S.; Assistant Surgeon to Uni- vcreity College Hospital ; Pi'ofessor Superintendent of the Brown Institute. Injunes and Diseases ofiiie Neck, /OKATHAN HUTCHINSON, Esq., F.K.a. ; Consulting Surgeon to the London Hospital ; Examiner in Surgery, RoyaJ College of Surgeons. England. Syphilis. n List of Authors. JONATHAN HUTCHINSON, Esq., Jcy.. F.R.C.S. ; Surgical Reyistiar to the London Hospital. Teianxxi, FURNEAUX JORDAN, Esq., F.R.C.S. ; Professor of Surgery, Queen's College, Birmingbam ; Surgeon to the Queen's Hospital. S/iocfc. SIR -SVTLLIAil MACCORMAC. M.A., D.Sc, F.R.C.S.; Surgeon to, and Lecturer on Surgery at.'St. Thomas's Hospital ; Examiner in Snrgery, Uni- versity of London. Hernia, HOWARD MARSH, ESQ., F.R.C.S. : Assistant Surgeon to, and Lecturer on Ana- tomy at, St. BnrtliolonieWs Hospital ; Surgeon to the Hospital for Sick Children, Great Orraond Street. I)i'oeases 0/ Joints. JO.SEPH MILLS. Esq., M.R.C.S. ; Anesthetist to St. Bartholomew's Hospital. Anlicated when it is accompanied by injury to some other important l)art, e.g. bv ;i dislocation or wound of a neighbouring Causes of Fracture. 3 joint, or by wound of a large blood-vessel, or of some internal cavity or organ ; a simple fracture may be complicated by an external wound, the fracture not being termed compound unless the wound in the soft parts leads down to or exposes the bone. Separation of the epiphyses may be considered along with fractures ; these injuries, which occur only in young subjects before ossification is completed, may involve the ends of any of the long bones, the upper and lower epiphyses of the humerus being those which are, perhaps, most frequently separated ; less frequently the epiphyses of other bones are involved, e.g. those of the OS calcis, acromion, olecranon, etc. Causes. — The causes of fracture may be divided into two great classes, predisposing and exciting. The predisposing causes include all those condi- tions, constitutional or local, in consequence of which the osseous tissue becomes unusually fragile, weakened, or diseased ; e.g. old age, rickets, certain nervous affec- tions, such as locomotor ataxy, general paralysis of the insane, etc., caries or necrosis, malignant tumours of bone, osteo-malacia, atrophy of bone from any car.se, absorption of bone from pressure of tumours, or syphilis, when the bone becomes the seat of gummatous deposits. Other predisposing causes of fracture are the male sex, in consequence of their more constant exposure to violence, and the shape and situation of particular bones, the long ones of the extremities being more frequently involved than short, thick bones, like the bodies of the vertebra?, etc. The exciting causes of fracture are external violence and muscular action. External violence, by far the more common cause, may act in one of two ways, either directly or in- dii-ectly. When due to direct violence the fracture takes place at the part struck, e.g. wlicn a blow on the 4 Manual of Surgery. nose fractures the nasal bones ; under these circuui- stauceSjthe soft tissues covering the bone are frequently bruised, or torn and lacerated, as the result of the same force that causes the fracture, so that an open wound is produced which leads down to the bone, and the fracture is consequently often compound. When due to indirect violence, the force acting at one spot is transmitted, and causes a fracture at a dis- tance from it, e.g. when a person falling upon the hand or shoulder fractures the clavicle. Muscular action is not a common cause of fracture when the bones are in a healthy condition, except in the case of the patella, which is often broken by the contraction of the powerful quadriceps extensor in an attempt to save the body from falling backwards. Much less frequently some of the other bones, e.g. the olecranon, os calcis, etc., are fractured as the result of sudden violent contraction of the muscles inserted into them. When the bones are in a softened or diseased condition, fracture of any of them, even the long ones of the extremities, may be produced in the same way ; and, doubtless, most of the so-called spontaneous fraxi- lures belong to this class, being in reality due to muscular action acting upon bones, which are weakened from some of the causes mentioned above as predisposing to fracture. In the same way separation of the epipliyses of the long bones is not uncommon in infants the subjects of congenital syphilis, owing to changes of an inflamma- tory character taking place at the junction of the shafts with the e])iphyses ; a somewhat simihir condi- tion is occasionally met with in children Avho are affected with " acute rickets " or " infantile scurvy," in consequence of effusions of blood taking place between the epiphyses and shafts, and also beneath the periosteum.* * Barlow: Med.-(Jliu-. Trans., vol. Ixvi,, 1883. Symptoms of Fracture. 5 Intra-uterine fracture. — Fractures occasionally occur in the foetus before birth, in some cases as the result of external violence, e.rj. a fall or blow on the abdomen of the mother ; in other instances, in conse- qaence of abnormal contraction of the uterus, or even of the muscles of the child itself. The fracture, which may be either simple or compound, may or may not have united at the time of birth. Intra-uterine fractures must not be confounded with those occa- sionally produced as the result of violence sustained during actual delivery. Symptoms. — The general symptoms of fracture are abnormal mobility, deformity, crepitus, and loss of power, with more or less pain, swelling, and ecchymosis at the seat of injury ; occasionally the patient is sen- sible of a distinct crack or snap produced by the giving way of the bone at the moment the fracture occurs. All these symptoms are not, however, present in every case, being modified by various conditions. Abnormal mobility is owing to the loss of con- tinuity in the broken bone, and can usually be detected by grasping the limb on either side of the seat of frac- ture, and then moving the fragments to and fro, or rotating them on one another. It is not, however, a symptom which is always present, for it is wanting in impacted fracture, and cannot, as a rule, be detected when a short or flat bone is broken, e.g. in the bodies of the vertebrae, vault of the skull, etc. Deformity., owing to displacement of the fragments of the broken bone, is, when present, always an im- portant sign of fracture. It may be the direct result of the violence that causes the fracture ; e.g. in im- pacted fracture of the lower end of the radius or neck of the femur ; or, as is usually the case, it may be due to subsequent muscular contraction ; e.g. in oblique fracture of the tibia when the lower frao^inent is drawn upwards above the upper by the action of the muscles 6 Manual of Surgery. of the calf ; or it may be the result of the weight of the limb dragging upon one of the fragments ; e.g. in fracture of the clavicle, when the outer fragment is drawn down by the weight of the arm. The parti- cular deformity will depend upon the direction of the line of fracture and also upon the nature of the dis- placement of the fragments ; thus it may be angular, or transverse or lateral, or one fragment may over- ride or be rotated on, or widely separated from, the other. In all cases the injured part should be compared witli the o})posite side of the body, as it is often only by a careful comparison made in this way that the deformity, if slight, can be detected. Deformity is not, however, always present ; it is often absent when one of two parallel bones is broken ; e.g. in fracture of the fibula, the tibia, acting as a splint, often i)re vents any displacement of the fragments from taking place. Again, when a short or flat bone is in- volved, there is often no displacement and consequently no deformity. Crepitus is the term applied to the rough gratmg produced when the ends of a broken bone are rubbed against one another. When present, it is always a valuable sign of fracture, but it is often absent ; e.g. in incomplete fracture, or when the fragments are im- pacted, or widely separated, so that they cannot be bi'ought into contact. It is also wanting if a portion of blood clot, muscle, or other tissue, is interposed between the fragments ; or if the fracture is not recent, and the ends of the bone have become covered o\er with inflammatory exudation. When a short or flat bone is fractured, it is often diflicult to detect crepitus, as also in cases where one of two parallel bones is broken ; e.g. in fracture of the fibula. I'he true or bony crepitus met with in fracture must be distinguished from false or " silk^en " crepitus, Treatment of Fracture. 7 as it is sometimes termed, which frequently accom})a- nies inflammation of the sheath of a tendon ; in the latter case there is simply a fine crackling very dif- ferent to the rough grating of fracture. When in the neighbourhood of a joint; care must be taken not to mistake the crackling, which often accompanies eflTu- sion into its interior or into an adjacent bursa^ for the crepitus of fracture. Loss o.f jjower or interference with function is usually present to a greater or less extent in the part where the fracture is situated ; more or less pain will usually be complained of, and in most instances swell- ing and ecchymosis will sooner or later show them- selves at the seat of injury. In cases of separation of an epiphysis, the general symptoms are identical with those of fracture, except that crepitus is either absent or much less distinct, owing to the fact that the line of separation runs through cartilage rather than bone ; for the same reason, the ends of the fragments are more smooth and rounded, not so sharp and irregular as in fracture. General principles of treatment.— In the treatment of any fracture there are three indica- tions to be arrived at, and, if possible, carried out, viz.: (1) The reduction of the fracture ; (2) the main- tenance of the fragments in their proper position until union is effected ; (3) the prevention and treatment of any complication, constitutional or local, that may arise. 1. The reduction or setting of the fracture, i.e. the restoration of the fragments (when displaced) to their proper position, should always be eflected with as little delay as possible, otherwise the muscles, as the result of the irritation to which they are subjected, become rigidly contracted, and considerable force will then be required to overcome the spasm. Great care should always be employed in manipulating the limb, 8 AfAxcrAL OF Surgery for if it is rougbly handled there is a risk of convert- ing a simple fracture into a compound one. In ordinary cases, e.g. in fracture of the long bones of the extremities, reduction is effected by the employ- ment of extension and counter-extension. The surgeon makes extension by drawing steadily and without jerking upon the limb below the seat of fracture, while an assistant makes counter-extension ; viz. fixes the limb on the proximal side of the fracture. In this way the extending force, which acts only on the lower fragment, is maintained until the ends of the bone are drawn opposite to one another ; by a little mani[)ula- tion, as, for example, by pressing gently on one or both of the fragments, they can usually be brought into proper position, and some further means must then be adopted in order to maintain them so. Inasmuch as spasm of the muscles is the chief cause of displacement in fracture, reduction will often be facilitated by the adoption of measures which tend to produce muscular relaxation. In some cases this can be effected by attention to the position of the part ; e.g. in fracture of the tibia and fibula, by bend- ing the knee so as to relax the muscles of the calf ; occa- sionally division of the tendons may be required before reduction can be effected ; e.g. tenotomy of the tendo A chillis is occasionally necessitated in the same frac- ture. Anaesthetics will often be found useful in similar circumstances, for when the patient is under their influence muscular spasm at once disappears. Reduction is, however, occasionally impossible, as, for example, in certain cases of firmly imyiacted frac- ture ; under these circumstances it is often better not to attempt it, preparing the patient for the defonnity which will be permanent. 2. Tlte maintenance of the fragments in their projjer po.ntion after the fracture has been set has next to be attended to, and this may be effected in various ways ; Treatment of Fracture. ■ g e.g. bj means of splints, bandages, or some form of special apparatus. Splints composed of many different kinds of material are employed for this purpose ; e.g. ■wood, tin, zinc, wire, guttapercha, felt, mill-board, leather, etc. Bandages containing some material, e.g. plaster of Paris, starch, gum and chalk, paraffin, silicate of sodium or potassium, etc., which hardens when dry, forming a firm, solid application accurately moulded to the part, are much used at the present time ; if necessary, they can be strengthened by the insertion of pieces of iron, tin, felt, or mill-board, between the layers of bandage. Some surgeons at once put up the fracture in one of the different varieties of solidifying apparatus ; e.g. a plaster of Paris bandage ; others prefer to apply some form of splint, e.g. the ordinary wooden ones for a few weeks, and then, when repair is well ad- vanced, to replace them with a stiff bandage. One great advantage of splints is that the seat of injury can be left exposed, whereas if a stiff bandage is emjjloyed the fracture is concealed from view, unless the bandage is interrupted, or slit up along its whole length after it has set, so as to allow of its removal from time to time. As a general rule, splints should be employed in cases where the soft tissues are much swollen, bruised, or ecchymosed, or where there is much displacement of the fragments and difhculty is experienced in reducing and maintaining them in position, care being taken that in the former case the bandages Avhich fix the splints are not applied too tightly. The seat of injury being left uncovered, some e\'aporating lotion can be ap])lied, the condition of the part can be examined from day to day without removing the apparatus, and if any displacement of the fragments takes place, it will at once be evident and can then be corrected. If TO . Manual of Surgerv. some form of stitf bandage is applied when the parts are much swollen, it will become loose when the swelling subsides and consequently allow of move- ment and displacement of the ends of the fractured bone. A stiff bandage may, however, frequently be applied at once with very good results, if none of the con- ditions just mentioned are present ; and in the case of the lower extremity it possesses this additional advan- tage, that, being light, it does not necessitate confine- ment to bed, and the patient, with the assistance of crutches, will often be able to get about in the course of a few days. Many modifications of the latter method of treat- ment are now employed, and a very useful one is that recommended by Mr. Croft, in cases of fracture of the lower extremity.* In the so-called "Croft's splints," a double layer of coarse flannel, shaped so as to tit the limb and form a kind of lateral splint, is ap- plied to each side of the leg and foot, the outer layer having been previously saturated with a solu- tion of plaster of Paris and water of the consistence of thick cream. A muslin bandage is applied outside the flannel so as to maintain it in close contact with the limb while the plaster is setting, and at the same time care must be taken that the fracture is kept in pro})er position. After the bandage has set, it is cut up along its centre, viz. in front of the limb at the line of junction of its two lateral halves, so as to allow of its removal from time to time for the purpose of exam- ining the fracture and the condition of the limb. In the application of splints there are certain rules which should always be observed ; viz. 1. The splints should be well padded, especially where they press upon ])oints of bone. 2. They should, if possible, in- clude the joints above and below the fracture, so as to completely fix the limb. 3. No bandages should be * Medico-Chir. Traus., vol. Ixiv. Treatment of Fracture. t\ applied beneath them. 4. The seat of fracture should be left uncovered. 5. The extremities of the limV), e.g. the lingers or toes, should be left exposed to view. When plaster or other forms of solidifying bandages are used, care must be taken not to apply them too tightly, otherwise, when they set, con- striction of the limb may be produced ; to prevent this, it is a good plan to first envelope the limb in a layer of cotton wool, or to apply dry next to the skin several layers of an ordinary flannel bandage. Whatever form of apparatus is employed, the frac- ture should always be examined the day after it has been put up, and subsequently from time to time ; if the limb is found to be painful aud swollen, and es- pecially if the toes or fingers are cold, numb, con- gested, or oedematous, the bandages or splints should be eased or removed and re-applied, other- wise there is a risk of gangrene supervening, for the occurrence of these symptoms shows that too much pressure has been used and that the circula- tion through the limb has become impeded. The special forms of apparatus which may be re- quired will be mentioned under the different fractures. The fracture bed, in cases of fracture of the lower extremity, should be fiat and firm ; if it tends to sink in the centre, a piece of board should be introduced between the mattress and the bedstead. Care should be taken that the sheets do not crease, and, if possible, a strong cord with a short stick attached to its lower end should be suspended over the bed, to assist the patient in raising or moving his body when requisite. Treatment of coiiipoimcl fractures. — The limb may be put up in a similar manner either in splints or in some form of stiff" bandage ; if the latter method is employed, an opening, or " window,'' should be cut in the bandage exactly over the T2 Manual of Surgery. fracture, or tlie bandage should be interrupted at the same spot with strips of iron hoop or pieces of strong wire, which are inserted between its layers as it is applied, in order to allow of the wound being examined and dressed when necessary. As regards the treatment of the wound itself, this will depend upon the nature of the injury. If there is a mere puncture in the skin caused by tlie sliarp end of one of the fragments, it may often be closed at once with a pad of lint dipped in the compound tincture of benzoin or collodion ; under this the wound \\all often rapidly heal, and the fracture being, as it were, converted into a simple one, will in many cases quickly unite without any suppuration. If, however, under this treatment the temperature rises, and the j)arts about the seat of fracture become hot, red, painful, and swollen, the pad of lint should be removed, and if there is any evidence of suppuration, the wound should be opened, and free vent having been aflbrded to the pus, it should be treated in the manner next described, or this method may be adopted from the first. If the wound is of some dimensions, and if its edges are lacerated and the surrounding tissues much bruised and swollen, no attempt should be made to close it ; under these circumstances, if seen within the first twenty-four hours (all bleeding having been arrested), the wound should be carefully cleansed and then thorouglily syringed out with a solution of carbolic acid (1 in 20) or some other antiseptic lotion, care being taken that the fluid comes well into contact with all its recesses. If a longer period has elapsed, a stronger solution should be used, e.g. one consisting of carbolic acid and spirit (1 in 5). Some means must then be provided for efficient drainage ; one or more of the ordinary drainage tubes may be inserted, and the wound should be dressed Treatment of Fracture. 13 and afterwards treated according to the Listerian method. In cases where the ends of the bones are much comminuted, the fragments, w^hen of small size or lying loose and separated from the periosteum, should, if pos- sible, be removed, for if left they will probably necrose. If the wound is small and the bone projects through it, it is sometimes necessary to enlarge the opening before reduction can be effected ; and if it is still impossible, the projecting portion of bone should be removed with a saw. When difficulty is experienced in main- taining the ends in apposition, it will sometimes be necessary to bring them together wdth sutures of silver wire. The wound must afterw-ards be treated on general principles, care being taken to prevent any accumu- lation or burrowing of pus, and the dressing being changed when necessary with as little disturbance of the fracture as possible. In cases of severe compound fracture, amputation of the limb is occasionally re- quired ; this is, as a rule, indicated when there is very extensive laceration and destruction of the soft parts with much splintering of the bone, and especially if the main vessels of the limb are wounded, or an ad- jacent large joint {e.g. the knee) laid open. In every instance the age and constitution of the patient should be taken into account, as well as the situation of the injury. A severe compound fracture in a young person of sound constitution may often be successfully treated, whereas in a person advanced in years, or broken down in health, the attempt to save the limb will be useless and often attended with danger to life; so also the prospect of recovery is ahvays much greater in the upper than in the lower extremity, owing to the greater repai-ative power of the former. Couiplicatioii^ dui'iug: treatiiii'iil. — During the treatment of any fi'acture, various accidents or 14 Manual of Surgery. conn:>lications may arise, some of which are local while others are of a general kind. (Edema and swelling of the limb are among the most common; they may be due to bruising and ex- travasation of blood, mingled with more or less of inflammatory effusion, or to simple passive congestion from tight bandaging. Under these circumstances not only does the limb become tense and swollen, but in many instances large blebs or bullae appear on its surface, containing a clear or blood-tinged serum. When these conditions are present the bandages should be slackened and some evaporating lotion applied ; if the soft tissues are much bruised, the skin should be painted over every day with tmct. benz. co. ; when bulliB form, they may be pricked and their contents allowed to escape, or left to themselves, for they generally burst or dry up and disappear in the course of a few days. Ulcey'ation and sloughing of the soft tissues over the seat of injury may ensue, and as a consequence a simple fracture may become converted into a compound one. Ulcers of a troublesome nature are also apt to form over bony prominences, in cases where the splinta are not well padded ; and unless care is taken, bed-sores may also appear over the sacrum, buttock, hips, etc., especially in old or debilitated subjects, when the fracture involves long confinement in the recumbent posture. Spasm of the mnscles of an obstinate nature is sometimes present, and as a consequence considerable difficulty is often encountered in keeping the fracture in proper position. As a general rule, it can be over- come by moderate pressure by means of bandages, though in exceptional cases tenotomy may be re- quired. Gangrene of the limb is occasionally met with, and, as a rule, it is the result of imjtroper treatment, Fat Embolism. 15 ?.//. loo tight baiulagiiig. Tlicrnfore, as already mentioned, the part should be frequently examined, especially during the first few days after the frac- ture has been put up, and if there is any evidence of coldness, numbness, livid ity, or swelling of the limb, or of the fingers and toes, the bandages should at once be relaxed, for if unrelieved gangrene is liable to supervene. Much less frequently gangrene is due to laceration of the main artery of the limb by one of the fragments, or to the vessels being nipped between or pressed upon by the ends of the bone. Venous thrombosis and embolism are sometimes met with. In most cases of fracture, thrombosis doubtless occurs to a greater or less extent in some of the veins in the neighbourhood of the injury. In rare cases a portion of clot may become detached, and, acting as an embolus, it may be carried onwards by the stream of blood along the large veins until it reaches the heart or one of the branches of the pulmonary artery ; there it may become arrested and give rise to sudden death from asphyxia. Fortunately this complication of fracture is very uncommon, but two cases of its occur- rence in simple fracture of the lower extremity, and followed by death, have come under my immediate notice.* Fat embolism is the term applied to a condition met with as a complication of simple, though much more frecjuently of compound, fracture, in which the ca])illaries of the lung, kidney, brain, spinal cord, and, in fact, of almost every part of the body have been found plugged with fatty emboli or globules of liquid fat. It is believed that it may occur to a slight degree in all cases of fracture, but especially so in severe cases accompanied by much crushing of the bone and its medullary cavity, when fluid fat is set free in large * Lancet, vol. i., p. 296; 1879. 1 6 Manual of SurgeHV. quantities. Under these circumstances the oil globules, gaining access into the venous circulation through the openings in the vessels about the seat of the injury, act as emboli and are carried on by the blood stream until they become arrested in the capillaries of the various tissues and organs. In order to detect their presence, the parts aftei removal should be stained with osmic acid ; the fatty matter will then be evident in the form of black globules and irregular masses of various sizes blocking up the capillaries and minute vessels. The symptoms of fat embolism are somcwjiat obscure ; they usually come on as a kind of secondary shock from twenty-four to forty-eight hom-s after the occurrence of the injury, consisting, as a rule, of dyspnoea with irregular action of the heart, and pallor, or cyanosis of the face; occasionally slight hsemojjtysis has also been observed ; the temperature may be lowered or run somewhat high ; in fatal cases the patient rapidly becomes collapsed, and sinking into a condition of coma, death may be preceded either by convulsions or paralysis. When recovery takes place, it would appear that the fatty matter is eliminated by the kidney, for its presence in the urine has been detected for several weeks after the injury. As regard treatment, it has been suggested that intravenous injections of ether might be of service along with artificial respiration ; when cyanosis is a prominent symptom, venesection might possibly give relief. In cases of compound fracture, other complications are frequently met with. Necrosis often results, small pieces of bone, which have been detached or stripped of their periosteum, subsequently dying. Suppurative periostitis or acute osteo-7vyelitis with extensive sup- puration may ensue, and, as a consequence, large por- tions of bone may necrose. Under theiie circumstances Complications of Fracture. 17 union will be retarded, the presence of the dead bone, which is often long in separating, uiterfering with the process of repair. Extensive sloughing of the soft tissues may also result, and, as in other injuries, erysipelas may also attack the wound. The general complications which are common to all varieties of fracture are as follows : shock; traumatic delirium, especially liable to occur in persons of intemperate habits ; hypostatic congestio7i of the lungs, often met with in old persons as the result of confine- ment in the recumbent position. Retention of urine for some days after the accident is not uncommon, in some cases as the result of shock, in others in con- sequence of confinement to bed ; tetanus may occur as after other injuries, but is a rare complication. In cases of compound fracture there is, in addition, the risk of severe traumatic fever, and this may run on to septiccemia and pycemia, complications which frequently prove fatal. After union has been eflfected, and the splints have been removed, other complications are frequently met with. (Edema of the limb is often present for a time, with stiffness of the joints above and below the seat of fracture, the latter condition being due to long confinement in a fixed position, and to the formation of adhesions around the tendons and between them and their sheaths. As a rule, these conditions will gi-adually disappear if the limb is used, and friction with some stimulating liniment emploj^ed along with passive movement. If the oedema persists, one of Mar- tin's indiarubber bandasres will often be found useful. Pain about the seat of fracture, of a somewhat rheumatic character, is frequently complained of for a considerable period, especially in the case of old people ; this also will, as a rule, gradually disappear in course of time ; but when severe and obstinate, relief may c— 21 1 8 Manual of Surgery. ofton be obtained by tlie internal administration of iodide of potassium, and counter-irritation over the seat of fracture by painting with tincture of iodine, or, if much thickening is present, by the application of some mercurial ointment.- Paralysis of the limb is occasionally met with, especially in the upper extremity, as the result of implication of the nerves in the callus which is formed at the seat of fracture ; under these circum- stances it is sometimes necessary to cut down upon the fracture in order to liberate the nerve. Crvtch par«72/*'is> '^'•^^' loss of power in the arm from the pressure of tlie ciiitches upon some of the nerves wliicli supply it, is often met with in fracture of the lower extremity, if the patient is allowed to walk about on crutches without hand-bars, or the arm-pieces of which are not well padded. Any or all of the nerves supplying the arm may be involved ; paralysis of the musculo-spiral is perhaps most common^ the patient then presenting evidence of wrist-drop. SJiortening of the limb often ensues, in many cases as the result of im2:)roper treatment, e.g. allowing the ends of the bone to overlap. After separation of an epiphysis it is sometimes met with as tlie result of actual arrest of growth, the epiphysial cartilage being so injured that the development of the bone is after- ward fi interfered with. Morbid growths springing from the bone, and usually of a sarcomatous or cartilaginous nature, may in rare cases develop at the seat of fracture, at a variable period after tht- injury. Process of repair. — The uniting material by which union is efiected in fracture is toi-med ca/Zw-s ; this consists, in the early stage, of simple inflammatory exudation or lymph, and the process of repair in simple fracture is essentially identical with that which occurs Repair in Fracture. iq in the healing of wounds by first intention in the soft parts, except that the lymph subsequently develops into bone instead of remaining as ordinary cicatricial tissue. As the immediate result of the injury, more or less extravasation of blood takes place into the tissues round about and between the ends of the bone, the periosteum being torn and the adjacent muscles lacerated to a greater or less extent. Inflammation ra])idly ensues, and there is an exudation of lymph into the adjacent parts poured out by the vessels of the bone, periosteum, and surrounding tissues. The consequence is, that between and around the ends of the bone, as well as into the medullary cavity, there is poured out a quantity of plastic matter which mingles with the blood clot already present ; in the course of a few days this gradually begins to consolidate, the blood clot becoming either absorbed, or remaining and assisting in forming the callus, the term applied to the uniting medium, as it becomes firmer and fibrous. At the same time, the periosteum at the seat of injury gradually disappears, becoming lost in the mass of callus, which, as it consolidates, forms a kind of fusi- form sheath or natural splint round the ends of the bone. The term ^;7-omszo?ia/ or temporary callus is applied to that which is poured out around the bone and within its medullary cavity ; while that which is formed between the broken ends is described as definitive or permanent callus. As the process continues, a new periosteum is formed from the outer or superficial layer of callus, which, after developing into fibrous tissue (and occa- sionally in children into cartilage or fibro-cartilage), subsequently ossifies and forms new bone, a deposition of lime salts taking place in its substance. This process of ossification usually commences about the end of the first, and is often considerably advanced by the end of the third week 20 Manual of Surgery. The result is that in the course of four to eight weeks the ends of the bone become firmly united by a mass of newly-formed osseous tissue, which at first is spongy and cancellous, and can often be felt as a distinct swelling surrounding the bone at the seat of mjury. The last stage in the process consists in the disappearance of the provisional callus ; this, after becoming dense and compact, undergoes a gradual process of absorption, and in the course of some months more or less completely disappears, so that the bone resumes its natural form, and the medullary canal is restored. By the time this is effected, the permanent callus poured out between the ends of the fragments will have acquired sufficient strength to maintain the continuity of the bone ; hence it would appear that it is the function of the former to support the fragments and to keep them in apposition, in fact, act the part of a temporary splint, until union is effected. The amount of provisional callus which is formed depends upon the nature of the fracture and also upon its after-treatment. If there is no displacement nor comminution of the fi-agments, and if they are kept in a state of complete rest, it may be entirely absent. If, however, they are much splintered, or not in perfect apposition, or if some movement is allowed, then it is often considei'able in amount, being poured out around the splinters or ends of the bone. In fracture of certain bones, e.g. the ribs and clavicle, provisional callus is, for obvious reasons, always present, and, as one would expect, it is more frequently met with in children than in adults, owing to the difficulty often encountered in the former in keeping the frac- ture completely at rest. In the case of compound fractures., when the external wound, being of small size, is at once closed Eepair in Fracture. 21 or sealed, and the fracture is, as it were, converted into a simple one, repair may take place in a similar manner. In many cases, however, and especially wlien the wound is large and accompanied by much laceration of the soft tissues or splintering of bone, union is efiected by a process of suppuration and granulation, identical with what occurs in healing by second intention in the soft tissues. Suppuration is excited at the seat of injury, and granulations spring up from the ends of the bone, as w^ell as from the adjacent soft parts ; the consequence is that the whole of the interior of the wound becomes lined with a layer of granulation tissue secreting pus, which bathes the ends of the bone. By the growth and development of these granula- tions into hbrous tissue the cavity of the wound is gradually filled up, and at the same time union is effected. The subsequent changes are identical with those which occur in simple fracture^ the fibrous tissue undergoing a process of ossification, so that the ends of the bone become surrounded and united by a mass of callus, which, after developing into bone, is more or less completely absorbed, and disappears. The process is, however, frequently complicated by necrosis ; small portions of bone, which have been separated at the time of injury, or had their su|)piy of blood interfered with, often die ; or the ends of the bone themselves, having been stripped of theperiosteum, or injured to such an extent that their vitality is destroyed, may subsequently necrose. Under these circumstances the wound will not Ileal so long as the dead portions of bone are present, for, acting as sources of irritation, they keep up suppuration. If of small size, they may make their way externally ; but when of some dimensions, it will often be necessary to enlarge the wound and extract 2 2 Manual of Surgery. them with a pair of forceps. When the ends of the fragments themselves necrose, the process is usually a very tedious one, for then separation is slowly effected, the dead portions of bone often becoming ensheathcd by new osseous tissue thrown out round about them ; under these circumstances they will frequently have to be removed by the operation of sequestrotomy. The length of time required for union varies in the different bones, and also depends upon the nature of the fracture and the age of the patient. In simple fractures of the low^er extremity occurring in healthy adults, the average period is from eight to twelve weeks ; in the case of the upper extremity, from four to eight weeks. In the case of children, where union is more quickly effected, the time required is somewhat shorter, while in old persons it will be longer. In severe compound fractures the period will often be three or four times that required in simple fracture. Defects in the process of union. — The pro- cess of repair may in certain cases be delayed beyond the usual period, and occasionally it is not effected by means of bone, or doos not take place at all ; under the latter circumstances the fracture is said to be ununited. Delayed union may be due to any of the causes mentioned below as giving rise to non-union. The treatment is partly constitutional, partly local. Attention should be paid to the general health, and an attempt made to promote union by stimulating the reparative process, e.g. by rubbing the ends of the bone gently together; shampooing the limb around the seat of fracture; "hammering" the limb, i.e. surrounding it with a piece of felt, and then per- cussing it forcibly with a mallet over the seat of fracture ; blistering the limb, or painting with tincture of iodine over the same spot, etc. In cases where the patient has been contined to bed A^ON- Union op Fracture. 23 in splints for the usual period, union often results if ho is allowed to get about on crutches with the liinlj in a stiff bandage. When the fracture has not been kept in a state of complete rest, repair will often take place if it is put up in some immovable apparatus. IVoii-unioii may appear under three different forms. 1. In ligamentous union,t\\Q most common variety, the ends of the bone are merely united by fil)rous tissue, so that a certain amount of movement is possible between them. 2. In false joint, or pseudarthrosis, a somewhat similar condition is present, but the movement is more free, the ends of the bones becoming smooth, rounded and enclosed in a kind of capsule formed of fibrous tissue, not unlike that of a joint. In well-marked cases their surfaces, of which one is often convex, the other concave, may be invested with a layer of im- perfect cartilage and lubricated by a serous secretion resembling synovial fluid. 3. In true non-U7iion the ends of the bone are quite separate, there being an entire absence of any unitinsc material. The causes which may give rise to these conditions are both constitutional and local. The constitutional include all those conditions wliich, by inducing a low state of health, interfere with the healthy nutrition of the tissues, and, conse- quently, with the process of repair, e.g. various acute affections, such as fevers, syphilis, the cancerous cachexia, phthisis, scurvy, chronic kidney disease, etc. Old age, pregnancy, and lactation are sometimes said to interfere with union, but as a rule their influence is very slight. The local causes are also various. Mobility of the fragments is probably the most common. This may be due to the splints or bandages 24 A Fan UAL of Surgekv. being applied too loosely, or in consequence of their removal before repair is completely effected. Separation of the fragments is another cause of non-union. This may be due to muscular action, as in the case of the patella, or to interposition of a portion of muscle or tendon between the ends of the bone. In cases of compound fracture, non-union is often due to actual loss of bone, removed either at the time of injury, or subsequently for necrosis. Inter- ference with the circulation of the blood may also prevent repair from taking place ; e.g. non-union is apt to occur in cases where the nutrient artery of the bone is injured by the line of fracture running through it ; or where blood is not freely supplied to both fragments, as in fracture of the neck of the humerus or femur ; or, again, in cases where a congested and oedematous condition of the limb is produced as the result of tight bandaging, or from extensive bruising of the soft parts accomjDanied by venous thrombosis. The treatment is partly constitutional, partly local. As regards the former, attention should be paid to the general health, and any constitutional con- dition which is present should be treated on ordinaiy princij^les. As regards local treatment, measures similar to those recommended in the case of delayed union (page 22) should be tried, and if they fail, more vigorous ones should be adopted, the object being to set up a more active inflammation at the seat of injury. This may be attempted in various ways ; e.g. by the introduction of acupuncture needles, or of a seton between the ends of the bone, by the subcutaneous division with a tenotome of the fibrous tissue which unites them ; by electro-puncture ; or by the injection of some stimulating liquid in the neighbourhood of the fracture. If these methods prove unsuccessful, the ends of Mal-Union of Fracture. 25 the bone should })C exposed, and one or other of tlie following plans adopted : ivory pegs are driven into holes bored in the bone with a drill ; or the ends of tlie bone are removed with a saw (the periosteum being as far as possible preserved) and the fragments then brought together by metallic screws or sutures of silver wire. The latter method, " wiring the fragments," is commonly adopted, and as a rule with good results, the sutures being either removed after several weeks or cut short and left permanently. When non-union is due to actual loss of osseous tissue, as in some cases of compound fracture, attempts have been made to fill up the gap by transplanting bone. When operative treatment has proved unsuccess- ful, and the limb is useless and an encumbrance to the patient, amputation maybe indicated, but even under these circumstances, and especially in the upper ex- tremity, some form of apparatus can often be adapted to the part, so that, though its usefulness is much impaired, it will, nevertheless, prove much more serviceable than an artificial limb. Union \%'itli deformity. — Union is sometimes accompanied by considerable deformity, and the function of the limb is in consequence seriously im- paired. This condition, "vicious union," as it is often termed, may be owing to restlessness of the patient, or to unskilful treatment, e.g. imperfect reduction of the fracture ; impro})er application of splints, in conse- quence of which the fragments are not kept in position or at rest ; removal of the splints before union is com- pletely effected and subsequent yielding of the callus, etc. Under these circumstances, union is often ac- companied by considerable projection of one or both fragments. Another form of vicious union is seen in cases when two contiguous bones become united by callus thrown out between them, e.g. in the fore-arm, leg, or ribs ; this deformity is, however, of little 26 Manual of Surgery. importance excL'[>t in the fore-arm, wlien the move- ments of 2)ronation and supination become interfered with. The treatment will depend on the nature of the deformity and the length of time which has elapsed since the fracture occurred. When there is projection of the fragments and the callus is not yet firmly ossified, the deformity will often gradually disap})ear under firm pressure properly applied by well-padded splints, or the limb may be forcibly straightened at once under anjEsthesia. If, however, a considerable period has elapsed, and firm bony union has taken place, it will often be necessary to refracture the limb either by manual force, or by the employment of a strong clamp, known as the osteoclast. In other cases, before the bone can be straightened, it may be necessary to divide it subcutaneously, or remove a w^edge-shaped piece of bone from the projecting angle. The shai-p end of one of the frag- ments, if projecting beneath the skin, may be treated as an exostosis and sawn oflT, but it will usually be found that, if allowed to remain, it will wear down and become rounded oflT, so that in course of time it will often gradually disappear to a great extent. The limb, after it has been straightened by any of these methods, should be put up again in splints and treated as a recent fracture, care being taken to prevent any recurrence of the deformity. "Wounds of bone are closely comiected with compound fractures. It will, however, sometimes happen that a kind of incised wound is produced, the periosteum and a portion of the thickness of a bone being divided as the result of a blow with some cutting instrument. Punctured wounds have already been referred to, and gun-shot wounds are discussed in the chapter on that subject As the injury to the bone is always accompanied by an open wound, the general Fractures of the Nose. 27 treatment will be identical with that of compound fracture. Contusions of toone are of common occurrence, Leing often met with in those that are superficial and exposed to external violence, e.g. the subcutaneous surface of the tibia, vault of the skull, etc. The injury- is often followed by inflammation of the periosteum, evidences of which will be present, and when the process is limited, the localised swelling, which fre- quently results, is. described as a "traumatic node." In other cases, e.g. as a result of a fall on the hip, the cancellous tissue of the neck of the femur may become more or less bruised or contused ; inflammatory changes of a subacute or chi'onic nature may subse- quently ensue, occasionally followed by an interstitial absorption of the osseous tissue, in consequence of which the limb may become permanently shortened. Special Fractures. THE FACE. Nasal bones.— Fracture of the nasal bones is often produced as the result of direct violence, e.g. a fall or blow on the nose ; it is in consequence usually attended by bruising or laceration of the soft tissues, and in many cases considerable swelling, sometimes accompanied by emphysema, speedily sets in, so that unless seen soon after the receipt of the injury, the detection of the fracture may be somewhat dilhcult. The fragments may be displaced backwards, or to one side, the bridge of the nose being in consequence either flattened or deflected laterally. If the fracture also involves the ?ac/r/'2/maZ hone there may be obstruc- tion to the flow of tears, and epiphora, owing to injury to the lachrymal sac or nasal duct. Fracture through the septum nasi^ or separation from its attachment to the vomer, may occur alone, or 28 Manual of Surgery. accompany a fracture of the nasal l)ones ; in some cases the cartilaginous septum is simply bent to one side, giving rise to a troublesome and characteristic deformity. Treatment. — When any displacement of the frag- ments is present, an attempt should be made to correct it as speedily as possible, for if allowed to remain, union rapidly takes place, and considerable difficulty will afterwards be experienced in treating the defor- mity. This can usually be effected by means of an ordinary pair of polypus forceps, introduced into the nostril ; on using them as a lever, or on separating the blades, the displaced fragments can usually, with a little manipulation, be guided back into the normal position, especially if the patient is ansesthetised. When once replaced, they will often remain so ; if, however, there is any tendency for the displacement to return, it can sometimes be prevented by the patient wearing in the nostril a short piece of gum- elastic catheter, or some form of plug. When the nose is bent to one side, it may be necessary to make lateral pressure from without, and for this purpose Adams's " nose truss," consisting of a pad adjusted by cog wheels and attached to a steed band wliicli passes round the head, will often be found useful. When the septum is deflected, it can usually be straiglitened under anaesthesia, by means of Adams's forceps, a pair of strong forceps with flat parallel blades, and at the same time the nasal bones, if depi-essed, can also be raised. As there is generally a tendency for the deflection to recur, the patient should for a time wear some apparatus to retain the septum in position, e.g. Adams's steel screw compressor, or an ivory plug. Upper jiiw siiid malar bone. — Fracture of Fractures of the Jaw. 29 the upper jaw is sometimes met with as the result of direct violence, its alveolar process being the part more commonly involved ; less frequently, the fracture takes place through the body of the jaw or one of the other processes, and it may also involve the malar hone and zygomatic arch. The fracture, which is often compound and accom- panied by bruising and swelling of the cheek, may or may not be attended by displacement of the fragments ; when the anterior wall of the antrum is driven in, considerable deformity is often produced, and when the alveolus is involved, there will be loosening and irregularity in the line of the teeth. Various complications may attend this fracture ; e.g. emphysema ; severe haemorrhage from a wound of the internal maxillary artery ; loss of sensation in the cheek from injury to the infra-orbital nerve ; in cases of compound fracture involving the antrum, a sinus often remains which is slow in healino:. Treatment. — "When any displacement of the frag- ments is present, an attempt should be made to correct it as soon as possible ; the depressed bone can often be raised from the mouth, or, if this is not possible, by means of an elevator introduced through a small opening in the cheek. When the alveolar process is involved, the frag- ments can usually be kept in position by one or other of the methods of treatment mentioned in the case of the lower jaw ; a jaw bandage should afterwards be applied so as to prevent, as far as possible, any movement of the part, and the patient fed on liquid food for several weeks. LiOw^er jau% — Fractures of the lower jaw are almost always compound, sometimes from external wound, but more frequently from laceration of the gum by the broken fragments. Any part of the bone may be broken, the commonest situation being tlirough 30 Manual of Surgery. the body, at that spot where it is specially weakened by the mental foramen and the deep socket for the canine tooth ; fracture through the symphysis is rare owing to the strength of bone at this point. Body. — In fracture through the body the symi)- toms are usually well marked, especially when, as is often the case, the bone is broken on both sides of the symphysis, for the central portion is then drawn down by the muscles attached to the hyoid bone. There is mobility of the fragments, with crepitus, loosening and irregularity in the line of the teeth, dribbling of the saliva from the mouth, and impairment of speech. When the fracture is compound, there is also laceration of and bleeding from the gums ; under these circumstances suppuration generally results, and the discharge making its way into the mouth and mingling with the saliva gives to the breath an offensive odour ; in cases where an abscess forms at the seat of injury, necrosis of a portion of the jaw frequently results. The inferior dental nerve visually escapes, but if it happens to be torn across by the fracture, there will be loss of sensation in the lip on the corresponding side. Angle or lower 2:>art of ramus. — In this situation the displacement of the fragments is usually slight, for the muscles on either side (masseter and internal pterygoid) maintain them in position. Keck. — In fracture through the neck of the jaw, the condyle is drawn inwards and forwaids by the external pterygoid ; crepitus is produced and pain is experienced upon attempting to open the mouth. Goronoid process. — The fractured coronoid process is drawn upwards and backwards by the temporal muscle, so that it produces an undue prominence in the temporal fossa. Treatment. — In cases where there is not much dis- placement of the fragments, tlrey can often be kept in position by a four-tailed bandage, or by la guttapercha Fractures of the Jaw. 31 Fig. 2. — Guttapercha Splint for Jaw. (From Pick's " Fractures and Dislocations.") splint (Fig. 2), moulded to the jaw, and fixed by a similar bandage. Any teeth which are com])letely loose and lie between the fragments should be re- moved, for their presence interferes with the process of repair ; those which are only partially loose should, if healthy, be allowed to remain, for they will, as a rule, soon become firmly adherent. When -difii- culty is experienced in keeping the fragments in position, as often happens when the fracture is compound, other means may be required. Ligaturing the teeth, i.e. bindinof tofjether those which lie on either side of the fracture, with wire or silk, is sometimes adopted, but has this disadvantage, that it tends to loosen the teeth, which are often already somewhat loose in their sockets. The ligature is also very liable to slip, and in many cases, e.g. when the teeth are absent or carious, it cannot be applied. The fragments may be wired together, as recom- mended by Thomas, by means of sutures of silver wire, which are passed through openings drilled in the bone on each side of the fracture (Fig. 3), or through the bone on one side and between the teeth on the other ; as the wire, if tied or fastened with a cross twist in the ordinary way, soon becomes loose, it is twisted with a key in three or four coils, which can be tightened up from time to time as they become slackened. Various forms of interdental splints are also em- ployed, e.g. moulds of guttaperclia, vulcanite or metal caps, etc., which fit on to the teeth for some distance on either side of the fracture. 32 Manual of Surgery, INEoon's interdental splint consists of two parts, an external splint adapted to the and chin attached by rods to a metal cap, which fits the teeth of the frac- tured jaw. Hammond's wire splint is made of a framework of iron wire, adjusted so as to encircle, on a level with their necks, all or several of the teeth on either side of the fracture. As it is important that the fracture, should, as far Fig. 3.— Thomas's Drill and Suture for Fractured Jaw. as possible, be kept completely at rest, talking should be prohibited, and the patient fed on liquids, or on soft food which requires no mastication. The mouth should, especially in cases of compound fracture, be frequently washed out with a solution of Condy's fluid, or some other disinfectant. Union, as a rule, takes place in from three to five weeks, though the process will be somewhat retarded if suppuration takes place, or if necrosis results. The Clavicle. The clavicle may be fractured in any part of its course, more commonly about its middle, less frequently Fractures if the Clavicle. 33 at either its sternal or acromial extremity. Thouch fracture may be produced as tlie result of direct apj)li- cation of force, e.g. a severe blow, or even of muscular action, e.g. a sudden and forcible swing of the arm, it is far more frequently tlie result of indirect vio- lence, e.g. a fall on to the shoulder or hand wlien tlie arm is extended. Sianfr. — In fracture thi-ough the shaft tlie bone usually gives way at its weakest point, viz. about its centre, or a little external to it, just at the junction of the two curves. The fracture, whicli is of very common occurrence in young subjects, is often of the incomplete or " greenstick " nature, the bone being bent, or only partially broken, the periosteum fre- quently remaining nntorn (Fig. 1). When complete, the line of fracture is sometimes transverse, but more commonly and especially when due to indirect violence, it is ol)lique ; under these cir- cumstances the amount of displacement is often con- si(k^rable. The inner fragment usually remains un- afiected, being retained in its place by the antagonistic action of the sterno-mastoid above, and the pectoralis major and subclavius muscles, and rhomboid ligament below ; though, in many cases, it appears to be dis- placed forwards, this is in reality due to the dej^ression of the inner end of the outer fragment backwards and behind it. The outer fragment, owing to the weight of the arm, which drags upon it, is usually drawn downwards, while by the action of the muscles passing to it from the chest it is drawn somewhat inwards and forwards ; lience, its outer or acromial end with the shoulder is dis])laced downwards, inwards, and forwards, while its inner or fractured end is drawn inwards and back- wards, so that it lies behind and usually beneath the fractured end of the inner fragment ; less frequently it is found above, and in rare cases it may lie anterior to it. D— 21 34 Manual of Surgery. The symptoms are as follows : Flattening and lowering of the shoulder, which is also drawn forwards and inwards, being approximated to the middle line; pain at the seat of injury ; impaired movement of the arm ; inclination of the head and neck to the affected side ; the elbow is often supported by the opposite hand to take off the wei^-ht of the limb ; if the finger is laid over the seat of fracture, crepitus can generally be detected on raising and rotating the shoulder, and at the same time pain will be produced ; the prominence formed by the fractured end of the inner fragment will generally be plainly perceptible beneath the skin ; in cases of transverse fracture, where the displacement of the fragments is often very slight, there may be an entire absence of any deformity. Sternal end. — Fracture of the sternal end of the clavicle, either internal or external to the attachment of the rhomboid ligament, is an injury of rare occur- rence ; in the latter case the displacement is often considerable, the outer fragment being drawn down- wards and forwards ; in the former case, which is much less common, there is not, as a rule, any marked displacement of the fragments. Aei'ossaml encl. — Fracture of the acromial end is of mucli more frequent occurrence, and two varieties are met with, according as the bone is broken between or external to the conoid and trapezoid ligaments. When the fracture is between the ligaments there is little, if any, displacement of the fragments ; on ro- tating the shoulder crepitus is produced, and perhaps slight irregularity will be felt at the seat of injury. When the fracture is external to the ligamonts there is a marked displacement of the outer fragment, its articular surface being turned forwards and inwards, with a sliirht inclination downwards, so that it lies nearly at a right angle with the rest of the bone, the position of wliich Ls not materially altered. Fractures of the Clavicle. 35 Separation of tlic epiphysis of the clavicle, a thin plate of bone at its sternal extremity, is a rare injury. Fractures of the cla\dcle, when the result of direct violence, may be compound or comminuted ; in these injuries, which are, however, of rare occurrence, the neighbouring large vessels, e.g. jugular or subclaAian veins, etc., are liable to be wounded. A simjJe frac- ture is occasionally followed by partial f)araiysis of the arm, the result probably of compression or laceration of the cords of the brachial plexus by the displaced frag- ments. Owing to the difficulty of keeping the frac- ture in a state of complete rest, union is invariably attended by the formation of provisional callus, and in cases where treatment has been neglected, or there is much displacement of the fragments, this is often excessive in amount, giving rise to a considerable swelling surrounding the bone at the seat of injury. Treatment. — In the treatment of the common form of fracture through the shaft there are three main indications to be carried out, viz. to raise the shoulder with the outer fragment, and at the same time to draw it backwards and outwards. To raise the shoulder, the arm should be supported in :i sling which reaches well under the elbow, or by strapping or bandages which pass beneath the elbow and o^er the opposite shoulder. To draw the shoulder outwards, a thick, wedge- shaped pad, with its broad end upwards, should be placed high up in the axilla, where it is kept in posi- tion by a strap which passes over the opposite shoulder. The arm being then bandaged to the side, the pad acts as a fulcnim, and the humerus as a lever ; the result is that the shoulder and outer fracrment are drawn forcibly outwards. In applying the pad, cai-e must be taken that too much pressure is not made 36 Manual of Surgery. upon the axillary vessels and nerves, or else the arm will become swollen, and either numb or painful. To carry the shoulder backwards, several different plans may be adopted. The elbow may be carried forwards, and the hand raised towards the opposite shoulder, so that the humerus m:iy l)car across the pad, and its upper end along witli tlie shoulder be forced backwards ; or a figure of 8 bandage may be applied to the shoulders and tied behind. In order to prevent the 1)andages from slipping, the turns may be stitched together, or stifTened Avith plaster of Paris or starch. If there is any tendency to swelling of the arm, it should first be bandaged from the fingers up to the axilla. Sayre's method of treating this fracture is as fol- lows : A loop at the end of a broad band of adhesive plaister is passed roinid the upper part of the arm, and the elbow having l»een drawn backwards, the strapping is carried trans- versely behind the back and round the chest. A second piece is then carried obliquely across the body, viz. over the sound shoulder, and beneath the elbow on the injured side, a slit beiug cut in it to receive the elbow and prevent it from slipping. By the first stiip the shoulder is drawn back- wards and outwards, while by the second it is raised (Fig. 4). Ellis's method consists in the application of an axillary splint or crutch, which is maintained in Fi 4.- Sayre's Mct.liOfl for Frac- tured Clavicle. Fractures of the Clavicle. 37 position by two straps, one passing over the opposite shoulder, the other round the chest ; the hitter also fixes the upper arm and keeps it to the side ; the fore-arm is supported in an ordinary sling (Fig. 5). If a patient will submit to conriiiement to bed, it will generally be found that the de- formity more or less completely disap[)ears in the recumbent pos- ture, for the weight of the limb being re- moved, the dLsplace- ment downwards is prevented; at the same time, the shoulder falling back and carry- ing with it the outer fragment, the dis- placement forwards and inwards is also counteracted ; the consequence is that the ends of the bone usually fall well into position. Mr. Bryant recom- mends that an attempt should be made to imitate what takes place when the patient is in the supine position, by placing a pad over the blade of the scapula below its spine, and then binding the bone firmly to the thorax by broad strips of strapping, which obliquely encircle the chest on the affected side and reach from the spine to the sternum. The arm should also be supported in a sling and the hand drawn upwards towards the op]iosite shoulder. In cases where no displacement of the fragments is present, as may occasionally happen in fracture through the shaft, or in fracture internal to the Fig. 5.— Ellis' Method for Fi-actiiroa Clavicle. (From Pick's " Fractures and Dislocatious.") 38 Manual of Surgery. rhomboid, or between the conoid and trapezoid liga- ments, all that is often necessary is to keep the arm fixed to the side and supjiorted in a sling. In fracture external to the conoid and trapezoid ligaments, in addition to a thick pad in the axilla, it will often be found necessary to apply a figure of 8 bandage behind the shoulders, in order to overcome the displacement forwards of the shoulder with the outer fragment. Union is, as a rule, effected in from three to four weeks. The Scapula. Fracture of the scapula may involve its body, neck, acromion, or coracoid process. Botly. — Fracture through the body is usually the result of direct violence and is often associated with injury to the subjacent ribs. It is not, however, an accident of very common occurrence, for the thick layers of muscles which lie both over and beneath the bone form, as it were, soft pads which serve to protect it. The fracture usually affects the infraspinous por- tion of the bone, running across it in an oblique or transverse direction ; or it may extend in a vertical direction right through the spine. Abnormal mobility and crepitus can generally be detected on moving the shoulder and uj^per part of the scapula with one hand, while the other is laid upon, or made to fix, the lower portion of the lx)ne. Jn iDuscular subjects, and when the fracture involves thy iiifraspinuiis fossii^ there will (jfteii be slight, if any, displacement of tlie fragments ; wlien, however, it 1 uus across the spine, some irregularity in its course can usually be detected. Acroiiiiou. — Owing to its exposed position, forming as it does the tip of the shoulder, the acro- mion is more frequently fractured than any other Fractures of the Scapula. 39 portion of the bone, and usually as the result of direct violence- Abnormal mobility and crertitus can be readily detected on i-aising and rotating the shoulder ; more or less deformity is present, the shoulder becoming flat- tened and somewhat depressed. On running the finger along the acromion, an irregularity can be felt at the seat of fracture ; pain is present and the movements of the arm are interfered with. There are two affections which simulate fracture of the acromion, viz. non-union of the acromial epiphysis, a condition which sometimes exists, and certain cases of rheumatic arthritis of the shoulder joint, in which, osteophytic deposits about the acromion are found lying loose and movable beneath the skin ; under these cir- cumstances, crepitation can usually be detected. Coracoid pi'ocess. — Fracture of this process is rare, lying as it does in a hollow protected by the cla- vicle above, the thorax internally, and the head of the humerus externally ; it is usually the result of direct violence. The only symptoms present will be mobility of the broken fragment, with pain and crepitus on manipulation ; if the coraco-clavicular ligament is riTptured, the fractured ])rocess may be drawn down- wards by the action of the biceps and coraco-brachialis muscles. Necli. — Fracture through the neck of the scapula is so rare that its occurrence has been doubted ; two varieties have, however, been described according as the anatomical or surcrical neck of the bone is in- volved. In fracture through the siirjfical ueck the line of fracture runs across the constricted portion of the bone opposite the notch in the superior costa, the cora- coid process being included in the detached piece. If the coraco-clavicular and coraco-acromial ligaments are not ruptured, there may be very little deformity ; if, 40 Manual of Surgery, however, tlioy give way, the broken fragment along with the arm is displaced downwards, so that the symptoms are very similar to those of subglenoid dis- location of the humerus ; viz. there is flattening and lowering of the shoulder, with prominence of the acro- mion and a depression beneath it; the arm is lengthened and somewhat separated from the side ; the head of the humerus can be felt in the axilla. The injury differs, however, from dislocation in the following points ; the coracoid process is displaced and moves with the arm, which is abnormally mobile ; crepitus can readily be detected ; on raising the arm, the deformity disappears, but at once returns when the ai-m is allowed to drop ; an irregular mass of bone, formed by the neck of the scapula, can be felt in the axilla, very diifereut to the smooth, rounded promi- nence formed by the head of the humerus, which alone is present in cases of dislocation. In fracture through the aMSJtoiiiical iicek the glenoid process only is separated from the rest of the bone ; the symptoms will be very similar, except that the coracoid process preserves its normal relation and does not move with the arm. Treatment. — In fracture through the body the fragments should be brought into position, and then maintained so by a })ad of lint, secured by strips of strapping which encircle half the chest. The arm should be fixed to the side by a body bandage and the elbow supported in a sling. In fracture through the acromion the elbow should be well supported by a sling, or by a broad strip of strapping (as in the case of the clavicle) which passes beneath it and over the opposite shoulder. A pad should be fixed in the axilla and the arm bandaijed to the side. In fracture through the neck a similar plan of treatment is required. Fractures of the Humerus. 41 In fi-acture througli the coracoid process the fore- arm should be flexed and carried across the chest, so that the hand rests on the opposite shoulder, in order to relax the biceps and coraco-brachialis muscles ; the elbow should also be supported in a sling. The Humerus. Fractures of the humerus may be divided into fi-ac- tures of the upper extremity, shaft, and lower ex- tremity. Upper exlreiuity.— Fractures of the upper extre- mity may be subdivided into fractures of the anato- mical and surgical neck, separation of the great tuberosity and of the upper epiphysis. They are usually produced by direct violence, e.g. a fall or blow upon the shoulder ; less frequently they follow falls upon the hand or elbow. AnatOESiicRl neck. — Fracture througli the ana- tomical neck, i.e. above the tuberosities and within the capsule of the joint, is not of common occurrence ; it may be either impacted or non-impacted. In the impacted form the small upper fragment is usually driven into the wide surface of cancellous tissue at the upper end of the lower one. The symptoms are as follows : the axis of the humerus is altered, being directed somewhat inwards towards the coracoid process, and the ell)ow being slightly separated from the side ; the arm is shortened and the shoulder somewhat flattened ; the acromion is more prominent than usual, and there is a slight depression beneath it ; the head of the himierus can be felt in the glenoid cavity, and in many instances some alteration in its shape can be detected ; crepitus is absent, unless the impaction is forcibly broken down. There is loss of power, with pain, stiffness, and swelling about the shoulder. In the non - impacted form less deformity is 42 Manual of Surgery. generally present ; a slight projection can be felt on the inner aspect of the joint, caused by the upper end of the lower fragment ; crepitus can be detected on rotating the arm, which is sliglitly shortened. It might be expected that the head of the bone, being severed from all its connections, and thereby depiived of its vascular supply, would necrose, but this result very rarely takes j)lace, fibrous or even osseous union being usually effected. This is probaljly owing to the fact that its separation is often not complete, its vitality being maintained through the medium of portions of the capsule which remain attached to it. When osseous union takes place the callus is mainly thrown out by the lower fragment. When the union is merely fibrous, considerable atrophy of the head of the bone is often produced. Treatment. — In impacted fracture all that is required is to keep the part at rest, by bandaging the arm to the side and supporting the elbow in a sling. Care should be taken not to break down the impaction by the employment of any force. If the soft parts about the shoulder are bruised and swollen, some evaporating lotion should be applied. In non-impacted fracture it is, in addition, some- times necessary to fix a small pad in the axilla, and fit a guttapercha or felt cap to the shoulder, so as to keep the parts in apposition and completely at rest. Surreal ueck. — Fracture through the surgical neck is the variety most commonly met with about the upper end of the liumerus, the bone being usually broken below the tuberosities and above the insertion of the pectoralis major and latissimus dorsi ; the fracture may be either impacted or non-impacted. In the no7i-impacted^ the more common variety, there is considerable displacement of the fragments. The upper fragment is rotated outwards, and slightly elevated under the coraco-acromial ligament Fractures of the Humerus. 43 by the muscles inserted into the two tuberosities. The lower fragment is drawn forwards, upwards, and inwards beneath the coracoid process, by the muscles passing from the trunk to the arm, and by the flexors of the arm ; at the same time the lower end of the shaft Ls thrown obliquely outwards from the side by the action of the deltoid The symptoms are as follows : the lower fragment forms a distinct prominence beneath the coracoid process, most marked when the elbow is raised ; the head of the bone can be felt in the glenoid ca\"ityj consequently there is no hollow immediately below the acromion, though a slight depression is often present a little lower down, viz. just below the end of the upper fragment ; the axis of the limb is altered, being directed upwards and inwards towards the coracoid process ; cre})itus can be detected on extending and rotating the limb ; the arm is shortened and abnormally mobile ; o^^dng to irritation of the branches of the brachial plexus by the lower fi-agment, 2>ain is often present, shooting down the arm. In the impacted form the lower fragment is usually driven into the upper. The symptoms are chiefly of a negative character, the usual signs of fracture being absent ; slight shortening is present, with impaired movement, deformity, and alteration in the axis of the limb ; crepitus is absent unless the impaction is broken down. The circumflex nerve, owing to its close relationship to the neck of the humerus, is liable to be wounded at the time of fracture, or it may afterwards become included in the callus by which repair is effected ; under these cir- cumstances, paralysis of the deltoid, followed by atrophy, is liable to occur. Treatment. — In impacted fracture the treatment is the same as in the case of the anatomical neck. In non-impacted fracture there is the triple 44 Manual of Surgery. displacement of the lower fragment to be remedied ; the displacement inwards may be counteracted by placing a thick pad in the axilla and bandaging the elbow to the side ; the displacement forwards by bandaging the elbow to the side of the chest in front of the lateral median line, so as to throw backward the upper end of the shaft ; the displacement upwards by siip})orting the hand only (not the elbow) in a sling, so that the weight of the arm may act on the lower fragment and di-ag it down (Fig. 6). To ensure the part being kept com- }>letely at rest, a gutta- p<;rcha or felt cap may in addition be fitted to the shoulder, and if there is any tendency to swelling of the lindj, it should be bandaged upwards from the fingers. In fractures of the neck of the humerus, union takes place in four to five weeks, when passive movement should be begun ; in the im})acted forms the patient should be warned of the stifihess and deformity which will be permanent. 8i*i>ai'sUion of tlio great tuberosity.— This injury nuiy occur alcdn-, but more commonly in connec- tion with a dislocation forwards of the humerus ; under these circumstances the detached portion of bone is drawn backwards by the muscles inserted into it, so that it lies under or external to the acromion process, wldle the head of the humerus is drawn forwards beneath the coracoid process. Fi G.— Treatment of Fracture of tlie Siiriiieal Neck. Fractures of the Humerus. 45 The symjUoms are usually well marked ; there is an increase in the breadth of the shoulder ; a projec- tion formed by the detached tuberosity can be felt at the outer and back part of the joint, while between this and the head of the bone, which lies beneath the coracoid process, a distinct gap or vertical sulcus is evident ; crepitus is absent unless the fragments are brought into aj)position with one another. Treatment. — An attempt should be made to bring the fragments into contact, and then to maintain them so by pads of lint and strapping, a cap being also moulded to the shoulder. An axillary pad will often be found useful, and the arm should also be supported in a sling and liandaged to the side. ISeparatsoii of upper epipliysis.— Separation of the upper epiphysis of the humerus, which includes the head and both tuberosities, is often met with in young subjects; occurring, as it does, just above the usual situation of fracture through the surgical neck, the symptoms of the two injuries are very similar. In separation of the epiphysis, howtver, the lower frag- ment is smooth and rounded instead of being sharp and irregular as in fracture ; crepitus is absent or much less distinct, owing to the fact that the line of separation runs through cartilage and not through bone. The treatment is the same as m tracture through the surgical neck. Shalt. — Fracture through the shaft of the humerus is often met with as the result either of direct or indirect force ; it usually occurs about the middle of the bone. If the fracture is above the insertion of the deltoid, the upper fragment is drawn inwards by the pecto- ralis major, latissimus dorsi, and teres major ; the lower fragment is drawn upwards l>y the coraco- brachialis and biceps, and outwards by the deltoid; 40 Manual of Surgery, consequently, shortening is present along with defor- mity^ the lower fragment jorojecting above, behind, and to the outer side of the upper one. If the fracture be below the insertion of the del- toid, the displacement is often very slight when the line of fracture is transverse; when, however, it is oblique, the lower fr.i:,nnent is drawn upwards by the rJceps and triceps so as to overlap the uj^per one. The muKCulo-spiral nerve, o^ving to its close relationship with the middle of the shaft of the humerus, is liable to be wounded at the time of fracture, or it may sub- sequently become included in the callus ; under these circumstances, if paralysis of the nerve accompanies or follows the injury, the patient will present evidences of " wrist-drop," with loss of power of extension and supination in the fore-arm. j!^on-union is more frequently met with as a complication of fracture through the shaft of the humerus, than in the case of any other long bone. Various theories have been advanced to account for the fact, viz, : (1) Interposition between the fi'ag- ments of the muscular tissue which surrounds, and is directly adherent to, the shaft of the bone. (2) Non- apposition of the fragments from imperfect support to the arm. (3) Injury to the nutrient artery of the bone. (4) Imperfect fixation of the shoulder joint. (5) The tendency to movement at the end of fracture, when, the elbow joint being fixed in splints, the fore- arm is flexed or extended. Treatment. — A rectangular splint reaching from the axilla to the fingers should be applied to the inner side of the limb, care being taken that it is well padded where it presses over the inner condyle and also at its upper end, which must not reach too high in the armpit; three short splints, reaching from the shoulder to the elbow, should also be ap2)lied to the anterior, posterior, and the outer aspects of the upper Fractures of the Humerus. 47 arm. In most cases the liancl and wrist only should be supported in a sling, the elbow and fore-arm being allowed to hang, so that the weight of the latter, by dragging on the lower part of the shaft, may counter- act the tendency to overlapping of the fragments, which usually exists. Stronieyer's cushion, a triangular wedge-shaped pad, is often useful in cases of compound fracture ; it is interposed between the chest wall and arm in such a way as to form a support for the limb, the elbow resting upon its thick end. Union, as a rule, takes place in five or six weeks, LiOi;ver extremity. — Pbur different forms of fracture are met with about the lower end of the humerus, viz. transverse supracondyloid, T-shaped, separation of either condyle and of the lower epiphysis. Transverse supracondyloid. — In this va- riety the shaft is broken across, just above the condyles; the line of fracture, though transverse, is generally some- what oblique from above downwards and forwards, so that the lower fragment is drawn upwards behind the upper one by the biceps, brachialis anticus, and triceps. The symptoms are very characteristic ; there is an irregular projection in front of the joint above the bend of the elbow formed by the upper fragment, which pushes forwards the brachial artery, and another behind, formed by the lower fragment and bones of the fore-arm. Crepitus and abnormal mobility are present, along with pain and swelling about the joint. The deformity can be easily reduced, but at once re-appears when extension is left off. The distance between either condyle and the olecranon will be norma], while between either condyle and the acromion it will be diminished. If the line of fracture runs in the opposite direction the position will be reversed, the lower fragment being drawn upwards in front of the upper one. 48 Manual of Surgery. This fracture is liable to be mistaken for dislocation of the radius and ulna backwards ; for in both injuries, which are common in young subjects, there is a prominence in front of the elbow and another behind, with loss of power, and pain and swelling about the joint. The diagnosis of fracture can, however, be n^ide by attention to the following ])oints' the presence of crepitus and increased mobility about the lower end of the liumerus ; the fact that the anterior projection, which is formed by the upper fragment, is rough and irregular, and above the bend of the elbow, not below as in dislocation, where, being formed by the articular end of the humerus itself, it is broad, smooth, and rounded ; the fact that there is no increase in the distance between either condyle and the olecranon, while shortening is present on measur- ing from the acromion to either condyle ; the fact that the deformity is readily reducible, but at once returns when extension is discontinued, will usually serve to distinguish fracture from dislocation. T-sliai>C€l fracttare into the joint. — In this variety there is, in addition to a transverse fracture above the condyles, a vertical crack or fissure running between them and involving the elbow joint. Swelling about the joint, owing to effusion into its interior, is always a prominent symptom, often rendering the diagnosis of the injury somewhat dilHcult ; the lower end of the humerus will probably appear to be somewhat increased in width, and crepitus can, as a rule, be readily detected on flexing and extending the fore-aim, or on grasping the two condyles and moving them upon each other. Separation of citlaer eonclyle, — Either con- dyle of the humerus may become separated by a simple crack or fissure, running ol)liquely across the lower end of the bone. In separation of the outer, or the whole of the inner condyle, the elbow joint is necessarily Fractures of the Humerus. 49 opened. In the case of the inner condyle, it« tip, which is more prominent and consequently mr»re liable to fracture, is often separated (" epicondylar fracture ") without the joint being ijivolved. There is not, as a rule, much displacement of the fractured condyle, though at times it is drawn down by the muscles attached to it, so that the characteristic projection on either side of the joint is lost. The elbow becomes painful and swollen, its movements are impaired, and crepitus can readily be detected. In fracture of the external condyle the musculo- spiral nerve or its subdivisions (^raore especially the posterior interosseous), and in fracture of the internal condyle the ulnar nerve, may become wounded at the time of injury, or afterwards included in the callus by which repair is effected. Under these circumstances symptoms of paralysis of these nerves will accompany or follow the fracture. Separation of lower epiphysis, — Separation of the lower epiphysis of the humerus, viz. of the two condyles with the trochlea and capitellum, is often met with in young subjects, as the result of a fall upon the elbow. Occurring almost in the same situation as the transverse supracondyloid fracture, the symptoms are very similar to those met with in that injury. In se- paration of the epiphysis, however, the fragments are more smooth and rounded than in fracture, and for this reason, crepitus is less distinct or altogether absent. The line of separation is also just above the joint, nearer to it than is often the case in fracture. In rare cases the trochlea and capitellum only are separated, the condyles being left attached to the shaft of the bone, the so-called " infracondyloid separation of epiythysis. " Treatuient. — JMost cases of fracture of the lower end of the liumerus may be treated witli an internal rectangular splint, reaching well up the arm and down E— 21 50 Manual op Surgery. to tljc lingers ; the elbow bhoiild be ke})t at a right angle, and the fore-arm, in a position midway between pronation and supination, should be supported in a sling. Some cooling lotion should be applied to the joint when evidences of synovitis are present. In separation of the lower epiphysis and in trans- verse supracondyloid fractui'e, when the fragments cannot be kept in position by this treatment, it is sometimes recommended to apply an angular splint, fitting the bend of the elbow, to the front of the limb, and a straight splint to the back of the upper arm, so as to push the U})pcr fragment backward, and the elbow with the lower one forward ; or the position of the splints may be reversed, the angular one being applied behind, and the straight one, reaching to the bend of the elbow, in front ; care should, however, always be taken that too much pressure is not em- ployed, otherwise there is a risk of the supervention of gangi'ciu; from com])r(3Ssion of the brachial artery between the shaft of the humerus and the anterior splint. At the end of two or three weeks passive move- ment should be cautiously commenced, the splints being removed and re-applied daily. When the joint is in\olvcd, it is sometimes advisable, especially with children, to commence at an earlier period, e.g. as soon as ten days after the accident. In most cases, however, more or less stiffness will remain for a time, and Avliere the elbow joint is implicated, the patient should be i)repared for the impairment in its move- ments, which is often permanent. Firm union will, as a rule, take place in from four to six weeks. In cases of compound fracture involving thfe elbow joint, an attempt should be made to save the limb, unless tJie soft tissues are extensively lacerated and theie is much splintering of bone ; any loose fragments h'RACrURES OF THE FoRE-ArM. 5I should be removed, and occasionally a piimaiy excision of the joint, cithor partial or conipletu, niay be re<|uii"cd. A plaster of Paris splint, interrupted at the elbow with pieces of strong wiie, iron hoop, etc., will be found a useful apparatus in these cases,- as it allows access to the wound for dressing, and at the same time keeps the part in a state of perfect rest. The Fore- Arm. Fractures of one or both of the bones of the fore- arm are of very frequent occurrence. Radiuis :iii€l iiliia. — Fracture of both i-;iKus and ulna is often met Avith, generally as (he result of direct violence, a fall upon the hand being more com- monly followed by fracture of the radius alone than of both bones. The usual situation is through their middle or lower third, their upper third being better protected by the thick covering of muscles. The line of fracture is usually transverse, both bones are broken on the same level, or nearly so. The upper fragments are drawn forwards by the action of the biceps, pro- nator teres, and brachialis anticus, the radius being someAvhat approximated to the ulna. The lower frag- ments are drawn together by the pronator quadratus, and upwards, either in front of or behind the upper fragments, by the flexor and extensor muscles. There is more or less shortening of the fore-arm, with, in many cases, considerable deformity, the lower fragments, which usually overlap the upper, forming a projection on either the anterior or })osterior surface of the limb ; crepitus can be readily detected, and abnormal mobility is' also present. Trcatineid. — The fore-aim should be bent to a right angle and placed in a position midway between pro nation and supination, i.e. with the thumb pointing upwards. Two straight splints, reaching from the 52 Manual of Surgerv. elbow to the fingers, should be. applied to the anterioi* and posterior surfaces of the limb. In this posi- tion the radius and ulna will be parallel with one another, and the interosseous space will consequently be preserved. The splints should be slightly broader than the limb, so that the bandages may not press upon the arm and force the bones together. In some cases it may be necessary to apply a narrow pad along the interosseous space, in order to keep the radius and ulna apart ; otherwise they might become united together by callus thrown out across the space, a result which would afterwards interfere with the movements of pronation and supination. Union is generally effected in from three to four weeks. Usicliuis. — Fracture of the radius alone may take place through its neck, shaft, or lower end, the latter situation being the most common. IVeck. — Fracture through the neck of the radius is an uncommon injury, and one that is often difficult to detect, owing to the fact that very little displacement of the fragments is usually present, the bone at this spot being surrounded by a layer of muscle. The movements of the fore-arm, especially supination and pronation, are interfered with ; on placing the finger over the fracture and rotating the hand, crepitus can be detected, and unless the fragments are interlocked, the head of the radius will not rotate with the shaft of the bone. The treatment is the same as in fracture through the shaft. Sliiift* — Fracture through the shaft of the i-adius is more common than fracture of the idna alone, for, being situated on the outer aspect of the liinl), it is more exposed to direct violence ; moreover, its shaft is not so strong as that of the ulna, and it also has a more direct connection with the wrist. It may be CoLLEs' Fracture. . 53 due to direct violence or to a fall upon the hand. The usual seat of fracture is about its middle; if above the insertion of the pronator teres, the upper fragment is flexed by the biceps and fully supinated by the supinator brevis ; if below, the upper fragment will be in a position midway between pronation and su2:)ination, the action of the supinator brevis being more or less counteracted by that of the pronator teres. The lower fragment is pronated and drawn towards the ulna by the pronator quadratus. The symptoms are usually well marked : a prominence is formed on the front of the upper part of the fore-arm by the upper fragment, and there is a depression at the seat of fracture, both fragments being drawn inwards towards the ulna. Crepitus is produced on pressing the fragments together, or on rotating the hand, and there is loss of power of pronation and supination, with abnormal mobility. The treatment is the same as in fracture of both bones of the fore-arm. When, however, the radius is broken high up, it is sometimes necessary to keep the fore-arm well supinated by means of an angular splint applied to the back of the upper arm and fore-arm, for, the upper fragment being fully supinated, the proper axis of the limb will not be maintained if the lower one is kept in a position midway between pronation and supination, as in the ordinary method. L.ower extremity.— Fracture of the lower end of the radius is very common, one variety being known as "Colles' fracture," after the celebrated Dublin surgeon, who was the first to accurately describe it. It is generally the result of a fall upon the palm of the hand when the arm is extended, and though met with at all ages and in both sexes, is more common after middle life, and especially in females. The seat of fracture is usually half an inch to one and a half inches above its lower end, just at the 54 . Manual of Surgery. weakest portion of the radius, i.e. where tlio yhaft begins to expand into the broad articular extremity, wliioli is mainly composed of cancellous tissue, covered witJi a layer of compact bone mucli thinner than that of tlie shaft itself. The line of fracture is generally transverse, but may be oblique from side to side, or from before backwards ; in some cases there is com- minution of the lower fragment, and not unfrequently the fracture is impacted, the compact tissue of the shaft being driven into the cancellous tissue of the lower fragment by the same force that causes the injury.* The amount of displacement varies ; in some cases scarcely any is present ; more commonly it ia considerable, and in Colles' fracture a veiy charac- teristic deformity is usually produced, viz. : The lower fragment, carrying with it the hand, is driven upwards and backwards behind the upper one by the direction of the force and the combined action of the supinator longus, extensors of the thumb, and radial extensors, so that a prominence is formed on the back of the wrist, with a depression above it. The upper fragment projects forwards, often lacerating the pronator quadratus, and is drawn by this muscle towards the ulna, forming a prominence on the front of the fore-arm just above the wrist from the flexor tendons being thrust forwards. There is some difference of opinion as to whether the fracture is generally impacted or not ; when the deformity is ])ermanent, and cannot be made to disap])car, impac- tion is probably present ; when, on the other hand, the fracture is readily r(;ducible, impaction is absent. * ]Mr. Clement Lucas lias recently shown that in Colics' fracture, in ailditinn to fracture of the radius, "there is usually either a fracture of the styloid process of the \ilna, or a tear of the internal lateral ligament of the wrist joint, and, in addition, fre- fjuently a rupture of the triangular fibro-cartilago," the latter becoming detached from the edge of the radius (Guy's Hoepital Reports, vol. xlii,). CoLLEs' Fracture. 55 The symptoms are as follows : pain and swelling about the wrist, with impaired movement, especially of pronation and supination. On viewing the limb sideways, its posterior surface presents a distinct prominence (formed by the lower fragment) just above the wrist ; a little higher up a marked depression will be seen. Its anterior surface presents a depression above the wrist, corresponding in position with the dorsal projection, and most marked on its radial margin; while higher up, and corresponding with the dorsal depression, a distinct prominence is seen, formed by the jirojection forwards of the upper fragment. On viewing the back of the limb it will be seen that the hand is drawn over to the radial side, so tliat its ulnar border is somewhat convex ; the styloid process of the ulna (or, when this is fractured, the lower end of the ulna itself) is unusually prominent ; the radial border of the wrist is slightly concave. When the styloid process of the ulna is not fractured, the tips of the two styloids will often be found on the same level. When the fragments are not impacted, crepitus can, as a rule, be readily detected, the deformity can be made to disappear, and the bones brought into good position. If, however, impaction is present, crepitus is absent, and the deformity is permanent, unless the fragments are forcibly loosened from one another. Treatment. — An attempt should be made to reduce the fracture, and when impaction is absent, or not very lii'm, this can usually be eflccted, the deformity then disappearing more or less comidetely. If, how- ever, the ends of the bone are so fixed that they cannot be disengaged by the employment of moderate force, union will take place between the impacted fragments, and the wrist will, in consequence, remain stitf and deformed. 56 Manual of Surgery. YU. 7. -Nelaton's Splint foi* Colles' Fractiu'e. In the treatment of this fracture many different forms of apparatus are employed. Two straight s]:)lints may be used, a palmar one reaching from the elbow to the lower end of the upper fragment, and a dorsal from the same point to the ends of the fingers. A thick ])acl should be placed over the end of the upper fragment, and another over the lower fragment, so as to press them into position. At the end of a week a shorter dorsal splint should be substituted, viz. one reaching only to the knuckles, so as to leave the fingers free. Nelaton's pistol splint (Fig. 7) is curved at one end like the handle of a pistol, so as to draw the hand over to the ulnar side ; it is usually applied to the back of the fore-arm and hand (less fre- -^^ v^s^s^ quently to the front) in conjunction with a short straight splint, reaching fiom the el- bow to the lower end of the upper fragment, applied to the front of the arm. The pistol splint should bo thickly pndded where it presses on the lowei' fr;ignicnt, and the palmar one where it presses on the radial border of the fore-arm and lower end of the upper fragment. Carr's splint (Fig. 8) is ai)plied to the palmar surface of the hand and arm in the prone position, the fingers grasping the cross bar which lies beneath the metacarpo-phalangcal joints ; a short straight Fiff. 8. -Carr's. Splints for Colles* Fracture. Fractures of the Ulna. 57 splint is also applied to the dorsal surface of the fore-ariii. Whatever treatment is adopted, care should be taken that the fingers are left free, and the patient made to exercise them after the first week. The splints may generally be removed at the end of three or four weeks, and gentle passive movement of the wrist joint should then be commenced, otherwise more or less stiflness of the part will remain. In many cases, how- ever, and especially in old peo])le, in spite of the most careful treatment, the wrist joint will never quite recover its normal shape or movement. Ulna. — Fracture of the ulna alone may occur through the olecranon, shaft, or styloid process, and in rare cases through the coronoid process. Olecranon. — Fracture of the olecranon is not uncommon as the result of direct violence, e.g. falls, or blows on the back of the elbow ; ' more rarely it is due to sudden and violent contraction of the trice})s muscle. More or less deformity is generally present, the broken fragment being drawn upwards by the action of the triceps. The nearer the fracture is to the tip of the process, the greater is the displacement, often to the extent of an inch or more. When the fracture is near its base, very little separation is often present, the fractured process being tken retained in position by the periosteum and fibrous tissue which invest it. When separation of the fragments is present, the prominence of the elbow is replaced by a depression, which is increased when the fore-arm is bent. Swelling rapidly ensues from effusion into the joint. The power of extending the fore-arm is lost. Crepitus is al)sent, unless the fractured process is drawn down into con- tact with the surface of the ulna. When no separation of the fragments lias occurred, the depression at the back of the elbow will not be present ; there will only 58 Manual of Surgery. be slight loss of power in the arm, and crepitus can readily be obtained. Union is usually effected by fibrous tissue, whicb may afterwards yield and allow of considerable separa- tion of the fragments ; the result is that the arm is often left considerably weakened, the power of ex- tending the fore-arm being more or less impaired. Treatment. — A straight splint should be applied to the front of the limb, more thickly padded where it fits the bend of the elbow, so that the joint may be very slightly bent ; it will generally be found that the fragments come into more accurate contact in this posi- tion than if the arm is kept perfectly straight. When separation of the fragments is present, the upper one should be drawn down by strapping, and a figure of 8 bandage, as in the case of the patella. As the fracture usually involves the joint, and is followed by effusion into its iiiterior, it will often be necessary to subdue the swelling by some evaporating lotion before the fracture can be put up. Union generally takes place in four to six weeks, and at the end of this period passive movement should l)e commenced, other- wise ankylosis of the joint may take place. In cases where separation of the fragments sub- sefpiently occurs from yielding of the fibrous tissue by which union is effected, a similar plan of treatment to that described in the case of the patella (page S3) may be adopted, viz. opening the joint and wiring the fragments ; a few cases of recent fracture have also been treated in the same way. Coronoitt process. — Fracture of the coronoid process is extremely rare, except as a comi)lication of dislocation backwards of the ulnn. The broken frag- ment may be drawn upwards by the brachialis anticus. Treatment. — The limb should be put up in splints at a right, or even at an acute, angle, in order to relax the niuscle which tends to displace tlie separated process. Fractures of the Hand. 59 Shaft. — Fracture of the shaft of the uhia usually occurs through its lower third, this being the weakest part of the bone ; it is most commonly the result of direct violence. Tlie lower fragment is drawn towards the radius by the pronator quadratus, the upper frag- ment retaining its normal position, or being slightly displaced forwards by the brachialis anticus. A slight irregularity is present in the course of the bone at the seat of fracture, crepitus can bo detected, and the movements of the fore-arm are impaired. The treatment is the same as in fracture of both bones of the fore-arm. Styloicl process. — Fracture of the styloid process sometimes takes place, often occurring in cases of CoUes' fracture. The Hand. Carpus. — Fractures of the carpal bones are of rare occurrence ; when present, they are usually due to direct violence, e.g. a severe crush or blow. Owing to their numerous ligamentous connections, very little displacement takes place, though crepitus is generally a prominent symptom. Treatment. — The fore-arm and hand should be sup- ported on an anterior splint, and some cooling lotion applied over the wrist to subdue the inflammation of the neighbouring joints which is usually present. Metacarpus. — Fractures of the metacarpal bones are not uncommon as the result of direct violence, the most common situation being through their middle or distal third. The displacement of the fragments is in some cases very sliglit, while in others it is considerable, the head of the bone dropping or sinking forwards towards the palm, and the fractured ends being dis- phiced backwards so as to form an angular projection on the back of the hand. Treatment. — In many cases an anterior splint witlj 6o Manual of Surgery. a palmar pad is all that is required. When there is much displacement of the fragments, a palmar pad pressing upon the head of the bone, and another one over the dorsal projection with anterior and posterior splints, will often be found useful. Bending the fingers over a ball or thick pad, and then bandaging them in this position, is another plan of treatment sometimes adopted. Union generally takes place in three or four weeks. Phalaiig'cs. — Fractures of the phalanges can readily be recognised by the presence of crepitus, ab- normal mobility, and displacement of the fragments. Treatment. — A narrow splint should be applied to the anterior suiface of the finger. The Pelvis. Fracture of the bones of the pelvis is usually the result of severe direct violence, and when compli- cated, as is often the case, witli injury to the bladder, urethra, and other contents of the pelvis, is always of a serious nature. 1. TBii-ougli crest of iliuin. — Fractures sepa- rating only a portion of the crest of the ilium are not generally attended by much danger. The nature of the injury is usually evident, for, in addition to more or less pain and bruising about the seat of fracture, there will be mobility of the broken fragment, with crepitus on manipulation. 2. Tlii'oiig-h pelvic basin. — Fractures involv- ing the pelvic basin are much more serious, owing to tlie fact that the viscera contained in it are so liable to injury. In many cases the fracture is multiple ; e.g. it may involve Ijoth rami of tlie pubes, and sometimes, in addition, botli rami of the ischium, so tliat the central portion of the pelvis is entirely separated ; or it may involve the rami of the pubes and ischium in front, Fractures of the Pelvjs. 6i arid the ilium behind, close to the sacro-iliac synchon- drosis, so as to separate one half of the pelvis. The symptoms of the injuiy are usually manifest, for in addition to the bruising of the soft parts, there is severe pain, especially upon any attempt atmovement, with inability to stand or sit erect : a line of ecchy- mosis is often present, extending along Poupart's ligament and the crest of the ilium, with discoloration of the skin over the sacrum and in the perinseum ; crepitus and abnormal mobility can often be detected on grasping the iliac spines or crests and attempting to rotate or move them on each other ; in some cases the displacement of the fragments will be evident, especially on examination by the rectum or vagina. When the bladder or urethra is injured there will also be evidence of these. complications. 3. Tliroiigli acetabitliiiii. — Fracture may take place through the rim or floor of the acetabulum owing to the head of the femur being driven violently against it. {a) Through floor. — Fracture through the floor may occur as a simple crack or fissure, or there may be extensive splintering of the pelvic bones. In the former case there may be no very evident symptoms, with the exception of pain, especially on attempts to move the limb or stand erect, or upon pressure on the pubes ; at first there is not any alteration in the length of the limb, but after a time slight shortening may ensue, probably owing to changes taking place in the cai-ti- lage of the head of the femur and acetabulum, and leading to absorption of. the articular surfaces of tlie bones. In the latter case, crepitus can be readily de- tected on any movement of the limb, and if the head of the femur is driven into the pelvic cavity, there will be shortening of the leg with inability to move it, deformity of the hip, and probably evidences of injury to the contents of the pelvis. 62 Manual of Surgerv. (b) Thi'ouf/k rim. — In fracture through the rim of the acetabulum, it is usually its upper and posterior ])art that gives way ; consequently the head of the femur is liable to slip out of its socket, and the injury is, therefore, frequently accompanied by a dislocation of the thigh on to the dorsum ilii. When this is the case, the symptoms are usually obvious ; in addition to those characteristic of dislocation, there will be distinct crepitus, and it will be found that the dislo- cation can easily be reduced, but will at once return when extension is discontinued. 4. Tlii-oiigli sacriiiii. — Fracture through the sacrum is of rare occurrence except as the result of gun-shot injury ; when due to other causes, e.g. severe crushes, etc., it is usually associated with fracture of the other pelvic bones, evidences of which will be present. 5. Tlii'oiigli coccyx. — Fracture through the coccyx, or dislocation of this bone from the sacrum, is sometimes met with as the result of direct violence, or occurring during the straining efibrts of parturition. The symptoms are pain at the part, increased on sitting, walking, and during the act of defsecation ; crepitus and abnormal mobility will sometimes be present, and on introducing the linger into the rectum a slight projection will probably be felt on its posterior wall. In some cases this injury is followed by i)er- sistent pain ("coccydynia") in the region of the coccyx. Treatment. — The patient should be kept in the recumbent position, and a bioad bandage, padded belt, felt or guttapercha sj^lint moulded to the part, applied to the pelvis so as to kei^p the parts com- [»l(itely at rest ; in many cases it will also be advisable to tie tiie knees together. In fracture of the acetabulum, extension should be emi>loyed by means of an outside splint, as in fracture pRACrURES OF THE pEMUK. 6^ of the thigh ; this is especially necessary when its riin is involved, in order to ju'event the head of the feiiiur from becoming displaced. Any complication which may be present, e.g. rupture of bladder or urethra, must be treated on ordinary piincii)les. In fas'ourable cases, repair will be effected in from six to eight weeks. The Femur. Fractures of the femur may be divided into fractures of the neck, great trochanter, shaft, and lower extremity. 1. Ncclc. — Fractures of the neck of the femur may be subdivided into two great classes, viz. intracapsular and extracapsular, according as the bone is broken within or without the line of insertion of the ca[);sular ligament. In many instances, however, the line of fracture lies partly within and partly without the in- sertion of the capsule. In either case the fracture may be impacted or non-im2:)acted. Intracapsular fracture is an injury of ad- vanced, life, being rarely met with in persons under fifty years of age ; it is especially common in the female sex, and is usually the result of slight indirect violence, e.(j. catching the foot and trippuig up, missing a step in going downstairs, etc. ; consequently it is not, as a rule, attended by any bruising or apparent injury to the soft parts about the hip. Its frequent occurrence in old people is no doubt owing to the alterations in structure and shape which take place in the neck of the bone as age advances. Not only is its nutrition impaired, as shown by the fatty degeneration of the cancellous and the thinning of the com})act tissue, but the neck of the bone itself also becomes more horizontal, being set almost at a right angle to the shaft ; consequently, becoming weakened from ])oth these causes, it is liable to t>nap and give way as the bd Manual of Surgery. result of the application of a very slight degree of violence. The fracture may be either impacted or non- impacted, the latter l)eing hy far the niont com in on. In the iioii-iiii|>actefl variety the amount of dis- placement of the fragments varies ; in most cases the lower fragment is drawn upwards, ahove and to the outer side of the upper one, and at the same time ro- tated outwards, so that its fractured surface looks more or less directly forward, while the upper fragment, being unacted upon by any muscles, retains its normal position. In cases where the perios- teum and reflection of capsule, which in\'est the neck of the bone, are not torn through at the time of the injury, the separation of the frag- ments may at first be very slight. The syiiiptoiiis are as follows : Alteration in the shape of the hip, which is some- what flattened. Alteration in the position of the trochanter major, Avhich is less jn-ominent than usual, and approximat(Ml to the anterior superior iliac spine and also to the median line of the body. On rotating the limlj it u'ill also l)e found that the trochanter moves Fig. 9.— The most common Fractures of the Upper End of the Femur. (From Pick's •' Fractures and Dislocations.") Fractures of the Femur. 65 through a smaller segment of a circle than on the sound side. To verify the altered position of the trochanter major, the following tests may be employed. (a) Nelaton^s line. — In fracture of the neck, as in a dorsal dislocation of the femur, the upjDcr border of the trochanter will lie above a line drawn from the anterior superior iliac spine to the tuber ischii. In the normal condition, the upper border of the trochanter should just touch this line. {b) Bryant's ilio-femoral triangle. — This (a b c, Fig. 10) consists of three lines; viz. a b, drawn from Fig. 10.— Bryant's Triangle. (From Bryant's " Practice of Surgery.") the anterior superior iliac spine to the upper border of the trochanter major, corresponding in the normal state to the u]')per part of Nelaton's line ; a c, drawn from the iliac spine at right angles to the horizontal plane of the recumbent body ; c B, drawn at right angles from a c to a b, where it touches the top of the trochanter. The line c B, the base of the triangle, is the test line for fracture of the neck ; in the normal con- dition it will, in an adult, measure about two and a half inches ; in cases of fracture, when the trochanter is drawn up (represented by the dotted line in Fig. 10), it will become shortened, and measure about an inch less on the injured than on the sound side of the body. F— 21 66 Manual of Surgery. (c) 3Iorris's hi-trochanteric or transverse measure- ment " consists in measuring the distance from the median line of the body to the antero-posterior line at right angles to the long axis of the body, through the top of the trochanter on each side. The distance is always less on the side of the fracture." 3. Crepitus, sometimes indistinct, but usually per- ceptible on drawing down the limb and rotating it in- wards, so as to bring the fragments in apposition. 4. Pain on pressure and especially on the move- ment of rotation. 5. More or less sweJlitig about the joint especially in the groin, but usually without any evidence of bruising. 6. Shortening of the limb, varying from half to two and a half inches. In some cases this symptom is absent at first, only showing itself after an interval of a few days ; under these circumstances it is probably due to the fact that the periosteum and reflection of the capsule, which invest the neck, remained untom at the time of the accident, but subsequently gave way as the result of some movement of the fragments, or owing to inflammatory softening of their structure ; or the fragments, which were originally impacted, may have become loosened and separated. 7. Eversion of the limb, the result partly of mus- cular action, but mainly of the weight of the leg, which causes it to fall or roll outwards ; in exceptional cases the limb is found to be inverted. 8. Loss of power in the limb, which is usually com- plete. Occasionally, when the periosteum and reflection of the capsule which invest the neck of the bone are untorn, the patient may be able to raise the limb and even stand or walk about, though with considerable pain and difiiculty. Union in this fracture is, as a rule, simply fibrous, or it does not occur at all, a false joint forming Fractures of the Femur, 67 between the ends of the bone ; in most cases, osseous union only occurs if impaction is present. This result is probably owing to the following causes : 1. The difficulty of keeping the fragments in perfect apposition and in a state of complete rest. 2. The presence of the synovial fluid between the fragments. 3. The small supply of blood to the upper fragment, viz. only through the ligamentum teres. The age and feebleness of the patient, and the atrophy and im- paired nutrition of the neck of the bone may also con- duce towards the same result. In the impacted fracture, which is much less common, the lower fragment is usually driven into the upper one, i.e. the neck of the bone is driven into the head. The symptoms are not so well marked ; there is less eversion and less loss of power in the limb, so that the patient sometimes stands or walks, though with difficulty ; crepitus is absent, and the shortening, which is present to the extent of ^ to 1 inch, cannot be made to disappear on extension, unless the impaction is broken down and the fragments separated. Union in this fracture usually takes place by osseous tissue, and the deformity is in most cases permanent. Extracapsular fracture of the neck of the femur is usually the result of direct violence, and though it may occur at any age, is most frequently met with in males under fifty years of age, i.e. during middle life. The bone is broken at, or just outside, the line of inser- tion of its capsular ligament, and in most cases more or less splintering of the great trochanter is present, for the same force that causes the fracture also drives the neck of the bone into the cancellous tissue at the base of the trochanter and breaks it into frai^ments. The fractui'e may be either impacted or non-impacted, the former beinj; most common, for the neck verv 68 Manual op Surgery. frequently remains firmly wedged into tlie trochanter and osseous tissue at the base of the neck. Owing to the fact that the fracture is generally the result of direct violence, e,g. a fall on the hip, considerable bruising and swelling of the soft parts is usually present about the joint. In the non-imjmcted variety, crepitus is very dis- tinct, and can be readily felt on laying the hand over the trochanter, especially if the limb is rotated at the same time ; shortening is present to the extent of from 1 to 2|^ inches, but can be made to disappear on making extension on the leg ; the limb is everted. In the impacted variety, crepitus is absent, unless considerable force is used and the fragments are sepa- rated ; shortening is present, but does not usually exceed an inch, and cannot be made to disappear on making extension, unless the impaction is broken down ; the limb is almost always everted ; there is less loss of power about the hip, the patient being some- times able to stand, or even walk, though with consi- derable pain and difficulty. Diag^uosis. — An impacted fracture differs from a non-impacted in the following points : 1. Crepitus is absent. 2. Shortening is usually less marked, and does not disappear on traction unless the fragments are separated. 3. There is less loss of power in the limb, and the patient can often raise it, and even stand or walk, though with difficulty. 4. Evidence of direct injury to the soft parts about the hip is more commonly present. 5. Inversion of the limb, though rare, is more common in the impacted than in the non-impacted variety. Severe contusions of the hip, when accompanied by e version and loss of power in the limb, may at first sight simulate very closely a fracture of the neck of the femur ; but the presence of shortening, the altered position of the great trochanter, and the presence of Fractures of the Femur. 69 crepitus (unless impaction has taken place), will usually distinguish a fracture from a contusion. In exceptional cases and especially when occurring in old persons, a contusion of the hip may be followed after a time by interstitial absorption of the neck of the femur, and under these circumstances slight shortening of the limb may gradually be produced. When a person, the subject of chronic rheumatic arthritis of the hip, receives an injury to the parts about the jcint, the shortening of the limb^ which often exists, and the presence of crepitus from the rubbing together of osteophytes, may cause the condition to simulate fracture of the neck of the bone. The history, how- ever, of the case, the fact that other joints are frequently affected, and that the patient suffered from pain and stiffness about the hip, with possibly some shortening of the limb prior to the accident, wUl usually serve to distinguish the true nature of the injury. From a dislocation of the hip a non-impacted frac- ture may be distinguished by the presence of crepitus, the mobility of the limb, and the fact that the head of the bone cannot be detected in any of the situations in which it would be found in that injury. In impacted fracture with inversion of the limb, the injury may be confounded with a dorsal or sciatic dislocation of the femur, as there is an absence of crepitus, the move- ments of the joint are restrained, and the position of the leg is somewhat similar. The absence of the head of the bone from the dorsum ilii or sciatic notch, and the free movement of the limb, especially under anaesthesia, will, however, usually distinguish a frac- ture. Separation of tlie upper epiphysis of the femur, which lies completely within the joint, has been described, but is of somewhat doubtful occurrence. Treatment. — In non-imjmcted intracapsidar frac- ture an attempt should be made to bring the 70 Manual of Surgery. fragments into apposition, and to maintain them so, in the hope that osseous union will occur. To eflfect this, extension should be applied to the limb by means of a weight, in the way described in cases of fracture through the shaft (page 72) ; the patient should be kept in bed for six or eight weeks, and some form of support or stiff bandage afterwards worn for about the same period. As, however, this injury is usually met with in old persons, v>^ho in many cases will not bear long confinement in the recumbent position, owing to a tendency to the for- mation of bed-sores or the supervention of hypostatic pneumonia, it will often be necessary after two or three weeks, or even less, to allow them to get about on crutches, wearing either a stiff bandage or a Thomas's splint, such as is often used in cases of morbus coxae ; under these circumstances the union will probably be fibrous, and the patient will in con- sequence be left with a weak or shortened limb, more or less lame for the remainder of life. Some surgeons, instead of employing any special apparatus, simply support the limb on pillows, or between sand- bags ; others, again, make use of the double inclined plane. In non-iTTipacted extracapsular fracture, extension by means of a weight (page 72) should always be employed, and in cases where there is much splinter- ing of the ends of the bone, a bandage round the hips will often be found useful in keeping the fragments in apposition. Firm osseous union will almost always take place. In impacted fractures of the neck no attempt should be made (especially in the intracapsular) to loosen the fragments and restore the limb to its proper length. Osseous union generally results, even in old j^eople, but the limb is left permanently shortened, and usually somewhat everted. All that is necessary is to keep Fracturf.s of the Femur. 71 the part at rest by means of a long outside splint, no extension being required, unless with the object of kee^nng the limb level and parallel with its fel- low. Great troclia.ntcr. — Separation of the great trochanter is met with as an independent injury, and also as a complication of extracapsular fracture. When occurring by itself, the sym])toms of this injury are mobility of the trochanter, with crepitus, which is usually distinct, unless the trochanter is drawn upwards and backwards on to the dorsum ilii, where it may form a distinct projection ; more or less pain and swelling are present about the hip, as the fracture is always the result of direct violence. If accompanied by fracture of tlie neck of the femur, evidence of that injury will also be present. Separation of the epiphysis of the great trochan- ter is rarely met with. Treatment. — A bandage round the hip, or some form of cap moulded to the part, will generally be found useful in keeping the fragment in position ; the limb should also be kept at rest by means of a long outside splint. Shalt. — The shaft of the femur may be fractured at any part of its course, its middle third at a variable level being the commonest situation. The line of fracture may be either transverse or oblique, and, in exceptional cases, longitudinal and almost parallel with the long axis of the bone, or even of a spiral nature. The injury, which is usually the result of indirect violence, is accompanied by well-marked symptoms ; there is, as a rule, considerable shortening with e version of the limb, loss of power, increased mobility, and crepitus ; more or less deformity, due to the displacement of the fragments, is usually pre- sent. In tlie upper third, where the line of fracture i^ 72 Manual of Surgery. often oblique, the upper fragment is drawn forwards and outwards, and also everted, while the lower one is drawn upwards and inwards, so that its fractured end lies above, behind, and to the inner side of that of the upi)er one ; rotation outwards of the lower fragment is almost always present. In the middle third the displacement is often much the same, though it will vary somewhat with the obliquity of the fracture. In the lower third the uj^per fragment is drawn slightly forwards and inwards, the lower one upwards Fig. 11. — Extension by Weight. and backwards, behind the lower end of the upper fragment. Treatment. — Fracture through the shaft of the femur may be treated in many different ways. Extension by a weight (Fig. 11) is a plan very universally adojDted at the present day. A long strip of plaister is applied to each side of the leg as high as the knee, a loop being left beneath the sole of the foot ; it is kept in ])lace by short pieces of strapping which encircle the leg transversely, and over these a bandage should be carried from the toes up to the knee, in order to fix the strapping and at the same time prevent any swelling of tlie foot. To prevent the strapping from chafing tlie skin, a thin flannel or domette bandage may be first applied to the limb be- neath it. To obtain a firmer hold on the limb, some sur- geons carry the longitudinal strips of strapping above Fractures of the Femur. 73 the knee, but not so high as the seat of fracture : to fix them, several turns of a bandage, or one or two pieces of strapping (not applied too tightly), are then carried round the lower part of the thigli, just above the patella. By this means there is less chance of the strapping slipping, and as extension is made from the lower part of the thigh as well as from the leg, there is less strain on the knee than if extension is made from the leg alone. A piece of wood (in length from one to two inches greater than the distance between the mal- leoli) should be fixed transversely in the loop left beneath the sole, so as to form a kind of stirrup, and take off all pressure from the sides of the foot and ankle. A strong cord is fastened by one end to the centre of the stirrup, and carried over a pulley arranged at the foot of the bed. A weight, varying in an adult from five to twelve pounds or more, is attached to the other end of the cord ; this, if it acts in a line with the axis of the limb, will make extension on the lower fragment, and thus overcome the contraction of the muscles, which tend to draw it upwards. Counter-extension may be made by a perineal band attached above to the head of the bed, but in most cases the weight of the patient's body will be sufficient, if the foot of the bed is slightly raised. To steady the limb, a long, straight, outside splint should be applied, reaching from the side of the chest to the foot, and three short splints, fixed by means of straps (so they are readily removable for the purpose of examining the fracture) to the front, back, and inside of the thigh, will also be useful in assisting to maintain the fragments in position. The tendency to eversion of the limb should be prevented, either by fixing a horizontal cross bar to the lov^^er end of the long splint, or by laying a sand-bag along its outei side. 74 Manual of Surgery. Elastic extension is a modification of the preced- ing method ; one end of a piece of strong indiarubl^er tubing being attached to the stirrup, the other end to the lower extremity of a Liston's long splint, counter- extension being made by a perineal band, as in the manner next described. Liston's long splint and perineal band (Fig. 12) is much less frequently used at the present time than it was some years ago. A long, straight splint, notched at its lower end, and reaching from the axilla to about four inches below the sole, is first fixed to the foot and ankle by a figure of 8 bandage, which Fig. 12. — Liston's Long Splint. ]>asses through the notches at its lower extremity. The fragments having been brought into position by traction on the leg and splint, counter-extension is made by means of a perineal band, i.e. a well-padded bandage, which passes in front of the gi'oin and behind the buttock, and the ends of which are passed through two holes at the upj^er end of the splint, where they are securely tied and tightened up from time to time, as the bandage becomes slackened. This method has several disadvantages as com- pared with extension by a weight, for the pressure of the perineal band is very liable to produce excoriation of the skin, and its a[)plication is often painful. Traction being made merely from the foot and ankle, considerable pressure is exerted upon those parts, and at the same time the foot becomes extended, so that Fractures of the Femur. 75 not only is the position irksome, but it is often fol- lowed by stiffness and weakness of the ankle joint from stretching of its anterior ligament. When a weight is employed the perineal band is not required, extension is made from each side of the leg, and the foot remains at a right angle with the leg, in a position which is comfortable for the patient, and not likely to be fol- lowed by stiffness of the joint. Desault's long splint differs from Liston's in the fact that its lower extremity, instead of being notched, has a lateral focft piece. Vertical extension (Fig. 13), recommended by Bryant, is very useful in the case of young children, where it is always difficult to keep the apparatus employed free from contact with urine and fseces. In this method, both limbs are swung at a right angle to the trunk from a bar fixed over the bed, the weight of the body act- ing as a counter-extending force. A Macintyre's splint (Fig. 14), or the double inclined plane, will often be found use- ful in fracture through the upper third of the shaft, where the upper fragment is tilted for- wards ; and again in fracture through the lower third, where the lower fragment is drawn backwards. Another plan of treatment, sometimes adopted under similar circumstances, con- sists in flexing the thigh upon the trunk almost to a right angle, and the leg upon the thigh ; the limb is then laid on its outer side on an angular splint, which 13. — Vertical Suspen- sion of Femur. 76 Manual of Surgery. reaches from the hip to the ankle, and several shoii; splints are also applied round the thigh. Erich sen advocates putting up the limb at once in some immovable apparatus, e.g. a starch bandage with a thick layer of cotton wadding beneath ; this should be cut up and trimmed on the second or third day, and then re-applied. The advantage of this method is that the patient may leave his bed and get about on crutchas after three or four days. Space prevents more than a brief reference to the numerous other plans of treating this fracture, viz. : Nathan Smith's anterior splint, a wire splint applied to the front of the leg and thigh, reaching Fig. 14.— Macintyre's Splint. from the foot to the groin, and by means of whicli the limb is swung. Hodgen's splint, where the limb is supported on a cradle composed of cotton sacking attached to two lateral bars of strong wire, wdiich reach from the upper part of the thigh to beyond the foot ; the cradle is swung from an upright post at the foot of the bed, and traction is made upon the cradle, which, in its turn, makes extension on the leg by means of strapping attaching the leg to the lower cross bar of the cradle, which projects for some inches beyond the sole of the foot. Thomas's splint, one sijnilar to that used in cases of disease of the knee joint being sometimes employed, along with four short splints round the thigh itself. Hammond's double splint, consisting of two long Fractures of the Femur, ii straight splints, applied to the outside of both limbs, and connected bj a cross bar below the feet. Bryant's double splint, similar to that employed in cases of disease or excision of the hip. In fracture through the shaft, union is generally ejSected in about eight weeks in the case of adults, but it is, as a rule, advisable to wear some form of stiff bandage for at least twelve weeks. In many instances some slight shortening of the limb will remain, even after the most careful treatment. L«OM er exti'emity. — Fracture through the lower end of the femur may be supracondyloid, i.e. just above the condyles and not involving the knee joint. The symptoms are very similar to those of fracture through the lower third of the shaft, the lower fragment being drawn backwards by the gastrocnemius, so that its fractured end forms a projection at the upper part of the popliteal space. Very frequently the joint is involved, the line of fracture being oblique, and running across either condyle, or through the intercondyloid space ; or it may be T-shaped, running transversely above the condyles and also between them into the joint. Under these circumstances considerable swelling of the joint is usually present, owing to effusion of blood and fluid into its interior ; crepitus and abnormal mobility can be readily detected on moving the joint, or upon grasping the condyles and mo\'ing them upon one another j when the condyles are separated, some in- crease in the breadth of the lower end of the femur is often apparent ; in addition there will be pain, loss of power, etc., in the limb. Separation of the lower epiphysis is sometimes met with in young subjects ; the symptoms are identi- cal with those of supracondyloid fracture, except that crepitus is less distinct or absent, owing to the •smoother nature of the surface of the fragments. 78 Manual of Surgery. Tliis injurj is liable to be followed by some arrest in the growth of the lower end of the femur. Treatment. — In siipracondyloid fracture, or in separation of the epiphysis, when the lower fragment is drawn backwards, the double inclined plane^ or a Macintyre's splint, will be found useful ; when the deformity cannot be overcome by flexing the knee in this way, division of the tendo Achillis, as recommended by Bryant, may be required in order to relax the gastrocnemius, the limb being afterwards put up in the same manner, or with extension by a weight, as in fracture through the shaft. In cases of fracture through the condyles involving the knee joint, the limb should be fixed on a straight back splint, and the accompanying synovitis treated with some cooling lotion ; lateral pressure, by means of side splints, will often assist in keeping the frag- ments in apposition. Passive movement should be commenced in about six weeks, otherwise considerable stiffness of the joint will probably result. In cases of compound fracture involving the knee joint, amputation will often be required ; the surgeon must, however, be guided by the age and general con- dition of the patient, as well as by the severity of the local injury. The Patella. Fractures of the patella may be transverse, oblique, vertical, or star-shaped, and comminuted. Transverse fracture, the commonest variety, is generally the result of muscular action, the bone being snapped across the condyles of the femur by a sudden and forcible contraction of the quadriceps extensor, when the knee is bent, as during an attempt to save the body from falling backwards ; in many cases the line of fracture is not directly transverse, but some- wliat oblique. PRACTURES OF THE PATELIA. 79 Vertical and comminuted fractures are always due to direct violence, e.g. a fall or blow upon the knee. Syniptonis. — In transverse and slightly oblique fracture there is usually more or less separation of the fragments, increased on bending the knee, the vipper one being drawn away from the lower by the muscles attached to it ; if seen directly after the accident, a distinct gap or depression will often be found in front of the joint between the fragments, and at the bottom of this the condyles of the femur can sometimes be felt. There is inability to stand and extend or raise the leg ; crepitus cannot be distin- guished unless the upper fragment is drawn down and brought into apposition with the lower one. If some hours have elapsed, an effusion of blood (heemarthrosis) or synovial fluid, or a mixture of both, takes place into the interior of the joint, which becomes swollen and distended, and under these circumstances the depression between the two fragments, which become more widely separated, disappears, and may be replaced by a distinct bulging ; at the same time the joint becomes more or less hot and inflamed, and evidence of synovitis appears. In exceptional cases, where there is no laceration of the periosteum and fibrous tissue investing and overlying the patella, separation of the fragments may not occur. In vertical and comminuted fractures there is usually little separation of the fragments, and under these circumstances crepitus can be readily detected. Mode of union. — In vertical and comminuted fractures, and in transverse, when, owing to the peri- osteum remaining untorn, there is little or no separation of the fragments, osseous union as a rule readily takes place. In most cases, however, of transverse fracture, difficulty is experienced in keeping the fragments in immediate apposition, for one or more of the following 8o Manual of Surgery, reasons; viz. 1. The contraction of the quadriceps extensor drawing away the upper fragment.* 2. Accumulation of fluid (blood or synovial) in the joint, distending it and consequently tending to separate the fragments. (That this is so, is proved by the fact that the difficulty in approximating them is usually in pro- portion to the amount of swelling.) 3. Interposition of blood clot, or of the fibrous and aponeurotic struc- tures which overlie the patella, between the frag- ments. The result is that union is generally effected by fibrous tissue, and as this usually tends to yield and stretch, the fragments of bone become, after a time, separated from one another, often to the extent of several inches, so that a weakened, and in some cases a more or less useless, limb remains. In exceptional cases, even when the fracture is treated in the ordinary way by means of splints, true osseous union is said to occur ; but this result is extremely rare unless the joint is opened and the fragments wired together in the way described. Treatoieiit. — In vei-tical and comminuted frac- tures, where there is not usually much, or any, separation of the fragments, the limb should be kept on a straight back splint, and some cooling lotion applied over the knee. In transverse fi'acture, where the fragments are generally widely separated, some means must be taken to bring them into apposition and to maintain them so, in the hope that close fibrous, if not osseous, union will result. The leg should be extended on the thigh, and the thigh fl.exed on the trunk, by means of a long back * According to INIr. J. Hutchinson, spasm of the muscles only causes separation at the moment of the accident ; as soon as the limb is at rest in bed. its agency ends {Brit. Med. Journal, Nov. 10, 1881). Fractures of the Patella. 8i splint with a foot piece, the lower end of which is raised, in order to relax the rectus muscle, which, if it remains contracted, • helps to draw away the upper fragment. Some surgeons, on the other hand, keep the limb in a horizontal position, believing that the muscle soon becomes relaxed and ceases to act. If seen immediately after the accident, and before any effusion has taken place, the fracture may be put up at once ; if, however, some interval has elapsed and the joint has become swollen and painful, the necessary pressure could not at once be borne. Under these circumstances an ice bag or an evaporating lotion should be applied to the knee, and then in the course of a few days, when the inflammatory symptoms have subsided, some means must be adopted to bring the fragments into apposition. The usual plan is to draw down the upper frag- ment by a broad strip of strapping, carried across the limb just above it, and then diagonally downwards and forwards round the splint ; a pad of lint should be interposed between the strapping and the limb above the upper fragment, so as to assist in pressing it downwards and at the same time prevent ulceration of the skin from the pressure of the strapping directly upon it. Another strip of strapping should be then carried in the reverse direction round the lower frasr- ment and splint, and in this way the two fragments can generally be brought into apposition with one another. To fix the strapping, a figure of 8 bandage should be carried above and below the knee, and to prevent both bandage and strapping from slipping, notches may be cut, or two nails fixed, on either side of the splint above and below the centre of the joint. In cases where the edges of the fragments tilt for- wards and tend to separate, a third piece of strapping, carried transversely round the limb, directly over the G— 21 82 Manual of Surgery. fragments, witli a pad of lint intervening, will some- times be fouixi useful. The splint should be kept applied for six to ei-ght "weeks ; at the end of this period it may be left off, and the patient allowed to get about on crutches, wearing a stiff bandage to prevent any flexion of the joint. This should be worn for from three to six months ; and then, if firm union appears to have taken place, tJie patient may begin to very gradually bend the knee. In most cases, however, the knee will be left more or less permanently weakened, as the uniting medium, which is usually fibrous, generally tends to yield ; under these circumstances, if a leather knee- cap is worn, it will afford considerable support, and materially increase the usefulness of the limb. Many other plans of treatment may be adopted with the object of bringing the fragments into apposition ; instead of ordinary strapping, indiarubber bands are sometimes used ; leather straps may be passed trans- versely round the limb above and below the fragments, and then approximated by means of longitudinal straps; a piece of strapping may be fixed round the limb above the upper fragment, and traction downwards made upon it, by means of elastic extension, or by a cord and weight susj)ended over a pulley at the bottom of the bed. Another method consists in applying a long strip of strapping to the front of the limb, and fixing it by transverse slips and a bandage, a loop being left free over the knee; pads of lint are placed beneath the sti-apping, above and below the fragments of the patella. A piece of stick is passed through the loop, which is then twisted up until the fragments are drawn into apposition. Malgaigne's hooks are not often employed at the present day, on account of the pain and irritation, with a tendency to suppuration, which they often Fractures of the Patella, 83 produce. They consist of a paii- of double hooks, which are passed through the skin, fixed in the two frag- ments, and then approximated by means of a screw worked with a key. A modification of this plan is, however, sometimes adopted, the hooks being fixed into pieces of strapping passed roimd the limb above and below the fragments, instead of into the skin and bone itseLf. Some surgeons put up the limb at once, or as soon as the swelling has subsided, in a stiff bandage, the fragments having been first brought together by strips of strapping in the way described. The advantage of this method is that it does not necessitate confine- ment to bed^ the patient being able to get about on crutches after a few days. When the joint is distended with fluid, another plan consists in drawing off the fluid with an as- pirator, instead of waiting for it to become absorbed. Care should ahvays be taken that the instruments used are perfectly clean, and it is advisable that the operation should be performed with careful anti- septic precautions. Subcutaneous division of the insertion of the quad- riceps extensor into the patella, as well as of the liga- mentum patellae, has also been adopted in a few cases Avith the object of ensuring perfect apposition of the fragments. Laying open the joint and wiring the fragments has recently been advocated by Sir Joseph Lister,"^ and is a plan of treatment which has now been adopted in a large number of cases with considerable success. The operation, which should always be carried out under the most careful antiseptic precautions, is performed in the following way : A longitudinal incision is ma-de over the centre of the joint, which is opened, and the fragments of the patella are * Brit. Med. Journal, 18S3; vol. i., p. 855. 84 Manual of Surgery. exposed ; any blood clot which is present in the joint or between the fragments is turned out, and the fragments themselves are cleared of the aponeurotic and fibrous tissue, which is often found lying in be- tween and over their broken surfaces. Each fragment is then bored obliquely with a drill, taking care not to reach its cartilaginous surface. Sutures of silver wire are then passed through the drill holes, and the frag- ments having been drawn together, the ends of the wire are twisted, cut short, and then hammered down on the bone, where they may be allowed to remain permanently, without causing any irritation. Free drainage should be provided for by the insertion of tubes in openings made at the back of the joint on either side. If all goes well, firm bony union will result, and the movements of the joint will be more or less com- pletely restored. The operation, however, is one which should not be lightly undertaken, nor without the most careful antiseptic precautions ; it should always be borne in mind that the usual plans of treat- ment, if carefully carried out, give, as a rule, very fair results. Wiring the fragments has in several cases been followed by suppuration in the joint, and, as a consequence, the limb, and even the patient's life, have been lost ; or if, after this complication {i.e. suppura- tion), recovery has taken place, the knee has been left more or less completely anchylosed. The operation is therefore, perhaps, more applic- able for old cases of fracture, where, in consequence of the fibrous tissue, by which union has been effected, having given way, the fragments have become separ- ated, and the limb in consequence rendered more or less useless. Under these circumstances the fragments should be exposed, and their broken surfaces refreshed and brought together with silver sutures in the way described. Fractures of the Leg. 85 The Leg. Tibia and fibula.— Fractures of the tibia and fibula are of frequent occurrence, it being more com- mon for both bones to be broken than for one to be fractured by itself. When due to indirect violence, the most common cause of fracture in this situation, the tibia usually gives way at its weakest part, i.e. about its lower third, and the fibula at a slightly higher level ; when due to direct violence, the bones are broken at the spot where the violence acts. In some cases, and especially when involving the upper part of the bone, the line of fracture is transverse, and under these circumstances the displacement of the fragments is often very slight. Much more commonly the line of fracture is oblique from above and behind downwards and forwards, and from without inwards, so that the upper fragment projects forwards beneath the skin (often piercing it and rendering the fracture compound), the lower fragment being drawn upwards behind it by the muscles of the calf. The symptoms of this injury are usually mani- fest ; in transverse fracture there is often very little deformity, but when it is oblique there will be the sharp projection of the upper fragment beneath the skin, with mobility, crepitus, pain, and loss of power in the leg. In fracture of the tibia alone, which is often the result of direct violence, the line of fracture is fre- quently transverse, and under these circumstances the symptoms may not be very obvious, for the fibula, remaining unbroken, acts as a splint, and tends to pre- vent much displacement from taking place ; in most cases, however, crepitus can be detected on manipu- lating the limb, and upon running the finger along the subcutaneous edge of the tibia some slight iiTegu- larity can usually be detected at the seat of fi-acture. 86 Manual of Surgery. Fracture of the internal malleolus is a common complication of Pott's fracture of the fibula. Separation of the upper and lower epiphyses of the tibia are described as rare injuries. Fracture of the fibula alone is often met with as the result of indirect violence, the bone usually giving way through its lower third ; less frequently it is due to direct violence, the fracture then taking place at the spot where the force acts. The symptoms of this injury are often obscure, for there is usually very little displacement of the frag- ments, and the patient can occasionally walk without much pain or difficulty. Crepitus and mobility can, however, usually be detected, if pressure is made alternately on either side of the suspected seat of fracture, or if the foot is rotated with one hand, while the fingers of the other are placed over the point where the bone is broken. Pott's fi'acture is the term applied to a fracture of the lower end of the fibula, associated with a disloca- tion outwards of the foot at the ankle joint. In this injury, which is usually the result of a sudden slip or twist of the foot outwards, the bone is broken from two to four inches above its lower extremity, the ends of the fragments being driven inwards ; the articular surface of the astragalus is displaced from the tibia, the foot being dislocated outwards at the ankle joint ; in some cases the inner malleolus of the tibia is also fractured, in others the internal lateral ligament is ruptured. The signs of this injury are usually obvious ; a well-marked depression can be felt at the seat of the fracture of the fibula ; the foot is twisted outwards, and its sole is everted by the peronei, owing to the fact that the fibula no longer offers any resistance to their contraction ; the inner malleolus, if unbroken, projects prominently beneath the skin ; if separated Dupuytren's Fracture. 87 the detached fragment can be readily felt, with a depression above it, and crepitus is easily obtained ; the heel is drawn up by the muscles of the calf (Fig. 15). Dtiptiytreii's fi'acture of the fibula is a rare inj ury, in which there is not only fracture of its lower extremity, but also laceration of the strong inferior tibiofibular ligaments (which remain intact in Pott's fracture) ; in some cases, a slip of the tibia is torn off with the ligaments, remain- ing connected with the lower fragment of the fibula. In addition, the foot is displaced upwards and outwaids, and the tibia is sometimes forced through the skin on the inner side of the ankle, so that the fracture is rendered compound. Treatment. — Most cases of fracture of the tibia and fibula, or of either bone alone, may be treated on a straight back splint, with a foot piece for the sole at right angles to it, and two side splints ; in the application of these, there are certain rules which should be Fig. 1.5.— Potfs Fracture. obsprvpd viV • 1 Tbp im'Tifcj (From Pick's " Frac- ouservea, viz. . 1. ±ne joints tures and Dislocations.") above and below the seat of fracture, i.e. the knee and ankle, should be fixed by the splints. 2. The inner border of the patella, the internal malleolus, and the inner side of the great toe should be in the same line. 3. There should not be any irregularity in the crest of the tibia. 4. The foot should be kept at right angles with the 88 Manual of Surgery. leg. 5. The heel should neither be allowed to drop nor raised too high, and its under surface should be well in contact with the foot piece. 6. Pressure should be taken off the back of the heel by means of an opening in the back splint beneath it, and by a pad placed between the limb and the splint, just above it. 7. The seat of fracture and the toes should be left uncovered. 8. No bandages should be applied be- neath the back splint. The fracture should be kept in splints for three or four weeks, and some form of stiff bandage afterwards worn for about the same period. When there is not much displacement of the fragments, and an absence Fig. 16. — Cliue's Splint. of bruising or swelling of the soft tissues, the limb may at once be put up in some form of stiff bandage, e.g. plaster of Paris, or a Croft's splint, and the patient in two or three days allowed to go about on crutches.* Some surgeons use Cline's splints (Fig. 16), viz. lateral splints with foot pieces ; if employed, care should be taken that the foot piece is at right angles with the side piece, not at an obtuse angle, as is generally the case, otherwise, tlie foot being kept fixed with the toes pointed, considerable weakness and stiff- ness of the ankle will afterwards remain, from the stretching of its anterior ligament. * In applying a stiff bandage to the lower extremity, whether in cases of recent fracture or after removal of splints, care should always be taken that the foot is kept at right angles with the leg while the bandage is setting. Pott's Fracture. 89 Macintyre's splint (Fig. 14) is often employed, and by means of the screw behind, it may be applied witli the limb straight or bent at the knee. The "fracture box," or "box splint," is useful when the soft tissues are much bruised and swollen, and also in some cases of compound fracture ; it con- sists of a board with a foot piece and movable sides, forming a kind of box in which the limb is supported on a pillow. If the limb, after being put up in splints, is sus- pended in a swing, it will be more comfortable for the patient, as he will be able to move it as he lies in bed without disturbing the fracture ; it may be swung by straps or bandages from the bed-cage, which should also be used in order to keep the weight of the bed clothes off the limb, or one of Salter's swings may be employed. If the limb is not suspended, sand-bags should be laid on the bed on either side of it in order to steady it. When there is much displacement of the fragments and difficulty is experienced in keeping them in position by any of the preceding methods, it will often be found that laying the limb on its outer side with the hip and knee bent will prove successful, for in this posture the muscles of the calf, which are the chief agents in producing the deformity, become relaxed. Occasionally subcutaneous division of the tendo Achillis may be required with the same object. In Pott's fracture there is, in addition to fi'acture of the fibula, the dislocation outwards of the foot, which has to be corrected. Some surgeons treat this fracture with a back splint and two side splints ; but when put up in this way there is often a tendency for the deformity to recur. When the displacement of the foot is well marked, it is safer to use Dupuytren's splint, i.e. a straight 90 Manual of Surgery. wooden splint, notched at its lower end, and reaching from the head of the tibia to about four inches below the sole of the foot (Fig. 17). This is applied to the inner aspect of the limb, a thick pad, not extending below the inner malleolus, being inter- i / \ posed between the lov,^er part of the splint and the leg. The upper end of the splint having been bandaged to the limb, the thick pad is made to act as a fulcrum, across which the foot is drawn to the lower part of the splint ; to this it is fastened by a figure of 8 bandage carried round the ankle and foot and through the notches at its lower end. This bandage should not be carried round the ankle higher than the external malleolus, otherwise it would press the fragments of the fibula inwards, and thus defeat the object of this plan of treatment, which is to draw the foot inwards and throw the broken ends of the fibula outwards. If the knee is bent, and the limb is either swung or laid on its outer side, the muscles of the calf will be relaxed, and in this way the tendency for the heel to be drawn up will be counteracted. In the Manchester Infirmaiy a modification of Dupuytren's splint is sometimes employed, and I have myself frequently used it with very good results. It consists (Fig. 18) of an inside splint with a foot piece at right angles to it, for the sole. The foot is first bandaged to the splint, care being taken that the sole and heel are well in contact with the foot piece. The upper part of the splint is then drawn across the thick pad (which, being fixed above the internal malleolus, acts as a fulcrum), and bandaged to the leg below the knee. The advantage of this splint is that Fi^. 17.— Dupuy- tren's Spliut. PO Tt\s Fr ACrURE-. 91 ^'■^■■■^^■^^' the foot, by means of the foot piece, is maintained at a right angle with the leg, instead of becoming extended, as is frequently the case when the common Dupuy- tren's splint is employed ; hence the stiffness and weakness of the ankle joint, which often remain after the latter is removed, from stretching of the anterior ligament, and from the long-continued faulty position of the foot, are to a great extent prevented. Pott's method of treating this fracture consists in flexins: the knee to a right angle and laying the limb on its outer side ; for this purpose an outside splint with a lateral foot piece may be employed, the pad of the latter being thicker than that of the leg piece, so as to press the foot inwards ; to the inner side of the limb a straight splint is applied, reaching not lower than the ankle, the two splints being bandaged or strapped together. In cases of Pott's fracture, where the displacement of the foot has not been completely corrected, con- siderable improvement will often follow the perfor- mance of osteotomy, i.e. subcutaneous division of the fibula and forcible strais^htening of the foot, the case being then treated as one of recent fracture. When both tibia and fibula are broken, union, as a rule, takes place in from six to eight weeks, some form of apparatus being usually required for from eight to ten weeks ; in the case of fracture of a single bone, six or seven weeks will generally be sufficient. The Foot. Fractures of the bones of the foot are of rare oc- currence, except as the result of severe crushes ; under Fig. 18.— Splint for Pott's Fracture. 92 Manual of Surgery. tliese circumstances several are usually involved, and the fracture is often compound. Simple fracture of the os calcis is sometimes met with as the result of falls on to the heel ; if broken transversely behind the attachments of the strong interosseous ligament, the detached fragment may be drawn up by the contraction of the muscles of the naif. In many cases, however, no displacement occurs, the strong ligaments maintaining the fragments in apposition, the only symptoms then present being pain and swelling about the heel, with crepitus on grasping the posterior part of the os calcis, and moving it from side to side. When the fracture is commi- nuted, the mobility of the fragments and the ready detection of crepitus will at once point to the nature of the injury. In some cases, as the result of sudden and forcible contraction of the muscles of the calf, the epiphysis, or even the posterior part of the os calcis, may become separated and drawn away. Simple frac- ture of the astragalus, as the result of indirect violence, is rarely met with, as are also fractures of the other tarsal bones. Fractures of the metatarsal bones and phalanges are always the result of direct violence, and resemble in theii- general symptoms the fractures of the corresponding bones of the hand. Treatment. — When the posterior portion, or the epiphysis, of the os calcis is separated and drawn away by the muscles of the calf, an attempt should be made to relax the latter and bring the fragments into apposition, by placing the limb on an outside splint, with the knee flexed and the foot extended. In fracture of any of the other bones, the foot should be kept at rest, either on a back splint with a foot piece, or by means of some form of stift' bandage. 93 ir. DISEASES OF THE BONES. James Greio Smith, Inflammation. Bone being a complex structure, made up of elements of very ditterent character, shows, when inflamed, a corresponding variety in pathological result. Firstly, we have the periosteum, composed of an outer layer of fibrous tissue, and an inner layer of small active cells. Secondly, we have the bone proper, with its abundant and comparatively inert matrix, impregnated with earthy salts, and its scanty supply of vessels and sparsely distributed cell elements. Thirdly, we have the maiTOW, a highly organised, ex- ceedingly vascular tissue, with very numerous cells and little or no matrix. As one or other of thes<> tissues is involved we get tliree leading varieties of inflammation : periostitis, or inflammation of the periosteum ; osteitis, or inflammation of the bone proper ; and endosteitis, or inflammation of the bony marrow. As, however, in every variety of inflammation of bone the process owes its existence and con- tinuation mainly to the medullary tissue, whether it is massed together in the central canal, or carried along the vessels in the Haversian systems, or con- tinued outwards under the periosteum, it will be readily understood that the varieties run into each other. Thus, periostitis usually accompanies osteitis, osteitis soon follows endosteitis, and so on. In the earlier stages the forms of inflammation are sufl&ciently capable of distinction, clinical as well as pathological In their later stages the gross results may become so 94 Manual of Surgery. Pip. 19— Femur, showing effects of supinirative and of osteo-plastic periostitis. Theshaft.in its upper two- thirds, is covered with a rough deposit of new peri- osteal 1)one ; in the lower third, where suppuration had taken place, there is a piece of necrosed lione, overhanpinK which are several irregular pointed masses de\ eloped in the Btripjied periosteum which had formed the ahscess wall. (Museum, Bristol Royal Inflrmary.) involved as to constitute in their totality diseases requiring separate description ; siicli are caries and nca'osis. Periostitis. — By periostitis is meant an inflammation com- mencing in, and chiefly confined to the periosteum. It is met with in two leading forms : 1. Sim2^le local jjeriostitiSj acute or chronic. 2. Diffuse infective 2)7'eiostitis, always acute. Simple local periostitis. — By this is meant a simple inflam- mation of an area of periosteum, rarely dangerous to life, and tend- ing to recovery by resolution or after development of new bone or the formation of abscess. Causation. — The simple form of periostitis nearly always arises either from local injury or from extension of inflammation from the underlying bone or overlying soft parts. The injury may be from a sudden blow, such as a kick on the shin, or from prolonged irritation, such as the pulsations of an aneurism. Chronic osteitis is always accompanied by periostitis, and an ulcer on the skin that is not distant from periosteum, as on the shin or scalp, will cause some degree of periosteal inflammation. Pathology. — TJie appearances of periostitis are simply those Periostitis. 95 of inflammation of t-he two tissues which enter into its composition. Inflammation of the outer fibrous layer causes it to swell and become red or livid. It loses its purely fibrous character, and becomes pulpy and oedematous ; it strips more readily from the underlying bone, and appears to be more inti- mately connected with the superimposed muscle. The layers of cells next the bone undergo proliferation, and these, with the inflammatory exudates, help to loosen the periosteal fibre from the bone. An exces- sive amount of proliferation in the " cambium " layer may elevate the fibrous layer some distance from the bone, stretching, or even tearing the vessels that pass between them, and so causing partial necrosis of the outer lamellae. The process may eventuate in several ways, which have been described as varieties, but are perhaps better described as simple terminations. 1. Resolution. — The inflammation may simply pass off in its early stages, no effects being per- ceptible beyond, perhaps, a slight production of new bone. 2. Periosteal abscess. — As a result of simple local inflammation an abscess, acute or chronic, may form between the fibre and the bone. This means that the vascular supply to the underlying bone has been cut off, and death (necrosis) of the outer layer of bone so nourished follows. An acute abscess is usually simply traumatic, and contains ordinary liquid pus. A chronic abscess has usually some pre- disposing influence, such as scrofula, when its contents are of the well-known cheesy nature, or syphilis, when the matter is greenish-yellow and thick. 3. Osteo-plastic per-iostitis. — The development of new bone is one of the most characteristic results of periostitis, and nearly always follows its existence in the chronic or subacute form. It is simply 96 Manual of Surgery. an increase of the normal function following a morbid increase of liistological activity. Alow degree of inflammation is necessary to the production of new bone by periosteum. It is found esj^e- I'^^'if^ cially underlying ulcers, in the S^MlM neighbourhood of deep inflam- mations of the bone, around a foreign body, and under many other similar conditions. If found accompanying an acute inflammation, it is never in the centre of it, but in the more out- lying areas, that the new bone is produced. These periosteal bony new growths are known patho- logically as osteophytes, or more correctly as 'periosteophytes, and clinically as periosteal nodes (Figs. 19, 20, and 21). ISyiiiptoiiis. — Pain of a bursting or throbbing character is the most prominent symptom of acute simple periostitis. The pain is increased by pressure over the part, and especially by tapping, and is nearly always woret at night. There is some defined swelling in the over- lying soft parts ; the skin is either normal in colour or slightly dusky. If acute abscess forms, the pain is intensified, and may be Fig. 20.— Tibia and Fl!)ula,show- in? the effects of osteo-i'las- tic periostitis. Tlie inter- ot'seous luemljrane is aliiiofit completely ossified, and the Ehafts of hoth bones are covered with rough perios- teal new growth which is carried outwards on to tlie flhrous septa between the muscles. (Museum, Bristol Royal Inflriuar.v.) agonising ; the swelling in- creases, and the skin becomes red. In chronic abscess there Periostitis. 97 is less pain, but the swelling will be more marked with vague fluctuation or Vjogginess. The skin in the early stages may be of normal colour, but later on it be- comes mottled, dusky, or red, ultimately showing the ordinary signs of perforation by abscess. In osteo- plastic periostitis, which is nearly always subacute or chronic, the swelling is hard and unyielding, and the pain may be slight and remittent. Pain is least marked in strumous periostitis ; in syphilitic periostitis it is always most severe at night ; in rheumatic periostitis the pain is shifting and uncertain as to locality and duration. Predisposing causes, local as from injury or irrita- tion, or constitutional as from syphilis, struma, or rheumatism, will be looked for to help in the diagnosis. Treatiiioiit. — In simple acute periostitis the patient must be put to bed, the jjart elevated as much as possible, and cold apjjlied either by ice or evajDorating lotions. Hot fomentations or lead and opiate lotions may 1>e used instead. If the pain is very severe a full dose of opium, and a liberal appli- cation of leeches to the part, will probably give much re- lief Should the pain still continue, and the febrile dis- turbance remain unabated after twenty-four hours or so, the danger of suppuration must be avoided by a free incision through the periosteum down to the bone, either subcutaneously by a tenotomy knife, or through the soft tissues by a scalpel. When acute abscess has formed, immediate and H— 21 Fig. 21. — Section through the Shaft of a Femiu', enor- mously tliickened from osteo-plastic periostitis. (Museum, Bristol Eoyal lufiiTuarj'.) 9^ Manual of SuRGERy. free incision is necessary. In chronic abscess con- nected with syphilis, opening may be delayed until a fair trial has been given to specific treatment. In strumous ' periosteal abscess it will be well, after opening, to scrape the denuded surface with a suitable instrument, as the underlying bone will probably be found carious. In chronic non-suppurative periostitis, where there is, in all probability, some development of new bone, repeated blistering is likely to be most successful, though the application of the oleate of mercury has had good results. Iodide of potassium is supposed to be beneficial in promoting bony absorption. Subcutaneous section in various directions, or the use of the gouge, especially if there is much pain, may occasionally be recommended. Diffuse infective periostitis, acute ne- crosis, acute diffuse periostitis. — This is a grave constitutional disease, locally manifested by septic sup- purative inflammation of the periosteum, resulting in more or less extensive death of bone, and frequently attended with all the signs of acute septicaemia. Causation. — The affection nearly always occurs before puberty, and in boys more frequently than in girls. Various local causes have been assigned, such as injury and exposure to cold and damp ; but the ultimate cause is probably constitutional. It some- times appears after the continued fevers, and frequently in connection with the strumous diathesis ; but in a considerable number of instances it is met with in individuals who have shown no previous signs of disease. Pathology. — The pathology of this disease is .still obscure. Some surgeons maintain that acute necrosis is always a result of osteo-myelitis ; others that it is a pure periostitis. It is certainly an in- fiamniation of medullary tissue, and this may be Per 10 s ti tis. 9 9 localised under the periosteum as well as in the central canal. Practically such a distinction holds good ; for we meet with a superficial acute necrosis of part of the outer shell, such as would be caused by a periostitis, as well as with a necrosis of tlie whole shaft, such as would be caused by an osteo-myelitis. The distinguishing marks of this form of periostitis are the rapidity and certainty with which suppuration supervenes, and the uniformity with which micro- organisms are found in the pus. The purulent fluid forces its way between the periosteum and the bone, completely severing the connection between the two, tearing through the nutrient vessels, and leaving the surface of the bone to die. The condition may be de- scribed as a septic abscess confined under gi'eat pressure between periosteum and bone. The results of such a condition in death of bone and septic infection of the system are readily understood. Symptoms. — The symptoms are nearly always urgent. A sudden access of high fever, often ushered in with a rigor ; profound constitutional disturbance, local deep-seated pain, with swelling or signs of suppuration in the soft parts overlying a bone, point to acute diffuse periostitis. At the outset local signs may be slight or absent ; but, as the disease progresses, they become more urgent. Delirium is frequently present from an early stage. The site is usually in one of the long bones, and especially in the tibia, femur, or humerus. The signs of inflammation, obscure at the beginning, in a ^-ery short time become marked with redness, puthness, and oedema of the skin, quickly to be followed by evidence of suppuration. At this stage symptoms of septicaemia, often of the most aggravated form, may supervene ; and the patient may die in a few days, or linger for weeks with abscesses in the joints or in other parts of the body. Not unfrequently, however, loo Manual of Surgery. and especially if the disease has been recognised and properly treated from the beginning, a favourable result ensues. Treatment. — The only treatment likely to be of benefit is early and free incision of the periosteum, wherever pain or swelling may localise the afiection. As a tendency to septicaemia already exists, the strict observance of the practice of antiseptics will be advisable. If done early enough, such incision is usually followed by a marked improvement in all the symptoms. Early incision not only minimises the risks of blood poisoning, but saves the bone from extensive denudation aud consequent necrosis. Supporting or even strongly stimulating consti- tutional treatment will be called for in all cases. No special drug is likely to be of benefit. The question of amputation, though it may arise, is not so likely to be pressing as in the allied disease of acute osteo- myelitis. Osteitis. — By osteitis is meant an inflammation in the substance of true bone, varying in intensity and duration, and ending in resolution, or in thickening of its tissue, or in various forms of degeneration. Causation. — The simple forms of osteitis are usually caused by injury. Frequently a diathesis or cachexia, such as scrofida, syphilis, or rheumatism co-exists with special forms of osteitis, and is credited with being either the active or the predisposing cause. Exposure to climatic influences (cold, damp, malaria) has been known to produce the disease. Patholoyij. — The effects of inflammalit>n in Vjone are produced almost entirely through its medullary tissue. The bone cells proper take little, if any, pai't. Each Haversian syistem, with its artery, vein, nerve, lymphatics and delicate cellular tissue in the central canal, and its concentric lamellae, arranged like the leaves of a roll of music around this canal, Osteitis. loi may be regarded as an ossicle or long bone in mii)iatiu-e, rei)eating in itself in detail what occurs in bulk in the whole bone. The first steps are vascular engorgement, inflammatory exudation, and cellular hyperplasia in the soft tissues lying in the canal. This increased activity is associated with a rapid solution and removal of the bone substance. AY here the bone is not compact, but areolar, the same thing goes on, but with more rapidity and vigour on account of the greater proportionate amount of the soft tissue. Bony rarefaction and cellular hyperplasia, always the initial result, may go on indefinitely to reach the dignity of a special variety of osteitis ; rarefying osteitis or caries. Should the inflammation be very acute, the rapid cellular overgrowth causes strangu- lation of the confined vessels, and the bone which depends on them for vitality dies ; necrosis. In the more chronic forms of inflammation the bone which is absorbed is replaced by new bone, often in excessive amount, causing ingrowths or outgrowths, with general increase in density ; osteo-plastic osteitis, osteo- sclerosis. Occasionally, again, the inflammatory pro- cess results in a localised collection of pus in the midst of the bony tissue, which increases by absorptive distension of the outlying bone ; abscess of hone. Each of these processes, as being terminal varieties of more clinical importance than the simple initial inflammation, will receive separate consideration. Symptoms. — The most important sign of simple osteitis is pain of a deep-seated boring or gnawing character, which is liable to exacerbations and remis- sions. The pain is usually worst at night, and is always increased by unrest or exercise. An ele- vated position of the inflamed part relieves the pain ; this is well seen in inflammation of the bones of the leg or foot, wliere the pain, aggravated by walk- in or. is at once relieved by elevation. There may be 102 Manual of Surgery. slight clnsky redness of the overlying skin, but some- times thei'e is abnormal paleness from oedema. Swell- ing of the soft tissues is usually slight ; enlargement of the bone is late in appearing, and is chiefly an effect of extension of inflammation to the periosteum. It is always diflicult and often impossible to dia- gnose simple osteitis from simple periostitis. In osteitis the deep boring character of the pain, and its continuation in varying intensity over long periods of time, without much apparent effect on the soft tissues, are the leading guides. In periostitis the pain is more superficial, and steadily increases in severity without intermissions, while swelling rarely fails to manifest itself at a compai-atively early stage. Percussion or tapping with the finger may be of assistance in form- ing a diagnosis. Tapping over the area of an osteitis causes a deep thrill of pain to shoot through the whole bone, which may last for some time afterwards ; in periostitis tapping causes a temporary aggravation of tlie superficial pain only. Pressure considerably aggravates the pain in periostitis ; it may not affect, or may even relieve the pain in osteitis. Trcatiiieiit. — The part must be put at rest, and elevated as much as possible. In the early stages of simple acute osteitis, the local abstraction of blood by leeching or cupping will usually relieve the pain and benefit the disease. Lead and opiate lotions, applied hot, are soothing. If the pain is very severe and the fever is high, drilling the bone in several directions, through a small incision made with a tenotomy knife, Vill nearly always afford relief and often effect a cure. Such drilling gives rest to confined and compressed exudations, relieves engorgement of vessels, and pro- vides drainage. In chronic cases, rest, with repeated blistering, or the application of counter-irritants, is beneficial. The last resort in every case is removal of part of the surface of inflamed bone, by trephine or Osteitis. 10 gouge. No case ouglit to bo alloNvod to drift into caries or necrosis or abscess, witliout a trial having been given to trephining or gouging. The constitutional treatment is generally that of the fevered state. Benefit has been derived from tlie ■iH^Himntai q j li I t'^^rnu^^ ! Li 1 1 1 ij('jiti d[i F ^^v 'ii ' MT-' i- l! f;;^^^^ Fig. 22. — Caries of the Bones of tlie Cranium. There is rarefaction, with destiuction of bony tissue, but no development of inflam- matory new bone. (Museum, Bristol Royal Infirmary-.) administration of mercury to the extent of ptyalism If the pain be very severe, opium is indicated. Any diathesis, rheumatic, gouty, syphilitic, or strumous, which may be supposed to influence or predispose to the complaint, is treated by its proper remedies. Varieties aiiro)T' frofjuontly tlio gi-anulations invade neighbouring Caries. 107 m\ tissues^ sprouting through the skin or into a joint ; fungating caries, or caries fungosa. In the more active forms an area perishes, and this, set free by the action of tlie living granulations around it, is left as a piece of dead bone in the centre of the in- flamed district; necrotic caries caries necrotica (Fig. 24). Occasionally one or more abscesses form in the heart of the fungating granulations to become united in one pus-con- taining cavity to be presently described as abscess of bone. Generally speaking, the final changes in rarefying osteitis resolve themselves into one or other of three groups : (1) Simple resolution and return to health, as in some cases of hip joint disease. (2) Caseation, fatty de- generation, or even calcifica- tion of the inflammatory pro- ducts ; conditions which may remain quiescent for years, but are rarely permanently harmless. (3) Most common of ali is breaking up of the granula- tions, and the formation of an open sinus through which the purulent matter and liony detritus are discharged. The naked-eye appearances t^ V•^-V y/i m Fit,'. 24.— Femur affected in its upper and lower thirds with ad- vanced rarefying osteitis, in its middle third with central necro- sis. In the middle of the shaft a small piece of necrosed bone lies loose in a cavity surrounded ]>y sclerosed bone, which is tra- versed by a long channel leading to an opening in the shaft liieher up. (Museum, Bri.«tol Koyal Infirmary. J loS Manual of Surgery. of carious bone are cliaracteristic enoiigli. The whole tissue is softened, so that it may be cut with the knife or crushed betw^een the fingers. Semifluid, fatty, or purulent material exudes from the surface on section or pressure ; and small collections of pus or cheesy material are often found throughout the diseased substance. AVhen macerated the increased porousness and fragility of the true bony material becomes very evident ; a macerated carious bone may not weigh one-tenth of that which it ought to w^eigh when healthy (Fig. 22). Symptoms. — The earliest signs of caries are simply those of chronic osteitis ; it is impossible to distino^uish the one from the other till evidences of suppuration appear. When, with a history of osteitis, redness, swelling, and obscure fluctuation come on in the soft parts, we may suspect caries. The same history w^ith the disease localised near a joint, and followed by signs of inflammation in that joint, also indicates caries. Unequivocal signs appear after the abscess has burst or has been opened, wdien bare softened bone may be felt with a probe at the bottom of the abscess cavity. When the first collection of matter is discharged the abscess walls collapse, leaving a sinus leading down to the diseased bone, through which watery pus and bony detritus are discharged. Such discharge, if of long standing, is usually very foetid. The granulations lining the sinus and overlying the diseased bone are usually of an unhealthy flabby nature, and merge impercejitibly into the surrounding skin, which is usually swollen and of a dusky red colour, over- lapping the sinus with thin irregular margins. Occa,- sionally, and particularly in caries of the bones of the hands and feet, the compact outer shell is con- siderably expanded and thinned out by the fungating granulations inside, forming one of the conditions Caries. 109 which used to be called spina ventosa. Such a con- dition is essentially a large chronic abscess in bone. In caries of bones lying at some distance from the surface, as the spine, the hip, or the femur, the sinus may pursue a long and tortuous course through the soft tissues. In such cases, also, t\vo or more sinuses may be found leading to the same diseased area. Treatment. — In the treatment of caries attention to the constitutional element is of special impor- tance. If the cause is scrofula, cod-liver oil and the iodide of iron are the most valuable medicinal remedies. Of equal value, however, are a varied and nourishing dietary, plenty of fresh air, and, if possible, an existence chiefly out-of-doors. For syphilis similar hygienic measures with iodide of potassium are indicated. Locally there is but one treatment of value for carious bone ; removal of it. Blisters, setons, absorb- ents, and the like are all useless ; the only plan that promises success, if the disease resists constitutional treatment, is to remove the sluo^oiie. — Inflammation of the bony marrow occurs in two leading forms : (1) Simple osteo-myelitis, acute or chronic ; (2) Diffuse septic osteo-myelitis, always acute. Simple osteo-myelitis is not of much clinical importance. In its acute form it is always the result OSTEO-Mi 'ELITIS. 115 of injury, and more particularly of fracture. Some degree of osteo-myelitis is essential to the healing process in fracture ; in compound fractures the in- flammation may be suppurative, and may extend some distance up the bony canal. In its chronic form osteo-myelitis specially lays liold of the pink marrow at the ends of the long bones. The important part which the marrow plays in all forms of bony intlaramation has already been pointed out, and need not further be dwelt upon. All such inflammations in the marrow at the ends of the long bones are intimately connected with one form of so-called scrofulous joint disease. DiHiise septic osteo-myelitis ; acute diffuse osteo-myelitis ; acute necrosis. — These names have been given to an acute septic inflammation diflused through the marrow of long bones, and usually terminating in death of the shaft. It is closely related to and probably pathologically identical with the disease already described as acute suppurative periostitis, with the synonym also of acute necrosis. The clinical features difler according to the situation of the marrow aflected, periosteal or endosteal. A third variety of septic osteo-myelitis, described by German writers as idiopathic and in- fective, is probably identical with the disease now to be described, and will not be sepai'ately considered. Causation. — DiflTuse septic osteo-myelitis occur.s under two distinct conditions ; firstly as a result of traumatism, where the medullary caAdty is opened and visibly exposed to septic influences ; and secondly, when it is found almost uniformly before maturity, and more especially in childhood, where there is no open wound, and no ^*isible passage for the entrance of micro-organisms. The first variety is now most frequently met with in military surgery, as a result of gun-shot wounds. In former times it was a common it6 Manual of Surgery. result of compound fractures treated in civil hospitals. Arising in children without visible traumatic cause, nothing is known of its remote etiology, though its immediate origin is undoubtedly to be explained by the production of micro-organisms. In some cases it is a manifestation of general septicaemia, and its occasional occurrence in several instances in the same hospital ward suggest an infective origin. Pathology. — When exposed to septic infection the marrow in long bones is only too favourably placed for the ditFusion of violent inflammation. Confined within a rigid shell, and in free communication from end to end by its abundant blood and lymph vessels, the medullary tissue, when inflamed, suffers double disaster from the rapidity of the spread of the inflam- mation, and the impossibility of relief by swelling. Its soft sensitive tissues are strangulated by their own proliferation, and the bone, cut off from its most im- portant blood supply, suffers death. In the compact bone the incompressible veins may serve to carry in- fection to the system, and fatty embolism from a similar source is not unknown. The naked-eye appearances of a bone affected with acute osteo-myelitis are striking and characteristic. The compact tissue is pink generally, or in patches ; the cancellous bone is of a bright or dusky red colour, and the marrow is transformed into a semifluid, often stinking material, made up of pus and difliuent fat, and exhibiting red streaks and patches representing injected vessels and extravasated blood. In some cases, especially in the non-traumatic variety, a sub- periosteal abscess forms. This is usually found where the compact bone is thinnest, and its fora- mina most numerous ; that is to say, above the epiphyses, near the joint. In this situation suppura- tive inflammation of the epiphysial cartilage is pecu- liarly liable to take place, leading to disjunction of Os teo-Myeli tis. 117 the epi}jliysis from the shaft, and producing the con- dition known as "acute epiphysitis." The usual termination of those cases which do not rapidly prove fatal from general septic infection, is in necrosis of the Avhole bone, or, more frequently, of the shaft Ijetween the epiphyses (Fig. 25). The further history of the disease is then simply that of necrosis of bone. The minute anatomy is a com- pound of cellular proliferation, vas- cular blocking, diffluence of fatty tissue, and general infiltration with micro-organisms. The bony tissue proper, suddenly cut oif from its nutritive supply and rapidly dying, has had no opportunity of exhibit- ing the signs of inflammation, and is essentially unchanged. Sf/mptohis. — Almost from the l)eginning diffuse osteo-myelitis has all the symptoms of a gi-ave disease. Its onset, often marked by a rigor, is signalised by high fever, with profound constitutional disturbance, and frequently delirium. There is severe pain in the part, which ra- diates in various directions ; and considerable tenderness on pressure. Duskiness of the skin, with some Fi diffuse swelling, soon appears, to be ra])idly followed by the forma- tion of abscesses. The patient either dies within a few days ; or the symptoms merge into those of septi- caemia, which, in its turn, pro^ es fatal ; or the course tr. r..— NciTdsiii nf the whole shaft of theTil.ia between the epiphyses, as a result of acute osteo-myelitis. The dead hone lies loose in a par- tially fornifd shell of new peril-steal bone. (Museum, Bristol Royal luflrniary.) ii8 Manual of Surgery. of tlie disease is diveiied into that of an ordinary necrosis. Very rarely, on prompt and judicious treatment, the progress of the disease is cut short, and the patient escapes Avithout either septicaemia or necrosis. The distinE^uishincj characters of the disease are its rapid onset, and the high fever attended v\'ith grave depression, very rapid pulse, and perhaps delirium. Locally the ditiuseness of the pain, the duskiness and cedema of the soft tissues, and later on the occurrence of abscesses at central and outlying points, are charac- teristic features. Treatment. — Immediately on its being recognised, diffuse osteomyelitis ought to be treated by the making of one or more free openings into the medul- lary cavity. The openings are made after free incisions in the soft parts, with gouge or trephine, and must be large enough to permit access to tlie medulla, and to j^rovide free drainage. It is a question whether the Ijest treatment would not be to remove the whole of the suppurating medullary tissue by scraping, and wash out the cavity with anti- septic fluids. Free incisions are made through the l)eriosteum in several positions, to prevent its being completely strijjpcd should subperiosteal supjiuration come on, as it is likely to do. These measures represent all that can be done to check the ravages of the disease. The case is closely watched, and if symptoms of septicaemia supervene, amputation is the only resource. Done sufficiently early, before the strength of the patient is gone, amputation in this disease has had siifficiently encouraging results. The treatment proper to necrosis of the shaft when this takes place is described under Necrosis. From the beginning constitutional treatuient of a Kuppoj-ting or stimulating nature must be rigorously Acute Ep^piivsitis. 1 1 9 Piiforced. Ammonia, ether, bark and alcoliolic stimu- lants, with concentrated and easily digested nourish- ment, must be administered in large and fref|uently repeated doses. Acute epiphysitis. — This is a form of acute osteo-myelitis, occurring in chikh-en near the ends of the long bones, and resulting in disjunction of the epiphysis from the shaft. Though, patholotrically, it probably does not merit the position of a distinct disease, its clinical features are so distinctive and its importance so great that it generally receives separate consideration. Causation. — Sometimes a blow or other injury is made to account for the disease, but most fre- quently no such cause can be assigned. It is probably always septic in immediate origin. This septicism may arise from general causes, or locally, from lymphatic infection carried from a sore to the bony marrow. It is found almost exclusively in children or young infants, and usually in such as are in feeble general health. Pathology. — Its pathology is probably identical with ordinary septic osteo-myelitis. It is peculiar in this, that the inflammation is most active and most destructive where histological activity is greatest, namely, in the parts close to the epiphysial cartilage. Suppurative inflammation in the marrow of this region causes a rapid disintegration of the cartilage, with consequent disjunction of the epiphysis from the shaft. The end of the shaft is surrounded with pus and debris of medullary tissue, which may force its way into the contiguous joint, or through the skin, or in both directions. That the focus of the inflammation is in the active tissue, abutting on the epiphysial cartilage, there need be no dispute ; that it starts in the cartilage itself, or in the epiphysis, as is maintained by some surgeons, is exceedingly doubtful. I20 Manual Of Surgery. Symptoms. — As already stated, the disease is found in unhealthy children during the first few months of existence. It is situated most frequently in the femur at the hip joint, and with diminishing frequency at the knee joint, the shoulder, the elbow, and the ankle. Locally it presents the ordinary signs of an acute inflammation rapidly going on to suppura- tion, and at a very early stage affecting the joint. The child is evidently seriously ill with high fever, and great depression of the vital powers. When the disease has existed for a few days, grating on move- ment with perhaps undue mobility, marking dis- junction of the epiphysis, will probably be found. The disease rapidly progresses, and may be fatal within two or three days. In cases that are not rapidly fatal abscesses form and bui'st, and recovery may take place after a tedious illness. The bone may become united, though its future growth is stunted. As the joint is implicated at a very early stage of the disease, it is easy to mistake it for a pure joint aflTection ; in- deed, it is frequently described among diseases of joints. Treatment. — To support the child's strength and to provide free exit for the pus are the leading indi- cations for treatment. Early and free incisions, with sufficient drainage and antiseptic dressings, give the best chance of cure. Indeed, with such treatment, it is surprising to find how great the recuperative power sometimes is. The disjoined fragment unites firmly to the shaft, the inflammation in the joint subsides, and the articulation may be left with free movement. If, after such treatment, signs of improvement are not apparent, amputation above the disease is the only resource left. Necrosis. — By necrosis of bone is understood a death of the wliole or some part of the bone without marked alteration in its structure, and following one or other of the varieties of acute inflammation. N'ecrosis. 121 Causation. — The immediate cause of necrosis is stoppage of the circulation, either through the vessels being torn by injury, or from their becoming Ijlocked as a result of the inflamma- tory process. The remote causes are those of the form of inflammation which gave rise to it. An acute form of necrosis is liable to follow any of the specific fevers, especially scarlet fever ; scrofula and syphilis predis- pose to the more chronic forms. Among local causes, injuries, as blows, Avounds, or amputations, hold the first place. A peculiar form of necrosis in the lower jaw is found among workers in phosphorus. In old people a variety, analogous to senile gangrene of the soft tissues, and known as senile necrosis, is met with. Pathology. — Necrosis has already been mentioned as a ])ossible termination of the three leading varieties of inflammation in bone. Generally speaking the va- riety of necrosis is deter- mined by the nature of the inflammation. Thus perios- titis, as a rule, causes a superficial necrosis of the outer layers of compact Figr. 2fi.— Tibia "howinsr in its ui>pt'r third siipcrfl.ial necrosis ; in its middle third necrotic caries (not ■well shown in drawing) ; and in its lower third total necrosis sur- rounded by an almost complete involucre of new l)onc. (Museum, Bristol Royal Infirmary .") 122 Manual of Surgbiry. bone {j)eriplieral necrosis) ; osteitis most frequently results in death of a portion of the cancellous or compact tissue {central necrosis) ; while endosteitis, if acute, causes death of the whole shaft {total necrosis). In every case the immediate cause of necrosis is thrombosis in the blood-vessels, induced either by injury or inflammation. The piece of dead bone thus cut off from its vital connections is essentially a foreign body, and acts as an irritant upon the sur- roundinsf tissues, causing the formation of an abscess. The suppurative process thus set up, with the con- comitant separation and disintegration or extrusion of the bone, along with certain conservative processes in the outlying tissues, constitute the chief features of the disease. In detail the pathological process is as follows. The outlines of the dead bone are marked ofl:' by k^ limiting area of thrombosis in the living tissue. Behind, up to, and in this thrombotic area, the ordinary process of rarefying osteitis is set up. The inflammation is most active in the immediate proxi- mity of the dead bone, and here the rarefaction soon proceeds to complete absorption, thus setting the dead bone free from the living. The granulations which sprout from the rarefied bone now act upon the dead bone as well, causing its absorjjtion or, rather, disintegration. The gap, gradually increased between the living and the dead and now loosened bone, is occupied by granulation tissue, bony detritus, and pus. Concomitantly there goes on a conservative de- velopment of new bone. This takes place in the periosteum, in the granulation tissue which occupies the medullary canal, and in the rarefied compact bone which lies around. The periosteum in such a case will have been stripped from the bone and elevated by the burrowing pus, so that there is always a little Necrosis. 123 ypaco between the periosteal new bone and the dead portion. The new growth starts in the periosteum, coverinc: the livini; bone at some distance from the Fig 27. — Diagrammatic Eepresentation of tlie Process of Neci'osis. The drawing is supposed to show a slice cut lougitudinally through a long bone which has suffered total necrosis of part of the shaft. aa. Shaft of healthy hone ; hb, necrosed portion ; cc, areolar new bone developed under the pcrinistcuni and in the mediillai-y canal ; dd. pralnllation^^ pproutinff from the new areolar hone surrounding the necroj^ed Jlortl. 28.-.V ..,.,,,,.,1 withtotniNe- ^^^ ^u Ordinary case rroisis of ilie iuiil(ilc third of its Shaft. +Vi, leii- bh;. This femur is from tlie first case rlpv<^/l Vilnnrnp«« \\\r (Aa. of ami-utatinn at th.- hip joint jicr- tieieU DlOOClieSS Dy eie- formed in Knplaiid in 1814. (Museum, vnfinii rw liv ^^,cmirr>l-»'a Bristol uujaniiflrmary.) \auon or oy JiiSmarcn S Necrosis. 127 method, and a rubljer tourniquet applied. The most convenient sinus is selected, and the under- lying cloaca exposed by suitable incision through the soft parts. If the cloaca is large enough to admit of its passage, the sequestrum is seized by a special forceps called necrosis forceps, and removed. If the cloaca is not large enough, it is enlarged by gouge or trephine, and, at the same time, the extrac- tion of the sequestrum may be facilitated by dividing it in the middle by bone forceps and removing it in lialves. The granulations lining the cavity from which the sequestrum has been removed are scraped out, and the whole cavity swabbed or irrigated with a strong antiseptic fluid. If there is bleeding the cavity must be plugged with strips of boracic lint, or of lint sprinkled with iodoform, or some such similar dress- ing. If, as frequently happens in cases of total necrosis, the new bone is small in amount and liable to become fractured, a splint must be applied and worn for some weeks. In most cases rest and elevation of the part will be advisable, though it will rarely be necessary to confine the patient to bed. In cases of extensive necrosis where septic absorp- tion with high fever are rapidly sapping the patient's health, and where an immovable sequestrum with advanced suppuration in the soft parts render mere sequestrotomy an operation not likely to be successful, amputation may be called for. Accidental injury to vessels or other structures by an extended sequestrum may be a reason for amputation. Quiet necrosis, or necrosis without suppura- tion, is the name given to a form of necrosis in which the signs of inflammation are slight or absent, and the sequestrum either disappears or is encapsuled without the formation of an abscess which opens externally. 123 Manual of Surgery. The dead bone is passively tolerated or quietly re- moved without any external signs. This form of necrosis is very rare. Phosphorus necrosis of the jaws is a pecu- liar form of necrosis which attacks the jaws of workers in phosphorus. The immediate cause is supposed to be the action of phosphorous acid on bone that abuts on carious teeth. An osteitis is thus set up which spreads outwards under the periosteum, and, becom- ing suppurative, elevates that tissue from the bone, thus causing its death. In this, as in other forms of necrosis of the jaws, there is always an excessive development of new bone around the sequestrum, rendering the process of cure tedious and difficult. Care in seeing to the cleansing of the teeth, and the use of the red amorphous phosphorus instead of the yellow variety, have been found to diminish the susceptibility to the disease. Diseases of Nutrition. A small and comparatively unimportant class of diseases of bone, depending neither on actual inflam- mation nor on specific constitutional dyscrasia, are described as diseases of nutrition. They may be sub- divided into hyperiro'phic and atrojyhic varieties. Diseases of Nutrition attended with Hypertrophy. Simple hyi>ertrophy of bone. — Most cases of enlargement of bone originate in inflammation from injury. Examples of simple overgrowth are best seen in cases where the ordinary pressure to which a long bone is exposed has been removed. The general increase in length which frequently occurs when a young person is confined to bed for a time is an example of this sort. Another example may be seen in the increase of length which a radius, Osteitis Deformans. 129 dislocated at its upper extremity and unreduced, may undergo. In the rare cases of simple overgrowth of one or more fingers or toes, or even of a whole limb, the bone simply participates in the general hyper- trophy. It is doubtful if the enlargement which follows rickets is to be regarded as simple hyper- trophy. Osteitis deforiiiaus (Paget). — This is a rare and extraordinary affection of the bones, probably inflammatory, attended with increase of bulk and frequently with distortion of shape. It occurs speci- ally in persons after the prime of life, is accompanied with considerable pain, and usually attacks several bones simultaneously or in succession. No specific cachexia has been found associated with the disease, and, though it may last over a number of years, it may produce little or no impairment of health. Locally the bone is enlarged in all its dimensions, rarefied in its compact portions, and thickened and roughened under the periosteum. The clinical features are elon- gation of the limbs from the bony overgrowth, and distortion in the shape of the spine, pelvis, skull and thorax, as well as of the limbs, from the weakness caused by rarefaction. No treatment has been found of benefit. The disease, after continuing for years, may become spon- taneously arrested, leaving the bones increased in bulk and in density. In a few cases malignant growths have appeared in the hypertrophied bones. Leoutiasis ossea (Virchow). — This is a curious disease limited to the bones of the skull and face, and marked by an increase in their thickness, so great that the patient is usually killed by compression of the brain or blocking of the nose and pharynx. The condition seems to be an enormous overgrowth, with increased sponginess of the diplbe. It always com- mences in early life. Billroth speaks of a similar J— 21 130 Manual of Surgery. affection found in the flat bones generally, and likens it to elephantiasis of the skin. The cause is unknown, and all treatment has been ineffectual Diseases of Nutrition attended with Atrophy. Simple atropliy. — Any diminution of nutritive supply may be followed by simple atrophy of bone. In old age thinning of the compact bone and rarefac- tion of the cancellous portions takes place in the bones generally, rendering them liable in favourable locali- ties, such as the neck of the femur, to fracture from slight causes. Interference with the blood supply, as in cases of fracture where the medullary artery is torn through ; destructive inflammation of the epiphysial cartilage in young growing bones ; diminution of function, as in anchylosis of the elbow, and all such influences, are followed by bony wasting. Fatty atrophy. — In all cases of atrophy of bone yellow marrow more or less completely replaces red marrow. In health, where there is no cancellous tissue, as in the centre of a developed long bone, the marrow is almost pure fat. It is the same in disease ; as the cancellous bone disappears the marrow in its meshes becomes fatty. This condition is specially seen in the long bones around joints that have been long inflamed and out of use. In such cases the red marrow may have completely disappeared, its place being taken by a tissue that is little more than fat ; the compact bone is reduced to a mere shell, and the cancellous bone is a delicate and friable tissue that can be cut with the knife and crushed between the Angers. The condition is seen in its most typical form in the bones of the thigh and leg after long- standing strumous disease of the knee joint. Frag^ilitas ossiuiii. — Though this term is appli- cable to .several conditions associated with diminished strength of bone causing a tendency to fracture on Scrofula of Bone. 131 slight provocation, it lias also a special significance as applied to children. A child may occasionally be found who has sufiered fracture of almost every bone in the limbs and not a few of the body before it has reached the tenth year. Running on a stone pave- ment, playing leap-frog, striking a smart blow, have been known to cause fracture in such cases. Some of the bones may have been broken several times in suc- cession^ uniting in the ordinary way and with average rapidity. No cause has been discovered beyond an excessive tenuity, with perhaps increase of density in the bony tissues. The children are usually fragile, but not diseased. A brittleness of bones may be caused by various diseases, such as aneurism of bone, new growths, ne- crosis, osteo-malacia, and atrophy. Constitutional Diseases of Bone. Under this heading are described a number of affec- tions of bone which are associated with definite and palpable constitutional disease, and which may appear in any or every bone of the body. They are scrofula, with its ally tubercle, syphilis and osteo-malacia. Scrofiila and tubercle in bone. — The rela- tions of scrofula to tubercle cannot here be discussed. The want of definiteness which for years has attached to the meaning of these terms is seen, perhaps, at its worst in diseases of bones. At present the tendency is to consider them pathologically identical, giving them the same causation (the bacillus tuberculosis), and combining the wide clinical divergencies in the assumption that they are different stages in the same afiection. (^See Arts, on Scrofula and Disease of Joints.) From a purely clinical point of view we can distinguish at least three forms of disease of bone, scrofulous or tubercular, as we may prefer to name them which may be described under this head. These 132 Manual of Surgery. are the miliary tubercle ; the mass of degenerate cheesy material often described as caseating tubercle ; and that form of low rarefying osteitis usually described as scrofulous caries. The miliary tubercle or nodule occurs in the marrow lying in cancellous bone, either as a part of general miliary tuberculosis or as started by local infection from a mass of caseating inflammatory ma- terial. As met with here, its structure and beha\T.our are the same as elsewhere. As a part of general miliary tuberculosis it is a fatal disease ; as origi- nating in infection from caseous products it may be either the forerunner of general tuberculosis or the indication of advancing and grave local disease in the bone. The mass of degenerate imflammatory material, known as caseating tubercle, is also chiefly met with in the cancellous ends of the long bones. In structure and behaviour, as well, in all probability, as in pathological origin, such masses are closely allied to those met with in scrofulous lymphatic glands. They may exist for prolonged periods, producing but few symptoms, and any change that they undergo is likely to be further retrogressive. The importance of such collections is enhanced from their proximity to joints, and their tendency to implicate these in their de- generate changes. Such masses contain in their substance little or no bony tissue. The osteitis which l)recedcd it will have greatly thinned, or completely destroyed the cancellated trabeculse. The best known and by far the most important form of scrofulous bone disease is the variety of caries to which it gives its name. Indeed, most examples of caries own scrofula as a predisposing cause. None of the bones are free from it, though it has decided jnedilections for certain sites. It is found most frequently in the bones of the hands and feet, in the Scrofula of Bone. 133 bodies of the vertebrae, and in the cancellous ends of the long bones. As caries of the carpus and the tarsus among the young of the poorer classes, it is, perhaps, the most common of all diseases of bone, running a very slow course, attacking one bone after the other, rarely capable of cure, and ultimately demanding amputation. As " strumous dactylitis " in children, it attacks the long bones of the hands and feet, expanding the compact shell, and transforming the medullary contents into fungating granulation material. Attacking the bodies of the vertebrae, it is ■well known as Pott's disease, or angular curvature of the spine. In the ends of the long bones it has a special importance, as being a frequent cause of one of the most intractable forms of chronic joint disease. In these instances the affection lies in the medullary cavity. Sometimes, however, it appears under the periosteum as a " strumous node," producing an abscess and superficial caries. Symptoms. — The symptoms of simple miliary tubercle in bone are those of general miliary tuber- culosis. A number of miliary nodules around a caseating focus produce no symptoms beyond its cause. A mass of tubercular caseated material usually produces slight or no symptoms till it breaks up and suppurates, when the symptoms are simply those of scrofulous caries. In scrofulous caries the onset is uncertain and the progress slow. Otherwise, the symptoms are simply those of ordinary caries, already described, plus the signs of the scrofalous diathesis. In strumous dactylitis the disease is somewhat peculiar in causing expansions of the bony shell, forming a chronic abscess within the bone, which, even after an exit for its contents has been provided, may continue to discharge indefinitely. Elsewhere perforation of the compact bone usually takes place before expansion is perceptible. 134 Manual of Surgery. Treatment. — Constitutionally the scrofulous ele- ment is treated by tlie ordinary remedies. Locally, before suppuration has commenced, counter-irritation by blisters or the actual cautery, the application of Scott's dressing, or the oleate of mercury, with elastic compression by rubber bandage, have been of benefit. Most frequently, however, suppuration takes place, and our efforts are then directed to the removal of the funsatinor granulations with the carious bone after the manner above described. In disease of the tarsus or carpus, excision or amputation is usually necessary. In strumous dactylitis amputation is usually performed ; but if a good portion of the expanded bony shell is removed, with the attached skin, and the cavity dressed from the bottom by some stimulating antiseptic material, cure may be got without amputation. In every case, before perforation has taken place, Listerism in all its details will be attended with the best results. Syphilitic diseases of bone. — Syphilitic diseases of bone may be considered under two heads, as they originate (1) from acquired syphilis, or (2) from congenital sypliilis. {See Art. on Syphilis.) Osseous lesions in acquired syphilis. — These occur as periosteal inflammations, frequently resultinor in caries and necrosis, and as chronic osteitis producing general thickening. They are recognised as tertiary manifestations. Pathology. — Syphilitic bony disease is most frequently met with as localised collections of small- celled inflammatory material between the periosteum and compact bone. Such collections may be regarded as gummatous tumours. They elevate the periosteum, forming hard, rounded elevations, and are known as 2)eriosteal nodes. Under appropriate treatment these nodes may disappear, but frequently they go on increasing in size ; the lowly organised inflammatory Syphilis of Boxe. 135 material breaks down and suppurates, forming a gummatous ulcer with sluggish granulations, which extend some way into the bone, rarefying and dis- integrating it. This is syphilitic caries. In bones which depend mainly upon the periosteum for their blood supply, as the fiat bones of the skull or face, such elevation of the periosteum by gummatous material may kill the bone by deprivation of nourish- ment, and the result is syphilitic necrosis. The least common form of syphilitic bony disease is where there is a general low form of diffuse inflammation, resulting in a hypertrophic thickening of the mass. This is known as syphilitic osteitis or sclerosis. Symptoms. — In addition to the ordinary history of syphilitic infection, certain local peculiarities suggest the specific origin of these complaints. The periostitic node is found most frequently on the tibia, the ulna, and the clavicle, and appears under the skin as a hard, rounded, and tender swelling. Pain is almost uniformly worst at night. If the swelling increases much in size and is about to suppurate, it extends chiefly at the margins, leaving a soft, often depressed, area in the centre covered with purple congested skin. When the skin breaks, the unhealthy granulations lie in a bed of carious bone, which is diagnosed in the ordinary Avay. On the skull, and especially on the forehead, syphilitic bony disease manifests itself usually as small areas of necrosis, leaving, w^hen the dead bone is removed, similar punched-out ulcers, which extend through the outer table, and frequently the inner table as well. In the neighbourhood of such ulcers that have been of any duration, there is usually some considerable amount of bony thickening. The middle line of the hard palate is frequently aflected, causing the fonnation of an opening between the nasal and oral ca\'ities. The nasal bones and parts of the jaws are also often 136 Manual of Sukgeky, involved. Nodes may grow inwards on the brain, producing cerebral symptoms. In syphilitic sclerosis, which by preference affects the long bones, shifting pains, with diffuse thickening, are the only local signs. In suppurative syphilitic bone disease the dis- charges are usually foetid and the wounds foul and unhealthy. In necrosis of the bones of the face the foetor is met with at its worst. Treatment. — The treatment proper to the consti- tutional disease is to be fully and systematically carried out. Till the constitutional treatment has had a fair trial, no operative treatment is to be instituted. Not only nodes, but even collections of semipurulent material may melt away under the administration of iodide of potassium or mer- cury, or both combined or alternated. If an abscess must be evacuated, it must be done through as small an opening as possible, as there is a tendency for large sluggish sores to follow injury to the skin. Local measures for the removal of carious or necrosed bone need not be carried out with so much energy in syphilitic as in strumous disease. For the dressing of the open sores nothing is better than iodoform. Surgical cleanliness in its most perfect form must be minutely observed. Osseous lesions in congenital s>i>liilis. — Tliese are met with chiefly in two forms : (1) as atrophic changes in the bones generally, and in special situations; (2) as hypertrophic growths (nodes or osteophytes) in various situations, but more especially in the skull. Atrophic changes in congenital syphilis are found most frequently in the bones of the skull, in the long bones, and in the teeth. In the skull the disease shows itself in very young children as a wasting of the bones at the sites of decubitus, that is to say, behind the eminence of the Syphilis of Bone. 137 parietal bone, in the occipital bone, and in tlie squamous portion of the temporal. The bone is either much thinned, so as to become like parchment, or is transformed into a gelatinous material, in which no bony tissue can be felt. This condition is known as cranio-tabes. {See Art. on Syphilis.) In the long bones the clianges appear usually in the neighbourhood of the epiphysial cartilage, and consist mainly in an excessive deposit of lime salts in the cartilaginous matrix, along with an overgrowth of the young medullary tissue, which absorbs and replaces the bone. The bone is thus made at once brittle and soft, liable to bend in bulk or to break in portions. It sometimes results in suppuration. When the disease is at its height the infant will not move the limb : it seems to hang paralysed and inert, and this appearance, with the wasting of muscle that always supervenes, has given to the condition the name of syi)hilitic pseudo-paralysis. In the teeth the condition is that first described by and named after Mr. Jonathan Hutchinson. It is a pegging and notching of the permanent upper central incisors. The teeth are too small for the spaces they have to fill ; they tend to become pointed, then cutting edges are hollowed out and crescentic, or notched and tuberculated. The lateral incisors are sometimes pegged also, and the canines are often too pointed. The cause is probably an old stomatitis interfering with the development of the tooth bulbs. {See Art. on Syphilis.) Hypertrophic chang^es in coiigfciiital sy- philis are met with as localised subperiosteal develop- ments of porous bone in the bones of the skull and in some of the long bones. In the skull they are known as Farrot^s nodes or osteo- phytes. They appear as broad flattened bosses, usually four in number, upon the four bones that surround the 138 Manual of Surgery. anterior fontanelle, but are found also skirting the sagit- tal and coronal sutures. Tliey are composed of spongy vascular bone with wide spaces. Such growths may attain to considerable thickness, as much as half an inch ; and they may extend laterally so as to cause prematui^e closure of the sutures. They very rarely break down and suppurate. They nearly always appear between the sixth and the twelfth months. Ill the long hones such nodes are usually found on the tibia or the humerus, appearing at about the same ajje and followino- the same course. Their site is near tlie epiphyses, and most frequently in the neighbour- hood of the knee and elbow joints. The treatment of the osseous lesions of congenital syphilis is simply that of the constitutional disease. Local measures are not called for. Mollities ossiiim ; osteo-malaeia ; iiiala- costcon, - This is a constitutional disease charac- terised by a general softening of the osseous tissue, rendering it liable to be bent or broken. Causation. — Almost nothing is known of the origin of this rare and extraordinary disease. In some few cases it is inherited. It is twelve times more frequent in females than in males, and among females more than two-thirds of the cases appear during the child-bearing period. Most usually it occurs during and after adult life ; but it has been met with at, and even before, puberty. Theories as to its being caused by a dissolving action of carbonic acid or lactic acid want confirmation. Pathology. — The essential features of the disease are, replacement of the medullary tissue by a dark-red grumous semifluid material, and rarefaction and absorption of bone. The disease advances centrifu- gally, beginning usually in the yellow marrow, and extending upwards and downwards into the red marrow in the cancellous bone, and outwards into the MOLLITIES OSSIUM. I 39 compact tissue. Rarely, however, does it attack the subperiosteal outer lamellae ; in the most advanced cases, where the greater part of the bone may have com- pletely disappeared, there nearly always remains a thin shell of comparatively healthy material which maintains the shape of the original bone. Into the substance of this pulpy, vascular material haemorrhages frequently take place, and small cystic cavities with fluid contents and well-defined walls are often formed. The salts are dissolved out as if by an acid, leaving a layer or zone of animal substance, which in its turn is broken up and diftusod in the new growth. Symptoms. — In the early stages the symptoms will be little more than obscure, shifting pains in the bone often described as rheumatic. No other sign of disease beyond, perhaps, general malaise and ema- ciation, may appear, till a spontaneous fracture or bending of bone takes place. An examination of the urine, revealing the presence of an excess of phos- phates with lactic acid, will now suggest a diagnosis, which will probably soon be confirmed by the occur- rence of other fractures and distortions. On the slightest provocations any of the long bones may bend or break, and the chest, pelvis, and spine may be dis- torted by the normal pressure they have to bear. In the pelvis the deformity, consisting of a diminution of the oblique diameters from pressure inwards by the heads of the femora, is a frequent cause of dithcult parturition, occa.sionally necessitating operative inter- ference. The softened ribs may permit the chest to collapse, and the patient may die from physical inability to breathe. In the worst cases the most extraordinary appearances may be produced from the exaggerated distortions. A few cases recover ; some live to a good old age while the disease continues ; most, however, are fatal. Treatment. — No treatment specially aimed at 140 Manual of Surgekv. the pathological condition has been found of the slightest avail. Treating symptoms we may give tonics and plenty of nourishment to maintain the strength, with opium to relieve pain ; while to prevent fractures and avoid distortion we may enjoin rest in the recumbent position. Tumours of Bone. Primary malignant growths ; sarcoma.— Recent investigations seem to show that all primary malignant tumours of bone belong to one or other of the varieties of sarcoma, Scirrhus, encephaloid, and epithelioma invade bone almost never except as secondary growths. Sarcomatous tumours in bone are of the ordinary varieties, i.e. round-celled, spindle-celled, mixed, and myeloid. Bone is frequently developed in their substance (osteoid sarcoma), but ossification is not confined to any one variety of growth. The best clinical classification is into central and peripheral sarcomata, that is growths arising in the medulla in the centre of the bone, and growths arising under the periosteum. Central sarcoma of bone arises usually in the cancellous tissue at the end of the shaft. As it grows it pushes the compact bone in front, expanding and thinning it. It extends along the medullary cavity in both directions, but rarely passes the articular cartilage to enter the joint. The thinned outer shell may be perforated at various points, and the overlying soft tissues are then invaded. In this state spontaneous fracture is liable to take place. All forms of sarcoma are met with in the centre of bones. Central sarcomata ossify less frequently than peri- pheral. They may attain to enormous dimensions, and are peculiarly liable to recur in internal organs Sarcoma of Bone. 141 after remo\ al. Like sareoaiata elsewhere, thej rarely invade the lymphatics (Fig. 29). Periplieral or subperiosteal sarcoma of boue arises, as its name implies, between the perios- teum and the bone. It burrows between these tissues, invad- ing the bone from the outside. Here also all varieties of sarcoma, are met with. Ossification is more common in peripheral than in central sarcoma. In the substance of periosteal sarcoma there is frequently developed a variety of osteophyte, com- posed of spicules, or closely-set lamellse, or hollow tubes, which are probably developed around the periosteal ves- sels, as they are draacijed out of the underlying bone by the growing tu- rn ours. Occa- sionally a thrill or bruit may be detected in the growth. Symptoms and diagnosis. — The early symptoms of central sarcoma are very similar to those of deep osteitis, namely, deep-seated pain of a gnawing or bursting character, with some tenderness. When Fig. 29. — Myeloid Sarcoma of Femur. «, Cy~t ; b, femur ; c. patella : d, tibia : r, fat ; /. cartilage. (From Pepper's "Surgical Pathology.") 142 Manual of Surgery. swelling comes on, the rapidity of its increase with absence of redness of the skin, or other signs of inflam- mation, point to sarcoma. When the growth has attained to considerable dimensions, and the outer shell of bone is much thinned, manipulation may produce a peculiar sensation of crackling. The skin stretched over the swelling is white and glossy, with blue veins cours- ing under it. Where the growth has escaped from its bony shell, the soft, boggy, semifluctuating nature of the tumour may be detected. Occasionally there is a bruit or even visible pulsation. In periosteal sarcoma there is less pain. The growth feels soft and boggy from the beginning, and in the early stages may even be mistaken for abscess. By deep pressure an overlapping margin of tumour substance may be felt, and this, with its firm connec- tion with the underlying bone, will help to distinguish it. In both central and peripheral sarcoma, a history of injury is curiously frequent, so frequent, indeed, that traumatism must be considered as predisposing, if not causal. It is possible to mistake sarcoma in the neighbour- hood of a joint for strumous disease. In those cases where cartilage is found in a sarcomatous growth, it is sometimes impossible to diagnose it from enchon- droma. Generally speaking, enchondroma is harder, and more tubercular on the surface, while it in- creases in size less rapidly. Clinically, it is usually impossible to distinguish the histological varieties of sarcoma. I'reatment. — The only treatment for sarcoma in l)one is to remove it. Such removal must nearly always involve amputation of the limb. In periosteal sarcoma it may be possible to remove the growth, and as much of the bone as may be imjjlicated, but very rarely is it wise to be content with this. In endosteal Sarcoma of Bone, 143 growths amputation must always be performed. If the growth is small and circumscribed, it may be possible, by amputating through the bone above the gro^vth, to remove the whole of the disease. But in most cases it will be wise to amputate through the joint above the disease. The disease extends along the medulla with such rapidity that only in the early stages is it likely to be unaffected, and thus the greatest security against recurrence is got by disarticu- lating the bone. When the intermuscular fasci?e are affected, amputation through the joint is still more necessary. Myeloid sarcoma is supposed to give the best results after amputation through the bone ; spindle- celled sarcoma ought always to be treated by disar- ticulation. In either case secondary recurrence, especially in the internal organs, and particularly in the lungs, takes place in many instances after operation. Secondary lualigiiaut g^'owtlis in bone* — All secondary malignant diseases in bone are endos- teal, unless they are direct extensions from contiguous growths, when they may be periosteal. Sarcoma in any situation may produce secondary disease in bone by infection from a distance. Carci- noma in bone is practically always secondary, most frequently it is metastatic, though in certain situations, as in the ribs from cancer of the breast, it is not uncommon as a direct extension of the disease. Ence- l)haloid, as secondary to disease of the liver, is not uncommonly found in bone. Epithelioma of bone is rare ; it always originates by direct invasion from the soft tissues. Osteo - aneurism ; pulsating: g^rowths of bone. — Midway between the benign and tlie malig- nant tumours of bone is the class clinically known as pulsating. Of such there are at least three distinct varieties. 144 Manual of Surgery. 1. The most common pulsating growths are soft sarcomata, in which, from the great number cf largo vessels, or from dilatations in their walls, a general distension of the mass takes place at each beat of the heart. Vascular thrills, or even perceptible pulsations, are not infrequently met with in ordinary myeloid or spindle-celled sarcomata ; the variety under considera- tion is merely one in which pulsation is an abnormally prominent feature. 2. As a second variety are classed certain vascular erectile tumours, composed of numerous interlacing small vessels, similar to ordinary ntevus of the soft tissues. Such are usually found on the skull, form- ing soft reddish elevations, which pulsate under the skin. 3. True aneurism of bone, though in many cases it has been confused ^vitll pulsating sarcoma, is now generally admitted to exist. It is simply a cavity in the interior of bone, containing blood, partly fluid and partly clotted, which visibly pulsates. It is in fact an ordinary aneurism, which happens to be located in the interior of a bone. Symptoms and diagnosis. — A growth in the sub- stance of a bone, which distends it, which pulsates, and which perhaps emits a bruit, may be sarcoma, or time aneurism. If the pulsation is distinctly expansile, and the vascular thrill very palpable, and the bruit is loud and well marked, we may suspect tiiie osteo- aneurism, though we can seldom be cei'tain. Compres- sion of the main artery checks the pulsation ; if it is a vascular erectile tumour it visibly diminishes in size ; if a pulsating sarcoma, it simply becomes less tense ; if a true osteo-aneurism, there is no diminution in bulk, but relief of tension will render palpable certain openings in the expanded bony shell. The last is exceedingly rare, and unless the signs are very definite indeed, we must conclude that the disease is Osteoma. 145 a pulsating sarcoma. An accurate diagnosis is usually impossible. Treatment. — Deligation of the main artery of the limb having in most cases been performed for pulsating sarcoma cannot claim many successes. A few cases of cure by ligation for simple osteo- aneurism have been recorded. In vascular erectile tumours of the scalp, or scapula, or other flat bones, ligation of the arteries entering them may produce cure. In pulsating sarcoma, amputation, on the lines laid down for ordinary sarcoma, is the only resource. JVoM-naalig^iiaiit gi'OAVths. — These are either localised over-growths of the tissues that normally enter into the formation of osseous tissue (cartilage, fibrous tissue, or true bone) ; or they are cystic de- velopments, simple or parasitic. Osteoma; exostosis. — With very few excep- tions, all bony tumours grow outwards ; the few that grow inwards are probably inflammatory. Practically, therefore, all osteomata are exostoses ; enostoses may be ignored. They are of three sorts : The ivory osteoma, or exostosis, is usually found on the surface of the skull, frequently on its cerebral aspect, as a smooth, hard, rounded growth, composed of exceedingly dense bone of a consistence resembling that of ivory. Most probably it is a true periosteal growth. The bone is arranged in parallel laminae ; the bone corpuscles are small and have long, slender processes ; and the blood-vessels are small and sparsely distributed. As it gets older the bone increases in density, sometimes to such an extent that its vascular supply is cut off, causing a quiet necrosis and separation, as in the stain's horn. The spongy osteoma, or exostosis, is found arising either from the neighbourhood of the epiphysis of a long bone, or from the flbro-cartilaginous insertion of some large mass of muscle. It is developed in K-21 146 Manual of Surgery. Pig. 30.— Transverse Section of a Simple Cancellous Exostosis, originating in tlie Linea Aspera of the Femur. There is no change in the structure of the Femur. (Museum, Bristol Koyal Infirmary.) cartilage, and is areolar or spongy, and not laminated, except on the surface. Usually it appears before puberty, and it may go on growing for an indefinite period. Its structure is that of ordinary cancellous bone. A layer of cartilage usually overlies the spongy osteoma, and in it may be found the microscopic appear- ances of ordinary intracartil a g i n o u s development of bone (Fig. 30). Hereditary mul- tiple osteoinata occur in children, and may affect most of the bones of the body. As the name implies, the disease is usually inherited. The tumours appear as hard, nodulated growths, situated mostly near the ends of the long bones, though they are found on other situations. They may be very numerous, and may go on increasing in number and in size for years, causing no harm, except through interference with movement of the joints. They are covered with cartilage, and are of the nature of spongy exostoses. The disease is veiy rare. Symptoms and diagnosis. — Unless it inter- feres with neighbouring tissues or organs, the signs of osteoma are purely physical. A hard, rounded, or iiTegular tumour firmly attached to bone, painless, and non-inflammatory, and with a history of very slow growth, are its leading characteristics. The situation of the ivory osteoma on the skull, its smooth rounded sui-face and small size, are diagnostic. The most common situation of the s])ongy osteoma is on the linea aspera of the femur (Fig. 30); it is found Enchondrohia. 147 also on the supracondyloid ridges of the humerus, and on the inner side may be confounded with a supracondyloid process. It is found also under the nail of the great toe (ungual exostosis), elevating the nail and causing much pain and inconvenience by pressure from boots. Exostosis is most readily confounded with enchondroma of bone, and particularly with ossifying enchondroma. The latter grows more rapidly, and is more irregular on the surface than the former. Treatment. — Unless it disturbs the function of neighbouring organs or produces some conspicuous deformity, an osteoma need not be interfered with. Situated close to important structures, as in the orbit, or on the inside of the skull, or near a joint, its re- moval is attended with some difficulty and risk. The growth is taken away by means of saw, chisel, gouge, or bone forceps. It has been found that unless re- moval is complete and thorough, recurrence sometimes takes place. Eiichondronia.— This is the most common of innocent tumours of bone. It is met with most frequently near the extremities of the long bones, and no doubt originates in many cases from the epiphysial cartilage. It is found either as a diffuse growth infiltrating the whole bony structure, or as a circumscribed outgrowth from the compact shell. The former is most common in the larger bones, the latter, often multiple, in the long bones of the hands and feet. Centres of ossification, or, more accurately, of calcification, are met with most frequently in the circumscribed enchondroma, and sometimes tliese are so thickly set as to constitute calcification of the whole mass. All the ordinary pathological changes found in enchontlroma generally are met with in enchondroma of bone. The tumours are usually slow in growth, but sometimes they increase with 148 Manual of Surgery. great rapidity, and may attain to enormous dimen- sions. jSymptoyns and cliaynosis. — A painless or but sliglitly painful hard or semielastic tumour of slow growth, attaclied to bone, nodulated on the surface, not invading the skin, and presenting none of the characters of malignancy, is probably an enchon- droma. A thin shell of periosteal bone sometimes surrounds it, when characteristic crackling on manipu- lation may be detected. If small and calcified it may be indistinguishable from a pure osteoma, though the irregular bosses on its surface are usually distinctive. Treatment. — In the circumscribed variety, com- plete removal of the growth, with gouging of the bony surface from which it springs, will probably effect a cure. If the growth is central, extending up the medullary canal, the limb must be amputated above the disease. Generally speaking, removal of the growth will cure in enchondroma of the bones of the hands and feet ; in enchondroma of the long bones amputation of the limb will be called for. Fibrous and fibro-cystic g^rowtlis. — As originating from the gums (epulis) or from the perios- teum covering the bones in the nasal cavities (fibrous polypus), fibrous tumours of bone, or rather of periosteum, are not uncommon. Elsewhere they are almost unknown. Instances of fibro-cystic growths, mostly in the femur, have been recorded, but they are so rare as to be clinical curiosities. Cysts ill boiie. — With the exception of denti- gerous cysts, simple cysts in bone are extremely rare. Most of those described as sanguineous cysts were probably sarcomata. Hydatid cysts may be found in bone as in every other tissue, but their occuiTenoe, particularly in England, is very uncommon. 149 III. INJURIES OF JOINTS. T. Pickering Pick. Contusions. — Joints are often contused by direct violence, siicli as falls, blows, or kicks. The injury ought always, but especiall}" in the young and delicate, to be regarded as of a serious nature ; for with very slight external evidence of injury a very considerable amount of mischief may be set up, or consecutive inflammation of the structures entering into the formation of the joint may follow and involve the integrity of the articulation. Thus, in delicate children, a contusion of the hip, from a fall on the trochanter, may be the starting point of hip joint disease, which may run its course to complete destruc- tion of the articulation. In some cases there is little to mark the injury beyond the history of the accident and pain, increased on moving the joint ; in other cases, rapid swelling of the articulation follows, indicating the effusion of blood, mixed w^th synovia^ into the cavity of the joint. In these latter the blood and fluid, under the in- fluence of appropriate treatment, is slowly absorbed, generally without leading to any permanent incon- venience. Treatment. — The essence of the treatment consists in perfect rest and the maintenance of complete im- mobility of the joint by the application of a splint ; and there is good rea-son to believe that in the majority of cases, if this treatment were thoroughly carried out, no untoward results would ensue. The limb should be raised, and cold, by means of evaporat- ing lotions, Leiter's tubes, or an ice bag assiduously 150 Manual of Surgery. applied. If the joiut is so much distended with fluid as to cause tension and severe pain, it may be relieved by means of the aspirator. Spi'niiis. — By the term "sprain" we mean a violent twisting or wrenching of a joint, whereby its liofamentous and tendinous structures are stretched or torn, but *in which there is no separation or displace- ment of the bony surfaces from each other. The amount of lesion which takes- place varies very much in different cases, from a slight tearing of a few ligamentous fibres to a complete laceration or detachment of one or more of the ligaments of the joint, with perhaps displacement of tendons from their sheaths, laceration of muscles or tendons, and con- siderable extravasation of blood. In some cases small scales of bone, to which the ligaments are attached, may be torn away, constituting the " sprain fractures " described by the late Mr. Callender. The lesions, therefore, of a severe sprain closely resemble, and differ only in degree from, those of fracture, with which they are very liable to be mistaken. Symptoms. — The immediate effect of a sprain is very severe pain, often of a sickening character. This is rapidly followed by a swelling, partly due to extravasation of blood into the surrounding tissues, and partly to effusion taking place into the cavity of the joint, as the result of inflammation which has been set up by the injury. After a short time, dis- coloration, extending for some distance above and below the joint, makes its appearance. There is, of course, inability to bear any weight on the limb, and any attempt to move the joint surfaces on each other is attended by increased pain. The degree and extent of these symptoms depend upon the amount of injury which has been sustained. The remote effects of this lesion are often per- manent pain and weakness ; or stiffness and even Sprains of Joints. 1 5 1 anchylosis. The former of these conditions may arise from imperfect repair of the torn structures, or from non-absorption of the effused fluid ; the latter from chronic inflammation causing adhesions within the joint, or in the sheaths of the neighbouring tendons. In some constitutional conditions, as the rheumatic or scrofu- lous, the subsequent inflammation may assume the characteristic type of these conditions, and may be very persistent. Treatment. — The treatment of sprains requires as much care and attention as the treatment of many graver injuries, and perhaps even a greater amount of judgment on the part of the surgeon ; for whereas rest is absolutely necessary for the repair of the lacerated tissues, too protracted rest is often mis- chievous, stiffening the joint and delaying recovery, so that it often requires great discrimination on the part of the surgeon to know how long to continue to keep the joint at rest and when to commence passive motion. Immediately after the receipt of the injury the limb should be laid on a pillow in the position most comfortable to the patient, or, what is perhaps better, loosely connected to a splint, taking care to leave the injured part exposed. This plan secures perfect immobility of the joint, and at the same time prevents stretching of the damaged tissues by supporting the limb. Cold assiduously applied, with a view to subdue inflammation and prevent further eflusion, will generally be found most agree- able to the patient. This may best be done by ii'rigation with spirits and water, which is to be preferred to the application of a bag of pounded ice, or Leiter's tubes, the weio^ht of which is fjenerallv a source of annoyance and discomfort. Sometimes warm applications, such as hot Goulard water with lauda- num, or poppy fom-entations, are more grateful to the patient, and may be then applied. As soon as the 152 Manual of Surgery. patient can bear it, equable pressure must be re- sorted to and will be found to be a most ])otent means of promoting absorption of the effused fluids. This can be done by means of a bandage wetted in lead lotion and carefully applied, the bandage being kept constantly damp with the lotion ; or strapping may be used. This treatment must not, however, be con- tinued too long, but as soon as the patient can bear passive motion without pain or renewed inflammation, systematic shampooing and movement of the joint must be resorted to, with friction, and the patient must be encouraged to use the limb as much aa possible without causing himself pain. 'Woitiids of joints. — These are always serious accidents, the severity depending partly upon the nature of the wound and the size of the articulation, but also, to a considerable extent, upon the age and general constitutional condition of the patient. The wound may be incised, punctured, or lacerated ; but the severity of the symptoms does not depend so much upon the extent or nature of the local mischief, as upon the fact that putrescible matter collects in the cavity of the joint and undergoes decomposition, setting up a serious train of symptoms and leading to complete destruction of the articulation. Medium-sized wounds are often, therefore, the most dangerous, especially if the edges are contused and lacerated, so that they cannot unite by adhesive inflammation and at the same time are not large enough to permit of the thorough drainage from the cavity of the effused fluids. If the wound into the joint is large, so that the articular surfaces are exposed, the nature of the injury is at once evident ; but if the wound is small, and particularly if it belongs to the class of punctured wounds, some doubt may arise as to whether the joint has been opened or not Tliia Wounds of Joints. 153 will generally be solved by the escape of synovia^ which will be at once recognised by its oily glu- tinous character. In some cases, however, this fluid does not exude ; but under no circumstances is it admissible to introduce a probe to clear up any doubt in the surgeon's mind, for it may have the effect of completing the perforation into the articular cavity, and thus inducing the very mischief which is to be dreaded. The standard rule in every case of wound in the neighbourhood of a joint, running in the direc- tion of the articulation, ought to be to treat the case as one of ivoicnd of the joint, until the subsequent progress of the case proves that no jDerforation has taken place, or that, if it has, the wound has rapidly healed, without setting up a serious amount of inflammation. Pathology. — When a joint is wounded it rapidly becomes filled with an accumulation of blood, folloAved almost immediately by synovial fluid, mixed with serum derived from the vessels of the synovial mem- brane and the clotted blood in the sac. Thus the joint is distended with a highly putrescible matter, to which air is admitted through the Avound. It therefore rapidly undergoes decomposition, and becomes con- verted into a septic material, which results in an acute inflammation of all the tissues of the joint. Thei'e are certain cases where this may not occur, even though no special treatment is adopted to pre- vent it. If, for instance, the wound is small, and is inflicted with a clean instrument, and if the edges are brought into immediate apposition, union by adhesive inflammation may take place ; no air is admitted to the joint, and no decomposition of the eflused fluids ensues. Thus, we find that a surgical wound may be made into a joint, as, for instance, for the removal of a loose cartilage, without any destructive changes taking place in the joint. Again, on the other hand, 154 Manual of Surgery, if the wound is large and the articulation freely opened, so as to allow the effused fluids to escape, no retention of decomposable matter takes place, and there is therefore no septic influence brought to bear on the part, and recovery may take place without any severe local or constitutional disturbance. If, however, the cavity becomes filled witli putrescible material, decomposition speedily sets in, if this material is brought into contact with impure air ; and acute inflammation running on to suppuration is the result. During the first twenty-four hours or so, the synovial membrane becomes intensely injected and red, and loses its natural lustre. Its fringes also become injected and swollen. The cavity becomes filled with a thin, turbid synovia, in which bacteria are commonly to be found on microscopic examina- tion. The ligaments become swollen and softened. The cartilages lose their natural lustrous appearance, and become opaque and yellow, loosened from the surface of the bone, and eventually they perish and become eroded, especially in their centres, or where the two articular surfaces are in contact. Tho articular ends of the bones become exposed and superficially ulcerated. The inflammation extends to the structures outside the joint, which become (edematous, and in which suppuration occurs. Later on, in about a week or ten days, the joint surfaces become covered with a layer of granulation tissue, and the cavity of the joint filled with a thick creamy pus. It is now impossible to recognise the various structures, which present a uniform gelatinous appearance, infiltrated with inflammatory products. In this way, the whole of the tissues of the joint are thoroughly disorganised and destroyed, and the bone surfaces laid bare and ulcerated. If the patient's strength has survived this pro- tracted disintegration, a reparative process now sets in. IVOUNDS OF JOINTS. 155 Granulations spring up from the exposed bony surfaces, and, coalescing, become converted into osseous matter, just in the same manner as in the union of a compound fracture, and complete synostosis takes place. SjTiiptonis. — If, in a case of wound of a joint, these untoward conditions are set up and the case becomes one of septic inflammation, within a few hours of the receipt of the injury great swelling of the joint comes on, accompanied by acute lancinating paiiL The swelling is at first eWdently due to effusion into the synovial membrane, and takes the shape of this sac ; but after a time the tissues external to the joint become infiltrated, and the swelling more globular. The skin is red, hot, and oedematous. The pain rapidly increases and becomes tensive in character. If the wound is left open, synovia, turbid and opaque and mixed with shreds of lymph, escape. The limb is semiflexed. Later on the pain becomes altered in character, and is de- scribed as throbbin£f. The swellingf and cedema around the joint increase, and the redness is of a more dusky hue. There is starting of the limb, especially at night, or as soon as the patient fiills asleep. The constitutional symptoms are very severe, especially during the first ten days or so, during which time absorption readily takes place through the synovial membrane. Later on, when this struc- ture becomes covered with granulation tissue which oflers a barrier to septic absorption, the fever often becomes considerably lessened. In the early stages the temperature is very high, the thermometer sometimes registering 105° or 106^ Tlie pulse is full and bounding ; the skin hot and dry ; the face flushed, and the tongue covered with a thick creamy fur. There is often nocturnal delirium, with restless- ness and inability to sleep. Or should the patient 156 Manual of Surgery. fall asleep, he will be awakened by the sudden, painful starting of his limb. Later on, when the fever lessens, it assumes a more hectic type. There are often rigors, and the patient may die from pyaemia, or, at a still later period, from exhaustion from the excessive discharge. If the wound in the joint is small, and unites by first intention, and the patient escapes the danger of septic inflammation, there will probably be some swelling, from eflusion into the joint, accompanied by heat and j)ain, which will pass off in the course of a few days, and the joint be completely restored, though it may be stiff and tender for some time. Treatment. — The first question which presents itself in considering the treatment of a case of wound of a joint is as to whether any operative interference will be necessary or not. And in deciding this question much will depend upon the joint implicated, its size, and whether it is situated in the upper or the lower extremity. Wounds of the joints of the upper limb, as a rule, do much better than those of the lower. To this, however, there are exceptions, for wounds of the wrist joint are particularly dangerous, while those of the ankle, unless complicated witli fracture, or exten- sive injury to the soft parts, often do well, and recovery takes place with a fairly useful limb. If the joint has been extensively opened, with much contusion and laceration of the edges of the wound, and especially if the articular ends of the bones are fractured or dis- placed, operative measures will probably be necessary. In less severe injuries an attempt should be made to save the joint. Under these circumstances, in con- ducting the treatment . much will depend ujwn the nature of the wound. If it is a small puncture or a cleanly incised wound, especially if it passes obliquely into the joint, an endeavour should be made to procure union by the first intention. The wound, if sufficiently Wounds of Joints. 157 largo to require it, should be sewn up with silver wire, and coated with collodion or some other material, which will completely exclude the air. The limb must be placed on a splint, so as to secure perfect immobility of the joint, and irrigation with cold water, or spirit and water, assiduously applied. This is much to be preferred to the application of an ice bag, the weight of which is often uncomfortable and distressing to the patient. If the joint swells the case is one of con- siderable anxiety to the surgeon ; but as long as the temperature does not rise to any considerable extent, the treatment must not be abandoned. If the pain is very severe, and tensive from the distension of the cavity, the fluid should be evacuated with the aspirator, and opium should be given to relieve pain and pro- cure sleep. If, however, the temperature rises, and suppuration has evidently taken place, long and free incisions must be made into the joint, which must be thoroughly washed out with some antiseptic lotion, such as carbolic acid lotion or tincture of iodine and water, and free drainage must be provided for. The syiinging out of the wound must be continued daily, and the part must be dressed with carbolic gauze, carbolic oil, boracic acid, lint, salicylic wool, or some such anti- septic material. If the temperature falls, and the dis- charge lessens, care must be taken to maintain the joint in such a position that, when anchylosis results, the patient's limb shall be of service to him. If, on the other hand, the high temperature is maintained, and the discharge continues profuse, and symptoms of hectic develop, amputation must be at once resorted to. If the wound in the joint is a large one, and par- ticularly if its edges are contused and lacerated so as to preclude all hope of obtaining union by first intention, the case must be treated on antiseptic principles from the first, so as to endeavour to prevent decomposi- tion. The joint should be thoroughly washed out with 158 Manual of Surgery. caroolic acid lotion (1 in 20), and every particle of foreign matter and blood clot carefully syringed away. A drainage tube is to be inserted, and if the wound is in such a position that complete drainage cannot be obtained, a counter- opening is to be made in the most dependent part, and a tube inserted. The external wound must now be closed by sutures, and the limb fixed on a splint and dressed with some antiseptic dressing. If, in spite of all the efforts of the surgeon, septic inflammation should supervene, the case must be treated in the manner before mentioned. Generally, however, it will be found in these cases, if antiseptic measures are rigidly carried out, that though sui> puration may come on, the discharge will be very slight in amount, and will be unaccompanied by fever, and that recovery will take place with comparatively little local inflammation or constitutional disturbance by complete bony union of the articular ends. Dislocation. The articular surfaces of a joint may become displaced from each other, either as the result of some injury, constituting the traumatic form of dis- location ; or from certain destructive changes taking place in the joint and surrounding tissues, so that the bony surfaces can no longer be retained in apposition, but are displaced in consequence of muscular con- traction, or the weight of limb or trunk (the patho- logical form of dislocation) ; or lastly, from some con- genital defect or malformation of the joint, in con- sequence of which the bones cannot remain in proper apposition (the congenital form of dislocation). A dislocation may be either partial or complete ; partial^ when the articular surfaces are displaced as regards their normal relation to each other, but are not completely separated, so that some portion of the articular surface of one bone is still in contact with Causes of Dislocation. 159 some portion of the articular surface of the other ; comjylete, when there is an entii-e separation of the two articular surfaces from each other. Dislocations may be either simple or compound. In the former the integument remains unbroken, while in the latter the displaced articular surfaces are exposed by a wound, and thus air is admitted into the ca-vity of the joint. A compound dislocation is one of the most serious accidents which can befall a limb. It is generally complicated with other injuries, and the lesion is usually attended with the most severe form of injflammation, which rapidly runs on to suppuration and complete destruction of the joint, so that bony anchylosis is the most favourable result which can ensue. If, however, the joint is small, as one of the phalangeal articulations, the injury may be recovered from without destruction or loss of motion. Causes. — The causes of dislocation have to be considered under two heads, viz. (1) predisposing, (2) exciting causes. Among the predisposing causes may be classed 1. Tlie ■ nature of the joint. Ball-and-socket joints, on account of the greater freedom of motion which they enjoy, are much more liable to become dislocated than, for instance, a hinge joint, where the amount of movement is much more limited. So that it may be laid down as a rule that the greater freedom of motion there is in a joint, the greater liability there will be to dislocation. 2. The situa- tion of the joint. Some joints are much more exposed to violence than others, and therefore more frequently dislocated. 3. The age of the patient. Dislocations generally occiu' in adults or middle-aged individuals ; being rare in children (with the ex- ception of those of the elbow joint) and in old people. 4. The sex of the patient. Males are much more liable to suffer from dislocation than females, on i6o Manual of Surgery. account of tlieii' greater exposure to serious injuries. 5. The condition of the structures round a joint may predispose to dislocation ; for example, where they Lave been stretched by previous injury or effusion. The exciting causes of dislocation are two-fold ; either external violence or muscular action. Violence may cause dislocation in two ways, either directly, froni blow on one bone entering into the formation of a joint driving it directly away from the other ; or indirectly, where a fall or blow on one part of the bone is transmitted to its extremity, and forces it away from the articular surface with which it is in contact. Symptoms. — The signs by which a dislocation may be recognised are : (1) pain, which is usually of a severe and sickening character ; (2) impaired mobility, so that the patient, to a great extent, is unable to perform the various voluntary movements of the joint ; (3) change in the shape of the joint ; (4) alteration in the relation of the bony prominences in the neighbourhood of the joint to each other ; (5) the displaced bone can sometimes be felt in its new situation ; (6) an alteration in the length of the limb ; it being sometimes lengthened, sometimes shortened, according to the position of the head of the bone ; (7) and an alteration in the direction of the axis of tlie bone. Dislocations may sometimes be mistaken for fractures ; the chief points of distinction are the im- paired mobility, the absence of crepitus, and the fact that when the deformity is reduced it does not as a rule recur ; whereas, in fractures, the displacement at once recurs, as soon as the extending force has been removed. Complications. — A dislocation is always com- plicated with injury to the structures entering into the formation of, or in the immediate neighbourhood Treatment of Dislocations. i6i of the joint. The bones, ligaments, muscleSj vessels, and nerves may all suffer. The bones are very fre- quently fractured ; in fact, in some joints, notably the ankle, dislocation rarely occurs without fracture. The injury to the bone may vary from the chipping off of some small fragment to the extensive comminu- tion of the articular extremity of the displaced bone. Occasionally fracture of the shaft of a bone may take place, with dislocation of its extremity. This some- times occurs in the humerus, where a dislocation of the head of the bone is complicated with fracture of the upper part of the shaft. The ligaments which connect the bones together are^ as a rule, more or less torn in all complete dislocations ; but in incomplete luxations they may escape laceration, being only severely stretched. The muscles which surround the joint are often much bruised and lacerated, and tendons in the neighbourhood, especially those which are connected with the capsule, are sometimes torn across. Arteries and veins in the vicinity of the joint may be compressed by the displaced bone, and all circulation through them arrested ; or they may be ruptured, though on account of their elasticity, especially as regards the arteries, this does not fre- quently take place. Kerves in the neighbourhood may be lacerated, contused, or compressed, leading to intense pain at the time of the injury, and subsequently to paralysis of the muscles they supply. Treatment. — In the treatment of dislocations the first indication is to endeavour to effect reduction as speedily as possible. If the patient is seen im- mediately after the accident, he will probably be faint and his muscles will be relaxed, and reduction can then be easily accomplished unless there is some mechanical impediment. If, on the other haud, he has rallied from the first shock of the accident, the muscles will be in a condition of active contraction, and will offer a L— 21 i62 Manual of Surgery. considerable impediment to reduction. Under these circumstances it is wiser to administer an anaesthetic. There are two principal modes of reducing dislo- cations, viz. by manipulation, and extension. Alanipulation aims at reducing a dislocation by making the bone retrace the steps by which it has become displaced. This is done by executing certain movements of the limb, which shall relax the liga- ments and disentangle the bones from each other, and cause the head of the displaced bone to recede into its socket, or put it in such a position as shall enable the muscles inserted into it to draw it back again into its proper place. Extension has for its object the overcoming of muscular and other resistance by a superior force, and by the application of extension to the limb to forcibly drag the bone back into its normal situation. There can be no question as to the superiority of the former method, as being the more scientific and the less likely to cause injury to surrounding structures, and it should always be employed in the first instance ; extension being reserved for those cases where manipulation has failed. Extension may be made by means of the hands of the surgeon or his assistant grasping the limb below the seat of dislocation, or if thought necessary, by a bandage or jack-towel fastened to the limb by a clove hitch. Or, if more force is required, some form of multiplying pulley must be employed. After a dislocation has been reduced, it is necessary to maintain the joint in a fixed position for some days, otherwise the bono may easily slip out of position again, the ligaments which should retain it in place having been stretched or torn. But this fixed position should not be maintained for too long, otherwise fibrous adhesions between the injured surfaces may take place, and thus an impairment of the movements UNR ED UCE D DlSL OCA TIONS. 163 of the joint, which it will be very difficult to remedy, may result. After about a week or ten days of perfect rest, the limb should be loosened from the bandages or splint, and passive motion should be gently and carefully applied to the joint. This pro- ceeding should be repeated daily by the surgeon (the limb being still kept bandaged) during the intervals Uui'educed Dislocation of tlie Femiu*. The acetaViuliim lias hocn partially filled with a dense fibroid material, and a new cavity formed for the head of the thigh bone. (After Astley Cooper.) of his visits for some time longer, lest some incautious movement of the patient should induce a recurrence of the displacement. ITiu'ediiced dislocations. — If a dislocation is allowed to remain unreduced, great and important changes take place both in the old cavity from which the bone has been separated, in the displaced bone it- self, and in the tissues against which it rests in its new position. In the ball-and-socket joints the old cavity generally becomes filled up with a fibroid material, 164 Manual of Surgery, and its circumference becomes contracted and less regular; the head of the bone becomes altered in shape ; its encrusting cartilage becomes absorl)ed, or else becomes converted into a dense connective tissue ; tlie structures against which the head of the bone rests become hollowed out, forming a cavity lined by a dense fibroid material, which sometimes partially ossifies. Between the two bones a synovial sac be- comes developed, and the cellular tissue around them becomes infiltrated with plastic matter and forms a complete capsular investment. Thus a fairly perfect false joint is formed, in which, under favourable circumstances, a considerable range of movement may be allowed. In the hinge joints the articular ends are altered in shape so as to be scarcely recognisable, the bony processes become rounded ofi", and the ex- tremities of the bones present a stunted, angular outline ; the cartilages covering them become me- tamorphosed into connective tissue. Secondary changes take place in the neighbouring structures ; muscles shorten and atrophy, and, if not used, undergo fatty degeneration ; vessels and nerves become incorporated in the altered structures in the neighbourhood of the new joint, and their functions partially interfered with, and all the injured tissues more or less infiltrated with a dense cicatricial material. The amount of movement which may be obtained in an unreduced dislocation will depend, in a great measure, on the nature of the joint, very much more motion, as a rule, being possible in a ball-socket than a hinge joint. In determining the question as to whether an attempt should be made to reduce an old dislocation, the introduction of anaesthetics has led us very con- siderably to modify the old rule laid down by Sir Astley Cooper, that it was improper to attempt the Dislocations of the Jaw. 165 reduction of a dislocation of tbe shoulder which had existed for a longer period than three months, or ot the hip that had been allowed to remain unreduced for more than eight weeks. Under the influence of an anaesthetic dislocations have been reduced after a much longer period than this, though it is always doubtful, when they have existed for a very long time, whether, if reduced, the limb would gain or lose in utility. In coming to a decision as to the advisability or not of attempting reduction, the amount of pain produced by moving the displaced bones on each other should always be taken into account. If the patient can move his limb without much pain, there is a fair prospect of his obtaining a serviceable false joint ; but if, on the other hand, any attempt to move his limb causes him pain^ it is better to attempt re- duction, as the patient will not be induced to suiii- ciently exercise his false joint to enable him to obtain any great degree of motion in it. In attempting the reduction of an old-standing dislocation, all adhesions must be first thoroughly broken down, and then an effort be made to replace the bone by manipulation or extension. Special Dislocations. Dislocation of the lower jaiv. — The lower jaw can only be dislocated in one direction, viz. for- wards (Fig. 32), unless accompanied by fracture. One or both condyles may be displaced. The former, the " bilateral," is the more common of the two, beins met with in about three to every two cases of " uni- lateral " dislocation. Causes. — This injury can only take place when the mouth is widely open. Under these circum- stances the condyle of the jaw is situated near the summit of the eminentia articularis, and either mus- cular contraction or violence may cause it to become t66 Manual of Surgerv. displaced forwards by forcing it over the summit oi the ridge. Thus the jaw is liable to become displaced during the act of yawning, shouting, or vomiting ; or it has been known to occur during the extraction of a tooth, the passing of a stomach-pump tube, or in taking a cast of the mouth. Symptoms. — -When the dislocation is bilateral ^ the mouth is wide open and the lower jaw advanced Fig. 32.— Dislocation of the Lower Jaw. Showing the posiiinn of the cdiidyle of tlie j;i\v in dislocation forwards. in front of the upper. It is iixed and almost im- movable. The chin is carried forwards, and the face, when viewed in iirofile, appears to be elongated. The lips cannot be approximated, and hence there is drib- l)ling of saliva, and deglutition and speech are im- paired. The condyle can be felt in front of its natural position, where a distinct hollow is to be perceived. In the unilateral dislocation the symptoms are not so marked, and the chin is generally inclined to Dislocations of the Clavicle. 167 the opposite side to that on Avliich the dislocation has taken place. The condyle can be felt in its natural situation on the sound side, and a certain degi'ee of movement is possible. Treatment. — Reduction can usually be effected by introducing the thumb, guarded with a napkin, into the mouth and making pressure downwards and backwards on the lower molar teeth, at the same time that the chin is elevated with the fingers ; or a wedge may be inserted between the molar teeth on one or both sides, according as the dislocation is unilateral or bilateral, and the chin forced directly upwards. Sir Astley Cooper recommends that the end of a piece of wood about a foot long should be introduced between the molar teeth of the two jaws ; by raising the other end of the wood, the lower molars are depressed, the upper teeth acting as a fulcrum, and the jaw levered back into its place. Nelaton believed that the immobility of the jaw and the difficulty in reduction arose from the coronoid process becoming fixed against the malar bone. He therefore recom- mends that reduction should be effected by directly pressing on these processes and forcing them back- wards. After reduction the jaw is to be fixed with a four- tailed bandage for at least a week, after which passive motion must be cautiously and regularly applied. The jaw, having once been dislocated, is very liable to become again displaced, and in some cases the struc- tures around the joint become so lax that the accident is constantly recurring. In old-standing dislocations an attempt should always be made to reduce it, for, even if it does not succeed, the effort will do some good by increasing the mobility of the bone in its new situation. Dislocation of the claAicle.— The clavicle may be dislocated at either extremity ; either fi'om i6S Ma.yual of Surgery. tlie sternum internally, or from the acromion process of tlie scapula externally. Dislocation at the sternal end may take place in three directions, viz. forwards, backwards, and up- Avards, named in their relative order of frequency. Dislocation forwards is caused by violence ap- plied to the front of the acromial end of the bone, as falls or severe blows on the front of the shoulder. This causes the sternal end of the bone to start forwards, a severe strain is put upon the ligaments of the articulation, they give way, and a dislocation results. The end of the bone is thrown forwards, downwards, and inwards, and rests on the anterior surface of the manubrium. Symptoms.— The signs of the injury are very marked, the prominence of the displaced bone on the front of the sternum being very characteristic. The shoulder is approximated to the median line, and all movements of the upper extremity are attended with pain. The only injury for which it is liable to be mis- taken is fracture of the sternal end of the clavicle ; ]3ut the abrupt outline of the projection, and the presence of crepitus is generally sufficient to dis- tinguish this lesion from dislocation. Treatment.— Reduction is to be effected by drawing the shoulders forcibly backwards, with the knee placed in the middle of the patient's back, between the two scapula?. After reduction there is often the greatest difficulty in maintaining the bone 33. — Dislocation of tlie Sternal end of the Clavicle forwards. Dislocations of the Clavicle. 169 in position. This is best done by placing a large pad in the axilla, and applying a ligure of 8 bandage to the shoulders. It is a good plan to instruct the patient to wear an ordinary hernia truss over the joint for some time after the injury, as a recurrence is very likely to occur. Dislocation toacRwards may be produced either by direct or indirect violence; by indirect violence, when a force is applied to the shoulder, driving it forwards and inwards ; or by direct violence when a force ls applied directly to the inner end of the clavicle. The articular end of the bone may be displaced back- wards, and either a little downwards or upwards from its normal position ; in the former instance lying behind the first piece of the sternum, in the latter lying above the level of the upper border of this bone. Symptoms. — There is a well-marked depression at the sterno-clavicular articulation, and the end of the clavicle can be felt at the front of the neck, or else it will be found to have disappeared behind the sternum. There is approximation of the shoulder to the median line of the body, and pain and inability to use the extremity. The head is inclined to the injured side. In addition to this, special symptoms may be present owing to pressure on neighbouring parts. There may be dyspnoea from pressure on the trachea ; dysphagia from pressure on the oesophagus ; or congestion of the head and face, and perhaps even semicoma, from pressure on the large veins at the root of the neck. Treatment. — Reduction may generally be accom- plished, as in the dislocation forwards, by placing the knee in the middle of the back, between the two scapulae, and forcibly drawing the two shoulders back- wards. To retain the bones in position a large pad sliould be placed over the spine and a figure of 8 170 Manual of Surgery. bandage tightly applied over the points of the shoulders. There is often great difficulty in retaining the bone in its place, and when this is so, and there are urgent symptoms of dysphagia or dyspnoea, it may become necessary to excise the end of the clavicle. Dislocation iipAvartls is of very rare occurrence, and can only be produced by indirect force applied to the shoulders in a very unusual direction, so that it is forced down- wards and inwards. The end of the bone is carried inwards as well as upwards, and rests on the uj^per border of the ster- num, between the sterno - mastoid and sterno-hyoid muscles. Syiiiptoms. — The sternal end of the clavicle forms a prominent swelling in its new position, in front of the trachea. The axis of the clavicle is directed forwards and upwards, and there is a considerable interval between it and tlie first rib. There is loss of motion in tlie extremity and approximation of the shoulder to the mesial line of the body. Treatment. — In order to effect reduction a large and hard pad should be placed in the axilla to act as a fulcrum, and the elbow pressed well in to the side of the chest. At the same time the end of the bone must be forced downwards by direct pressure upon it. In oi'der to retain the bone in position after reduction, a pad must be placed in the axilla and the arm bound to the side, the shoulder being at the same time raised by carrying the bandage under tlie point Fig. 3-t.— Dislooation of tlie Sternal end of the Clavicle upwards. Dislocations of the Claviclr lyi of the elbow and over the opposite shoulder. This may be supplemented, if necessary, by a pad over the joint, securely bandaged so as to make direct pressure on the sternal end of the bone. Dislocation of the acromial end of the clavicle ought more correctly to be described as dislocation of the acromion process of the scapula, in accor- dance witli the usual nomenclature of disloca- tions, where the more distal bone is the one usually spoken of as being dislocated. This injury is more common than dislocation at the sterno - clavicular joint, and almost invari- ably takes place in one direction, that is to say, the clavicle is displaced upwards on to the acro- mion process. Some few cases have, however, been recorded where it has been displaced beneath this process. It is generally caused by a direct l>low on the scapula, especially if the blow be given from behind, so as to drive the point of the shoulder for- wards. Syiiiptoiiis. — The signs of the ordinary dis- location are unmistakable. There is a marked prominence, produced by the outer end of the clavicle riding on the top of the acromion process of the scapula ; the shoulder is depressed and approximated to the middle line of the body, and the patient is unable to raise his arm upwards over his head. Fi£ 35.— Dislocation of the Acro- mial eud of the Clavicle. Manual of Scrgfry Troatiuoiit. — Reduction can generally be accom- ])lisliecl by drawing the points of the shoulders back- wards, and at the same time making direct pressure on the prominent end of the clavicle ; but there is great difficulty in maintaining the parts in apposition after reduction. This is best done by placing a pad over the joint and firmly strapping it in this position by a broad nebbing carried over it and round the point of the elbow, and afterwards binding the arm to the side. Dif^locatioii of the liiiiiici'ii«». — Dislocations of the shoulder occur much more frequently than at any otlier articulation. The head of the humerus may be displaced in five different directions, viz. (1) forwards, inwards, and slightly downwards (the siihcoracoid) ; (2) down- wards, and slightly for- wards, and inwards (the si(hglenoid) \ (3) back- wards, inwards, and slightly downwards (the subspinous) ; (4) for- wards, iixwards, and upwards (the subclavi- cular); and (5) forwards and upwards (the sujrra- coracoid). 1. Siibcoracoi*!. — This is by far the most conmion form of disloca- tion of the shoulder joint. The head of the bone is thrown forwards, inwards, and ■slightly downwards, so tliat the anatomical neck of the humerus rests on the anterior edge of the glenoid cavity, immediately below the coracoid process of the scapula. It lies above the tendon of the subsca])ularis muscle, which is frequently torn ; when this is not Fi-. 36. -Sul)coracoid Dislocation of the Humerus. Dislocations of the Humerus. 173 the case, the neck of the bone is embraced by the fibres of the muscle, and this often proves to be a serious impediment to reduction. Causes. — This form of dislocation may be pro- duced either by a direct blow or fall upon the shoulder, the force being inflicted in such a manner as to drive the head of the bone forwards and inwards ; or by falls on the elbow or hand, when the arm is extended from the side. In these latter cases it would seem probable that in many instances the head of the bone is f»i'irnarily displaced downwards, and that the subsequent alteration in its position to beneath the coracoid process is due to muscular contraction, or to the du-ection in which the violence was applied. Symptoms. — In many particulars the signs of all forms of dislocation of the shoulder joint are the same, and it is principally by the alteration in the direction of the axis of the bone, by its lengthening or shorten- ing, and by the presence of the head of the bone in its new situation, where it can be felt, that the differ- ential diagnosis between the various forms can be established. The signs common to all dislocations of the shoulders are : (1) pain ; (2) flattening of the shoulder; (3) apparent projection of the acromion process; (4) a depression beneath this process; (5) rigidity or impaired mobility about the joint ; and (6) the presence of the head of the bone in a new situation. To these may be added two special signs, which will be found useful in substantiating the diagnosis in doubtful cases. The one was pointed out by the late INEr. T. Callaway ; it consists in taking the vertical circumference of any shoulder in which dislocation exists by means of a tape carried over the acromion and under the axilla, when an increase of about two inches over the sound side will be found to be an invari- able concomitant. The other is known as Dugas's guide. "If the fingers of the injured limb can be 174 Manual of Surgery. |)laced l)y the patient, or by the surgeon, upon the sound shoulder, while the elbow touches the thorax, a condition that obtains in the normal condition of the joint, there can be no dislocation." The principal signs by which the subcoracoid dis- location may be diagnosed from the other forms are : (1) An alteration in the direction of the axis of the bone. Tlie elbow is generally thrown backwards and away from the side, and the bone is directed inwards, away from its nor- mal direction. (2) The head of the bone can some- times, in thin per- sons, be easily felt beneath the cora- coid process ; but in stout people it cannot always be perceived, though even in these there is generally a greater fulness than natural of the anterior fold of the axilla. (3) There is usually a Aery slight lengthening of the arm. 2. Subglenoid. — In this dislocation the head of the bone is displaced downwards, and at the same time a little forwards and inwards. It rests on the axillary border of the scapula, just below the glenoid cavity, between the subscapularis above, the long head of the triceps behind, and the teres muscles below. Causes. — It is caused much in the same way as the subcoracoid dislocation, by falls on the elbow or hand when the arm is extended away from the side. 37. — Subglenoid Dislocation of Hum ems. the Dislocations of the Humerus. 175 Wlicn the arm is in this position the head of the bone projects below the lower margin of the glenoid cavitj and stretches the inferior part of the glenoid ligament. Any sudden force applied to the limb while the bon-^. is in this position tears the ligament, and the head of the bone becomes displaced downwards into the axilla. If it remains in this position, a subglenoid dislocation is the result^ but in the majority of instances it is forced away from this position by a continuance of the violence which caused the primary displacement, or is drawn upwards by muscular action and one of the other forms of dislocation results. Symptoms. — The common signs which charac- terise all dislocations of the shoulder are more pro- nounced in this form than in the preceding, and there are, in addition to these, certain special signs by which this dislocation may be differentiated from the others. The elbow is thrown considerably away from the side, and there is not the same inclination backwards as in the subcoracoid variety. Instead of the fulness of the anterior fold of the axilla, which was present in the subcoracoid dislocation, there is in these cases a depression, due to drawing downwards of the pectoralis major at its attachment to the humerus. The head of the bone can be felt in the axilla, and there is considerable lengthening of the arm. 3. Subspinous. — In this dislocation the head of the bone is driven backwards and downwards, and rests on the back of the scapula in the infraspinatus fossa, immediately beneath the spine and between the infraspinatus and teres minor muscles. Malgaigne has also described another variety, in which the head rests beneath the acromion process. It seems, how- ever, to be merely a less complete form of the same luxation, and differs only in the fact that the symptoms are not so marked. Causes. — This form of dislocation may be 176 Manual of Surgery. jH'oduced by direct violence, i.e. by blows struck on the front of the shoulder ; or by indirect force, in the same way as the subcoracoid dislocation, the initial displacement being downwards, and the head of the bone being subsequently forced or drawn into its position beneath the spine. The reason v/hy the dis- placement in these cases is generally forwards (sub- coracoid), is probably on account of the great jjectoral muscle, passing from the front of the chest to the upper part of the humerus, having a tendency to pull the bone in this direction. Symptoiiis.— In the subspinous dislocation, in addition to the symptoms common to all forms, we find that the axis of the humerus is directed back- wards, so that the elbow is advanced in front of the body, and the bone is at the same time rotated inwards, so that the fore- arm is thrown across the front of tlie chest. There is some lengthening of the arm. The head of the bone forms a considerable prominence on the dorsum of the scapula, and there is a marked depression beneath the 'joracoid process. 4. Subclavicular. — This form of dislocation is very rare, and is an exaggerated form of the sub- coracoid. The head of the bone is thrown forwards and inwards, and also upwards, so that it rests on the front of the chest, internal to the coracoid process, and immediately beneath the clavicle. Fig. 38. — Subspinous Dislocaiiou of the Humerus. Dislocations of the Humerus. 177 Causes. — The dislocation requires great force to produce it, and is caused by tlie head of the bone being violently driven against the anterior part of the caj)- sular ligament. There is, therefore, in these cases considerable lace- ration of the mus- cles attached to the tuberosities of the humerus. Symptoms.— There is generally no dithculty in at once coming to a decision as to the nature of the case, the presence of the head of the bone in its new situation being most pal- pable, so that it can be not only felt, but seen, forming a globular prominence beneath the pectoral muscle. On account of the great displacement, the acromion is very prominent, and the hollow beneath it well marked. There is shortening of the arm, and the elbow is carried outwards and back- wards. 5. Siipracoracoid. — This is a mixed form of accident, the dislocation being secondary to fracture of the coracoid process. The head of the bone rests between the fractured coracoid and acromion processes, in contact with the anterior border of the clavicle. As far as I am aware, only three cases of this injury have been recorded. Treatment. — There are three different modes of I'educing dislocations of the shoulder joint : (1) by M— 21 Fig. 39. —Subclavicular Dislocation of the Humerus. TTg Manual of Surgery. manipulation ; (2) by extension ; (3) by mechanical appliances. By manipulation. — The simple plan recently in- troduced by Kocher appears to be the most efficient means of reducing dislocations by manipulation. The patient is seated in a chair, and the surgeon, standing in front of him, gently presses the elbow to the side, the fore-arm having first been flexed on the arm. The humerus is now rotated outwards until the fore-arm is at a right angle with the body. In many cases this is all that is necessary, and the head of the bone will be felt to recede into its place. Should it not do so, the elbow is now to be raised from the body and rotated inwards, until the hand reaches the opposite shoulder. By extension. — There are several plans by which dislocations of the shoulder may be reduced by extension. The simplest and best is by the heel in the axilla. The patient is placed on a low couch, and the surgeon, seated on its edge and facing the patient, places his heel in tlie axilla, and, taking the patient's wrist, draws the arm steadily downwards. After sufficient extension has been made, should the bone not recede into its place, as it often does, he brings the arm across the front of the patient's chest. The foot then, acting as a fulcrum, forces the head of the bone upwards and outwards, and so effects re- duction. Another plan, which sometimes succeeds when others fail, consists in laying the patient flat on his back, and having fixed the scapula by means of a jack-towel passed over the shoulder girdle, and held by an assistant standing at the foot of the bed, making extension vertically upwards. Many other plans, too numerous to mention, have been advocated at different times, all of which have proved efficient. It will generally be found, however, that one or the other methods mentioned above will succeed in effecting reduction, unless in the case of Dislocations of the Humerus. 179 old unreduced dislocation, when it may be necessary to have recourse to the pulleys. By 'pulleys. — The patient having been brought thoroughly under the influence of an anaesthetic, all adhesions are to be thoroughly broken down. The scapula is fixed by a leather collar, which encircles the shoulders, and is fastened to a staple on the sound side of the patient. The pulleys are to be attached to the lower end of the humerus, and extension made in a horizontal direction and continued until the head of the bone is felt to move, when the surgeon should endeavour to manipulate or push the bone into place. After reduction the arm must be bandaged to the side, with a pad in the axilla, and maintained in this position for a week. Passive motion must then be commenced. The surgeon must daily remove the bandage, and care- fully and cautiously move the joint in every direction ; the arm being still kept bandaged^ between his visits, for another three weeks, when the patient may be allowed to begin to use his arm, at first with care, and he should avoid all violent exercise for some time longer. Accidents occasionally occur in reducing old- standing dislocations of the shoulder joint. Of these, rupture of the axillary artery is the most common, and would appear to result, in some cases, from the vessel having become adherent to the bone, and becoming lacerated in breaking down the adhesions. The axillary vein may also be injured, though less commonly than the artery. The humerus may be fractured, the brachial plexus bruised or lacerated, and finally the skin, subcutaneous tissue, and muscles torn, as the result of excessive force employed in the reduction of a dislocation. In determining the point as to whether an at- tempt should be made to reduce an old standing dis- location of the shoulder, a great deal njust depend i8o Manual of Surgery upon the amount of motion which the patient enjoys, and how far this motion can be carried on without pain. If, after three months or longer, there is a fair amount of movement of tlie head of the bone in its new situation, it is better to abandon all attempts at reduction, since the patient will probably have a more useful arm than if the attempt at reduction succeeded, without being exposed to the risks which must attend such a proceeding. Dislocation of the elbow. — Dislocation of the elbow joint is a common accident, occurring fre- quently in young people. Both bones may be dis- placed backwards, forwards, inwards, or outwards ; or a combination of two of these forms may occur, and lioth bones be dislocated backwards and outwards, or backwards and in- wards. One bone only may be displaced ; thus, the ulna may alone be displaced ])ack wards, or the ra- dius may be dislocated forwards, backwards, or outwards. Dislocation ot both hones of the fore - arm hack- wards. — Tliis is by far the most common luxation of the elbow, and is usually caused by falls on the palm of the hand. The dislocation may be complete or incomplete. In the complete form the coronoid process of the ulna is lodged in the olecranon fossa of the humerus, while in the incom- plete form it rests on the trochlear surface of the bone. In some cases the dislocation is complicated with Fig. 40. — Dislocation of both Bones of the Fore-arm backwards. Dislocations of the Elbow. i8i fracture of the coronoid process, but as a rule this does not occur. Syniptoiiis* — There is considerable deformity about the joint, the olecranon stands out prominently behind the elbow, and the triceps can be felt to be separated from the bone. In front of the joint the rounded end of the humerus can be plainly perceived. The head of the radius forms a globular swelling ])ehind the external condyle. The fore-arm is flexed and supinated, and there is undoubted shortening. The injury may be mistaken for transverse fracture of the lower end of the shaft of the humerus ; but in these cases the relative position between the condyles and the olecranon pro- cess is unaltered, and this constitutes a ready means of distinguishing the one injury from the other. Dislocation ot both bones of tlie forc-arni foi'Avards. — This is a very rare form of dislocation, and can only take place when the fore-arm is in a con- dition of extreme flexion, and usually occurs from falling backwards on the i)oint of the elbow. The dislocation may be complete or incomplete. When complete the olecranon is quite in front of the con- dyles ; in the incomplete form the tip of this process rests against the articular surface of the humerus. Symptoms. — The fore-arm is considerably lengthened and usually bent on the arm. The l)rominence of the olecranon is entirely lost, and the condyles of the humerus can be felt at the back of Fig. 41. — Dislocation of the Bones of the Fore-arm forwards. (After Brjaut.) i82 Manual of Surgery. the joint, with the triceps muscle tightlj stretched over them. The sigmoid cavity of the uhia and the head of the radius can usually be felt at the front of the bend of the elbow. JLatoral dislocation of t>otSi l>oiics of the fore-arm. — The lateral dislocations of the elbow are almost always incomplete, the luxation outwards being the more common of the two. In the outward dislo- cation, the sigmoid cavity of the ulna rests against the capitellum or radial head of the humerus, and the radius projects beyond the external condyle. In the dislocation inwards, the sigmoid cavity of the ulna rests against the internal condyle, and in consequence of the fore-arm becoming pronated the head of the radius lies a little below and in front of the articular surface of the humerus. Symptoms. — In both forms of dislocation tliere is great distortion and increased width of the joint. The fore-arm is flexed and pronated. In the dislocation outwards the head, of the radius can generally be recognised forming a prominent swelling, and in the dislocation inwards there is a marked and elongated projection on the inner side of the joint, caused by the internal border of the great sigmoid cavity. In both the relation of the olecranon to the condyles is altered. The dislocations backwards and outwards and ha/ik- vsards and inwards differ from the common dislocation backwards merely in the fact that the bones of the fore-arm are thrown a little to the radial or ulnar side of their normal position, and therefore the tip of the olecranon will be found to be approximated to one or the other condyle. Dislocation of tlie ulna alone is a very rare form of injury, and one about which we know very little. It always takes place backwards, and may be recognised by the projection of the olecranon Dislocations of the Radius. 183 behind the joint, at the same time that the head of the radius is felt rotating in its natural position. Treatment. — In all the above described dislo- cations, reduction can generally be etFected by the same plan. The patient is seated on a chair, and the surgeon, standing in front of him, places his foot on the chair and his knee in the bend of the injured elbow, 80 that it shall press against the upper part of the bones of the fore-arm. He at the same time takes hold of the patient's wrist and slowly and forcibly bends the fore-arm, and the reduction is soon effected. Others recommend that the knee should be pressed against the lower end of the humerus, and the fore- arm forcibly extended, and theji flexed. In old- standing dislocations all adhesions must first be thoroughly broken down before any attempt is made at reduction^ and in some cases it will be found necessary to resort to pulleys. It rarely happens that reduction can be effected after a longer period than five or six weeks, and there is great danger in using the pulleys, if much force is employed, of fracturing the humerus. Dislocatioii of the head of the radius.— The head of the radius may be dislocated backwards SLnd forwards, and also, though rarely, in a direction outwards. There appears to be considerable difference of opinion as to whether the forward or backward dislocation is the more common. The injury in both cases is produced in the same way, by falls on the hand : in the one instance, the lower end of the radius being driven backwards and the head tilted forwards, producing the anterior dislocation ; in the other the whole bone being driven back- wards and the head displaced on to the back of the condyle. In the forward dislocation the fore-arm is semi- flexed and fixed midway between supination and 184 Manual of Surgery. pronation, and the head of the radius can be felt in the hollow just above the external condyle. In the backward dislocation the fore-arm is slightly flexed and maintained in a position of pronation. The limb is inclined outwards from the elbow point. Tlie head of the radius can be felt forming an easily recognised projection behind the external condyle. Dislocation outwaiMl is a very rare form of injury, in which the head of the bone is displaced outwards and upwards above the external condyle. It can be easily detected in this situation beneath the skin^ which is tightly stretched over it, and can be felt rotating during supination and pronation of the fore-arm. Treatment. — These various dislocations of the radius may be reduced in the same way. The upper arm is to be grasped by an assistant just above the elbow, and firmly held. The surgeon then extends the wrist, and after he judges that sufficient exten- sion has been madcj suddenly flexes the fore-arm on the arm, at the same time endeavouring to push the head of the radius back into its place. Dislocation of the ^vrist is a very rare acci- dent, and is caused by falls on the hand. The bones of the carpus may be displaced either backwards or forwards, the former being much the more common accident of the two ; and the deformity which is produced resembles very much a Colles's fracture, but the position of the styloid processes and their relation to each other and to the bones of the hand at once establishes the distinction. These dislocations are to be reduced by extension. Dislocation of the radius from the ulna may take place at tlie radio-carpal joint from violent twists. The radius may be displaced either forwards or back- wards. The carpal bones are not often displaced from one Dislocations of the Wrist. 185 another, head of Tlie most frequent dislocation is that of the the OS inagnum, from violence, during extreme flexion of the wrist. The head of the bone easily to be recognised as a prominent globular IS swelling on the dorsum of the hand. The most common dislocation in the hand is that of the proximal phalanx of the thumb from its meta- carpal bone. The phalanx is gene- rally displaced backwards, and the head of the metacarpal bone being driven for- wards is button- holed between the two bellies of the flexor brevis pol- licis, often causing great difficulty in reductioiL The thumb presents a very characteris- tic deformity. The proximal phalanx is bent backwards almost to a right angle with the metacarpal bone, and at the same time the terminal phalanx is flexed. The head of the metacarpal bone can be felt on the palmar aspect. Reduction is to be effected by forcibly adducting the metacarpal bone into the palm of the hand, by bending the phalanges backwards and hyper-extending, and then, by suddenly flexing the thumb on the metacarpal bone, reduction may be accomplished. If this does not succeed it will be Fig, 42.— Dislocation of the Metacarpo-pbalau- geal Joint of the Thixmb. i86 Manual of Surgery. necessary to divide siibcutaneously the tendons of the flexor brevis pollicis, or, as Dr. Humphrey has sug- gested, draw them aside with a hook, introduced through an incision made on either side of the joint. Liixations of the other joints but rarely happen, except as the result of severe crushing violence, and present nothing special as to their nature or treatment. Dislocation of the liip. — The hip joint may be dislocated in four difierent directions, viz. (1) upwards and backwards, on to the dorsum of the ilium, (2) backwards, into the sciatic notch, (3) down- wards, into the obturator foramen, and (4) inwards, on to the pubes. It must be borne in mind, however, that the head of the bone does not always occupy the same position in these dislocations, but may, as Mr. Bryant says, "rest at any point around its jacket." These varieties are therefore only adopted for purposes of classification and description, and as indicating generally the various directions in which the head of the bone may be displaced. Causes. — There seems to be very good ground for believing that the majority of luxations of the hip, unattended with fracture, are primarily disloca- tions downwards, and are produced w^hile the thigh is in a condition of forced abduction, and that the position which the head of the bone will subse- quently occupy depends upon the amount of flexion and rotation which may be present at the moment of the accident. When the thigh is abducted the greatest strain is put upon the weakest part of the capsular ligament. The head of the femur bulges over the lower and inner shallow margin of the cotyloid cavity, and presses against and strains the lower and inner, that is, the weakest part, of the capsular ligament. If any severe force is now applied this portion of the ligament gives way, and the head of the bone is primarily displaced downwards. If at this time the Dislocations of the Hip. 187 limb is in a condition of Mexion and inward rotation, the initial violence which produced the dislocation being continued, the head of the femur is forced round the lower and outer margin of tlie cavity, and dislocation backwards, or backwards and up- wards, is the result. If, on the other hand, the thigh is extended and rotated outwards, the head of the bone is forced in the opposite direction, round the inner margin of the cavity, producing dislocation on to the piibes. Whereas, if the abduction is unaccom- panied by rotation in either direction, the bone remains in the primary position into wdiich it was displaced, that is to say, downwards. Though this is true of the ma- jority of dislocations of the hip, it seems probable that the dislocation backwards can take place directly, and this even without fracture of the acetabulum. dislocation on f o the dorsnni ilii. — This is the most common form of dislocation of the hip, occurring as frequently as the other three dislocations together. The head of the bone generally rests on the dorsum of the ilium, just above the facet which marks the origin of the reflected head of the rectus muscle, but may vary in position. Sometimes it is situated considerably higher on the dorsum ; sometimes in advance of this position, in some cases so much so Fig. 43. — Dislocation on to the Dorsum of the IHiun. 1 88 Manual of Surgery. that the head of the bone rests iu the notch between the anterior superior and anterior inferior spinous pro- cesses of the ilium. This is known as the " sujjra- spinous " dislocation. The head of the bone is always above the obturator internus muscle, and it is from this circumstance that Bigelow distinguishes it from the sciatic dislocation ; the one luxation being "above," the other "below the obturator internus." Symptoms. — There is a marked distortion about the hip, which appears to be wider and flatter than natural. The trochanter is less prominent, and ap- proximated to the crest of the ilium ; the head of the bone can generally be felt beneath the glutei muscles ; the limb is considerably shortened, sometimes as much as two or three inclies ; the thigh is flexed, rotated inwards and adducted so that the axis of the femur runs across the lower third of the sound thigh, and if the patient were in the erect position the ball of the great toe would rest on the sound ankle. The voluntary movements of the joint are quite abolished, and only a slight amount of passive flexion, adduc- tion, and inversion is permitted. The vessels in the groin may be noticed to have lost their su])port, and a hollow behind them can generally be easily per- ceived. The dislocation may be diagnosed from fracture of the neck of the thigh bone by the fixed position of the limb, by the inversion, by the absence of crepitus, and the presence of the head of the bone in its new position. Treatment* — An endeavour should always be made, in the flrst instance, to efiect reduction by manipulation. The patient must be placed on his back on a low couch or the floor, and thoroughly anaesthetised. The surgeon stands over his patient and flexes the leg on the thigh and the thigh on the pelvis. The flexion is to be carried to its extreme limits ; the knee being at the same time Dislocations of the Hip. 189 somewhat adducted and brought well over the middle line of the body. While the flexion is maintained the limb is to be abducted to its fullest extent, and then rotated outwards and brought suddenly down into the extended position. By this series of man- oeuvres the head of the bone will be made to retrace the steps by which it has been dislocated, and reduction will generally be accomplished. Should it not succeed, recourse must be had to extension by means of pulleys. The patient must be laid on his sound side, and the pelvis fixed by a perineal band attached to some stationary object behind the patient's head. The pulleys are to be connected to the lower part of the thigh, which is to be flexed on the abdomen, and exten- sion made at right angles to the trunk. Sir Astley Cooper recommended that the patient should be laid on his back and extension made across the lower third of the sound thigh. But this plan would en- danger the integrity of the ileo-femoral ligament, which must be tense, with the thigh extended ; whereas, it is relaxed when the thigh is flexed and would thus facilitate reduction. 2. Dislocation backwards. — In this dislo- cation the head of the bone may rest on any part of the posterior surface of the ischium, below the ob- turator intern us muscle. It may rest on the margin of the notcli, or on the structures passing through it. It may rest on the spine of the ischium or against the tuberosity, opposite the smaller sacro-sciatic foramen. Symptoms. — The signs by which the dislocation backwards is characterised are very similar to those of the iliac dislocation, but are less pronounced and less marked. There is distortion and flattenins: about the hip, and the trochanter is displaced, thougli not to the same extent as in the former dislocation ; it is usually a little above and some distance behind its normal situation. There is shortening to the extent 190 Manual of Surgery. of aVjout an inch. The thigh is flexed, rotated iii' wards and adducted, though to a less extent than in the dorsal dislocation. So that, with the patient in the erect position, the ball of the' great toe rests on the great toe of the sound foot. The axis of the femur is directed across the sound knee, instead of across the lower third of the thigh. The facility with wdiich the head of the bone can be felt will depend in a great measure upon its position. In some cases it can be made out with ease; in others it can only be perceived with the greatest difli- culty, or perhaps not at all. Active movement and al- most all passive movement is abol- ished, flexion being the only motion which is permitted. Treatment.— Reduction is to be effected in the same manner as was employed for the dorsal disloca- tion, and will generally be accomplished by manipula- tion, witlioutthe aid of the pulleys. By flexing the thigh on the pelvis, abducting and rotating outwards, the head of the bone is made to retrace its steps, just as in the dorsal dislocation, and it is, without difficidty or any great expenditure . of force, returned to its socket. If failure should attend the attemi)t to re- duce the dislocation by manipulation, the pulleys nnist be applied in the same manner as in the previous Fig. 4i. -Dislocation backwards of the Head of the Femur. Dislocations of the Hip. 191 case. The patient must be laid on his sound side, and with the thigh flexed as much as possible on the pelvis, extension made at right angles to the trunk. This may be supplemented, if there is any difficulty, by a bandage or towel placed under the upper part of the thigh and pulled directly upwards. This will assist in raising the head of the bone over the mar- gin of the acetabulum. 3. Dislocation into the obturator foramen. — In this dislocation the head of the bone generally rests on the obturator ex- ternus muscle, close to tlie inner margin of the obturator foramen ; but in some instances it may be displaced still farther inwards, and rest on the rami of the pubes and ischium, at about their point of junction. Symptoms . — There is an appearance of flatteninsf and de- formity about the hip. The trochanter is not so prominent as natural, and in its normal position there is a depression. The fold of the buttock is on a lower level than on the sound side, and there is a hollow in front below the middle of Poupart's ligament. If the patient is in the erect position, the body will be bent forwards, owing to the psoas and iliacus being put on the stretch, and will be tilted over to the injured side, from obliquity of the pelvis. This Fig. 45. — Dislocation of tlie Femur downwards into tlie Obturator Foramen. 192 Manual of Surgery. will give the appearance of very considerable length- ening, though the actual amount is very slight, and in some recorded cases no increase in length has been found after the most careful measurement. The limb is abducted and advanced in front of the other, and the toes are generally pointed straight forwards, though in some cases there may be slight eversion. The adductor muscles are stretched and form a tense cord, extending from the pubes to the middle of the thigh. The facility with which the head of the bone can be felt depends upon its position. If it rests on the obturator membrane, it cannot be distinctly felt through the muscles; but if it is displaced farther inwards and rests on the rami of the pubes and ischium, it can easily be felt in the perinseum, and sometimes even the dimple on it can be detected beneath the tense skin. A certain amount of passive motion is possible, and the patient may soon be able to perform a certain amount of flexion by his own efforts, but any attempt at extension is attended with severe pain. Patients in whom this dislocation has been allowed to remain unreduced, are often able to walk without pain, and with very little difficulty. Treatineiit* — This form of dislocation can generally be reduced by manipulation. The patient is to be laid on the floor, and the surgeon, standing over him, grasps the ankle with one hand and the knee with the other, and flexes the thigh on the pelvis, at the same time slightly abducting it. He then rotates the thigh forcibly inwards, and, adducting it, brings the knee down to the floor by a movement of extension. Another plan, which is said to answer equally well, consists in circumducting the knee inwards after flexion, until it is brought as far as the middle line of the body ; then rotating outwards and extending tl.e. thigh. Dislocations of the Hip. 193 A combination of extension with manipulation sometimes succeeds in reducing this dislocation. The thigh is tirst flexed on the abdomen, and then the head of the bone is forcibly dragged upwards and outwards into its socket, the surgeon standing over his patient and fixing the pelvis by placing his foot on the horizontal ramus of the pelvis. Reduction by extension with pulleys must be con- ducted in the following manner ; counter-extension is made by a girtli or belt, which is to encircle the j)elvis, and is fixed to a staple in the wall on the pa- tient's sound side. Another girth is placed round the upper part of the injured thigh; and passed under the pelvic gii'th to prevent it slipping. To this is attached the pulleys, which are fixed to a staple in the wall on the same side as the in- jured limb. Extension is now made so as to pull the bone outwards and upwards, and at the same time the ankle is grasped and drawn towards the middle line of the body. Dislocation 011 to the pubes. — In this dis- location the position which the head of the bone assumes varies %ery much. Generally it is found resting on the junction of the horizontal ramus of the pubes with the ilium, but it may be placed on any part of the pubes, even as far inwards as to be in contact with its spine. Sometimes it is displaced in N— 21 Fig. 4(5.— Di^-location of the Femur ou to the Pubes. 194 Manual of Surgery, front of the pubes, lying a little to the inner side of the anterior inferior spinous process of the ilium. Symptoms. — This luxation is, perhaps, of all dislocations of the hip, the one most easy of recogni- tion, on account of the fact that the head of the bon« is generally plainly to be perceived as a rounded swelling just above Poupart's ligament. There is also considerable deformity about the hip, and a general appearance of flattening, with absence of the prominence of the trochanter. There is slight shortening of the limb, and the knee and foot are very considerably everted, and more or less abducted fi'om the middle line of the body, and the knee cannot be approximated to the one on the oppo- site side of the body. There is often great pain down the front and inner side of the thigh, from stretching of the anterior crural nerve. A certain amount of flexion and outward rotation is possible, but any inward rotation or extension is impossible. Treatment. — Reduction by manipulation should first be attempted, and wdll generally be found to succeed. The patient is laid flat on his back on the floor, and the thigh flexed in an abducted position, so that the knee is carried beyond the line of the side of the body. The thigh is now circumducted inwards, so that the knee is over the median line of the body. This circumduction inwards must not be carried too far, otherwise the head of the bone will be forced past the socket, and a displacement backwards be the result. The thigh is now rotated outwards and extended, so as to bring the knee down to the ground. Rotation inwards appears to succeed in some cases equally as well as rotation outwards. Extension by pulleys must be applied as follows : the pelvis having been fixed by a perineal band fastened to the wall a little above and behind the line of the body, extension is made in a direction iDlSLOCATlONS OF THE pATELLA, 1 95 downwards and outwards. After this has been done for some time, an assistant lifts the head of the bone, by means of a towel, over the brim of the acetabiilnm. After reduction, in all forms of dislocation of the hip, the patient is to be kept in bed on his back with his legs tied together and the limb supported with sand-bags. At the end of about two weeks passive motion must be commenced and continued daily, great care being exercised to prevent a recurrence of the displacement. The patient must not be allowed to use his leg' for some weeks longer. Dislocation of the patelSa. — The patella may be dislocated outwards, inwards, or edgeways. Dislocation outwards is far the most common displacement, and may be complete or incomplete. It is produced either by muscular contraction, by the violent action of the quadriceps extensor cruris (and hence is said to occur more frequently in knock-kneed individuals), or by direct violence, that is, a blow on the inner edge of the bone. Symptoms.— The leg is extended, or slightly flexed and fixed in this position ; the knee is flattened and broader than natural, and a depression is to be felt in the position the patella normally occupies. In the complete dislocation the bone can be felt on the outer side of the joint ; in the incomplete form it presents a prominent swelling on the outer part of the articular surface of the femur, its internal border being lodged in the notch, and its external border projecting prominently under the skin. Dislocation inwards appears to be always produced by direct blows on the outer edge of the bone. Like the former dislocation, it may be com- plete and incomplete, and the symptoms are much the same, with the exception that the patella is found on the inner instead of the outer side of the joint. 196 Manual of Surgery. Treatuieiit. — The patient liaving been placed under the influence of an anaesthetic, the thigh is to be acutely flexed on the pelvis, the leg at the same time being extended on the thigh. The margin of the patella which is farthest from the centre of the joint is to be forcibly depressed. This will have the eflect of raising the other edge, which, being tilted over the condyles, is immediately drawn by the action of the muscles into its natural position. Dislocation edgeways (or vertical rota- tion) of tlie patella. — In this peculiar dislocation the patella undergoes a vertical rotation around a longitudinal axis through its own centre. In conse- quence of this one border projects prominently under the skin, and the other is lodged in the intercondy- loid notch, its surfaces being directed inwards and outwards. It occasionally happens that a complete rotation takes place, and the bone is turned com- pletely round, so that the articular surface presents anteriorly. This accident is generally produced by a direct blow on the edge of the patella while the limb is in a semiflexed position. It has been said also to occur from violent muscular contraction Avhile the leg is twisted, as in jumping with the foot inverted or everted. Symptoms. — The position of the patella at once establishes the nature of this accident ; its prominent border can be felt forming a hard, well-marked ridge under the stretched skin, with a depression on either side of it. The limb is com])letely extended, and any attempt to flex it is attended witli very great pain. Treatment. — As a rule, reduction may be accom- plished by suddenly and forcibly bending the knee while the patient is under the influence of an anaes- thetic \ or, should this fail, the bone may be induced to undergo a retrograde vertical rotation by pressury Dislocations of the Kxee. '97 on the prominent margin of the bone after tlie thigh has been acutely flexed on the pelviss and in this way reduction may be effected. After the reduction of any of the dislocations of the patella there will probably be some swelling and effusion into the joint, and the limb must be kept fixed on a splint and cold applied to the part. Pas- sive motion must be commenced early, and the knee supported for some long period with a knee cap or bandage, since these disloca- tions, having once taken place, are very liable to recur. Dislocation of the knee is a very rare form of injury, and is always the re- sult of very great violence. It may occur in four princij)al directions : forwards, back- wards, inwards, and outwards, and any of these dislocations may be complete or incom- plete. As a rule, however the antero-posterior disloca- tions are complete ; the lateral ones are incomplete. Causes. — These injuries are generally produced by some violent strain or wrench of the knee, as in a person jumping from a carriage in rapid motion, or a fall from a horse, the foot being entangled in the stirrup, so that the patient is dragged along the gi'ound. In the dislocation forwards the displacement is usually complete, and the popliteal surface at the back of the tibia rests against the anterior surface of Fig. 47.— Dislocation of the Knee forwards. igS Manual of Surgery, the lower end of the femur. Often there is a slight lateral displacement as well. The condyles of the femur, projecting in the ham, sometimes compress or lacerate the popliteal vessels. Syinptouis. — The deformity produced is very great. There is considerable shortening ; there is a projection in front of the knee, above which can generally be felt the patella, freely movable, and the quadriceps extensor is quite lax and loose. Behind tlie joint the condyles of the femur may be recognised by their rounded form on a lower level than the tibia in front. The limb below the knee is generally cold and swollen, and the pulsation of the tibial arteries diminished or absent. Occasionally severe pain is complained of from pressure on the popliteal nerve. In the dislocation backwards the anterior surface of the upper margin of the tibia rests against the posterior surfaces of the two condyles of the femur, and the displacement is therefore not so great as in the forward dislocation. Sj^nptoius. — There is shortening of the limb, though not to the same extent as in the previous case, and the knee is generally semiflexed, but may be ex- tended. The prominence of the condyles in front is well marked, and beneath them is a transverse de- pression. The patella can be felt resting in the groove between the two condyles. The head of the tibia is to be plainly felt in the ham, where it forms a projec- tion among the muscles of the calf. In the incomplete form of these antero-posterior dislocations the symptoms are the same as in the com- plete form, but are less marked. As a rule, in the incomplete form the popliteal vessels and nerve escape injury. Treatinciit.— The reduction of these disloca- tions is generally easy, on account of the amount of laceration of surrounding structures which usually Dislocations of the Knee. 199 accompanies the injury. The patient is to be laid on his back and steady extension and counter-extension employed, the surgeon at the same time endeavouring, by direct pressure on the displaced head of the tibia, to push it back again into its proper position. After reduction, the limb is to be maintained on a splint for two or three weeks, and cold lotions or ice applied. At the end of this time passive motion should be commenced and employed carefully and cautiously. It is advisable that the patient should wear a knee cap for some time, inasmuch as, the ligaments having been extensively torn, a recurrence is likely to result unless some artificial means of support is employed. If the popliteal artery has been compressed by the displaced bone, the circulation in the tibial vessels will probably return after reduction has been eflfected. If, on the other hand, it has been lacerated, gangrene will probably supervene, rendering amputation neces- sary. Lilocatioii of the semilunar fibro-carti- 1ag:es. — These cartilages may be displaced in two directions, either inwards, towards the spine of the tibia, or outwards, so that they project beyond the margin of the tibia. In the first variety the circum- ference of the cartilage is torn away from the capsule of the joint and is turned inwards, so as to occupy the intercondyloid notch. In the second variety the cartilage is displaced away from the centre of the joint, so as to project beyond the articular surface of the tibia. There appears to be some difference of opinion as to whether the internal or external cartilage is most frequently displaced. The accident is generally caused by some sudden twist of the leg or foot while the knee is flexed. Thus a patient, while walking, may strike his toe against a stone or some inequality in the ground, and by this means displace one of the fibro-cartilages of his knee. {See page 256.) Syan|>toGns. — The patient is suddenly seized with an acute and sickening pain in the knee, often so severe as to cause him to fall. The limb is semi- flexed, and he is unable to extend it, any effort to do so being attended with increased paiii. If the carti- lage has been displaced away from the spine of the tibia, it may be felt projecting under the skin ; but if it has been displaced inwards, it will not probably be felt, though there may be a projection on one or other side of the ligamentum patellae, and a depression may be felt between the head of the tibia and the condyle of the femur. The injury is usually followed by rapid effusion into the joint. Treatment. — Reduction may usually be effected by forcible flexion of the knee to its fullest extent, Dislocations of the An'kle. 20 f and then, when the patient's attention is directed elsewhere, so that tlie muscles are off their guard, suddenly extending the leg on the thigh. After re- duction the knee must be kept quiet on a splint, and the synovitis treated by cold. The patient should be instructed always to wear a knee cap, for the accident having once taken place is very liable to recur. Dislocation of the head of the iibula, occasionally, though rarely, takes place. It may be dislocated forwards or backwards. When the bone is dislocated forwards its head is thrown on to the an- terior surface of the outer tuberosity of the tibia ; in the dislocation backwards it rests against the posterior surface of the same bone. The head of the bone can be felt in its new position, and this, together with the alteration in the direction of the axis of the fibula, at once denotes the nature of the injury. The head of the bone can generally be returned to its place by direct pressure, with the leg flexed, so that the biceps is relaxed. It is, however, exceedingly difficult to retain it in position, and the patient is likely to recover with some permanent deformity. This does not appear, however, to interfere much with his powers of progression. Dislocation of the ankle. — The ankle joint, on account of its great exposure to injury, is frequently dislocated ; the dislocation, in the majority of instances, being complicated by fracture. The bones of the tarsus may be displaced from the tibia and fibula in five different directions, viz. outwards, inwards, back- wards, forwards, and upwards. Dislocation outTiards. — This variety of dis- location is by far the most common, and may be com- plete or incomplete. It is always accompanied by fracture of the fibula, and when incom})lete is called " Pott's fracture " ; when complete it is sometimes 202 Manual of Surgery. known as " Diipiiytren's fracture." The cause of the accident is almost always a fall on the foot, in which it is twisted outwards. In Pott's fractiu'e the fibula is first broken, usually about two or three inches from its lower ex- tremity. The internal lateral ligament next gives way, or else, what is more common, the internal malleolus is broken off, and the astragalus be- comes partially displaced from the articular surface of the tibia, undergoing a rotation on its own horizontal axis, so that the outer margin of its superior surface rests against the articu- lar surface of the tibia. Symptoms. — There is great distortion of the foot, which is twisted, so that the sole is everted. There is a marked projection under the skin, on the inner side of the foot, of the internal malleolus or its fractured extremity ; and on the outer side of the leg, above the external malleolus, is a depression, where the two fractured ends of the fibula form a retirinor aiiscle with each other. (islocatioii backwards may be complete or incomplete. In the former the trochlear surface of the astragalus is thrown behind the lower end of the tibia, which rests on the neck of the astragalus and scaphoid ; in the latter the two articular surfaces do not clear each other. There is a marked appearance of shortening of the foot. In front of the ankle is a prominent transverse ridge, terminating in an abrupt margin. Behind, the heel is very prominent, and the tendo Achillis tense. The toes are pointed downwards. Dislocation forwards is not so common as the jn-eceding dislocation, and is generally incomplete, the anterior margin of the tibio-fibular arch resting on the summit of the articular surface of the astragalus. In these cases there is an apparent elongation of the foot ; the heel is less prominent than natural ; and the space in front of the tendo Achillis is filled by a hard swelling, which may be recognised as the lower ends of the tibia and fibula. The tendo Achillis is lax, and is not so prominent as in the natural condi- tion of parts. Trcatinont. — Dislocation backwards can gener- ally be reduced with much greater facility than the forward dislocation. They are both to be reduced in the same way as the lateral dislocations, with or without division of the tendo Achillis, according to Dislocation of the Astragalus. 205 the necessities of the case. After reduction the limb may be put up in a pair of side splints and main tained at rest for two or three weekSj when passive motion must be commenced. Dislocation iipwai'ds. — This dislocation con- sists in a separation of the tibia and fibula at theii lower articulation, and a forcing upwards of the astragalus between the two bones. The injury appears to be always caused by falls from a gi'eat height on to the feet j from this cause the ligaments connecting the lower end of the tibia and fibula are torn, and the force being continued, the astragalus is jammed up between them. There is great widening of the ankle, the malleoli stand out prominently and approach the level of the sole of the foot ; the relations of the astragalus are obscured, and there is an entire absence of motion in the ankle joint. Reduction may be accomplished by forcible ex- tension, but in some cases it has been found impossible to move the bone from the position in which it has become wedged. Recovery has, however, been said to have taken place with a fairly serviceable limb. Dislocation of the astragalus. — The astra galus is occasionally displaced from all its articu- lations in a direction forwards, backwards, inwards, or outwards ; or the bone may undergo a very pecu- liar rotation, either horizontally, so that the long axis of the bone is directed across the joint, or it may be turned on its side, so that the upper and under sur- faces of the bone look inwards and outwards. Dislocation fovAvards is the most common form of displacement, the bone being shot out for- wards from its socket and generally undergoing a partial rotation, so that the head is inclined to one or other side. The dislocation may be complete or incomplete. 2o6 Manual of Surgery. The accident is usually caused by a fall or twist of the foot while it is extended on the leg. The displaced bone forms a distinct tumour upon the instep ; in front a rounded globular swelling, which under the tense and stretched skin is readily recognised as the head of the astragalus, and behind this its trochlear surface forms a projection in front of the tibia, which appears to be more or less sunken and shortened. Dislocation backwards. — In rare instances the astragalus may be displaced backwards from all its articulations, the accident being produced by twists or strains of the foot while in a condition of flexion. In these cases the most marked sign is the presence of a hard prominence just above the heel, between the tendo Achillis and the malleoli ; the foot is appa- rently shortened, and there is a prominence of the tibia in front. I^ateral dislocations are, if complete, always compound, and arc generally, but not always, accom- panied by fracture of one or the other malleolus. When the astragalus is thrown outwards the foot is displaced inwards, with great projection of the ex- ternal malleolus ; when the bone is displaced inwards the position of the foot is reversed. "Version of tlie astragalus.— This consists in a rotation of the bone either on a horizontal or vertical axis, and is produced by violent strains or twists of the foot, while it is in a position of neither extreme flexion or extension. The diagnosis of the injury is involved in considerable obscurity, and is generally to be made by negative, rather than any positive signs. Thus the history of the accident, the loss of motion at the ankle, and evident severe injury, without any marked displacement or pro- minence of the astragalus, raay lead to a conjec- tural diajrnosis. Dislocations of the Foot. ^o) Treat ineiit.— Ill all the various forms of disloca- tion of the astragalus, an attempt must be made to effect reduction by steady traction of the foot, with the knee bent, and the patient fully under the influence of an anaesthetic. If this should fail the tendo Achillis, and any other tendon which may be felt on the stretch, should be divided, and the attempt renewed. Failing this the limb must be put up in some apparatus and the issue of the case awaited. If, as often happens, sloughing of the tense skin over the bone takes place, the astragalus should be at once re- moved, by an in- cision running parallel to the ten- dons. If no slough- ing takes place the patient may re- cover, with a fairly useful limb. Siibastraga- loid disloca- tion.— This form of dislocation con- sists in a displace- ment of the rest of the bones of the tarsus from the astragalus, this bone remaining in its proper position in the tibio-fibular mortise. These dislocations are described as taking place in four directions : backwards, forwards, inwards, and outwards. Of these, the dislocation backwards is much the most common. They are generally pro- duced l)y violent strains or twists of the foot, much in the sauie way as the other dislocations about the Fig. 49.— Subastragaloid Dislocation. 2o8 Manual of Surgery. astragalus \ but in consequence of the greatest strain being thrown on the ligaments which connect the bone to the scaphoid and os calcis, they give way first, and the subastragaloid dislocation results, the ankle joint remaining intact. In the dislocation backwards there is generally some twisting of the foot as well, so that the bones of the tarsus are disi)laced outwards or inwards, as well as backwards, and the head of the astragalus rests either on the outer or the inner side of the scaphoid, where it forms a globular swelling, which can readily be recognised as the head of the bone under the tightly stretched skin over it. When the bones of the tarsus are dislocated backwards and outwards, the foot is everted, so that the sole is directed more or less outwards. The inner malleolus is prominent and well marked under the skin, and the outer malleolus buried, the os calcis projecting beyond it. In the dislocation backwards and inwards the position of the foot is reversed ; it is inverted, the sole looking inwards, the outer malleolus is prominent, and tlie inner one buried. The diagnosis of this injury from dislocation of the astragalus may be made by ob- serving the unaltered relation of the malleoli to the astragalus, and by the recognition of the fact that there is no shortening such as takes place in complete dislocation of the astragalus, from approximation of the OS calcis to the tibio-fibular arch, and that a certain amount of motion is permitted in the ankle joint. Trcatmciit. — There is sometimes the greatest difficulty, in these cases, in effecting reduction ; this has been ascribed to various causes : to the hitching of the tibial tendons round the neck of the bone ; to the sharp jjosterior margin of the under surface of the astragalus beini; Iodised in the interosseous oroove of the OS calcis ; to the under surface of the neck of the astragalus being wedged against the shaip posterior Dislocations of the Foot. 209 margin of the dorsal surface of the scaphoid ; and lastly, to fracture of the astragalus, the broken portion of bone preventing reduction. The manner in which extension should be made in these cases is by pulling the foot forwards, at the same time that the surgeon, by placing his knee against the front of the lower part of the tibia, presses the bones of the leg, and with them the astra- galus, backwards. The tendo Achillis, or other tendons, if tense, may require division ; and failing all efforts at reduc- tion^ the same treat- ment must be adopted in these cases as was recommended in those of dislocation of the astragalus. The other tarsal bones may occasion- ally be displaced from each other ; one of the most common forms is the " medio-tarsal " dislocation, where the anterior tarsal bones are displaced from the calcaneum and astragalus. Or single bones may be dislocated ; the OS calcis, the scaphoid, or the internal cuneiform. The cuboid is said to be never displaced alone. Ex- tension, combined with pressure on the prominent bone, will generally succeed in effecting reduction. Dislocation of the metatarsal bones and ptialang^es occasionally takes place, but they present nothing of a special character either as regards their nature or treatment. 0—21 Fi?. 50.— Subastragaloid Dislocation. 2IO IV. DISEASES OF JOINTS. HowAKD Marsh. Synovitis. Inflammation of the synovial membrane of the joints may occur in a variety of forms. Thus, it may be, as to its intensity, acute, subacute, or chronic ; as to its products, serous or piinileiit; while as to its cause, it may be local when dependent on some mechanical injury or over-exertion; or general (or, as it is vaguely termed constitutional) when due to struma, rheumatism, pyaemia, etc. Although acute and chronic synovitis merge insensibly into each other, through the various grades of the subacute form, they yet, when typical examples are selected, present a strong contrast, alike in respect to their morbid anatomy, their symptoms, and their results. Acute synovitis. — For the purposes of descrip- tion it will be convenient to select an instance in which the affection has been produced by local injury such as a severe wrench. The changes that take place are in all respects analogous to those met with in inflammation of any of the connective tissues. The membrane becomes vividly injected with blood, so that its surface presents a bright red appearance, involving especially the various folds and processes, whose colour forms a striking contrast with the pearly wliiteness of the arti- cular cartilage ; while here and there are to be seen minute petechial specks, or larger extravasations of blood which has escaped from over-distended vessels. Becoming ra}>idly loaded with exudation products, the membrane is rendered velvety and succulent, and so swollen that it overlaps and obscures the borders of Synovitis. 211 the arfcicnlar cartilage, and lies closely packed iii all the recesses of the joint. At the same time, the syno- vial fluid rapidly increases in quantity, and becomes charged with inflammatory products, so that the articular cavity becomes distended. The fluid is at first clear, but is afterwards mixed with leucocytes and flakes of fibrine which give it a cloudy appearance ; and commonly also with a small admixture of extravasated blood. Having advanced to this stage, when all its characteristic features as an acute inflammation have been developed, synovitis, under the influence of treatment, may subside, and undergo resolution ; cell i:)roliferation ceases, exudation products are absorbed, the blood-vessels regain their normal calibre, and the membrane recovers its natural appearance. In other cases, however, which from the first are more severe, or in wliich appropriate treatment is not brought to bear, the synovial fluid is rendered turbid and milky by cell exudation, and is soon converted into completely formed pus. Should pus thus resulting be evacuated early, under safeguards against septic infec- tion, repair may occur, and the membrane gradually return, in part or altogether, to its normal conditioiL In many instances, however, an acute purulent synovitis passes on to destructive changes, involving the membrane itself, the ligaments, and articular cartilages, and even to some extent the ends of the bones forming the joint, so that a general arthritis is established (page 235). In suhaeute synovitis, changes similar to those described as occurring in the early stage of the acute form are met with. They are, however, less marked, and of lower intensity. In chronic synovitis, whether («) primary and induced by some local cause too mild in its action to excite acute inflammation, or {h) remaining after acute inflammation has subsided, the synovial membrane is 212 Manual of Surgery. unduly vascular (often rather from venous congestion than from active arterial injection, such as is present in the acute form), swollen, and succulent, and loaded with exudation products, which, as the case proceeds, may either undergo development into fibrous tissue, so that the membrane becomes thickened and indurated, or pass into a state of fatty or " pulpy " degeneration. The amount of fluid in the articular cavity may be but little increased ; but generally it is in con- siderable excess, so that the synovial membrane is distended. The fluid is largely diluted with serum, and often highly albuminous, but as it contains few exudation cells, or flakes of fibrine, it is either only slightly opalescent, or remains quite clear. Although often prolonged over considerable periods, chronic synovitis usually at length undergoes resolution, and the changes above described are slowly repaired ; fluid is absorbed, swelling subsides, and the tissues return to their normal degree of vascularity. The symptoms of acute synovitis are pain, of a tense, bursting, or burning character, worse at night, and aggravated by the slightest movement of the joint, but generally not associated with those spas- modic startings of the limb which occur when the deeper structures are afiected ; swelling, which, as it is due mainly to effusion into, and as it takes the shape of, the synovial membrane, is very charac- teristic ; in very acute cases swelling is due in part also to effusion into the soft structures around the joint ; heat detected when the hand is lightly placed on the surface, tenderness on pressure, and in severe cases, a faint surface blush. The joint is somewhat flexed, and is kept in the position of greatest ease, so that the capsule and ligamentous structures are relaxed. Muscular atroi)hy, detected on measurement, is generally present early ul the case, and sometimes is well marked even in a few days. These various Synovitis, 213 symptoms, after persisting for a time, may gradually subside, and recovery may take place, the usual result when appropriate treatment has been adopted. The affection, however^ is very apt to be prolonged into the chronic stage. Treatment. — The. fii'st step in the treatment of acute synovitis must always consist in placing the articulation at complete rest. This, in the joints of the upper extremity, is effected by means of well-titting splints ; while, when the joints of the lower extremity are involved, not only must splints be used, but the patient must be confined to the horizontal posture. The position of the joint is a matter of great importance. It must be borne in mind that the attack may, through the formation of adhe- sions, leave the articulation fixed ; and also that, as the result of softening of the ligaments, and reflex spasm of some of the surrounding muscles, there is a marked ten- dency, especially in the hip and knee, to the production of defoiTuity. The joint must, therefore, be very gently brought into a position in which, should it be left stiff, it may still be useful. To effect this, and while splints are being applied, an ansesthetic may, particularly in children, be used with advantage, both to produce muscular relaxation and to save pain. Subsequently care must be taken that no deformity is allowed to occur. Other means to be adopted vary with the case. At the present day leeches are seldom em- ployed, nor are they often required ; yet when the in- flammatory process is very acute, and sudden in its onset in strong adults, the application of eight or ten leeches has a very markedly beneficial result. Much relief also is obtained by cold evaporating lotions, tlie application of an ice bag, or by irrigation with iced water. Should the synovial cavity become rapidly distended, the fluid may be drawn off with the aspirator, the utmost care being taken to avoid 214 Manual of Surgery, the entrance of septic matter. The removal even of three or four drachms from the knee joint will often give great and permanent relief. Should the case be seen at its very commencement, or in the first few hours after the attack has set in, the inflammatory process may sometimes be checked by the application of a Martin's indiarubber bandage, which should, however, not be put on tightly. Tliis method is appropriate in instances in which synovitis has been produced by a sprain, or wrench, particularly in such joints as the ankle and the elbow. Adequately treated, acute synovitis usually subsides in the course of from three to eight or ten days, and re- covery gradually takes place. In some instances, how- ever, the affection runs on to suppuration ; a result indicated by an increase of pain and swelling, the appearance of a distinct blusli on the surface, and the presence of oedema of the soft parts around the joint ; by rise of temperature to 101° to 104°, often by the oc- currence of a rigor ; and by an increase of the symptoms of general illness, the patient being restless, and unable to sleep or take food, and showing rapid loss of flesh and strength. The treatment necessary under these circum- stances is that laid down for acute arthritis (page 237). Subacute and chronic synovitis. — As in the acute foim, the joint must be kept at complete rest. Small 'blisters are often useful. They should be applied in a series of three or four ; one healing before the next is put on. In tedious cases the blis- tering may be continued for three or four weeks, or may be superseded in adults by the application of the benzoline cautery. If the joint still contains fluid, or if thickening of. the synovial membrane remains, uniform pressure by means of the indiarubber bandage, carefully adjusted twice or three times a day, should be used. Under this application swelling will often completely disappear in the course of a very few days. Rheumatic Synovitis. 215 Should this plan fail, the joint may be covered with the v.nguentum hydrargyri or the unguentum hy- drargyri compositum spread on lint, and over this the elastic bandage may be adjusted. Rest must be main- tained as long as there is heat or pain in the joint ; or while either of these symptoms or any increase of stiffness is produced by tentative exercise. Later, the joint may be douched with hot salt water and rubbed with stimulating liniments, and passive move- ments (provided they do not produce swelling, heat, or stiffness, that does not quickly subside) may be used. In some instances the joint remains dis- tended with a large quantity of fluid, constituting one of the forms of hydrops articuli. The treatment of this condition is described at page 233, Rlieuuiatic synovitis. — The morbid anatomy of rheumatic synovitis corresponds closely with that of simple synovitis of a like grade of severity. The in- flammatory process, however, often extends more widely, and involves the subsynovial and periarticular tissues. The cartilages, in severe cases, are swollen or even eroded, and the ligaments are inflamed and softened. Suppu ration, though it is very rare, does occasionally take place. The characters of the synovial fluid vary with the intensity of the case. Generally, it resembles that of simple synovitis, except that it is more rich in fibrine. Rheumatic synovitis usually ends in reso- lution in the course of from three or four days to a fortnight. Not rarely, however, when inflammation has extended to the ligaments and periarticular tissues much stiffness may remain ; or even a tiTie fibrous ankylosis may take place, rendering the joint perma- nently fixed. In the subacute and chronic forms of the disease the tendency is towards the organisation of the inflammatory products, and it is to the con- traction of this newly-formed fibrous tissue in the thickened capsular and other ligaments, and in the 2i6 Manual of Surgery. periarticular tissues, that the stiffness of the joint so frequently met with is due. Sym])toins. — Acute articular rheumatism is cha- racterised mainly by the suddenness of its onset and the severity of the local symptoms The joint becomes rapidly swollen from effusion into the syno- A'ial cavity and perisynovial tissues. The surface temperature is raised to 100° or 104°; the skin over the joint is exquisitely sensitive, and often presents a distinct Hush, and movement is extremely painful. Tliere is, however, in the condition of the joint itself, nothing conclusive as to the nature of the case. Diagnosis turns on collateral circumstances : the absence of injury; the sudden development of the affec- tion after a chill ; the history of previous attacks of a similar character ; the presence of acid sweats ; the coincident occurrence of rheumatism in other parts : while should any doubt at first exist, this is often soon cleared up by the appearance of the disease in some other joint. Acute rheumatism differs from acute gout in the fact that it may occur at any age after early infancy, whereas gout is most common between forty and sixty ; that in gout the symptoms, especially the pain, are more inteiTnittent or paroxysmal, often entirely disappearing during the day, and retiirning with agonising intensity during the night ; in gout, too, the joint is much more red and sensitive, and the pain much more violent. In gout the general health is little disturbed, and the pulse and temperature are but little above the normal. In the majority of instances the first attack of gout affects the great toe, while in subsequent attacks the history that the great toe joint has been involved may be taken as a strong presumption as to the gouty aature of the affection. The presence of deposits of urate of soda either in the ears or the finger joints will also be highly important evidence of irout. while the Rheumatic Synovitis. 217 examination of the blood for uric acid would, if it were thought advisable, still further assist in diagnosis. Treatment. — Much of the suffering attending acute rheumatism is due to the dragging weight of the limb, and great relief is often afforded by supporting the joint upon a splint. A splint is also advisable, since it keeps the joint in a satisfactory position and pre- vents deformity (to which there is sometimes a strong tendency in cases in which the ligaments are inflamed and softened), which might subsequently lead to serious results. The joint should be covered with lint soaked in belladonna liniment or lead and opium lotion ; or be sprinkled over with a solution of atropine and morphia, *nd wrapped in cotton wool. The plan of freely blistering the joint, as advised by Dr. Herbert Davies, sometimes gives speedy relief. Experience, no doubt, shows that the aspiration of a joint that has suddenly become tensely distended gives great relief, but the operation cannot be said to be free from risk, and cannot be reijarded as desirable in these cases. Should the extremely rare event of suppuration occur the case must be treated as described at page 237. In severe attacks affecting the knee and the wrist, there is a formidable tendency, as the result of softenincr of the ligaments and reflex muscular spasm, to displacement and distortion. Should this result be threatened, no time should be lost in supporting the joint by the application of efficient splints. Chronic, rheumatic synovitis. — In this con- dition (often left after the acute form has subsided) the affected joint remains enlarged, tender on pressure, painful on movement or when the part is warm in bed, and so stiff and weak that the patient cannot lift any object, or bear any weight on the limb. Usually several joints are affected ; the knee, shoulder, and the small joints of the fingers are most often, the liip, 2i8 Maxual of Surgery. perhaps, the most seldom attacked. The afiection is rerj erratic, often changing from joint to joint, and varying in its severity with the weather, temperature, degree of damp, etc., and especially with the patient's general health. The disease may last for many weeks or even months, while in some cases the joints are left per- manently weak, stiff, and painfuL In some cases the disease assumes, from the first, a chronic and insidious form, attended with pain, weakness, and stiffness, and with creaking and grating ; and goes on to changes in- volving the cartilages and articular ends of the bones, the former becoming fibrillated and worn away ; the latter eburnated and "lipped " at their articular mar- gins. In a thii'd group so much effusion occurs into the synovial cavity as to constitute one of the varie- ties of hydrops articuli (page 232). Treatment. — Rheumatic subjects should wear flannel underclothing in warm as w^ell as in cold weather, so that a uniform temperature of the surface is maintained, and any joint that is affected should be enclosed with a woollen knee cap or similar covering. Though fatigue must be avoided, the patient should be advised to keep the joint in gentle exercise (except during sharp attacks), for a fixed condition of the articu- lation certainly increases the tendency to stiffness. It is a good plan to direct the patient to practise the carrying of the limb through its full range of movement, or to have gentle passive movement regularly performed. Local treatment consists in douching and bathing the joint with the hottest water that can be borne without pain, and in the use of the hot vapour bath and of shampooing. For the management of cases m which the joint is distended with fluid see page 233, When joints are the seat of long-standing rheu- matism, relief is often obtained by strapping with soap plaister or the emplastrum ammoniaci cum hydrargyro. The continuous electric current, in a mild form, is Gout. 219 80Juetimes very useful, both in the relief of pain and in arresting atrophy of the surrounding muscles. General treatment comprises the use of alkalies (bi- carbonate or citrate of potash), with bark or some bitter tonic, if the patient is in weak health. In anaemic cases, quinine and iron should be given. Potassium iodide, in small doses, combined with an alkali, is often beneficial. Free excretion, both by the bowels and kidneys, should be promoted by the use of afierient mineral waters (of which, probably, the Huny^di Janos is the best), and of diluent drinks. A damj) climate should be avoided. Great benefit is obtained from residence at such of the health resorts as are placed at a considerable level above the sea, and at which hot baths, douching, and shampooing, can be obtained. The most suitable are Buxton and Harrogate in England ; and, on the Continent, Aix-les- Bains, Baden, and Wiklbad. i>liilis. — Afiections of the joints are among the rarest manifestations of syphilis. Yet it is pro- bable that they are more common than has hitherto been supposed. They may be met with at any period, both in the secondary and tertiary stages, and also in the inherited form of the disease. {See page 250, vol. i.) 1. In the secondary stage, during the prevalence of skin eruptions, ulcers of the tonsils, plastic iritis, etc., one or more of the joints (most usually a single articulation, and that either the knee or the elbow) may be the seat of an affection consisting of gum- matous infiltration of the subsynovial tissue and eff'usion into the synovial cavity. In these cases thickening of the periarticular tissues in the form of ill-defined indurations, or sometimes of distinct nodular deposits, may sometimes be detected. In their general character, however, these affections present little to distinguish them from ordinary chronic syno- vitis, and their true nature is suggested only by tlieir origin apart from the common causes of synovitis, Syphilis of Joints. 225 and the fact that the subjects of them ha,ve had, or are still suffering from, other forms of syphilitic disease. Their main features are their persistency, and their strong tendency to relapse. Pain, heat, and stiffness are usually but little marked. A woman, the subject of secondary syphilis, was lately seen at St. Bartholomew's Hospital, in whom synovitis of the elbow joint with effusion disappeared under the use of iodide of potassium three times, but at once re- lapsed as soon as the iodide was discontinued. Ulti- mately, however, complete recovery took place. 2. In other instances, in the tertiary jieriod, the disease consists of an osteitis and periostitis of the articular end of one of the bones forming the joint, leading to the formation of node-like outgrowths similar to those met with in other examples of syphi- litic osteitis, and accompanied with gummatous in filtration of the synovial membrane and effusion into the cavity of the joint. 3. In some instances, again, though rarely, the joint is involved by the breaking down of a large gumma in the subcutaneous tissue, and the subsequent ulcera- tion attending the process. In one case the knee joint was involved in the course of syphilitic necrosis of the patella. Some of the most obstinate examples of syjihilitic affections of the joints are those in which the disease is combined with chronic gout, rheumatism, or osteo-arthritis. In infants syphilis takes its origin as a subacute inflammation involving the line of junction of the epiphysis with the shaft. Here, as the inflammatory process advances, a soft granulation tissue is formed, and ulceration ensues', with the result that the epiphysis often becomes detached from the shaft ; caries may extend so as to involve the bone for some distance. In many cases no matter forms, and the joints themselves escape ; but in other instances suppuration occurs, the structure of the p— 21 2 26 Manual of Surgery. epiphysis is broken down, and the articular cavity is involved in the extension of the disease. The diagnosis of these cases may be attended with considerable difficulty. A joint affection, however, may well be suspected to be syphilitic when it occurs apart from local injury in a person who gives no history of gout or rheumatism, but who has had syphilis ; and when ordinary forms of treatment fail ; when other syphilitic lesions are jiresent ; and when the irregular thickening or nodular swelling of the synovial membrane and periarticular structures re- sembles gummatous infiltration of these tissues rather than any of the usual forms of chronic inflammation. In some cases nocturnal pains, depending on osteitis and periostitis, are well marked. Treatment consists in the use of splints to maintain the joints at rest, and the administration of iodide of potassium. In obstinate cases the iodide salt should be combined with the liquor hydrargyri per- chloridi, and the joint should be strapped with mer- curial ointment and soap plaister, or a liniment of the oleate of mercury may be rubbed in. The disease is very obstinate and very prone to relapse ; treatment must, therefore, be persistently carried out, and must include the remedies for chronic gout or rheumatism, when these affections are present. PysBinia, and other acute specific diseases. — A general group of cases of synovitis is formed by those examples which are developed in the course of pyaemia, puerperal and scarlet fever, gonorrhoea, variola, typhoid, dysentery^ and some other conditions. In all alike the affection results from the presence in the blood of some septic material derived from the primary disease ; and in all alike the process at work, though not, perhaps, identical with, is analogous to and well illustrated by that observed in pyaemia. In their general clinical characters these various forms of Pymmia of Joints. 227 synovitis strongly resemble each other, though they present considerable diflerences in their severity, the structural changes to which they give rise, and the subsequent condition of the joints in which they have had their seat. Pyaiinia. — Tnpy?emia the joints maybe attacked at any period of the disease, which, it must be remem- bered, though often acute, is sometimes chronic, and prolonged over many months. In acute cases, often the first symptom of blood poisoning is synovitis of the shoulder, the knee, or some other joint, and soon other articulations are involved. {8ee page 148, vol. i.) In the worst cases several joints are attacked in rapid succession. In these instances the synovial mem- brane is acutely inflamed, and the joint rapidly be- comes distended with flaky pus, often mixed with blood, giving it a red or grumous appearance j and the mem- brane itself, the ligaments, and the cartilages undergo destructive changes ; the skin becomes red, shining, and perhaps cedematous, and the joint within tiiree or four days becomes completely disorganised, the capsule bursts, and the surrounding soft parts become widely involved. In less severe examples the inflammation is subacute, and the synovial cavity is distended vsdth pus, so that its outline is marked out by a flaccid swelling, in which fluctuation is extremely obvious ; the skin, however, is unaltered, and there is so little heat or pain that the patient makes no complaint of the joint, the condition of which may be easily over- looked, or be only accidentally discovered ; while on post-mortem examination little swelling or redness of the membrane is to be observed ; and the ligaments and the cartilage present no obvious change. In some cases, again, sjTiovitis is acute and plastic, and is followed by firm fibrous, or bony ankylosis ; while in others, large readily fluctuating collections, not in- volving the joint itself, form in the periarticular tissue, 2 28 Manual of Surgery. yet without redness or other signs of acute inflamma- tion. It is remarkable that in some examples of pyremia the local manifestations are entirely confined to the joints, w^hile in other instances the joints entirely escape. Prognosis. — In cases in which the patients survive, and repair takes place, the efiusion may be slowly absorbed, and the joint may regain free movement. In the majority of instances, however, there is con- siderable stiffness, often firm, fibrous, or bony anchy- losis, frequently associated with serious distortion. Treatment. — In consequence, in the less acute cases, of the large amount of effusion which takes place, and which is associated with relaxation of the ligaments, and, in acute cases, in consequence of the rapid disorganisation of the joint, there is a strong tendency to the displacement of the articular ends of the bones. This is especially the case in the knee and wrist. Moreover, the joint is frequently the seat of excessive pain, aggravated by movement. It is essential, therefore, that the limb should, from the first, be carefully supported on a splint. When the disease is acute and attended with suppuration, matter should be at once evacuated under strict antiseptic precautions, and free drainage should be provided. When effusion is more passive, and there is no pain or redness of the skin, the fluid may be drawn off with the aspirator. The removal of fluid is advisable. With care the operation may be safely conducted, while, if fluid is left, the fibrine remaining after its moi'e liquid parts have been absoi'bed will lead to the formation of adhesions and the development of ankylosis. In cases in which joints have become disorganised, amputation may, should the patient survive, become necessary. The operation must generally, however, be delayed till the active stage of septic infection has GONORRHCEAL SYNOVITIS. 229 passed, and the temperature is no longer high or widely fluctuating. In scarlet fever synovitis resembles that met with in pyaemia in being sometimes acute, and leading to rapid disorganisation of the joint, by extension of the inflammation to the deeper structures, and some- times subacute or chronic ; in affecting one or several joints ; and in its general course, and termination. The treatment is the same as that of synovitis, depending on pyaemia. The same may be said of synovitis occur- ring in the piterperal state. The joint affection is essentially pyemic in its character. Often the knee is the only joint affected, and the inflammatory process is throughout subacute. The mischief, how- ever, soon spreads to the deeper structures, is very persistent, is accompanied with severe pain, and tends to induce deformity and to terminate in fibrous anky- losis. In some instances many joints are involved, and the case runs the usual course of an acute pysemia. OoiiorrSi€Eal or urethral synovitis, — It is now well known that not only gonorrhoea, but also simple purulent urethritis, such e.g. as sometimes occurs after the use of catheters, may give rise to synovitis. In this affection, for which urethral synovitis or arthritis is a better name than either gonorrhccal synovitis or the old term gonorrhoeal rheumatism, usually one joint, and that a large one, is attacked. The knee is most often affected, but the hip, the ankle, and the wrist are not rarely attacked, while a very troublesome form is that which involves the ankle and the contiguous tarsal joints and the fibrous structures in the sole, with the result of inducing a very aggra- vated form of flat foot. The disease, though sometimes acute, and passing on to suppuration, or even to com- plete disorganisation of the joint requiring amputation, is for the most part subacute (often it is very chronic) 230 Manual of Surgery. and characterised rather by plastic exudation than by coj^ious effusion. The ligaments and the periarticular structures are involved in the inflammatory process, and the tendency to the formation of new fibrous tissue is strongly marked. Bony ankylosis, though it is I'are, may occur. The attack may be ])receded by an increase of the urethral discharge. Often, how- ever, the amount of discharge is unaltered by the onset of the joint disease ; while sometimes discharge is con- siderably diminished. The disease, attended by pain, heat, and moderate swelling, often persists in a form much resembling subacute or chronic rheumatism, now subsiding, and presently returning with increased in- tensity for many weeks or months, and at length leaving the joint permanently stiif. It is not rarely symmetrical. In those cases in which several of the larger joints are attacked {e.g. both the knees and both the hips, or the ankles and the knees) the patient may be left completely crippled. Even the joints of the spine may be afiected, and cases are on record in which in the course of difierent attacks every large joint has become fixed. The affection is very rare ; i.e. its jiercentage among cases of gonorrhoea is very small. Sometimes the affection is ushered in by slight fever and a sense of chilliness, or the occurrence of a distinct rigor. In other instances the premonitory sym])toms are absent, and the first sign is that one of the joints is hot, tender, painful, and swollen, as in subacute iheumatism. A notable fact respecting the affection is that in some individuals it is repeated with every attack of gonorrhoea. Urethral synovitis, though occasionally met with, is very rare in the female sex, A correct diagnosis is very im])ortant, and here, as in so many other cases, it is readily made if the mind of the sui-geon is on the alert. In any case in Avhich arthritis, simulating subacute rheumatism, especially when monarticular, occurs in a person who has never Synovitis in Typhoid Fever, 231 had rheumatism, and when the attack tends to be prolonged and persistent, the question of the presence of urethral discharge ought to be inquired into. Treatment must be addressed : (a) To tlie arrest of the urethral discharge. (6) To the local manage- ment of the joint attack. The treatment of the uretlu'al discharge must vary with the gonorrhoea! or other origin of the affection, the stage it has reached, the amount and character of the urethral secretion. (For directions on these points see Art. XXIII., vol. i.) The joint should be placed at rest. When heat and other symptoms have subsided under the use of cold applications, a course of small blisters (one healing before the next is applied) should be f)rescribed, and the joint may then be covered with mercurial ointment spread on lint, and over this an elastic rubber bandage may be adjusted ; or the part may be strapped with soap plaister. Iodide of potassium is often useful in five-grain doses in the after stages of the disease. Iron tonics will be called for if the patient is anasmic and weakly. If he is gouty, lithia or colchicum should be used. {See under Gout.) Motion may sometimes be restored by move- ment of the joint under an anjEsthetic, followed by daily passive movement, hot douching, and shampooing. In the course and after the subsidence of tyi>9aoicl lever, and less frequently of variola, one or more of the joints may be attacked either with a subacute synovitis (this is the most common form), or with a plastic inflammation involving also the ligaments and the cartilages, or very rarely by an acute suppurative arthritis. The joint most fre- quently attacked, at least in typhoid, is the hip, but other joints occasionally suffer. There is developed synovitis, rapidly leading to effusion, distension of the capsule, and often to spontaneous dislocation, an occurrence that is sometimes unfortunately overlooked 232 Manual of Surgery. till the patient is convalescent from his fever. The plastic form of arthritis is usually subacute and at- tended with considerable pain. It leaves the joint stiff, or in severe cases completely ankylosed, and this often, where treatment has not been applied, in a very inconvenient position. Suppurative arthritis, happily very rare in connection with the exanthemata, presents the general features, and requires the treatment de- scribed at page 237. Hydrops Articuli. Hydi'artlirosis, hydi*arllirus. — In this affec- tion, often vaguely spoken of as dropsy of the joints, the synovial cavity becomes distended with a chronic serous or watery effusion. The condition is produced in several ways. It may remain after acute synovitis has subsided ; or it may arise in the course of chronic synovitis, especially when this is of rheumatic origin ; or it may be developed apart from any of the usual signs of inflammation, in the form apparently of a mere passive exudation, much resembling the simpler forms of hydrocele of the tunica vaginalis. The morbid anatomy of the first two varieties is the same as that of clironic synovitis. In the third form, which, however, is rare, the synovial membrane is anemic and pale, or presents a white or yellowish, macerated appearance. In cases of long standings the membrane itself and its subserous layer become thickened by new fibrous tissue ; and its processes and fringes undergo hypertrophy, present numerous tufts and pedunculated growths, and often contain nodules of cartilage. In some cases the major part of even a large swelling of the joint is due to the close packing of these synovial fringes, and the quantity of fluid present is very small. As time goes on the ligaments become elonijated, and displacement occurs ; or the Hydrops Articuli. 233 joint is loose, weak, and insecure wlien weight is thrown upon it. In many cases large bursal collec- tions are formed in the neighbourhood of the joint. The fluid of hydrops articuli (which may amount to as much as three pints or even more) is a thin, often turbid, form of synovia, containing in many instances flakes and fibrinous shreds. The aflection is most common in the knee. It may be limited t-o one knee joint, but often both are ultimately attacked. It occurs also in the shoulder and elbow, and, though very rarely, also in the other joints. Often single, it seldom involves more than two joints in the same patient. Syiuptoms. — The knee joint, which may be taken as the best example, is largely distended, cool and pain- less, but weak, and its movements are embarrassed. Fluctuation is very obvious. The patella, unless dis- tension is too great, can be pressed down so that it strikes the femur. The synovial membrane, in old cases, is thickened ; and indurated folds and fringes, or even masses of cartilage, can be felt. The bursa under the semimembranosus muscle in the ham is often enlarged, and may extend for some distance down the calf. The patient cannot walk far, and finds going upstairs a great diificulty. The disease is most com- mon in men between thirty and sixty, but it may be met with in females, and at any age after puberty. Treatment. — In the early stage, especially when hydrarthrosis is of inflammatory origin, the joint must be kept at complete rest by means of firm leather or other splints, cut away so that there is space for blistering. A succession of blisters, one and a half to two and a half inches square, should be applied at in- tervals of four or five days, or as they severally heal ; or counter-irritation may be produced, either by iodine paint, or by rubbing in the unguentum hydrargyri biniodidi over a space of two or three square inches. After the blistering (continued for 234 Manual of Surgery. three or four weeks) the joint should be compressed by a carefully applied indiarubber bandage, under which may be placed lint spread with mercurial ointment or with oleate of mercury; or the joint may be aspirated and the treatment, by ela.stic pressure be continued. When all these means fail (and it must be confessed this is often the case), the method has been recom- mended, and occasionally practised, of removing part of the collection with a trocar and canula, and in- jecting the synovial cavity with a solution of tincture of iodine in two or three parts of water. Though it sounds formidable, this proceeding, carefully employed, seems to involve very little danger. Its success, how- ever, is very doubtful; for though it produces con- siderable inflammatory effusion, similar to that following the injection of a hydrocele, the fluid often soon re-accumulates, and the disease continues to progress. As an ultimate step, provided the patient is under thirty and in sound general health, the joint (antiseptic precautions being strictly carried out) may be opened by two free lateral incisions and the fluid evacuated ; drainage tubes, or, better, strips of guttapercha tissue, should then be introduced, and retained for two or three weeks wliile shrinking of the synovial cavity is taking place. In a case of hydrops articuli of rheumatic origin, in a man aged twenty-six, Mr. Willett, at St. Bartholomew's Hospital, opened the knee joint, scraped the synovial membrane, and washed out the joLut with a solution of chloride of zinc (ten grains to the ounce). The patient made a favourable recovery. The temperature never rose above 102 "2°, and was normal after the sixth day. Six months later the patient was found to iiave retained a very useful joint, free from swelling, and possessed of considerable movement. Arthritis. 235 Arthritis. Wlien inflammation attacks a joint, it always begins either in the synovial membrane or in the bones. Neither the ligaments nor the cartilage are suljject to piimary inflammation. The changes they undergo are always secondary. Though, however, the affection originates in the synovial membrane or the bones, it usually soon extends to the other structiu-es, so that all alike are involved. This condition is termed arthiitis. Arthritis has many forms. It may be either acute or chronic, traumatic, infective (as in pyiemia, gonoiThcea, etc.,) or diathetic (as in struma, gout, rheumatism, etc.). Of these varieties, some only will here be noticed, while others, e.cj. the pya3mic, gonorrhceal, etc., are described elsewhere. Syiiiptoins. — Attacked with acute inflammation, the joint is placed in the position of greatest ease, in that, namely, which it habitually occupies during rest, and in w^hich the articular ends are relieved as far as possible from mutual pressure, and the liga- ments and the capsule are as far as possible relaxed. The shoulder remains w-ith the arm close to the side ; the elbow and knee are somewhat flexed ; the wrist a little dropped ; tlie ankle a little extended ; the hip, in a typical case, is flexed, abducted, and rotated outwards. The local symptoms are those of acute inflammation, i.e. pain, heat, swelling, and often some redness of the skin. Pain is throbbinij or bursting in character, often so intense that the patient screams with agony if the limb is moved, or even if the bed is jarred. Nocturnal exacerbations are severe, and, w^henever he attempts to sleep, the patient is disturbed by spasmodic startings and jumpings of the limb, the latter symptom indicating that the ai-ticular ends beneath the cartilage are affected. Increased heat is 236 Manual of Surgery. easily detected, either by the hand or the surface thermometer. Swelling, which is usually considerable, is due mainly to fluid in the joint, but it depends in part on swelling of the synovial membrane, and eflfusion into the periarticular tissues. Constitutional disturbance is often severe, and the temperature ranges from 100° to 104°. When carefully treated from its onset, the aflfection may subside ; but often it advances to suppuration. This event is indi- cated by further rise of temperature, and often by the occurrence of rigors, as well as by an increase of pain and swelling; the integuments become red and oedematousso that they pit on pressure ; soon, as the ligaments become either softened or destroyed, the articular ends of the bones tend to undergo displacement ; grating is often detected, and the patient loses sleep and appetite, be- comes flushed and emaciated, and has copious perspira- tions. In some cases the quantity of matter formed is not great ; in others matter rapidly increases, and unless evacuated, bursts through the distended and softened capsule, and becomes widely difl'used through the limb, which is largely oedematous ; the skin is ruddy or dusky, and pits deeply on pressure, and it be- comes evident that not only the joint itself, but also the adjacent soft structures of the limb, are dis- organised. I>iag'nosis. — Abscess outside a joint may resemble acute arthritis. In external abscess, however, there is no uniform distension of' the joint, but the swelling is irregularly placed, and both it and the fluctuation to which it gives rise are confined to one aspect of the articulation, and are noticed also to be superficial to the various bony prominences and strong ligaments, e.g. the patella or the ligamentum patellae ; or the olecranon and triceps tendon. The joint is not fixed, and admits of ni ovemcnt without severe pain; fluctua- tion is distinct ; tliere is no abnormal mobility of Arthritis. 237 the ends of the bones on each other, and no grating. Constitutional disturbance is not severe. Acide traumatic arthritis sometimes occurs from a severe crush or wrench j it usually, however, follows a wound in which infective changes have taken place. This is a very dangerous form, prone to pass on to suppuration, and rapid disorganisation and destruction of the joint, attended with high temperature, rigors, and severe constitutional disturbance. Acute infective arthritis, met with in pyaemia, puer- peral and scarlet fever, and other allied conditions, is almost equally formidable j the symptoms are usually acute ; suppuration ensues, and the joint is quickly destroyed. Another variety of acute arthritis is that which is secondary to disease of the articular ends of the bones, as met with chiefly in young subjects during the growth of the epiphyses. Here, as sup- puration about the epiphysis advances, the articular cartilage is perforated, and pus, or the detritus of the ulcerative process, escaping into the interior of the joint, leads to a violent arthritis, which, in the course of a few days, entirely destroys the articulation. Yery rarely acute arthritis occurs from the extension of erysipelas or cellulitis to the interior of a joint, or from the bursting into it of an abscess in the neighbouring soft parts, e.g. when abscess in the popliteal space bursts into the knee joint. Treatiiieiit. — In acute arthritis, the first point is to secure rest in a favourable position. Should suf)p\n-ation ensue the matter must be evacuated antiseptically. Should disorganisation of the joint occur, the question of amputation presents itself. Where, however, arthritis has arisen, in the course of pyaemia or puerperal fever, or of any of the exanthemata such as scarlatina or typhoid, the general condition forbids the operation, and the treatment must be expectant, in the hope that a 238 Manual of Surgery. stiff joint may be oLtaiiicd ; or that, later, as the original disease subsides, amputation may be ventured upon. In the arthritis secondary to disease in the articular ends of the bones, which sometimes is very rapidly destructi^•e, and which is most frequent in subjects under eighteen, and common in children of five or six, amputation may be called for. It can, however, as a rule be avoided, by freely opening, washing out, and draining the joint ; by maintenance of complete rest ; and by the continued use of antisep- tics. It should be resorted to only when the patient's general condition is threatening to become serious to life, as shown especially by rapid wasting, failure of strength, and increasing pallor, the results of pain, and loss of appetite and sleep. Should acute arthritis decline, recovery and the restoration of the functions of the joint may be promoted by the means alluded to for the treatment of the subacute and chronic forms of synovitis. The acute arthritis of infants^ described by Mr. T. Smith,"^ is referred to under Epiphysitis. Epiphysitis. The rapid growth which in early life takes place between the epiphysis and the shaft of the long bones, involves an instability, as the result of which healthy nutrition is apt to be supplanted under the influence of feeble health, struma, or local injury, or the pre- sence of some septic or other irritative material in the blood, by inflammatory action. This process, termed epiphysitis, is not usually met with after the age of eighteen or twenty, when nearly all the epiphyses have coalesced with the shafts. It is most common under the age of ten. It may be acute, subacute, or chronic; but in all cases alike, one of the main dangers is that the disease may extend into, and lead to infla.mmation * St. Bartbol. Hospl. Reports, vol. x. Epiphysitis, 239 of, the noigliljonring joint. It is now well known that a very large number of examples of joint disease in children are secondary to disease originating in one of the adjacent epiphyses. (>S'ee page 119.) The acute arthritis of iiiTants, described by Mr. T. Smith, is a case in point. Here, generally in infants under a year, and often only a few weeks old, sometimes from local injury, sometimes from absorp- tion of septic material from the umbilical cord, or other source, the epiphysial line of growth becomes the seat of acute inflammation, quickly running on to suppuration, with the result that ptis, breaking down the soft tissue of the epiphysis itself, travels towards, and soon bursts into the joint, sometimes by a mere pin-hole orifice, but often by a large, ragged opening in the articular cartilage. U]oon this, acute inflam- mation of all the structures of the joint ensues. The articular cavity rapidly becomes distended with pus, the synovial membrane, ligaments, and cartilages are destroyed by ulceration, and even the articular ends of the bones themselves are lost, so that disorganisa- tion of the joint is complete ; the capsule bursts, and a large, plainly fluctuating periarticular abscess hold- ing sometimes as much as fifteen ounces, is formed, and burrows widely in the limb. This affection may involve any of the large joints, but the knee, hip, and shoulder most often suffer. Sometimes several joints are attacked in quick succession. The malady is often fatal by exhaustion. On the other hand, when the case is seen early, and matter is evacuated before the joint is involved; or if, when pus has reached the joint, the articulation is at once freely opened and drained, many patients recover, and may even retain perfect movement of the limb. In other instances, though the patient recovers, the joint is left useless and flail-like, the ends of the bones consisting of mere stumps connected by fibrous tissue. 240 Manual of Surgery. The treatment consists in the immediate anti- septic evacuation of pus (if possible before it reaches the joint), free drainage by strips of guttapercha tissue, the use of a splint to prevent deformity, and of liquor cinchonse and brandy to support the strength. In subacute or chronic epiphysitis in older chil- dren, the disease, which is often dependent on struma, usually begins at the junction of the epiphysis with the shaft, and spreading through the substances of the epiphysis towards the joint, produces either chronic synovitis ; or, if matter bursts suddenly into the articulation, a violent and destructive general arthritis. Syiuptoiiis. — In acute epiphysitis the joint is kept in a fixed position, and is stiff, painful, and ten- der. There may be obvious swelling of the articular end of one of the adjacent bones, with tenderness on pressure and redness of the skin. Within a few hours after it is reached the joint becomes distended and the swelling rapidly increases, so that an abscess bursting through the capsule forms a collection of from two or three to as much as twelve ounces among the muscles of the limb. In epiphysitis of less vio- lent character the symptoms are of a similar nature, but of proportionately diminished severity. In all cases of epiphysitis the surgeon's chief anxiety must be to avert the impending affection of the joint. In the early stage the limb must be kept at rest on a splint ; in acute cases one or two leeches are often very useful. Should matter form it must be at once let out. When swelling, local tenderness, pain, and high temperature indicate that matter is probably enclosed in the epiphysis, an incision should be made over the tender spot, and the epiphysis should be cautiously perforated. If matter is found, an adequate j)ortion of the superficial wall of the cavity containing it should be removed so that pus EriPHi 'SJ T/s. 241 may readily escape towards the surface. Though not invariably, yet frequently, the cases described by Brodie, as chronic abscess in the articular extremity of the tibia (a similar condition is met with in other bones), are examples of chronic epi^^hysitis, followed by suppuration. When the epiphysis at the growing end of one of the bones (the upper end of the humerus and tibia, the lower end of the femur, radius, and ulna) has been long involved in slight chronic inflammation, the increased blood supply may lead to increased growth, and the limb may become an inch or even two inches longer than its fellow. On the other hand, should epiphysitis have been acute and destructive, the sub- sequent growth of the bone may be to a gi'eat extent arrested. Last year I saw a girl, aged nineteen, at St. Bartholomew's Hospital, whose humerus, the upper end of which had been the seat of destructive epiphysitis in infancy, was four inches shorter than its fellow. A formidable and not rare effect of acute e})iphy- sitis and ulceration in the line of junction with the shaft, is the complete detachment of the epiphysis. The upper epiphysis of the femur, when thus separated, being left without adequate blood supply, perishes, and forms a sequestmm. In the case of other epiphyses^ how- ever, though necrosis is still the rule, repaii- may occur, and the epiphysis may regain its attachment. Duiing epiphysitis, especially at the upper end of the tibia, though no complete separation occurs, the connection of the epiphysis and the shaft may be so weakened, that, either at the time, or during subsequent use of the limb, the junction may yield, and a deformity which is very difficult to remove, and which greatly impaii-s the use of the limb, is produced. Should displacement be observed, it must be at once arrested by appropriate mechanical support. (^—21 2 42 Manual of Surgery. ScEOFULOUS Diseases of the Joints. We are still without a concise and adequate defini- tion of scrofula, or its synonym, struma. We can only say that it is a defective condition of the general health, with a tendency to various forms of chronic inflamma- tion, as of the lymph glands, cancellous bone, mucous and synovial membranes, and the skin, tending to pass on to suppuration and caseation of the efiiised pro- ducts. In a considerable number of instances well- marked tubercle is present, while in other cases of more limited duration or of lower intensity, no histo- logical elements beyond those of mere chronic intiam- mation are produced. The scrofulous process arises either when healthy nutrition fails and deviates, apart from any obvious external cause, into a low form of chronic inflammatory action of the type just men- tioned ; or when the same result follows disturbance of nutrition by some local agency, such as injury, etc. {See page 131, and page 216, vol. i.) Tlie chief clinical characters of scrofulous inflam- mations are their origin, either spontaneously, or as the result of some trivial local injury which in a healthy subject would have been quickly repaired ; their ten- dency to suppuration and caseation ; their proneness to advance, extend, and relapse ; their occurrence chiefly in phthisical families ; their multiple develop- ment in the same family, or in the same patient ; and their prevalence between the ages of three and seven, a period of life during which general tuberculosis and tubercular meningitis are more frequent than at any other time, and when local injury is certainly not more common than it is a few years later. When we meet with children who come of a phthisical stock, and who sufler without any obvious cause from a variety of tedious local inflam- mations ; when, in the same family, several cliildren Sm UMO us Joint Disea se. 243 are affected ; and when it is observed that as one inflammatory lesion is slowly repaired, or while it is still in progress, others are developed under con- ditions that exclude the ordinary exciting causes of inflammation in healthy subjects, we appear to be dealing with a morbid condition quite as defi- nite as manv to which distinct names are assigned, and one for which, at least for the sake of conve- nience, some general heading should be used. Yet former conceptions of scrofula, as to its inve- teracy, its inevitably destructive action, and its association with any profound dyscrasia, undoubtedly require revision. These chronic inflammatory pro- cesses, which we gi'oup under this name of scrofula, are very much what they are allowed to become. Probably no affections are more dependent on exter- nal conditions, on the difference between careful treatment. and neglect. Many a child, who, between the ages of three and seven, is the subject of various forms of scrofulous inflammation, such a-s caries of the spine and of tlie tarsus ; ophthalmia or otor- rhoea or oza^na, if w^ell managed, subsequently becomes to all appearance perfectly healthy, and remains free from any return of these affections. Present experience, indeed, clearly demonstrates that the traditional view of scrofula has been derived from cases in which the disease, allowed to run its course, has attained a stage of development and assumed characters which appropriate treatment would easily have prevented. In short, when it is opposed in its outset and subsequently by suitable treatment, scrofula in the great majority of cases is merely a chronic in- flammatory process, formidable in no other sense than 'that it is tedious and prone to relapse. These observa- tions w-ill now be applied to scrofulous diseases of the joints. These affections are most often developed between 244 Manual of Surgery. the ages of three and seven or eight, and although they not rarely commence after this period, they grow more and more infrequent as age advances. The disease takes its origin either in the synovial mem- brane or the ends of the bones, but with what relative frequency it is not easy to say. It must here suffice to state that synovitis is common in all the joints except the hip, though here also it is cer- tainly met with. In this joint disease most fre- quently begins in the bones, either the head of the femur or the acetabulum. When disease arises in the articular ends it commences either just beneath the cartilage (subchondral caries), in the epiphysial line of growth, or in some spot in the cancellous tissue, often in the neighbourhood of the ossific nucleus. It sub- sequently involves the joint by extension of the in- flammatory process, either gradually or by the sudden entrance of pus into the articular cavity. Symjytoms. — Scrofulous synovitis, of which a good illustration is found in the knee, is usually chronic, constituting white swelling or tumor albus. It may, however, be more or less acute, either when it follows injury, or is secondary to disease originating in the bones. In the usual chronic form the joint is a little flexed, and cannot be completely straightened ; movement, though it may be free in the middle range, is restricted before the extreme natural limits are reached ; there is, though it may be slight, pufiy swelling of the synovial membrane, most apparent where the joint capsule is thin. Some abnormal heat may be detected with the hand or the surface ther- mometer, but it is often inappreciable. Pain, it is most important to notice, is often entirely absent ; lameness, though almost invariably present, may be so slight as to escape all but a very observant exami- nation. Muscular wasting soon occurs, and is often one of the most trustworthy symptoms. For the Strumous Joint Disease. 245 symptoms met with in particular joints, see under " shoulder," " elbow," etc. All the above symptoms must be critically inves- tigated, for undoubtedly incipient strumous disease is unfortunately often overlooked, and the aflfection, thus left to itself, steadily advances, and frequently, by involving other structures, passes on to a general arthritis. Under these circumstances the membrane becomes thickened and gelatinous (pulpy degenera- tion), the ligaments and cartilages are eroded, or in great part destroyed, and the joint on manipulation is often abnormally "loose"; while in the knee, hip, and wrist serious displacement occurs. Effusion is seldom present in any large amount, but slow suppuration may lead to the formation of flaky or cheesy pus. In other instances the inflammation is plastic, and the efiused lymph undergoes organisation, so that although the disease has never assumed an active form, and no suppuration has taken place, firm fibrous or even bony ankylosis may occur. These cases of " quiet " strumous disease, ending in absolute stiffness^ are more common than many suppose. When mischief begins in the ends of the bones (^^ee Epiphysitis) the joint is at first free ; but there is enlargement, to- gether with pain, tenderness, and puffy swelling at the seat of disease, and local heat ; while, as soon as the joint is reached, the symptoms of synovitis, above described, become apparent. Sometimes synovitis remains slight and subacute, often with intervals of apparent recovery ; in others, when the joint is suddenly inoculated with pus, acute arthritis is immediately developed. Treatment. — It is a law to which no exception can be safely made, that a strumous joint must be kept at absolute rest. The view that, because the disease is '' constitutional," local treatment is not so important as that the patient should have exercise in 246 Manual of Surgery. the open air, is completely erroneous. Fresh air is, of course, of the highest value as an adjunct to local treatment. Yet local treatment must invariably stand first. If these joints are, from the onset of the disease, kept at rest, their recovery, often with completely free movement, is, in the great majority of cases, merely a question of time. Even those that are more or less stiff are strong, useful, and free from defor- mity. For the details of the treatment of hip disease see page 287. The knee is best enclosed in leather Fig. 51.— Leather Splint for Knee. splints {see Fig. 51) till all active disease has sub- sided. Then Thomas's splint may be used. The re- maining joints should be kept in leather splints (Figs. 52, 53, 54), these being removed every two or three days, while the skin is gently sponged and dried, and then immediately re-applied. In the meantime, the patient must not put his foot to the ground, or make any use whatever of the joint. Everything depends on the absolute manner in which these rules are carried out. If matter forms it should be evacuated anti- septically. The pei-iod required for recovery must vary with the case ; from three months, to nine or even twelve months, being the necessary time ; while if the disease is already of long standing the time must be extended to eighteen months or even two years. Excellent recoveries may be thus secured, in cases Strumous Joint Disease. 247 that v/oiild otherwise come to excision or amputation. It is quite certain that if the patient is well fed, and is in a well-aired room, or in the open air when the weather is suitable, enforced rest will not materially impair Fig. 52.— Leather Splint for Elbow. the general health. The period of rest must in each case be determined by the previous duration of the disease, and the readiness, or the reverse, with which Fig. 53.— Leather Splint for Wrist. the symptoms subside. As a rule, however, rest should be maintained for at least three months after all signs of disease have disappeared, and active exercise should be very gradually renewed. The danger always is that it may be resumed too soon. It is a common belief that if joints are kept long in a hxed position they will become stitf. This is a fallacy. Stitlhess 248 Manual of Surgery. results when inflammatory action has led to ankylosis. Hence the surest way to avoid this result is to subdue the inflammation by rest. Many a joint retains unimj)aired motion after it has been at rest for six months, or even for upwards of a year. In those cases, and tliey undoubtedly occur, in which stifihess follows long rest, the result is due not to rest, but to the plastic character of the inflam- matory [)rocess. Another fallacy is that joints often become permanently fixed by muscular rigidity ensuing during enforced rest. Such a result is, to say the least, very rare. With local rest must be combined a dry climate, fresh air near the sea, where this is practicable, nutritious diet, warm clothing, and tonics, of which cod-liver oil is the best during cool weather, and the more easily digested preparations of iron in the summer months. Before leaving this sul)ject reference may be made to "senile scrofula," a term given by Sir James Paget'^ to cases in every respect resembling scrofulous affections as they are met with in children and adolescents, except that they occur in persons from fifty years of age and upwards, some- times in patients past seventy. Diseases of this nature attacking the joints, usually the wrist and elbow, but occasionally the hip, knee, and other articulations, either spontaneously or after some slight local injury, run sometimes a chronic, but, in other * Ciin. Lectures and Essays. Fig. 54. —Leather Spliut for Ankle. Pulpy Degeneration. 249 instances, a rapid and destructive course, quickly- going on to suppuration and disorganisation of the joint. Even in their milder forms they prove little amenable to treatment, which should be that already laid down for scrofula : while when they are acute they quickly advance to a stage in which amputation may become necessary. Pulpy deg^eiieration. — Tins term has como down to us from Sir B, Brodie, who applied it to in- stances in which " the syno^^.al membrane was con- verted into a brown pulpy soft mass, from a quarter of an inch to an inch in thickness, intersected by white membranous lines, and studded with red spots, formed by small injected blood-vessels," while " vascular fringes projected into the cavity of the joint, a good deal resembling, both in appearance and structure, the appendices epiploicae of the large intestine. The semilunar cartilages were entire, but were in a great measure concealed by the pnlpy substance projecting over them. The cartilages were in a state of in- cipient ulceration. " Observing that at the commence- ment of these cases there was neither pain, tenderness, nor other sign of inj3ammation present, that the en- largement of the joint began almost imperceptibly, and increased steadily, and that there was no pain even on movement, Brodie held that the disease was "no more inflammatory in its origin than morbid growths generally are in other organs." Later re- search, however, has shown that these changes are not dependent on any form of new growth, but that they are due to an insidious and frequently intractable form of chronic inflammation of the synovial membrane, often tubercular in character. Hence, by common consent, the term pulpy degeneration is dying out, and is now seldom mentioned, except (as here) to avoid confusion as to the sense in which it was originally used. 250 Manual of Surgery. Loose Bodies. These are most common in tlie knee, but tliey are also occasionally found in the elbow, hip, and shoulder. In the other joints, though not unknown, they are extremely rare. They present the following varieties : 1. Though Hunter's view, that coagulated blood in a joint might undergo conversion into a mass of cartilage or bone, was erroneous, those loose bodies which present a merely fibri- nous structure may possibly (though clear proof is wanting) be derived from altered blood clot. 2. Blood extravasated into a synovial fringe may become organised and form a peduncu- lated body, and, when the stalk ^, ^ ^ -, ^ srives way, fall loose into the 55. — Loose Body from ^ • i • , a Joint. synovial cavity. fepecimens exist to show this. 3. When a synovial fringe or a patch of sub- synovial tissue has become, from injury or some other cause, enlarged and thickened, and when it is caught and dragged upon by the movements of the joint, its base is gradually drawn out into an elongated pedicle, and it becomes a floating body. Such a body may long remain attached ; l)ut its stalk may at length give way so that it falls free into the cavity of the joint (Fig. 55). Bodies of this origin consist of con- nective tissue and fat, often mixed with inflammatory products, covered with endotheliujn. 4. Synovial fringes, hypertrophied in the course of chronic rheumatic disease, or of osteo- arthritis, often become converted into cartilaginous bodies by over- growth of the cartilage cells, which, as pointed out by Loose 'Cartilages. 251 Rainey and Kolliker, are normally present in them. These bodies remain for a time attached Ly a pedicle (Fig. 56), but this at last gives way and they become free. Such bodies consist of hyaline cartilage, or of fibro-cartilage which, however, may undergo calcareous degeneration, or be converted into true bone. 5. After a severe contusion or other local injury, a portion of articular cartilage may, as desciibed by Sir James Paget, undergo " quiet necrosis," that is, may perish independently of any overt sign of inflammation, and be shed into the joint (Fig. 57). In other cases the mass so necrosed and cast off includes not only the articular cartilage, but also a portion of the sub- jacent bone (Fig. 58). 6. Or a piece of cartilage, or cartilasfe and some of the sub- jacent bone, may be chipped off, and fall into the joint. 7. The nodular masses that form about the joints in osteo- arthritis may project into the articular cavity attached by a thread of synovial tissue acting as a pedicle. In many cases the pedicle at length snaps and they are free (Fig. 59). 8. Mr. Shaw has recorded a case in which a loose body was found, on removal, to contain the point of a broken needle. Probably the needle, accidentally embedded in the subsynovial tissue, had, by causing irritation, led to the formation of the body which had subsequently become detached. Joints in which loose bodies are contained are Fig. 56. -Loose Bodies in Joint. 252 Manual of Surgery, often otherwise healthy, or subject from time to time merely to slight inflammatory attacks when the body is caught between the articular sur- faces so as to inflict mechanical injury. In classes 4 and 7, and often in class 3, the joint is the seat of chronic rheumatism, or osteo- arthritis. In hydrarthrosis the synoyial membrane often presents nodular masses of cartilage, or thick fringes that produce analoijous symptoms. Loose bodies are fi'equently single, but their number is subject to wide yariety. In osteo-arthritis there are often as many as from six to twenty or more. Lately, at St. Bartholomew's Hospital, Mr. T. Smith remoyed 415 bodies from a knee joint ; of these only five or six were attached. The jmthology of this remarkable case was obscure. Symptoms. — These yary with the nature of the body itself, and the condition of the joint in whicli it is present. In a typical case (e.g. of quiet necrosis, or in \yhich a mass of cartilage has formed in a hypertrophied synoyial fnnge, and has become detached, the joint being otherwise healthy), the patient while walking is seized with such agonising pain, coming on as suddenly as if he had re- ceived a blow, that, losing all power in the limb, he falls, oyercome witli a sense of momentary faintness. Sometimes the joint remains freely moyable, and the patient can walk, when in Fig. 57.— Loose Body from Joint. A, Anterior, !ind b, pos- tf rior gurfacc. Fig. 58.— Loose Body from Joint. Loose Cartilages. 253 the course of a few minutes the pain goes off. In other cases the limb becomes fixed at an angle of about 130*^, and any attempt at movement causes unbearable suffering. This stiffness may remain for a time, and then, on some movement of the limb, suddenly dis- appear. It may, however, continue till the joint is surgically manipulated. {See page 258.) The accident Fig. 59.— Loose Bodies from Joint. is followed by sharp synovitis indicated by pain, heat, swelling, and stiffness lasting two or three days. Often the patient detects the body, and ascertains either that it remains in one situation (when attached), or shifts to different parts of the joint. Probably loose bodies are most commonly felt in the pouch over the external condyle of the femur. The agonising pain alluded to is produced when these bodies are caught between the joint surfaces, so that the liga- ments are severely stretched and the articular surfaces contused by the powerful leverage with which the bones act upon each other. The articulation remains fixed when the body is caught and held like a stone in the hinge of a gate, but usually the cartilage slips away as pressure increases, and the joint is freely movable again. The symptoms may return frequently when the body 2 54 Manual of Surg fry. is of moderate size and movable. But when it is large, and can be cauglit only in certain positions, the attacks occur at wider intervals ; once a month, or even in three or four months. In osteo-arthritis, or other conditions in which the joint is extensively diseased, the symptoms are much less characteristic ; but there is still the occurrence of sudden pain coupled with arrest of movement, and the fact that either the patient or the surgeon detects the body. Treatment. — Formerly the complications ensuing upon wounds of the large joints were so formidable that the removal of loose bodies by cutting down upon them (the " direct method ") involved, as numerous published tables have shown, a mortality of at least twenty per cent. This was considerably reduced by the introduction of the valvular or " indirect method." In this, an instrument like a large-sized tendon knife, but with its blade mounted on a long shank, is passed through the skin at a distance of an inch and a lialf from the cartilage, and is carried horizontally onwards till the body is reached. The synovial membrane is then freely divided, and the knife, when it has been slightly withdrawn, is moved from side to side in the subcutaneous fat, so that a space, or a pocket, is formed. Into this the cartilage is slipped. Here it may be allowed to remain permanently, or, when the wound in the synovial membrane has healed, it may be cut down upon and removed. A serious drawback to this method is that it is apt to fail, even in the hands of experienced operators, either because the synovial membrane has been insufficiently divided, or a large enough space has not been formed in the peri- articular fat for the reception of the cartilage, or because the cartilage is not free, but still attached within the joint. Hence, at the present day, when it is the ex- perience of every surgeon that if due precautions are Loose Cartilages. 255 taken to avoid the entrance of septic materials tlie large cavities, like the peritoneum, may be safely opened, the direct method is almost exclusively in use. It is thus performed : The cartilage is securely held (at some spot where the joint capsule is thin) by transfixing it with one or two strong steel needles, (of which a trustworthy assistant should have charge), exposed by a careful dissection, and extracted. Any bleeding should be arrested before the joint is opened. If the body is attached its pedicle must be divided, having, should it appear vascular, been first tied with fine catgut. The wound is then brought together with fine catgut sutures, which should include the synovial membrane, and dressed with carbolic gauze ; and the limb is placed on a back splint so that absolute rest is maintained. Healing generally takes place by the first intention, and there is no rise of temperature. This proceeding, properly carried out, is so free from risk that it may be recommended without hesitation in cases in which the joint is free from advanced disease, and the patient is sound and not far past middle age ; and it may be regarded as in all respects preferable to the indirect method. In instances of osteo-arthritis or rheumatic disease, in otherwise sound patients, in whom multiple adventitious bodies materially interfere with the functions of the joint, all those that are completely loose, or that can easily be removed, should be extracted; while others should be left till they become trouble- some ; in elderly or unsound patients it is best not to operate, especially if, as is not rarely the case, a knee cap or a pad and bandage suffices, as the joint is no longer the seat of vigorous movement, to relieve the symptoms. The diagnosis between cases of loose bodies and cases of internal derangement of the knee joint may be gathered by referring to page 257. 256 Manual of Surgery. Displaced Semilunar Cartilage. Hey, under the title of internal derangement, and Sir Astley Cooper under that of subluxation of the knee joint, were among the first to point out the main clinical symptoms of cases in which the semilunar cartilages of the knee are displaced. The general impression that the internal cartilage is most often involved is probably true, but cases are not rare in which the external is at fault. The following conditions are met with : (a) In a healthy joint, during a violent effort, often of rota- tion, one of the cartilages at some part of its circum- ference may either protrude or slip inwards, in rela- tion to the condyle of the femur. In such cases either a prominent rim or a deep sulcus may exist over the site of the cartilage. (6) The strain on the carti- lage may be so great that its marginal attachments are partly or completely torn through, and the disc may be displaced, its anterior portion slipping back entirely behind the corresponding condyle ; or the whole cartilage slipping inwards, so as to lie in the middle line, in the intercondyloid notch of the femur, (c) The cartilage may not only be uprooted at its cir- cumference, but be also torn across, so as to slip about like a pedunculated loose body, (d) The end attach- ment of one of the cartilages may be torn away, bringing with it a fragment of the tibia, (e) In cases of old synovitis, especially in rheumatic subjects, the attachments of the cartilages become elongated, so that, acquiring too wide a range of movement, they fre- quently slip out of place. {/) After injury, the external cartilage, and perhaps the internal, though I have seen no examples, may become enlarged and thickened, so that on certain movements of extension and rotation it protrudes widely, and can be very dis- tinctly felt. I have met with two cases in which this condition was very clearly marked. (^) R. W. Displaced Cartilages. 257 Smith has recorded a case in wliich the internal cartilage was accidentally transfixed by a hackle pin, and apparently torn, or partially separated, from its connections, so that it could be felt protruding beneath the cicatrix of the wound, where it interfered considerably with tlie movements of the joint. Displacement of these cartilages, though most common dui-ing the vigorous period of adult life, may occur, as the result of injury, in children of six or eight, or in elderly persons whose joints are the seat of chronic rheumatic eiiiision. {See page 200.) Syiiiptoins. — These vary with the nature of the case. When in a healthy joint the cartilage is diiven, by a sudden screw movement of the femur and tibia on each other, out of place, but without lacera- tion of its attachments, the pain at the moment is as severe as that attending the slip of a " loose cartilage," and the joint is found partially flexed and "locked," and peuhaps with some deviation of the axis of the tibia, often in the direction of abduction. The i)atient cannot usually move the joint, yet on manipulation, though it is locked against full extension, it admits of partial flexion. Sometimes the disc is felt protruding ; or it may have so slipped inwards as to cause a deep tucking in of the skin ; often, however, nothing can be seen or felt on external examination, and the accident must be inferred from the " locked " condition of the knee. In a few hours all the signs of a more or less acute synovitis generally come on. When the attachments of the disc are widely torn, the cartilage, from the moment of the injury, slips freely about, and the joint goes " in " and " out " with every attempt at movement. Subsequently the sHp becomes less frequent, and occurs only on certain movements, usually of flexion, or flexion combined with rotation. E— 21 258 Manual of Surgery. Many patients know exactly how to put the "joint out," and can thus materially help the surgeon in formincj a diamiosis. In cases in which the attach- nients of the cai-tilage have become relaxed by chronic synovitis, or otherwise, the joint is liable to become suddenly locked and painful on any casual movement ; e.g. as the patient rises from his chair, turns in bed, or crosses one knee over the other. Sometimes tlie lock is only momentary ; in other cases the joint remains fixed. The slip is at first followed by synovitis, but after a time the joint becomes more tolerant, and the subsequent heat and swelling are little marked. In the intervals between the attacks the joint is, to all appearance, normal. Treatment. — In many cases, though the " slip " causes some momentary pain, and is followed by two or three days of synovitis and lameness, the cartilage at once passes back into its place, and does not, there- fore, lock the joint. In others it remains displaced so as to lock the joint until it is set free, either by some accidental movement, or by manipulation of the limb. If overlooked, the displacement may remain for some weeks, or even months. Many patients know how either to move the limb, so as to effect reduction, or to direct a passer-by to do so. Sometimes one movement has the desired effect, sometimes another. The plan most likely to succeed is to bend the knee to the fullest extent ; a movement which, by relaxing all the ligaments, and separating the articular surfaces of the bones as far as possible from each other, tends to disengage the cartilage; then to freely rotate the tibia upon the condyles of the femur, at the same time that the bones are drawn as far as they can be aj)art, and then suddenly, but not with undue violence, to carry the limb into full extension. During these movements firm ])ressure with the thumb should be made on the cartilage at any point at wliich it seems Displaced Cartilages. 259 over-prominent, or where there is tenderness. Some- times reduction is effected with a snap, to be distinctly felt or heard. In many cases an anaesthetic is highly advisable, or, indeed, necessary, in order to secure muscular relaxation and so limit the amount of force that is required to extend the limb. In these cases of slipping cartilage it is not enough merely to efiect reduction. Means must be taken to prevent a return of the displacement. For this purpose, one or other of the clamps shown in Figs. 60, 61, will be found extremely useful. Fig. 60 shows a light semicircular steel spring, passing behind the joint, and ending in two plates, which embrace the edges of the patella and make pressure on the lateral parts of the joint. Fig. 61 shows two jointed bars, one for the outer and one for the inner sides of the joint, connected above and below with steel semicir- cles, and fastening above and below the patella with straps. To either clamp a pad for pressure over any part of the cartilage that protrudes may be added. In a case, in which the cartilatie was torn across, 1 • • • the joint remained useful after the lacerated disc had been removed. This example, together with others that have been recorded, is important, as showing that the removal of the semilunar cartilages involves no Fig. 60.— Clamp for cases of Displaced Cartilage. 26o Manual of Surgery. material impairment of the function of the joint. Such an operation, however, can be very seldom required, and ought never to be undertaken until all other means, especially the use of the clamps described above, modified according to tlie case, have been tried and have failed. In instances in which displacement has followed recently on an injury, or relaxation of the attachments of the cartilages re- sulting from recent synovitis, the use of the clamp Fig. 61.— Clamp for Cases of Displaced Cartilage. may be discontinued after from three or six montlis to a year. In some cases, however, it must be per- manently worn. Many patients find themselves able, when wearing the clamp, to play tennis or take any form of active exercise without recurrence of the slip. In those rare cases in which lepeated attempts have failed to secure reduction, the joint will gradually acquire fairly free movement as the cartilage adapts itself to its new position. Tumours of Joints. Very important cases are occasionally met with in which the question arises whether we have to Tumours of Joints. 261 deal with some inflammatory or other disease of a joint, or with a new growth in the articuhir end of one of the bones. Tumours that imitate joint disease most commonly involve the original growing ends of the bones, that is, the upper end of the humerus and tibia, the lower ends of the femur, radius, and ulna. Hence the question of diagnosis between tumours and joint disease mainly, though by no means exclusively, concerns the shoulder, the wrist, and the knee. Tumours near joints belong generally to the sarcomatous group ; some are myeloid in structure, some round or spindle-celled. Some, however, are entirely cartilaginous, or sarcomatous with a large admixture of cartilage. Some spring from the interior of the bone, while others, probably the majority, are subperiosteal. In the course of their growth they impinge upon iand at length come to occupy the cavity of the joint, and lead to the entire destruction of the synovial membrane, ligaments, and cartilages, as well as the articular end of the bone in which they have originated ; and to wide displacement and deformity of the joint. The likeness of a new growth to joint disease is sometimes so close that great care is required to avoid an error that may lead to disaster. This is the case when the new growth is soft and elastic, and when it is seated in the immediate vicinity of, or has even extended to, the synovial membrane, so that both by its position and its consistence it may be mistaken for a mere inflammatory thickening of the latter structure \ and when, moreover, as not rarely happens, the growth, by interfering with the circulation, has led to effusion into the cavity of the joint. Such tumours, which are usually subperiosteal, generally grow towards the joint in the form of fleshy or spongy, ill-defined or flattened lobes surrounding the bone, and merging im- perceptibly into the adjacent soft structures ; or of 262 Manual of Surgery. firm nodules closely abutting on the joint. The joint diseases which they may closely resemble are {a) syno- vitis attended with some eifnsion, but mainly character- ised by considerable pulpy thickening, and induration of the synovial membrane ; (h) certain forms of chronic rlieumatism or osteo-arthritis with synovial effusion, and irregular nodular enlargement of the articular ends of the bones. The main points indicating the presence of a new gi'owth are the following : A new growth is irregular and, as a rule, extends in some directions obviously beyond the confines of the joint. The shaft of the bone, as well as its mere articular border, is dis- tinctly enlarged ; the swelling at the part most remote from the joint is often hard, nodular, lobed,or tuberose ; one bone only is afiected; movement of the joint within certain limits may be free. Enlargement is usually rapid and continuous, so that in three months the disease has attained considerable size ; the lymphatic glands may be enlarged. Pain, heat, effusion, and dis- tension of the cutaneous veins are symptoms on which in respect to diagnosis little dependence should be placed. In new growths pain may be either slight, moderate, or severe ; heat of the surface and general rise of temperature may be as marked as they are in mere inflammatory joint disease ; the cutaneous veins are often enlarged and conspicuous in some forms of synovitis. Some guidance may be derived from observing whether the patient presents any evidence of the strumous or of the rheumatic diathesis, or is suffering from disease of any other joint ; and the history of the case, and of the patient's family, should be inquired into. Should doubt remain, the disease should be very closely watched, careful measurements should be taken, and the case should be treated as if the affection were inflammatory, with rest and well- fitting splints, or with such remedies as the features of each particular case may suggest. It may even be Excision. 263 advisable, due care against septic infection being taken, to remove a portion of the disease for micro- scopic examination, so that diagnosis may be completed and the appropriate treatment entered upon ^vitllout delay. Treatment.— The treatment of tumours of the articular ends of the long bones involving the joints is laid down in Art. ii. Here it will be sufficient to remark that the choice must lie between amputation of the limb, and enucleation of the growth ; or in the case of the upper end of the humerus, or the lower extremity of the ulna or radius, excision of the end of the bone. The latter proceeding may be adopjted when the tumour is either myeloid or cartilaginous, and not too extensive ; but in other instances amputation should be performed. As some uncertainty usually remains, an incision ought always to be made into the tumour before amputation itself is proceeded witL The Question of Excision in Joint Disease. In estimating the value of excision as a means of treating diseases of the joints it is at once ap- parent that the question, far from turning on any simple issue that can be concisely stated, is one in the discussion of which several important con- siderations have to be taken into account. This, however, is not always borne in mind. Some authori- ties are, as many think, too ready to look at excision merely as a surgical operation, whose success is in itself enough to secure a verdict in its favour. But the fact that the wound will heal rapidly, so that the patient will be up and about in a few weeks, is not enough to justify a lesort to such an operation as the excision of a large joint. It must first be shown that there are no means of a less heroic kind that will secure a still better, or even an equally good, result. 264 Manual of Surgery. Operations rest in different cases on different principles. Now the principle of excision is the same as that of amputation, or the removal of an eye-ball or a testis. That is, it abandons all attempt to cure disease, and falls back on the somewhat primitive expedient of cutting away the part in which the disease is placed. Although there are many circumstances in which the surgeon is driven to adopt this kind of operation {e.g. in dealing with malignant disease), it is obvious that it should be avoided whenever, in the interest of the patient, it is possible to do so. It must be remembered also that the necessity for an operation often depends on the stage which surgery has reached. Many operations formerly called for have, as surgery has improved, been to a great extent, or even entirely, set aside. Some thirty or forty years ago the treatment of inflammatory diseases of the joint was so little understood, that these affections commonly went on from bad to worse and to the development of formidable complications, until amputation of the limb was the only course that remained for relieving tlie patient from intolerable suffering, and enabling him to follow some occupation, or even for saving his life. At this period a great advance was made when Sir W. Fcrgusson and others introduced excision as a substitute for amputation, and endeavoured, by re- moving the affected joint, to save the remainder of the limb. Since that time, however, our knowledge of diseases of the joints has been considerably in- creased, the means of forming an early diagnosis have been attained, and the efficacy of early treatment on the principle of complete rest has been amply demonstrated. It has also come to be well known that, if due precautions are taken, a joint in which suppuration has occurred may be freely oj)ened and drained as safely as any other large abscess cavity, and that in the majority of cases thus treated the patient Excision. 265 recovers with a very serviceable limb. Under these circumstances, it would, at first sight, appear that the necessity of resorting to any large operation, whether amputation or excision, involving the sacrifice of the affected joint, had been set aside, and that the broad principle of conservative surgery, the cure of disease rather than the cutting away of the organ in which the disease is placed, would be as applicable in the case of the joints as in any other field of practice. Arguments for excision. — There are, however, three grounds on which some surgeons still advocate the frequent resort to excision as a means of treating strumous joint disease : (1) that the operation saves time ; (2) that, as tuberculosis is present^ recovery without operative interference is very improbable; (3) that by removing the structure in which tubercle is deposited, the danger of general tuberculosis is averted. None of these arguments will bear close examination. 1. In the first place, the time saved (in other words, the rapidity of repair after excision) turns on the period of the disease at which the opera- tion is performed. In many cases of long- standing disease, in which the tissues have become widely degenerate, so far from time being saved, the wound often never heals at all ; or it heals only after a period (extending over many months, or even over two or three years) that would have much more than sufficed for cure by continuous rest. In many instances the disease is entirely unchecked, or con- siderably aggravated by the operation. The only cases in which rapid healing can be depended upon are those in which such sli^fht changes have taken place that continued rest w^ould certainly lead to recovery, and often to the restoration of perfectly free movement in the joint. Besides, it is obvious tljat rapid repair is not everything. If it were, 266 Manual of Surgery. amputation ought to be performed in many compound fractures, and even for many lacerated wounds. 2. To the proposition that as tubercle is commonly present, recovery without operative interference is im- prol)able, the reply is, first, that microscopic investiija- tion shows that tubercle is often absent in the eai-ly stages of tliese affections ; and secondly, that whctlior tubercle is present or absent, cases which are treated by rest will, in all but very exceptional instances, end in recovery, a fact attested by the circumstance that excision is scarcely ever performed for patients in the middle or upper classes. 3. The view that excision averts or largely di- mmishes the liability of systemic infection is met by the observation, first, that tubercle is, as already men- tioned, often absent ; that general tuberculosis is rare as a sequel of articular disease (page 287); that even in cases in which tubercle is present, it is impossible to ensure its complete removal by excising the affected joint, or to guard against the existence of other and more active centres of infection elsewhere, e.g. in some part of the lymphatic system. Obvious drawbacks to the general resort to ex- cision are, first, that repair will not take place unless the patient is in fairly good general health. Hence, to secure what are termed good results, the opera- tion must often be performed early, that is, when rest alone would have sufficed to effect a cure. At later stages the operation frequently entirely fails, the wound remaining unhealed, suppuration continuing, and the case, unless amputation is performed, ending fatally by exhaustion or amyloid disease. Secondly, the limb after excision is, as a rule, much less useful, even when favourable repair has taken place, than after recovery without operation. After excision of the knee in patients under ten (and the conditions for which the advocates of excision Excision. 267 employ tlie operation, are much more common before than after that age), the limb is, in many instances, so short and deformed by gi'adual yielding that it is in great part or entirely useless. These remarks, unavoidably much condensed, are not intended as a sweeping condemnation of excision, but as supporting the view that the operation is one, even at present, of very limited application, and one that is destined in the future to fall more and more into disuse. In the case of the joints, as in that of the eye, the testis, and numerous other instances, true progress lies in the direction of cultivating early diagnosis, in diffusing a knowledge of the great importance of attacking disease before serious structural changes have occurred, and in the adequate application of the principle of rest. When all this has been done, the necessity for such a proceeding as excision will very seldom arise. Cases adaiAed for excision. — In the meantime, however, there are various instances in which ex- cision should be adopted. These, in the case of the hip, are mentioned at page 293. In the knee, excision is mainly of use in cases (a) in which the bones are in good condition, but where, as the result of subacute synovitis of long standing, attended with relaxation of the ligaments, so much displacement has occurred that the limb cannot be brought into a serviceable position ; (b) in which, though displacement is limited, the synovial membrane is the seat of extensive pulpy degeneration, a con- dition in which repair is very unlikely to take place. The operation is not generally suitable when the patient is under five or even seven ; when disease is acute ; when the bones are extensively involved ; or when the general health has broken down. As to the value of excision in the other 268 Manual of Surgery. articulations, the slioulder joint is comparatively seldom diseased, it is easily kept at rest, and shows a strong tendency to gradual recovery, it is lial)le to no de- formity, and although the joint almost invariably be- comes stiff, compensatory movements at the elVjow and between the scapula and the trunk are so free tliat the limb remains useful. Hence, excision is very seldom either called for or performed, and certainly the limb, after it, is generally much less serviceable than after repair by continued rest. The elbow is, of all the joints, that in which ex- cision yields the best results. As growth takes place at the upper extremity of the humerus, and the lower extremity of the ulna and radius, the removal of the elbow joint ends of these bones does not materially affect the length of the limb, nor is length here a matter of much importance. If sufficient bone is removed to prevent ankylosis, and if the anconeus is preserved, free motion and considerable power are secured ; the amount of repair to be effected is com- paratively small. • Yet even in this instance it is only in cases that have been utterly neglected that excision can be necessary ; for if the joint is kept at rest and in good position, the disease will very rarely indeed become serious ; on the contrary, it will undergo steadily advancing repair. Even when suppu- ration occurs, if the joint is opened antiseptically, provision made for free drainage, and rest is continued, recovery will still, as a rule, ensue. Excision of the wrist for disease is a rare operation, generally attended with very limited success. There are but very few cases in which disease of this joint, when adequately treated by rest, does not end in re- covery, and the restoration of considerable or even un- impaired movement ; whereas, after excision, the move- ments and strength of the hand are alike very seriously impaired. Usually the removal of any of the carpal Amputation in Joint Disease. 269 bones that are provoking prolonged suppuration is better than a systematic excision. In the case of the ankle, as in. that of the wrist, excision is both rare, and, as a very general rule, in- advisable. In the early stage disease readily yields to treatment by continued rest ; in the later stage it is very rarely confined to the end of the tibia and tibula ; it much more commonly involves the tarsus al^o, so that the astragalus and perhaps some other bones must be removed ; it is difficult to perform the operation without injuring surrounding tendons and other im- portant anatomical structures ; repair is tedious, and the limb is a])t to be subsequently less useful than it is after a Syme's amputation of the foot. As to excisions in patients over twenty-five, it must here suffice to say, that although successful cases have been recorded, the operation in the case of the hip and the knee is so formidable to life that it cannot be generally recommended. Amputation is almost constantly the safer alternative. In the other joints, especially the elbow, excision may, in properly selected cases, jT^eld good results in healthy subjects in whom disease is not acute, and in whom the bones are not extensively involved. The Question of Amputation in Joint Disease. It has been pointed out that inflammatory affec- tions of the joints are amenable, in a degree that was entirely unsuspected even a few years ago, to appro- priate treatment ; and the opinion has been expressed that when, instead of being allowed to advance until serious structural changes have occurred, these diseases are adequately treated in theii* incipient period, excision will fall almost entirely into disuse. The same may be said of amputation for joint disease, although it will probably in the future become the more common operation of the t\vo. As matters 270 Manual of Surgery. at present stand, however, disease, in a considerable number of instances, reaches an incurable stage, and becomes associated with various complications, and amputation is all that remains to be done. The grounds for resorting to the operation may refer either to the joint itself or to the general condition of the patient. Thus, in some instances in which the disease has become so advanced that there is no probability ol repair by rest and its accessories, the ends of the bones are so extensively involved that excision is inadmissible; in others copious suppuration and wide burrowing of matter through the limb preclude excision ; in acute disease, should the question between excision and amputation arise, amputation, as a rule, had better be performed. As regards the general condition of the patient, it must, as already said, always be remembered that satisfactory repair after excision of a large joint will take place only when the patient is in fairly good health. Hence, a state of exhaustion or feebleness, and the cachexia of advanced tuberculosis, are condi- tions which tend to preclude repair, or at least to render it very doubtful. In these cases, on the other hand, amj^utation is usually followed by rapid recovery. The age of the patient is a very important point. Subscribing to the great principle of conservatism, every surgeon, if his choice were free, would prefer excision to amputation. Experience, however, has amply shown, that in many cases amputation is the better operation. In children under five the articular ends of the femur and tibia are so largely cartilaginous, that firm union after excision often fails to take place. In adults, say after, at the latest, thirty years of age, the risks of excision are so great, and those of amputation so comparatively small, that the latter operation should, as a rule, be performed. In dealing with the advanced forms of Disease of Shoulder Joint. 271 joint disease, it is very important not to misjudge the case so as to allow the period at which amputation would succeed to pass by. The grounds for resorting to the operation without further delay have reference chiefly to the patient's general condition. So long as this is not unfavour- able, expectant treatment by rest, etc., may be persevered in ; but should it be found that the patient is steadily losing appetite and strength, that he is also losing flesh (always a highly impoi-tant point), that the temperature remains high, that sweating is copious, and that the pulse is becoming smaller and more rapid, further delay is dangerous. Especially in these cases must a watch be kept for the appearance of albumen in the urine, and for enlargement of the liver, as evidence that amyloid degeneration of the viscera has commenced. Formerly it was supposed that this condition precluded operative interference, but it is now well known that if the suppuration on which it depends can be arrested, this complication will generally disappear. This is the case, however, only when amyloid degeneration is of recent date. When it is of long standing, not only is it irremedi- able, but it is extremely likely to determine a fatal result if amputation is performed. Diseases of Individual Joints. ^\\^\\\Ae,v*— Strumous affections of the shoulder joint are common in childhood and early adult life. Disease may begin either as synovitis, the most usual form, or as epiphysitis of the humerus, soon extending to the joint itself. In either case the aflection is generally subacute ; often so insidious that it is apt to be overlooked. Pain is often absent, or very slightly marked ; it is felt in or around the joint, or near the insertion of the deltoid. The most prominent symp- toms are wasting of the deltoid and of the scapular 272 Manual of Surgery. muscles, and stiffness of the joint, the scapula following the humerus both when the patient moves the arm, and when an attempt is made to rotate the humerus in the glenoid cavity. The arm remains at the side, and no deformity is produced. Suppuration is rare, but in epiphysitis abscess may form beneath, and at length point at the anterior border of the deltoid, or in the axilla. The shoulder is so easily kept at rest, its movements being so readily performed between the scapula and the thorax, and at the elbow, that disease of the joint, though it may be tedious, shows a marked tendency to recovery. Treatment consists in main- taining rest by keeping the arm bandaged to the side ; and if it is thought necessary, a leather shield splint may be moulded to the joint and upper half of the arm. Even in early cases rest should be continued for at least three or four months. If abscess forms it should at once be opened antiseptically. In epiphysitis necrosis is rare, and operative interference is seldom required. Should a sinus, however, remain unclosed, in spite of continued rest of the joint, it should be carefully explored. If a sequestrum is detected it should be removed, but generally no carious or inflamed bone should be gouged away. As the result even of slight disease this joint usually remains stiff, and the question of endeavouring to restore movement by manipulation presents itself. The necessity of interference after mere sprains or contusions is now well understood ; but when stiffness has followed disease manipulation will veiy seldom be attended with benefit, while it will often be in- jurious by provoking a return of inflammatory action. This is especially the case in strumous disease. Acute arthritis is common in this joint in infants under two. As its result, a large collection of matter is rapidly formed beneath the deltoid, sometimes extending forward under the pectoral Disease of Elbow Joint. 273 muscles as well as into the axilla. The upper end of the humerus is often completely destroyed, and with the loss of the epiphysis the subsequent growth of the bone is arrested, and the arm may ulti- mately be three or four inches shorter than its fellow, and remain weak and flail-like. Treatment consists in the early evacuation and free drainage of matter, and in supporting the strength of the patient by the means already described (page 240). In pycemia and septicannia the shoulder is often the seat of the rapid formation of a large abscess, which gives the joint a globular or rounded outline. Fluc- tuation is very distinct. In some instances, how- ever, effusion is merely serous, and may undergo absorption. Charcots disease and osteo-arthritis are common in the joint. In the latter, the articulation becomes stiff and painful ; cracking or grating is felt on movement, muscular wasting is marked ; and pain of a dull aching or gnawing character is complained of either in the joint itself or the outer part of the arm beneath the deltoid. As the disease advances the articular surfaces become altered in outline, and the head of the humerus, enlarged by osteophytic growths around its margin, is found to be displaced upwards and forwards so as to imitate the appearance of subcoracoid dislocation. This should be borne in mind, and in any case of obscure injury of tlie shoulder in an elderly person careful inquiry should be made into the previous condition of this joint before any step is taken to effect the reduction of what at first sight may be erroneously mistaken for a recent dislocation. For the treatment of osteo-arthritis see page 278. Si/plnlitic disease of this joint is extremely rare (page 224). I have never met with, any instance of it. The elbow. — Strumous disease, both in the form of synovitis, and of osteitis, beginning either in the S— 21 2 74 Manual of Surgery, articular end of the humerus or the ulna, is of very frequent occurrence. The joint is more or less, but sometimes very slightly, restricted in its various movements ; puffy swelling, especially over the head of the radius and by the sides of the tendon of the triceps (giving the joint an appearance of increased width when viewed from behind) is well marked ; there is often, but by no means invariably, increased heat of the surface ; muscular wasting, especially of the arm, is a constant, often a very early, symptom. The disease is generally chronic, but it may be acute, and pass on quickly to the formation of matter, distending the synovial membrane and pointing either at the outer or inner aspect of the joint. Pain is seldom a marked symptom, and is often so entirely absent that parents, and even the surgeon, may be misled. Stiff- ness, puffy swelling, and muscular wasting, are, in fact, the most reliable symptoms. Treatment consists in the use of well-fitted leather splints, confining the joint at a right angle (Fig. 52), the arm being kept in a sling. Matter, if any form, must be evacuated, a "window" being cut in the splint to allow of di'ainage. Though stiffness sometimes remains when inflammation is plastic, perfectly free movement is often regained when treatment has been applied early and has been sufiiciently prolonged. The splints must be continued for from three months to nine months, or even, in older cases, for a year or more. When the articular ends of the bones are carious it is useless to gouge away the inflamed struc- tures. With rest the osseous tissue will very usually regain a healthy condition ; but this failing, or where the extensively diseased synovial membrane continues to suppurate in spite of long-continued rest, excision will be indicated. Acute arthritis of infants is frequent in the elbow. The joint, often within two or three days, Disease of Wkist Joint. 275 becomes the seat of a large abscess, and the ar- ticular ends of the bones, as well as all the ligamen- tous structures, are rapidly destroyed, so that the humerus and bones of the fore-arm are widely movable in all directions on each other. In early cases, if matter is at once evacuated, this extensive destruction may be avoided, and the joint may regain all its nor- mal movements, while in cases in which treatment has been neglected the joint remains weak, loose, and flail-like. The elbow is a common seat of Charcofs disease, and often presents, in a characteristic form, the changes induced by this affection. The joint becomes, sometimes very rapidly, enlarged and deformed by the accumulation of fluid in the interior, and in adventitious periarticular bursal sacs ; and also by the destruction of the articular surfaces of the bones and the heaping up of irregular osteophytic masses about the ends of the shafts. The joint admits of ab- normally free motion and coarse gi'ating is felt. There is, however, little or no pain, and the patient uses the limb freely. Osteo-arthritis often involves this joint, though less frequently than it does the knee, hip, and shoulder. The usual symjitoms of slowly increasing stiflhess, pain of a dull wearing character, cracking and creaking on movement, together with the presence of the disease in other joints, frequently, among the rest, in the opposite elbow, will render diagnosis very easy. For treatment see page 278. In the course of pi/ceynia and other forms of blood poison- ing, the elbow (an articulation, however, which often escapes) presents lesions, the features and treatment of which have been described (page 227). Syphilitic disease of the elbow joint is not rare, and probably many instances of chronic and relapsing inflamma- tion in adults, attended with thickening of the synovial membrane and not yielding to the prolonged use of rest, have been of this character (page 224:) 276 Manual of Surgery. ^Wx\%\, — In children and young adults, and even occasionally in old persons (page 248), strumous affec- tions are prone to attack this joint, which becomes slightly flexed, swollen, and pufly, both on the dorsal and palmar aspects ; normal depressions between the tendons are lost, and the part assumes a smooth fusi form outline, the result of synovial thickening. A well-marked feature is impairment of the movements of the hand, especially of pronation and supination ; and the power of grasping objects firmly is lost. Muscular wasting of the fore-arm is always present ; pain and surface heat are very variable symptoms ; they are often absent in cases in which the joint is in a state of advanced disease. Treatment. — The joint must at once be enclosed in leather splints {see Fig. 53), and the fore-arm supported in a sling, the patient being forbidden to make any use of the limb. Cases are very rare in which recovery will not follow, if this plan is adopted early and continued for the necessary period of from three to six months. In advanced cases the time must be extended to a year, or even longer. If suppuration occurs, matter should be evacuated, and drainage provided for. When, in spite of three or four months of rest, suppuration continues to be free, it should be ascertained, with as little disturbance of the structui-es as possible, whether any of the carpal bones have become necrosed and loose. If any are so found they should be re- moved ; but if the bones are merely inflamed, or in a state of caries, they should be left for repair by a still longer period of rest ; for here, as in all other cases, the gouging away of inflamed or caiious bone will have the effect of aggravating rather than of removing the disease. In cases of extensive disease some surgeons resort to a systematic excision of the wrist joint. Very generally, however, a better result will be obtained by long-continued rest, combined Hip Disease. 277 with the removal of any sequestra that are from time to time found to be loose. It is difficult, without ex- perience, to credit the amount of repair that will follow this treatment by rest pei-severingly maintained. Osteo-arthritis frequently attacks this joint, which becomes stiff, particularly as regards pronation and supination, and painful ; swelling, usually slight, in some instances becomes considerable, as the result of ganglionic enlargement involving the sheaths of the flexor and extensor tendons. Such cases are always tedious, but much good may sometimes be done by placing the limb in splints, carefully evacuating any large collections that may have formed, by antiseptic [juncture, blistering the joint for five or six weeks, and tlien applying Martin's -indiarubber bandage, to secure uniform pressure. In the management of yycemic and other forms of blood poisoning, affecting the wrist, the main points, locally, are the support of the joint so as to prevent deformity, and the early antiseptic evacua- tions of matter. Syphilitic disease of this joint ap- pears to be very rarely met with. I have never seen it. Hip. — The remarkable features of GJiarcofs disease of the hip are detailed in Art. xxix., vol. i. Osteo- arthritis of this joint was formerly designated morbus coxae senilis, or from the fact that, especially in males, the hip is often the only joint attacked. Monarticidar rheumatism. — The affection commences, usually in persons over forty-five (thougli it may be met with earlier), with j>ain about the joint, or at the back of the thigh in the course of the sciatic nerve, or in the neighbourhood of the knee ; gradually increasing lameness and stiffness, so that the patient is unable to stoop or dress himself ; and wasting of the muscles of the thigh and hip. As the disease advances all the symptoms become more pronounced. Pain is often constant and severe. The limb becomes gradu- ally shortened and everted, and on examination it 278 Manual of Surgery. is found that, as the result of absorption of the upper border of the acetabulum and head of the femur, the trochanter has become displaced so as to lie considerably above Nelaton's line (page 283) ; shrinking of the limb continues, and lameness becomes extreme. These cases are often, in their early stage, mistaken for sciatica. A correct diagnosis, however, can at once be made ])y testing the movements of the hip. Treatment. — The patient should wear flannel over the joint, so as to secure warmth at a uniform temperature, and should take moderate exercise. Complete rest promotes stiffness. Blisters and liniments of opium and belladonna often diminish pain. Hot fomentations and douching give re- lief, and many patients find great benefit from the hot douche treatment at Buxton, Harrogate, Wildbad, Baden, or Aix-les-Bains. If r.rates or deposits of uric acid are present in the urine, five grains of the citrate of lithia should be given once or twice daily in potash water. Usually the limb remains in a position of exten- sion, and no splints or other mechanical appliance are of any service. Occasionally by manipulation, under an anaesthetic, motion may, for a time, be increased by the detachment of osteophytes around the joint and the rupture of adhesions, but, as a rule, forcible movement aggravates rather than improves the con- dition of the limb, and it should not, therefore, be adopted without careful consideration. Acute injlani. mation of the hip joint, developed in the course of jjy- cemia and other kinds of blood poisoning, is formidable in the highest degree. Pain is usually very severe, the joint quickly becomes disorganised, and the patient is threatened with death by exhaustion. The joint must be, at the very outset of the disease, placed at rest by the application of a weight to the foot, com- bined with the use of a Thomas's splint, or of an interrupted long splint, and matter should be evacu- ated, either by the aspirator or by antiseptic incision, Hip Disease, 279 and free drainage be provided. In young subjects, should other conditions be favourable, amputation may sometimes be performed ; but in adults this step generally cannot be ventured upon. In the coui'se of typhoid fever the hip (apparently more often than any other joint) is liable to be attacked with inflam- mation, attended with the same symptoms as are met with in ordinary hip disease. The affection is usually subacute, and rarely goes on to suppuration ; serous effusion, however, is often considerable, and spontaneous dislocation is apt to occur. In any case, therefore, should the patient complain of pain, careful examination should at once be made, and if the joint is found stiff and sensitive on movement, weight exten- sion should be applied (page 287), the limb should be supported between sand-bags, and a cradle placed over the foot to prevent pressure by the bed clothes. In gonorrhceal rlieumatism the hip is veiy liable to be affected. The symptoms are those of an acute or subacute and very persistent inflammation, which often leaves the limb completely fixed by adhesions within and around the joint. Suppuration, though very rare, is occasionally met with. In its active stage the case must be treated on the plan given at page 287. Subsequently, in order to restore movements, manipula- tion, under an anaesthetic, followed by hot douching, shampooing, and passive movements, and repeated, if necessary, at the end of a fortnight or three weeks, will be required. These means will often succeed, but no undue violence must be used; nor should forcible movement be persisted in if it is followed by severe pain that does not quickly subside, or by marked swelling about the joint. Strumous Disease of the Hip Joint. This affection presents so many special features as regards its symptoms and diagnosis, the course it takes, 28o Manual of Surgery. and tlie treatment it requires, that it is convenient to describe it under a separate name. It must, how- ever, be understood, that it diflbrs in no material respect from those chronic diseases of the other joints, which are generally regarded as strumous or scrofulous. Although met with at any age up to puberty, and occasionally in middle and even in advanced life, hip disease most frequently begins in child- hood between the ages of three and seven. It origi- nates most commonly in the bones, i.e. in the upper end of the femur, or in the floor of the acetabulum. The frequency of disease in these structures is pro- bably due to the fact that, being centres of rapid growth, their nutrition is unstable, and apt, on any disturbance, to pass into inflammatory action ; and it is easy to see that as these parts themselves are within the capsule, disease in them must almost inevitably provoke a general arthritis. In a certain number of cases disease commences in the synovial membrane. The view formerly held, that it had its starting point in the ligamentum teres, or in the articular cartilage, is now known to have been erroneous. Synovial cases, though they are sometimes acute, generally take a mild course, yield readily to treat- ment in their early stage, and often end, though conval(!Scence is tedious, in complete lecovery. Cases in which the bones are afFectod are much more serious. If carefully treated they, like the synovial form, end in satisfactory recovery, though this may be long delayed. But when neglected they pass on to caries or necrosis, supjiuration, and great deformity, and frequently to a fatal result. I>iag°iiosis. — Well-established hip disease may be recognised almost at a glance; but in the early period, when it is so highly important to form a cor- rect opinion, diagnosis is often attended with great difficulty, first because the symptoms are very slightly Hip Disease. 281. marked, and, secondly, because almost all the indi- vidual symptoms of hip disease are also the symptoms of disease either of the spine, or of some neighbouring part. Hence, a correct oi)inion can be reached only by observing and comparing a number of slight signs, any one of which alone would be quite inconclusive. Syinptoms. — These will be stated in the order in which they would present themselves in an actual case : 1. Lameness is always present, but it may be so slight that it is easily overlooked. It is due to the fact that the joint is either in a stiff or distorted condition, or is too sensitive to bear any weight. There is, however, no form of lameness that is in the least degree characteristic of kip disease. The symptom must always be studied in conjunction with other evidences of the disease. 2. Fain. — This is very variable both in degree and situation. Sometimes it is so slight, or entirely absent, that the disease is not suspected. Sometimes it is severe from the first. It may be in the joint itself, or transferred to the nerve peripheries, and so be felt either in the knee or the inner side of the thigh or the leg. It must, however, be borne in mind that pain may be referred to these situations in several other diseases, as of the lumbar spine or the sacro-iliac joint, cancer of the rectum, and abscess or aneurism in Scarpa's triangle; in any case, in fact, in which the trunk or higher branches of either the obturator or anterior crural, which both supply the hip joint, are iriitated. 3. Altered position of the liiuh. — In a typical case, in the early period of disease, the joint is liexed, ab- ducted and rotated outwards. Many theories have been advanced to explain this position. It is, how- ever, merely that of greatest ease, and that which we unconsciously adopt as we sit at rest with the limbs flexed on the trunk, the knees apart, and the heels 282 Manual of Surgery. touching. This position relaxes all the ligaments of the joint. Thus, flexion relaxes the front of the capsule, abduction the Jigamentum teres and the outer band of the ilio-femoral ligament, rotation outwards the inner band of this ligament and the back of the capsule. This position of the limb, however, is generally not at once obvious when we examine the patient. In- stead of it we find that the diseased limb is extended, and parallel with its fellow, that tlie lumbar spine is arched forward (lordosis), that the pelvis is dej)ressed on the affected side, and that the limb looks longer than its fellow. This attitude is thus explained. Obviously a limb that is fixed in a position of flexion and abduction (which, in other words, is pointed for- wards and outwards) is useless for progression (Fig. 62). To overcome this difficulty, the patient, by curving the lumbar spine forwards, rotates the pelvis on its transverse hori- zontal axis, and so makes the femur point down- wards instead of forwards ; and by curving the lumbar spine laterally, so that the pelvis is raised on the sound and depressed on the affected side, he brings the femur inwards towards the middle line (Fig. G3). The apparent lengthening of the limb is due merely to the fact that the pelvis on that side is depressed ; in otlier words, apparent lengthening always indicates that the limb is abducted. As to real lengthening of the limb this probably never occurs. I have never recognised an instance of it. In the later period of disease, the powerful adductors, under the influence of reflex irritation, draw the Fig. 62. Hip Disease. 283 i^HB^^^Hai Fig. 63. limb inwards so that it now becomes flexed and adducted, instead of flexed and abducted (Fig. 64). Here, again, the limb occupies a position (crossing the opposite thigh) in which it is useless. To meet the difficulty the patient curves his spine laterally so as to draw up the affected side, and so brings the femur outwards, till it is again parallel with its fellow, witJi the result, however, of producing apparent shortening of the limb (Fig. Go). Thus apparent shortening always dej^ends on adduction. At a still later period the limb undergoes real shortening as the upper border of the acetabulum and the head of the femur become absorbed, and the trochanter is carried upwards by muscular action, more or less above Nelaton's line (drawn from the anterior iliac spine to the tuberosity of the ischium). Another cause of real shortening is arrest of growth of the limb. 4. Loss of jiiovement in the joint is the most constant and the most reliable sign of hip disease. Even in the very earliest stage some loss of motion is so constantly present that completely free movement is in itself almost enough to prove that the joint is sound. Various condi- tions, however, it must be remem- bered, may interfere with flexion and extension of the thigh on the trunk, e.g. psoas abscess will often prevent full extension, while abscess under the glutei will limit flexion. It is necessary, therefore, to ascertain whether, when the Fig. 64. 284 Manual of Surgery. limb is semiflexed, the femur will rotate freely in the acetabulum. If the ball-and-socket movement is free, it may be concluded that the loss of flexion and ex- tension is due to some impediment outside the joint, but if rotation, as well as the other movements, is lost or distinctly impaired, it must be concluded that the joint itself is diseased. 5. Muscular loastimj^ always an important symp- tom, due mainly to reflex atroj)hy, but in part to disuse, is constantly present in estab- lished disease, and may even be well marked in three or four weeks. It shows itself as flattening of the hip and loss of the fold at the lower border of the gluteus, and also by shrinking of the thigh, accompanied by a flabby condition of the muscles, detected by measuring the two limbs at the same level. 6. Swelling. — This may be due to general fulness about the joint, perhaps with enlargement of the glands in Scarpa's triangle, and to the presence of abscess, which may be found at any aspect of the articulation. For examination the patient must be undressed, and lying on some firm surface, so that the real position of the limb can be made out. The surgeon must see whether the knee can be brought down without producing anterior curvature of the lumbar spine (lordosis) ; whether the heels are level ; and whether the anterior iliac spines are horizontal. If when the knee is down the spine is curved forward, it shows that the thigh is flexed. The amount of flexion will be disclosed by raising the knee till the spine is straight. If the iliac spine on the suspected side is depressed {see Fig. 63), it indicates that the limb is Fig. 65. Hip Disease. 285 abducted, and the degree of abduction will be shown by carrying the limb outwards till the iliac spines are restored to the same level. If, however, the iliac spine of the suspected side is drawn up (Fig. 65), it indicates adduction, the amount of which will be brought out by adducting the limb till the pelvis is again hori- zontal. The real position of the limb will thus be ascertained. Flexion, and extension of the thigh on the trunk, and rotation of the femur in the acetabulum should now be investigated. This test must be very gently applied, but each movement must be carried to its full natural range, for it is only when the extreme limits are approached that slight restrictions of move- ment become apparent. Muscular wasting of the limb and swelling about the joint should next be looked for. Sometimes when the joint is grasped from before back- wards, between the finger and thumb, enlargement of the upper end of the femur will be detected. Tenderness on carefully applied pressure, either in front of or behind the joint, is sometimes a marked symptom. Jarring of the heel or knee is a worthless test. It often makes a timid child shrink, though the joint is per- fectly sound, while often it causes no uneasiness, although hip disease is well marked. When these various signs have been investigated a conclusion is generally readily formed ; but some- times early diagnosis must rest on two or three slight yet distinct symptoms carefully pieced together, in the absence of some symptoms that are often spoken of as characteristic. Thus there may be no pain either in the hip or knee, no complaint when the knee or heel is jarred, and, to a casual examination, no flexion and no lameness. Close investigation, however, shows that there is slight apparent lengthening, together with slight limitation of complete flexion, slight mus- cular wasting, and slight lameness. In another case the only symptoms ai-e stiflhess and occasional pain 286 Manual of Surgery, (which paients regard as a " growing pain " or rheum- atism), and limitation of flexion and rotation of the femur in the acetabulum. Thus a thorough and critical, but always gently conducted examination, is required. The conditions between ^;vhich, and hip disease, mis- takes are most frequently made, are disease of the spine accom panied with psoas or iliac abscess, disease of the sacro- iliac joint,* abscess under the glutei, from whatever cause, infantile paralysis, congenital disloca- tion o^ the hip joint, and, in young children, lordosis, due to acute rickets, an affection which imitates hip disease in the circumstance that the limbs are often tender on movement. Complications. — In a very large proportion of cases in which the disease is allowed to advance, and in some even in which treatment has been at once brought to bear, suppuration will occur. Matter is usually formed within the joint, and passes either through the cotyloid notch, or through the bursa under the ilio-psoas, to reach the surface in Scarpa's triangle, or through the thin posterior part of the capsule to appear under the glutei. Some abscesses, however (especially those that appear late in the disease), are outside the joint, and are due to suppuration around the remains of inflammatory exudation. Abscesses may present at any part of the joint, but a common situation is under the tensor fasciae femoris, on the outer part of the limb. When the acetabulum is affected matter may form within the pelvis and present above Poupart'g ligament. Occasionally pus in this situation forms a communication with the intestine, so that faeces escape into the abscess cavity. This complication, happily rare, is usually fatal. Two serious complications, amyloid degeneration of the viscera, and tuberculous meningitis, must here be re- ferred to. Amyloid degeneration, indicated by albumin- uria and enlargement of the lia^er and spleen, though Hip Disease. 287 nsually met with only when discharge has been copious and prolonged, is sometimes present when suppuration is still recent. A watch should therefore be kept for it in all cases in which considerable discharge is going on, for if suppuration can be arrested when the amy- loid change is recent, the latter may entirely disappear. At a subsequent period, however, it is not only incurable, but it very greatly increases the risk attending operative^ interference. Tuberculosis men- ingitis was formerly, when hip disease was so often allowed to reach an advanced stage, much more common than it is at present. But^ it is still not very rare, and may occur even in cases in which no suppuration has taken place, and at any period, even, indeed, after the joint affection has long been cured. This is a complication that always passes on to a fatal termination. Pulmonary phthisis is de- cidedly rare as'a complication of hip disease. Treatment. — This consists, in the early period of the disease, in absolute rest, and the removal of any deformity that is present. These ends are best secured by extension by means of the weight and pulley. The patient is placed on a firm mattress, with a board beneath it. The weight is applied by means of the well-known stirrup made of stout strapping, the ends of which extend half way up the thigh, so that the ligaments of the knee are not subject to any undue strain.* The weight, which takes effect rather by its constant action than by its amount, should not exceed three or four pounds in children under ten, and five to eight in patients from ten to twenty. Heavier weights than these are seldom required. A long splint should be applied to the opposite or sound side, to keep the patient on his back in the horizontal position. As to the affected limb, this must be })laced in the position to which the disease has brought it, * This is not shown in the figures. 288 Manual of Surgery. Lordosis due to flexion must be removed by raising the limb till the spine is straight (Fig. ^^). If the pelvis is de])ressed on the affected side, the limb must be abducted (Fig. 67) till the two iliac spines become horizontal ; if, on the contrary, the pelvis is drawn up on the diseased side, the liml) must be adducted till the pelvis is again square (Fig. G8). When these directions have been carried out, when, in fact, the real has been Fig. %urru\ving of pus, and tiie formation of numerous Excision /x Hip Disease. 293 fiinuses about the joint, formerly so common, is pievented, the tissues are relieved from the pre- judicial action of retained pus, fever is avoided, and th,: period of suppuration is largely curtailed. fxeif^ioii ill lii|» disi^ase.— With the majority of suigeons excision of the hip is a very un- popular o^z^eration ; for when it is performed for advanced disease, and when the health has be- come impaired, tlio wound frequently remains unhealed, su})puration remains as free as before the operation, and the patient still continues to lose health and strength. In short, the proceeding does little or no good, either locally or as regards the patient's general condition. INIeeting with this disap- pointing experience, some authorities, liolding the view {see page 265) that the disease is attended with the local deposit of tubercle, and, therefore, little likely to undergo rejiair without operative interference, and pointing to the advantage of removing the affected structures, and so of averting the risk of systemic in- fection, recommend that the operation should be per- formed at an early period, as soon, in fact, as sup- puration is detected. In the early stage, however, it is now well known that ]>roperly conducted treat- ment by rest, and the evacuation of matter, will lead to recovery with a much more useful limb than that which is ol^tained by excision. There are, however, certain conditions for which it is advisable to perform excision, although tlie result of the operation must often be very doubtful. These are : 1. When the whole head of the femur, or M'hat remains of it, has become necrosed and detached, so as to form a loose sequestrum. Tliis proceeding, how- ever, is not, strictly speaking, an excision, but merely an operation for dead bone. 2. When, in spite of three or four months of com- plete rest and free drainage, suppuration remains 294 Manual of Surgery. copious, and the general liealtli is giving "^^'^y, pro- vided, however, that there is no evidence of extensive disease, either of the femur or the pelvis, or wide burrowing of matter in the limb. When the fenuir is the seat of chronic osteo-myelitis, whicli sometimes involves the greater part of the shaft, amputation is the only adequate operation ; and when the pelvis is largely diseased, excision will be useful only in securing free drainage. The gouging away of carious bone from the pelvis will very seldom be attended with any good result. 3. When, along with continued suppuration, there is so much displacement of the upper end of the femur that the limb cannot be brought into good position without operation. Here excision may serve the double purpose of removing distortion and of arrest- ing suppuration. In any of the above conditions the appearance of enlargement of the liverj or of albumen in the urine, showing that amyloid disease of the viscera has set in, may be an additional ground for excision, for if the operation can arrest suppuration, the internal organs may perfectly recover. When, however, amyloid disease is of long standing, the operation will not only be useless, but attended with considerable danger to life. Excision is now performed with nuich less violence and destruction of parts than was formerly the case, when the custom was to strip the whole upper end of the femur, to force it out through the wound, and saw across the shaft below the trochanters. The operation vir- tually consists merely in removingthe head of the femur, or its remains, by dividing the neck. The trochanter major, in all but exceptional cases, is preserved, and the attachment of its muscles and the surrounding soft parts are as little as possible interfered with. Operation. — An incision down to the back of the joint is made about four inches in length, and Amputation in Hip Disease 295 extending from tlie base of the trochanter upwards in the course of the fibres of the glutei. The wound is retracted, and the capsule, if still present, is opened. The finger is then passed in to ascertain the con- dition of the bones and the relation of the neck ; a small saw, guided by the finger, is next introduced ; the neck is sawn through wheio it appears to l)e sound, and the detached portion is removed, with as little injury as possible to the surrounding parts, by ex- tracting bone forceps. Should it be clear tliat the trochanter is extensi\'ely carious it must be removed, but this step, it must be noted, largely interferes with the future usefulness of the limb. The floor of the acetabulum must l)e carefully examined, and any sequestra removed, and sliould tliere be perforation and abscess in the pelvis, free drainage should be proviresents no features calling for detailed description. The disease is usually not confined to the joint, but involves, at the same time, the adjacent tarsal articulations, and is often associated with a very troublesome form of flat foot, resulting from relaxation of the plantar ligaments, a condition which, along with stiftness of the ankle joint itself, greatly cripples the patient. The local treatment consists in protection against cold and damp, and the use of the hot douche or steam bath, moderate exercise, and some support for the plantar aich. When, however, the joint is swollen and tender no mechanical support can be borne, and the patient should be provided with boots of very soft leather or cloth, with low heels and wide soles, while warmth and hot douching are per- severed with, and the rules stated on page 278 are care- fully followed. The ankle and the neighbouring tarsaj joints, together with the fibrous structures of the sole, including all the ligaments, are not larely the seat of urethral urethritis (page 229) of an acute and severe type. In cases of rapidly increasing Hat foot in young adidts, the presence of gonorrhoea must not be over- looked. The affection often assumes a severe form, and the arch is completely lost. It is necessary to kee}) the patient for a time completely off his feet while the treatment indicated on page 231 is being followed. And for some months the patient should rest his feet as much as possible, and should wear either the surgical sole, or some equivalent support. 3^4 V. INJURIES AND DISEASES OF MUSCLES, TENDONS, FASCIA, AND BURS^. AViLLiAM J. Walsh AM. Muscles. ^Vouiids of muscles, like those of other soft tissues, may be incised, lacerated, punctured, or con- tused, and call for but few remarks. When a muscle is divided transversely to its fibres, the cut ends con- tract, causing the wound to gape. They should, there- fore, be approximated as much as possible, by placing the part in such a position as to relax the muscle, and sutured with animal ligature, as catgut or kangaroo tail tendon, the wound closed, and the parts placed at absolute rest. When the wound is deep, or longi- tudinal to the fibres, a drainage tube had better be in- serted, as the discharge is likely to be pent up by the bulging of the fiesliy belly of the nmscle. Should the muscle have lost its contractility, and appear so lacerated or contused that it must obviously die, the injured portion may be cut away. Wounded muscle generally unites by fibrous tissue, but the formation of new muscle fibres has in a few rare instances been observed. Riiptiire.— Subcutaneous ruptuie of a muscle may be caused by a sudden or violent involuntary action, as in trying to save a fall, or during vomiting, or an attack of tetanus or delirium. The muscles, per- haps, most frequently ruptured in this way are the pectoralis major, deltoid, rectus fenioris and abdomi- nis, gastrocnemius, adductors of tlie tliigh, and ox- tensor brevis of the foot. The rui)ture may be c(jm- plete or partial, and may occur through the mriscuiar Jnjuries of AlrscLEs. 305 tissue itself, or at the insertion of the muscle into either its tendon or the bone. Union generally takes place by fibrous tissue, but sometimes suppuration occurs, and an abscess results. Symptoms. — The rupture is attended by local pain, perhaps by a sensation of tearing or snapping. When a few tibres only are torn, the inj ury may escape notice, though it may be followed for many months by pain and stiffness, which may be attributed to rheuma- tism. In complete rupture the function of the paii is lost. The ruptured ends retract, causing a hard swelling above and below the rent, which can often be felt as a gap ; or blood may be extravasated be- tween the ruptured ends, giving rise to a fluctuating swelling, and subserpiently, as it makes its way to- wards the surface, to ecchymosis and discoloration of the skin. Treatment. — The ends of the rujttured muscle should be approximated by carefully applied bandages or s})lints, whilst evaporating lotions or an ice bag should be used to control blood extravasation and prevent inflammation. Should a blood tumour form, it should not be opened, as the blood will in time be pro- bably absorbed. Jf, however, suppuration occurs, an early exit should be given to the pus. Iiillauiiiiatioii aud abscei^is. — Inflammation of muscle, or myositis, may follow an injury such as a strain or rupture of a few fibres ; or it may spread to the muscle from the tissues around. It may also occur idiopathically, and is then generally spoken of as rheu- matic ; and it is of frequent occurrence in septicaemia and pyaemia, when it usually quickly ends in suppura- tion. The chief symptoms are pain increased on move- ment, swelling, and, when the aflected muscle is super- ficial, heat and redness. Except when the result of pyicmia, it usually teriuinates in resolution. Should U— 21 3o6 Manual of Surgery. an abscess form, rigors followed by fluctuation, and later j^ointing, or signs of deep suppuration, will bo present. The treatment indicated is rest, soothing applica- tions, belladonna or opiate liniments, and, where pus has formed, an early incision. Hypertrophy, or simple increase in size, may occur both in the voluntar}'- and involuntary muscles. Familiar examples of the former are seen in the muscles of the limbs of athletes ; of the latter, in the bladder and intestines, as the result of obstruction to the passage of urine and faeces. Ati-opliy and degeiiei'sitioii.— The chief de- generative changes in muscle are : (1) simple atrophy ; and (2) granular, (3) fatty, and (4) waxy or vitreous degeneration. In simple atrophy the muscular fibres merely waste and get smaller, but do not lose their striation, and are capal3le of being completely re- stored ; whilst in the other forms the fibres undergo distinct pathological changes, and their function is en- tirely and permanently lost. Simple atrophy may occur from a variety of causes. In surgical practice it is, perhaps, most frequently met with as a conse- quence of the disuse of a part, as for example trom chronic joint disease. The granular, fatty, and waxy degenerations occur as the result of acute febrile disease, lead poisoning, scrivener's palsy, disease of the nerve centres, etc. Though sometimes occurring alone, they are often intermixed. They may all be present, as well as simple atrophy, in the following diseases, of which a short account is given. Progressive muscular atrophy is a disease of adult life, and consists, as the name implies, of a slow and nearly always progressive atrophy of the voluntary muscles, and consequent increasing weakness and paralysis. The cause of the disease is often obscure. It has Progressive Muscular Atrophy. 307 been attributed to excessive exercise, exposure to cold and wet, to syphilis, fevers, lead poisoning, and injury of the spine. It is often hereditary, and is more com- mon in the male sex, and in the middle period of life. Pathology. — Although it is still thought by some to be essentially a primary disease of the muscles, it is now generally held that the wasting of the muscles is secondary to disease of the multipolar nerve cells in the anterior cornua of the spinal cord. These cells, amongst other pathological changes in the grey and wliite substance of the cord, have been found atrophied and degenerated ; but whether such changes should be regarded as inflammatory or degenerative is still undetermined. The muscles ajDpear paler than natural, and in various stages of atrophy. They are said by Charcot to undergo simple atrophy only ; but other observers have noticed, in addition, granular, fatty, and vitreous degenerations. Sym'ptoms. — The short muscles of the thumb and little finger, especially those of the right side, are generally first afiected ; then the interossei, giving to the hand a characteristic claw-like appearance (the main en griff e). Thence the atrophy spreads up the arm to the muscles of the trunk, or missing those of the fore-arm falls upon the deltoid, or attacks the muscles of the opposite hand. In rare instances the atrophy starts in some of the muscles of the trunk, and very excep- tionally in those of the lower extremity, but it is ex- ceedingly uncommon for it to spread to them. Previous to the atropliy, pain and cramps or fibrillar tremors in the muscles are commonly noticed. In the later stages the limbs become variously deformed from unequal wasting of the muscles, and the unbalanced action of their antagonists. The muscles respond both to the faradic and continuous current, but more and more feebly as the disease advances, till in tlie later stages they cease to do so altogether. The reflexes, which may 3o8 Manual of Surgery. at first be increased, steadily diminish, 1 ut are nevei quite lost till the muscle is entirely destroyed. The sensibility of the skin is never affected, neither does it undergo atrophic changes ; the bladder, the rectum, and the sexual functions are not interfered with. The patient usually dies from some bronchial trouble, con- sequent upon the weakness of the respiratory muscles. Treatment. — Tliere is no known remedy for the disease, but phosphorus, arsenic, and cod-liver oil may be given internally, whilst blisters to the spine, galvanism, and the hot baths of Aix-la-Chapelle should be tried. Pseiido-hypei'tropliic paralysis is a disease of early life, and consists essentially in a great increase of the interfibrillar connective tissue and fat, attended with simple atrophy of the muscle fibres. It is charac- terised by muscular wasting and increasing para- lysis, and in typical cases by apparent hypertrophy of the muscles of the calves and gluteal regions. The cause of the disease is obscure. In many cases it is undoubtedly hereditary, and occurs in several mem- bers of the same family. It is much more common in boys than in girls, and when inherited descends through the female line. Pathology. — Whether the disease should be regarded as one essentially of the muscles, or the condition of the muscles as secondary to a lesion of the spinal cord, is still a disputed point, as opportunities for examining the cord have been few. The muscles in the early stages shew a great increase of the interstitial connec- tive tissue and infiltration with fat, whilst in the later stages the fibres are found to have undergone atrophy, and to be more or less completely replaced by fat. The muscles hrst affected are usually those of the lower extremity, especially of the calf and buttock. Later all the voluntary muscles may be implicated, though the hypertrophic changes in these are seldom so marked. Symptoms. — The onset of the disease is very PsEUDO-HyFERTROPHIC PaRALYSIS. 309 gradual. The child is unsteady on its feet, stumbles in walking, and readily falls. Later, as the extensor muscles of the knees and extensors and flexors of the hips become more affected, equilibrium in the upright position is maintained with diflicalty. He stands with his feet far apart, so as to widen his base of support, his heels frequently drawn up from the ground by the contraction of the muscles of the calves, and his shoulders carried backwards, and the lower part of the spine in consequence thrown into a state of lordosis. The lordosis disappears on sitting, and apparently depends on the tilting forAvards of the pelvis, due to the weakness of the hamstring muscles. In walking, the body is swayed from side to side in order to bring the centre of gravity at each step well ov er the leg that is on the ground, llising from the recumbent position is difficult. He lirst turns on his face, then gets on his hands and knees_, and then, extending his knees, places his hands on them, and then higher and higher up the thighs, pushing his body up by these means ; *' climbing the thighs/' as it has been called. If the child is seen during the hypertrophic stage, the muscles of the calf, and probably those of the buttock and loin, are found enlarged. The enlarged muscles feel lirm and hard, but on testing them with the faradic current their motor power is found diminished ; and if a small piece of muscle is removed by Leech's trocar it will show the characteristic pathological changes. In rare instances the pseudohypertrophic change has been ob- served in all the muscles ; but, as a rule, it is limited to those mentioned, the other muscles, especially the lower portion of the pectoralis major and latisBimus dorsi, appearing wasted. The patellar reflex is at first diminished, and is later absent. The intellect is often weak, but at other times unaffected. The disease is very chronic in its course, and is attended in its later stages by contraction and distortion. The patients 31 o Manual of Surgery. usually die of exhaustion or from the rcbpiratory muscles becoming affected. Treatment — Shampooing and faradisation in the earlier stages may be useful ; in the later stages nothing has been of any avail. Ossifiratioii of muscle may occur as the re- sult of chronic irritation or inflammation. The osseous material, which has the structure of normal bone, is deposited in the proliferating connective tissue between the muscle fibres, causing the latter to atrophy. Ex- amples of ossification are occasionally met with in the adductor muscles in persons who ride a great deal (rider's bone), and it was formerly not uncommon in the deltoid muscle of soldiers, as the result of shouldering arms (the drill bone). I have seen it in the rectus in cases of Cliarcot's disease of the hip ; and Abernethy relates the case of a boy in whom bone was constantly developed in the muscles after a blow or other injury. Specimens of ossification of the muscles of the back, and of the vastus internus, are to be found in various museums. Blisters, with the in- ternal use of mercury or iodide of potassium, appear to have given i-elief in some instances. Tiinioiii'S. — Primary tumours in muscle are rare ; but fatty, fibrous, myxomatous, and more rarely enchon- dromatous and sarcomatous growths have all been met with. Blood and hydatid cysts are of more frequent occurrence, and syphilitic gummata are ])articularly common. Secondary growths are more often met with, the muscles, in common with the other tissues, being not infrequently affected in the general dissemination of carcinomatous and sarcomatous growths. Muscle may, of course, also be involved in the extension of epitheliomata from the skin or mucous membrane, and in sarcomata growing from the periosteum or bone. Injuries of Ten pons, 311 Tendons. ^VoiiikIs. — The tendons perhaps most frequently wounded are tliosc. of the flexorn aud extensors of the fingers. They nlxiuld be carefully united by animal sutures, kangaroo tail tendon being one of the best, and the parts placed at rest in such a position as to approximate the divided ends. When the injury has been overlooked, or union fails, the divided ends, which are often widely separated by muscular con- traction, become adherent to the sheath and surround- ing tissues, and the function of the muscle is impaired or lost. AVhen the patient is young, and the local and general conditions are favourable for operation, an incision should be made over the cicatrix of the former wound, the ends of the divided tendon searched for, freed from adhesions, refreshed by shaving off the last half inch of each obliquely in opposite directions so as to bring them together splice-wise, and sutured as in a recent wound. These operations, tliough often disa[ipointing, are sometimes attended with very brilliant results, as in a case recently under the care of my colleague, Mr. Willett, where, after suture of both the flexor sublimis and profundus tendons in the palui, a perfectly movable finger was obtained. Where, however, the patient is old, or of a broken- down constitution, or where there is evidence of extensive destruction or of adhesion of the tendon, little can be expected from suture, and in the case of stiff finger amputation is then attended with less risk. Where a considerable portion of tendon has been lost, attempts have recently been made by Herr Gluck to restore the lost part by uniting the divided ends with a leash of catgut, on the supposition that this will become organised, lie claims successful results. Kiiptiirc. — Subcutaneous rupture of tendons may occur during some sudden or involuntary action of the 312 Manual of Surgery. muscles, and is not an uncommon accident in men beyond the middle period of life. It is most frequent in the plantaris, and tendo Achillis, and long tendon of tlto biceps. The rupture is often attended with an audible snap, and with a sensation to the patient of having been struck, followed, in the case of the plantavis or Achilles tendon, by lameness or inability to walk, and some local bruising and extravasation. After rupture of the long tendon of the biceps the short head contracts into a hard lump on putting the muscle into action, whilst a deficiency is felt in the situation of the long head. Ivupture of the inner head is said generally to follow. Treatment. — The parts should be placed at rest in such a position as to approximate the ruptured ends as much as possible. In the case of the plantaris or tendo Achillis, the foot should be fixed in full exten- sion in plaster of Paris, and the leg flexed upon the thigh for a few days to relax the calf muscles. The treatment of ruptured biceps has not hitherto been very successful. In an otherwise healthy subject an attempt might be made to unite it by suture should it ap})ear possible to reach the ruptured tendon without opening the shoulder joint. The metJiod of union of a tendon when ruptured subcutaneously is similar to that wlu'ch occurs after tenotomy. A small cell exudation is formed between the divided ends, and is converted into filjrous tissue, which ultimately cannot be distinguished from the rest of the tendon. Dislocsitioii of a tendon from \\n sheath or groove, popularly known as a rick, is not an uncommon accident, though one often overlooked. It is most liable to occur to the til»ialis jiosticus and the peronei where they pass behind the ankle, the long tendon of the biceps as it lies in the bicipital groove, the tendons in the ^ore-arm, and the small muscles of the back and 2 'h NO-S\ NO VI T/S. 313 of tlio neck. It is usually due to a sudden twist or a strain, and is attended by pain and partial or complete loss of voluntary movement of the afl'ected muscle, and consequently by lameness, or stiffness of the back or neck, etc., according to its situation. On examina- tion, the displaced tendon may often be felt, but is liable to become obscured by swelling and ecchymosis. Treatment. — A dislocated tendon, though readily reduced by manipulation, is difficult to kee[) in place. A pad and bandage should be applied, and the part in the case of the ankle or wrist placed in a well-fitting plaster of Paris splint. To retain the tibialis posticus or peronei in their place, an anklet with a properly arranged pad must subsequently be worn, and it may even be necessary to divide the tendon, or to pass a tenotome into the sheath for the purpose of fixing the tendon to the sheath by inflammatory adhesion. TcBio-s>iiovitis, or inflammation of sheaths of tendons, is most frequently met with in the subacute form and in the extensors of the thumb and wrist, but it may occur in the tendons about the ankle, in the long tendon of the biceps, etc. It is usually the result of excessive exertion, and is attended by a localised swelling over the afl'ected tendons, which is painful on ]iressure and movement, and gives when grasped during action of the part a characteristic creaking or crepitation. The inflammation is at times more acute, and may terminate in sui)puration ; or if neglected may become chronic, and last for many weeks or months. Treatment. — The part should be placed at rest on a splint, or a plaster of Paris or a Martin's bandage may be applied. When more acute a few leeches or hot fomentations, or if preferred an ice bag or cold lotions, may be necessary. If pus forms, free incisions should be made, followed by passive movements to prevent adhesions between the tendon and the sheath. When chronic, blisters, painting with iodine, strapping with 314 Maaual of Suncerv. ammoniacum and mercury j^laister, or Scott's dressing followed by elastic support, sliould be tried. Paroiiycliia teii€liiio<>>a is an acute septic inflammation of the sheatli of a tendon, and con- stitutes one of the varieties of whitlow. It is most common in the thumb or one of the fingers, but is occasionally seen in the toes. It is generally due to a poisoned wound, but it may follow a mere scratch or prick of the part in a person out of health, in whom, moreover, it may occur spontaneously. Tlie inflammation, which is of an erysipelatous and septic character, may begin in the sheath of the tendon itself, or, as is more commonly the case, in the tissues super- ficial to it, or in the periosteum covering the phalanx. As soon as the sheath is involved serious consequences will follow if a timely incision to relieve tension is not made. Thus, in consequence of the unyielding nature of the fibrous tissue forming the sheath, the blood-ves- sels of the tendon may be strangled by the inflammatory ejffusion, and the tendon die, whilst the inflammation may extend into the palm, and under the annular ligament to the nniscular [ilanes of the fore-arm. When the periosteum is attacked, necrosis of the phalanx and destruction of one or more phalangeal joints, or even of the wrist joint, may occur. Symptoms. — There is intense pain, often shooting ujD the fore-arm, hardness, throbbing, and acute tender- ness on pressure in the aflected finge)-, and later, in the palm ; but fluctuation on account of the tenseness is not usually present. If allowed to run its course, the back of the tinger and hand becomes red, swollen, and oedematous, and the palm infiltrated and tense ; an erysij)elatous blush, accompanied by oedema, extends up the fore-arm along the course of the lymphatics, whilst the lymphatic glands become tender and enlarged. Severe constitutional disturbance is often present, and the patient is greatly exhausted from GANGLioy. 315 pain and want of sleep, and maj even succumb to blood poisoning or septicaimia. Treatment. — The surgeon should not wait for fluc- tuation, but as soon as there is hardness and throl)biMg pain, should make a free incision in the middle line of the finger extending into the sheath. In slighter cases, where the inflammation is superficial, the sheath should not be opened. The hand should be then placed on a splint, well raised by a sling, and a large poultice, or some hot moist antiseptic dressing, if pre- ferred, applied. In severe cases nothing will be found to give greater relief than placing the hand and fore- arm in the arm bath for several hours, the temperature of the water being kept up the while. iSTot withstanding this, if suppuration ensues in the palm, back of the hand, or fore-arm, early and free incisions are impeiative. Dead bone must be removed when loose, and in severe neglected cases am^nitation may be necessary to save the patient's life. A saline or calomel purge is usually required at the onset, with opium in some form to relieve the pain. After suppuration has occurred, a tonic and supporting treatment is called for. Passive exercises may be required for long periods after healing to prevent stiffening of the fingers or wrist. Oaiigliou Is a simple or compound cyst formed in connection with a tendon. A simple ganylioii con- sists of a closed sac composed of fibrous tissue lined with pseudo-epithelium, and containing a clear gela- tinous colloid m.aterial. The sac does not communicate with the interior of the sheath of the tendon, and consequently is non-adherent to the tendon. It is not known exactly how these ganglia are producecL They are variously ascribed to a protrusion of the synovial lining through the sheath, with subsequent obliteration of the neck of the pouch thus formed ; to a cystic degeneration of the ceils in the synoviid 3i6 Manual of Sukglkv. fringes ; or to a dilatation of the subsynovial follicles described by Joselin. Tliey are most frequently met with on the extensor tendons at the back of the wrist ; more I'urely on the flexors, either in front of the Avrist or near the Aveb of the lingers, and on the tendons on the dorsum of the foot. They form smooth, globular, or sometimes lobulated, circumscribed, movable swellings, evidently connected with a tendon. They are semitiuctuating, or tense, and almost solid- feeling, often translucent, and non-adherent to the skin. In size they vary from a hemp seed to a walnut, or even larger. They are generally painless, but give rise to a sensation of weakness in the wrist or lingei*s. Simple ganglia may be simulated by pouch-like protrusions of the synovial membranes of the carpus and tarsus, from which they may generally be distinguished by the pouches liaving deep connec- tions, and having no apparent relation with any tendon, and by the synovial membrane appealing swelled in other places. Treatment. — They should be broken by pressure of the thumbs or punctured with a tenotome, and their contents S(|ueezed out, and firm pressure applied by means of a piece of sheet lead, a pad of lint, and a bandage. Should they refill, a second puncture should be made, the interior of the cyst scarified with the ]»oint of the tenotome, and pressure reapplied. This failing, a seton should be passed through the cyst wall, or the cyst dissected out. A comjwund ganglion is a dilatation with thin serous fluid of the sheaths of several tendons, with complete or partial obliteration of the portions of the sheaths in contact. The sac generally becomes slightly thickened, and soft and velvety on its internal aspect, so that it resembles a mucous rather than a serous membrane. Melon-seed bodies, like those contained in some bursae, are generally found in the interior. Affections of Fasc/.f.. 317 Although it may occur in other situations, it is more common in connection with the flexor tendons as they pass under the annular ligament, and is then known as the palmar bursal ganglion. This generally forms an elongated swelling, constricted at its centre by the annular ligament, and extending into the palm and a variable distance up the fore-arm. Fluctuation can be obtained by pressing alternately above and below the annular lii^ament. Sometimes this ^ancflion involves the tendons of the thumb or little finger, or both. Treatment. — Painting with liniment of iodine, blisters, and pressure should first be tried,^ although they seldom efTect a cure, as all operative procedures are attended with much risk, and should only be undertaken as a last resource. Several methods of operating, as puncture, incision in the palm, division of the ligament, etc., have been advised. I have seen all attended with success. But, on the other hand, I have further seen all of them followed by diffuse suppuration, glueing together of the tendons, abscesses amongst the muscles of the fore-arm, and even by death. The operation that, in my opinion, is attended with the least danger and the best success, is an antiseptic incision both above and below the ligament, with evacuation of the melon-seed bodies, and free drainage. The hand and fore-arm should, of course, be placed on a splint. Injuries and Diseases of Fascia. Rupture. — The fascia, as that of the front wall of the abdomen^ or that in front of the thigh, may be ruptured subcutaneously during some sudden or violent effort. Such a rout in the fascia is liable to remain ununited, allowing the muscles which it ought to confine to start forward during contraction. Protru- sions of this nature through the abdominal fascia may 3i3 Manual of Surcerv. readily be mistaken for ventral hernia. Some form of elastic support should be applied. I>ui>u>'ti'cii's coiitraetioii, or contraction of tlie palmar fascia. — The cause of this affection is not very evident ; it has been variously ascribed to gout and rheumatism, and to habits oi- occupations necessitating flexion of the fingers or mechanical pressure on the palm of the hand. It is more common in men than in women, and is said to occur more often in the upper and middle classes than in the lower. Patliology. — The contraction occurs in that portion of the fascia which is prolonged on to the sheath of the flexor tendons and is inserted into the periosteum of the second phalanx. The bones, ligaments, and tendons are not afiected. Sympfoms. — It generally begins in that part of the fascia which is continued on to the little or ring finger, whilst later it may involve that of the middle finger also, and in rare instances the fascia attached tc all the fingers and even the thumb. The affected fingers are drawn gradually more and more down- wards towards the palm, till they become, in severe cases, firmly fixed, and in contact with it. The con- tracted portions of the fascia form prominent ridges running from the affected fingers a variable distance into the palm, and can be made more tense on trying to strnighten the fingers. Where the afiection has existed some time the skin becomes adherent to the fascia and is thrown into transverse puckers. It may be distinguislied from a contracted tendon by the latter forming a tense cord, which can be traced up- wards under the annular ligament, and by the tissues of the i)alm appearing natural and not puckered. Froui arthritis deformans it may be diagnosed by the joints being unaffected. Treatment. — In the incipient stages steps should be made to prevent the contiaction increasing by the Bursitis. 319 U30 of some of the linger s])lints that have been in- vciiited for the purpose. When confirmed it is best treated by diAdsion and subsequent exteiasion. Much discussion has of late taken place as to whether a single division or multiple subcutaneous divisions of tlie fascia should be made. The writer, from an experience of both, has no hesitation in recom- mending the latter. But a very small tenotome must be used, and great care taken not to wound the skin. The liand and fore-arm should be afterwards placed on a splint, and the lingers gradually extended by elastic tension. (For contraction of the plantar fascia see Talipes, page 338.) Diseases op Burs^. BursaB, whether naturally existing as over the patella, or olecranon, or formed adventitiously from irritation or constant pressure on a part, as under a neglected corn or over the outer side of the foot in talipes varus, are liable to become acutely or chroni- cally inflamed. Acute biBB'sitis, though aj)parently sometimes arising spontaneously, can generally be traced to a blow, fall, or other injury. It is attended with the usual signs of acute inflammation, and is very apt to run on into suppuration, and, if a timely incision is not made, to become diffuse, and of a plilegmonous character. Treatment. — A few leeches, or an ice bag may be applied if seen early, but a free incision should be made as soon as there is any evidence of suppuration. CBii'oiiic bursitis. — Chronic inflammation may give rise to several different pathological conditions, in all of which the burs?e are more or less enlarged and generally contain serous fiuid. (1) Their walls are usually Ijut slightly, if at all, thickened, and the fiuid is merely an increase of the normal 320 Manual of SuKcr.Rv, bursal secretion. They then appear as more or less globular, fluctuating, tense, and sometimes flaccid swellings, and when superficial may be translucent. (2) In other cases their walls become distinctly thick- ened, whilst small, flattened, sharp-edged, ovoid, or sometimes irregularly shaped masses of fibrin known as melon-seed bodies, are found floating in a serous or dark-coloured fluid in their interior. The formation of these bodies has been attributed to the moulding of fibrinous deposits by constant movement, to the break ing-olF of thickened synovial fringes lining the bursa, and to changes in blood which may have been extravasated into the interior of the bursa. Again, in place of melon-seed bodies, or together with them, fibrous cords may be found stretching across the cavity. The presence of melon-seed bodies may often be detected by the crackling sensation they communi- cate to the touch when the bursa is handled. (3) The walls may become greatly thickened from inflamma- tory infiltration, and probably in part from the con- centric deposit of fibrin in their interior. A small central cavity usually remains, but in some instances they become solid throughout. In either case they give rise to a firm non-elastic solid-feeling tumour, and are often productive of great inconvenience. The treatment will necessarily somewhat vary in detail according to the situation of the bursa. (See Diseases of Special Bursa?.) In simple enlargement, painting with tincture or liniment of iodine, or firm and equable pressure, will often disperse them. If this fails they should be punctured with a small trocar arnl tlie fluid evacuated, any melon-seed bodies con- tained in them squeezed out, and pressure applied. Wlien creat thickenincj of the walls has occurred, or the buisa lias become solid, the only treatment is to dissect it out. Bursitis. 321 Diseases of Special Burs.e. The bursa patcllcC is, of all the bursse, the one most often affected. Chronic enlargement, and, some- what less frequently, acute inflammation, are very often met with ; and from the frequency with which they occur in housemaids and others who have much kneeling, are known as the housemaid's knee. When chronically enlarged, the bursa ai)pears as a prominent tumour in front of the patella and ligamentum patella3, tense, flaccid or solid to the touch, according to the degree of distension and condition of its walls. When acutely inflamed it is liable to be mistaken for disease of the knee joint, the more so should the inflammation, as is sometimes the case, become diffuse and burrow around tlie joint under the expansion of the vasti. In the one, hoAvever, the patella will be behind the swelling, whilst in the other it will be in front of it. Treatment. — In simple enlargement, should paint- ing with iodine or pressure fail, the bursa should be punctured, the fluid let out, and the joint firmly strapped and placed on a back splint for a few days. When solid or much thickened, a vertical incision should be made over it and the bursa dissected out. As the capsule of the joint is very thin, and may be easily opened, care must be taken during the dissection to hold the knife close to the bursa, and not to drag the tissues too forward. Acute inflammation should be treated on the general principles already indicated. Should suppuration occur, a free vertical incision should be made over tke centre of the patella ; or, if the suppuration has become diffuse, two lateral in- cisions will ensure a better drain. Bursa over the olecrauou, called the miner's bursa from the frequency wivh which it is enlarged in miners, is particularly apt, after a blow or fall upon V— 21 322 Manual of Surgery. the elbow, to become acutely inflamed. The inflam- mation is generally of a severe phlegmonous charactei', and extends a considerable distance above and below the back of the elbow joint, for disease of which it may be mistaken. The freedom of the joint in front, and the presence of a soft spot over the situation of the olecranon, are points which serve for the diagnosis. Free incisions should be made as soon as suppuration occurs, and the arm put at rest on an angular splint. Kecrosis of a small portion of the olecranon is not an uncommon result. The dead bone should be removed when loose, great care being taken not to injure the elbow joint. The bti&'sa beneath the seiuiiiieiiBbraii- Oiiiiis frequently becomes enlarged, giving rise to a tense or scmifluctuating, and usually globular or ovoid swelling in the popliteal space. The absence of pulsation and of signs of inflammation, and the facts that the inner hamstring tendons can be traced over it, and that it becomes flaccid or disappears on flexing the knee, should prevent it being mistaken for other swellings in this region. Painting with iodine, firm strapping, or blisters will usually disperse it. Should these fail, puncture or antiseptic incision must be resorted to, operations, however, that should never be undertaken lightly, as the bursa often communicates with the knee joint. The bursa over the tuber isehii is apt to become chronically eidarged, and its walls thickened, in persons whose occupations necessitate long sitting, and is then known as the coachman's or weaver's bot- tom. It is usually a source of great annoyance, and generally requires dissecting out. Tlie bursa over th<^ ^jreat trocliantcr may, when enlarged and inflamed, simulate hip disease. It may be distinguished from it by the absence of the chaiacteristic deformity of the latter aflection ajid of Bursitis. 323 dead bone or any communication "wdtli the joint on opening the inflamed bursa. The biu'sa under the tendon of the psoas, when enlarged, produces a deep-seated, fluctuating swelling in the groin. It may be mistaken for a psoas abscess or an aneurism, but the absence of spinal disease and signs of suppuration in the one case, and the fact that the artery is above the swelling in the other, should generally serve to distinguish them. It should be remembered that the bursa may communicate with the hip joint, (For bunion see Hallux valgus.) 324 VL ORTHOPEDIC SURGERY. W. J. Walsham. Wry Neck. Wry neck or torticollis is a distortion produced by tlie conti'action chiefly of the sterno-mastoid, and to a less extent of the trapezius and scalene muscles. A somewhat similar distortion may be produced by strumous and rheumatic disease of the cervical verte- brae, or by cicatricial contraction following burns or sloughing of the neck, or by paralysis of certain muscles. Such, however, are described in the articles on Diseases of the Spine, etc. Causes. — Wry neck may be congenital or acquired. When congenital, it has been attributed to disease of the nervous system producing a spastic contraction of the affected muscles, to a malformation in utero, or to some injury of the neck inflicted at birth. The acquired form may be the result of the head having been held for a long time in a distorted position, as from stiff neck after cold or injury, or from inflamma- tion of the cervical glands after scarlet fever, etc. ; or it may be the result of hysteria, or of spasm of the muscles due to irritation of the spinal accessory nerve from some central nerve aflection. PatJiology. — When the deformity is of some stand- ing the ligaments are shortened, and the intei-vertebral cartilages compressed on the affected side ; whilst in severe cases the bodies of the cervical vertebrae undergo rotation and slight lateral compression, and their articular processes are altered in shape and direction. The affected muscles undergo more or less fibrous degeneration. lVj?y N^ECK. 325 Symptoms. — The head, supposing the right sterno- niastoid to be affected, is drawn forwards and towards the right shoulder, and at the same time rotated so that the chin points to the left. The left side of the neck is unnaturally convex, the right unnaturally concave, whilst the mastoid on that side stands out prominently, and both the sternal and clavicular portions of it can be felt. The features on the affected side are, in the congenital form, markedly smaller tlian on the other. In severe and long-standing cases slight elevation of the right shoulder and scapula, and some lateral curvature of the dorsal spine, are generally present. The diagnosis is usually quite easy. From cervical caries, wry neck may be distinguished by the absence of the characteristic signs of the former, i.e. pain on movement and on percussing the head or vertebrae, rigidity and thickening, the patient's in- ability or unwillingness to rotate his head, and the tendency of the chin to drop forward. It is also important to diagnose the spasmodic and hysterical from the non-spasmodic and congenital. In the non- spasmodic the sterno-mastoid becomes tense on trying to straighten the head, in the spasmodic it gi-adually yields ; in the non-spasmodic it becomes relaxed on bending the head towards the affected side, but in the spasmodic contracted. The history will further distinguish the congenital from the other forms. In the hysterical there will be other signs of hysteria, and the head can be straightened under chloroform. Treatment. — In the congenital form, except in very slight cases in infants where exercises and manipula- tion alone may suffice, division of the sterno-mastoid is necessary. This, along with manipulation and exercises, will often be sufficient ; but in severe cases instrumental treatment will also be required. The sterno-mastoid is best divided immediately above the 326 Manual of Surgery, clavicle, as liere it is chiefly tendinous, and further removed from the important structures wliicli lie beneath it. A puncture should be made to the inner side of the tendon, and the sheath having been opened, a blunt director should be passed beneath the muscle and the division made towards the skin with a blunt-pointed tenotome guided by the director. Tense bands of contracted cervical fascia will now generally start up. These it is not safe to divide, but they may be made to yield by forcibly rotating the head and pressing upon them wdth the fingers. The puncture should be allowed to heal with the head in the deformed position, which it will do in two or three days. I usually put the patient through a series of exercises, consisting of various active and passive move- ments of the head and neck, for a fortnio-ht or so before the operation, go on with them again when the wound has healed till the deformity has disappeared, and I advise their continuance for some time afterwards to prevent a relapse. In severer cases indiarubber bands, so arranged as to make traction in the desired direction, are used in the intervals between the exercises and at night. Where an instrument is necessary, I prefer the one shown in the accompanying woodcut (Fig. 69). The spasmodic form is often very intractable. When such remedies as bromide of potassium, Indian hemp, or conium have failed, the spinal accessory nerve may be stretched. It is readily found at the spot where it enters the sterno-mastoid, the posterior belly of the digastricus, under which it previously emerges, serving Fig. 69. — InstriTinent for Wry Neok with Cog-wheel Action. Scoliosis. 327 as a good guide to it. In this, as in tlie liysterical form, the sterno-mastoid should not be divided. T have obtained the best success in hysterical cases by placing tlie head in the straight position in a poro- plastic collar, whilst giving hysterical remedies. Scoliosis. Scoliosis, or lateral curvature, is a compli- cated distortion in which the spine forms two or more lateral curves with their convexities in opposite directions ; whilst the vertebrae involved in the curves are rotated on their vertical axis, so that the spinous processes turn to the concavity of the curves. It ia more common in the young than in the old, in girls than in boys, and in the upper and middle classes than in the lower. Although most frequently met with in delicate and rapidly growing girls from fifteen to twenty-one, wanting in general muscular strength, it is occasionally seen in those who are strong, robust, and country-bred. It may also occur as one of tlie complications of rickets, and as the result of the falliiig in of one side of the chest consequent upon contraction following empyema, and in very rare instances as a congenital deformity. Causes. — When the normal spine is inclined laterally, the pressure on the intervertebral cartilages and articular processes is increased on one side and diminished on the other. If this unequal pressure is continued for long periods, the articular cartilages under certain conditions will remain permanently compressed, while the articular processes become altered in direction and shape ; in this way a permanent curve either to the right or to the left may be produced. Any circumstance, therefore, that causes the spine to incline for long periods to one or other side may be regarded as the exciting cause of lateral curvature ; but it must not be lost sight of that 328 Manual of Surgefv. for the exciting causes to become operative, certain predisposing conditions appear to be necessary. These may be summed up as want of tone in the muscles and ligaments, or structural weakness of the bones such as may be induced by (1) heredity, (2) general debility, (3) the strumous diathesis, (4) rickets, (5) rapid growth, etc. The exciting causes may be classed as ; 1. Any condition causing 2)^f^nanent or habitual obliquity of tJie pelvis, and the consequent throwing of the spine over to one side, such as a natural inequality in the length of the legs, knock knee, flat foot, congenital dislocation of the hip, use of a wooden leg, habit of standing on one leg, sitting cross-legged, etc. 2. A one-sided position of the body in sitting or lying down, or induced by following certain employ- ments such as nur.sing a child, carrying heavy weights, etc. 3. Contraction of one side of the thorax following empyema, etc. 4. Unilateral contractions of the spinal muscles induced by paralysis of the opposing muscles. There are various other theories as to the cause of lateral curvature, of which space will not permit the discussion, such as contraction of the spinal muscles on one side induced either by disease of the nervous system or by debility of tlie muscles on the opposite side, unequal contraction of the serratus magnus, etc. Pathology. — In a typical example [see Fig. 70) the spine presents a double curvature, an upper dorsal and a lower lumbar, or, more correctly speak- ing, a dorso-lumbar. The dorsal has generally its convexity to the right, the lumbar its convexity to the left. The curvature which depends directly upon the exciting cause is called the primary ; and the other which forms in the opposite direction to counter- balance the loss of equilibrium occasioned by the first, Scoliosis. 329 the secondary or compensating. Either the dorsal or the lumbar may be the primary curve, and vice versd. less commonly the spine forms an apparently single /jurve, with the con- vexity either to the right or to the left ; but in such cases there is always a slight com- pensating curve above and below, although these may not be ob- served externally. In other instances there may be four or even five curves duly com- pensating each other. The intervertebral car- tilages, and to a lesser extent the bodies of the vertebrae involved in the curve, are com- pressed wedge-wise, the base of the wedge look- ing towards the con- vexity of the curve ; whilst the articular processes are contracted and flattened on the concave side and elon- gated on the convex. In addition to the lateral deviation, the vertebrae forming the curves are rotated on their vertical axis, so that the front of the bodies looks towards the convexity, and the apices of the spinous processes towards the concavity of the curve. Asa consequence of this rotation, although there may be Fig. 70.— Lateral Curvature of the Spine. (From a specimen iu St. Bartholomew'sHospitaOIuseum.) 330 Manual of Surgery. considerable lateral deviation of the bodies of tlie vertebrse, the apices of the spinous processes may be out little deflected from the middle line. The cause of this rotation has been variously explained. The theory which has perhaps found most favour, and to which only space will permit of reference, is that of Dr. Judson, of iSTew York, "It is based on the fact that the posterior portion of the vertebral column, being a part of the dorsal parietes of the chest and abdomen, is confined in the median plane of the trunk, whilst the anterior portion of the column pro- jecting into the thorax and abdominal cavities, and devoid of lateral . attachments, is at liberty to, and physiologically does, move to the right and left of the median plane." As a result of the lateral compression and of the rotation of the vertebrae the transverse processes and ribs on the convex side are abnormally separated from one another and are carried back- wards, whilst those on the concave side are closer toijether than natural and are carried forwards. The ribs, moreover, on the convex side are more hori- zontal than natural, and their angles form a hump in the dorsal region and cause the scapula to be raised and to project, while those on the concave side run more obliquely than natural, so that in severe cases they may be in contact with the iliac crest. There is thus much distortion of the thorax and undue prominence of the left breast. The pelvis, except in cases of rickety curvature, is not, as a rule, de- formed, although in severe lumbar curvature it may be obliquely placed. Of the condition of the muscles in the earlier stages very little is known ; in the later they have been found atrophied and undergoing fatty degeneration. Syiiiptoiiis. — The incipient stages of lateral curvature are frequently overlooked, and it is often not until it has become well marked and permanent Scoliosis. 331 that the surgeon is consulted. Ofttimes the patient is brought to him for the shoulder or hip growing out, for round shoulders, or pain in the back, the parents perhaps declaring, if the question is asked, that the spine is quite straight. In such cases, and whenever there is a suspicion of lateral curvature, a thorough examination in drill posture, with the l>ack fully ex- posed, should be made. In the earlier stages there may be but little deviation of the apices of the spinous processes, and what little there is may be made to disappear on suspending the patient or placing him in the prone position. There may be a slight projection of one scapula, however, or an apparent prominence of one iliac crest, or it may be a mere want of symmetry on the two sides of the sjiine, which may best be detected by placing the patient on a low seat and looking down the back from above, whilst along with this there will usually be more or less obliteration of the normal lumbar curve and a general tendency to stoop. In severer cases the deformity will generally be unmistakable, although the amount of deviation of the spinous processes, and prominence of the scapula and iliac crest will vary con- siderably, according to the character of the curve. In the common form, in which there is a longer dorsal curve with its convexity to the right, and a shorter lumbar with its convexity to the left, the right shoulder is generally elevated, and the angle of the right scapula and right crest of the ilium and left breast are pro- minent, whilst the backward rotation of the lumbar transverse processes on the left side cause the lumbar muscles to protrude and give a greater sense of resis- tance on pressing on this side of the spine. In the long and apparently single curve the deformity is often extreme. The ribs on the convex side project prominently backwards and form a hump in the dorsal region, and cause great elevation of the corresponding 332 Manual of Surgery. shoulder and projection of the scapula, whilst those on the left side are huddled together and depressed, in some instances overlapping the crest of the ilium. At times the single curve is confined chiefly to the lumbar region ; the prominence of the crest of the ilium on the concave side, and the backward rotation of the lumbar transverse processes and the conse- quent projection of the spinal muscles, are then the most marked feature ; whilst at other times the curve is limited to the upper dorsal region, the chief cha- racters then being the projection of the scapula on the convex side and the prominence of the trapezius, which may form an apparent tumour and give, as pointed out by Mr. Adams, a doubtful sense of fluc- tuation. Diag^nosis. — Lateral curvature may have to be distinguished from hysteria and from caries of the vertebrae attended with lateral instead of angular deviation. In hysteria there is no rotation, and the curve, although apparently permanent, will generally disappear on assuming the diving position and bending the back with the knees straight till the finsrers touch the ground. Other evidences of hysteria will also commonly be detected, but if any doubt remains an anaesthetic should be given. In caries there is also no rotation ; and pain will be elicited on motion, or on gently percussing the spine or tapping the head or shoulders. {See also Caries; Art. ix., vol. ii) Treatment. — The treatment must necessarily vary according to the severity and nature of the deformity. When there is evidence of general and muscular debility the general health and muscular tone should be improved by appropriate remedies, avoidance of late hours, crowded assemblies, and the like. The exciting causes of the deformity must be sought for, and, if possible, removed. Thus, all occupations necessitating one-sided positions, bad habits of sitting Scoliosis. 333 or standing, carrying heavy weights, etc., should be avoided or given up. When there is fiat foot or knock knee these should be remedied ; where one leg is shorter than the other, a boot ^vith a high sole must be worn. These means, when combined with a judicious selection Fig. 71.— Exercises for Lateral Curvature. of muscular exercises and partial recumbency, will generally be sufficient in slight cases to cure or greatly lessen the curvature. In severer cases the degree of improvement will be proportionate to the amount of osseous deformity ; whilst where there is much rigidity and confirmed structural change little or no improve- ment must be expected, and it will generally be found necessary, at least in hospital patients, to employ, in 334 Manual of Surgery. addition to exercises, some form of meclianical suppoH to prevent the curves from getting worse, to relieve pain when present, and to improve the outward appearance. The exercises should be directed both to strengthening the spinal muscles generally, and those in particular which tend to correct the curves. Amongst the former may be mentioned swinging by the hands from a bar, forcibly stretching an indiarubber cord attached to the floor, the use of dumb-bells, chest expanders,' the extension motions of drilling, etc. An excellent exercise, which of late has been advocated by Dr. Busch in Germany, and Mr. Roth in this country, is to bring the patient's body over the end of a couch or table, and then, whilst he is prevented from falling by an assistant holding the legs, he is instructed to alternately flex and extend the body at the hip, whilst the surgeon resists his efibrts (Fig. 71). For strengthening those muscles in particular that tend to straighten the curve, the back should be manipulated till that posture is found in which the curves are the least marked. In this position the patient can only hold himself by muscular action, and at first for only short periods at a time. By frequently practising this posture the muscles thus brought into play are gradually strengthened, till at last the improved position is maintained without effort. For further strengthening these muscles, Mr. Both advises that the patient should exercise whilst in this improved position, especially advocating the movements above described. Dr. Busch, for tliis purpose, recommends that whilst the patient is thus supported over the end of the table the surgeon should make forcible pressure with his hand alternately in the dorsal and lumbar cur\ e, at the same time bending the body to the right and left respectively. Another device, especially indicated in lumbar curvature, is to place the patient, as recommended by Scoliosis. 335 M. Bouvier and later by Mr. Barwell, on a scat raised several inclies on the side corres})onding to the convexity of the lumbar curve ; the tilting of the pelvis thus produced, when the patient holds himself upright, counteracts the curves by its tendency to ])roduce others in the opposite direction. A similar effect may be obtained by placing a high sole on the boot, and during riding by sitting on the off side of the saddle. None of these exercises should be carried to the extent of exhaustion, and rest on the back for half an hour to an hour should be taken after them. The back should be further supported by the use of a reclining chair, a good substitute for which may be made by raising the front legs of an ordinary chair on two bricks. Where there is much stooj)- ing my elastic brace (see Fig. 72) will be found useful, but should only be worn a few hours a day. At night time the patient should sleep on the side opposite to the dorsal curve ; or on a Wolffs suspensory cradle. In the advanced cases, where a spinal support is thought necessary, a poro-plastic felt jacket or plaster of Paris case applied during suspension may be used ; or, if a steel instrument is preferred, that known as Baker's stays, Chance's support, or one of the many other forms without arm crutches may be adopted. AiNTEIlO-rOSTERIOR CURVATUKE OF THE SpINE. This term is generally restricted to those cases in which the spine is bent either in a backward or for- ward direction, as a result of unequal compression of the intervertebral cartilages. The antero-posterior curvature of the spine depending uj^on disease either Fii,'. 72. — Walsliani's Solid Rubber Shoul- der Brace. 33^ Manual of Surgery. of the cartilages or of the vertebrae is known as angular curvature, and is described under that head in the Article on Diseases of tlie Spine. When the curvature is convex forwards it is called lordosis ; when convex backwards, kyphosis. liOrdosis. — Iiiciirvatioii, or a curving of the spine with the convexity forwards, should be regarded as a symptom rather than an actual disease. In the lumbar region, in which it is most common, and in the cervical region, it is merely an increase of the normal curve ; in the dorsal region it is a reversal of it. In the lumhar region it sometimes appears to be here- ditary ; generally, however, it is there formed as a com- pensating curve to restore the equilibrium of the body when this is disturbed by the tilting forward of the pelvis, as in congenital dislocation of the hip, hip disease, rickets, etc. Or it may be formed as a com- pensating curve in caries with angular curvature in the dorsal region ; or it may depend upon contrac- tion of the psoas muscle, consequent upon inflamma- tion or abscess in its substance. In the cervical region it is generally compensatory to occipito-atloid or atlo- axoid disease. In the dorsal region it is very rare, but occasionally occurs as a compensating curve to caries of the lower cervical, lower dorsal, or lumbar vertebrae, and sometimes in double lateral curvature. The treatment should rather be directed to the cure of the occasionmg cause than to the removal of the lordosis, which in itself is not usually of a permanent nature. liypliosis.— Exciii'vatioii, or posterior curva- ture, is a general curving of the spine with the convexity backwards, or an exaggerated condition of the normal dorsal curve depending upon unequal compression of the intervertebral cartilages. It is often seen in infants and in delicate and rickety children who have been allowed to sit up too early or for too long KypHosis, 3117 perio;ls. In growing girls and lads it is brought on by slouching habits, and in older persons may be acquired by occupations necessitating stooping ; hence its frequency in watchmakers, clerks, agricul- tural labourers, etc. It may also be induced by chronic bronchitis and chronic rheumatism. Sometimes it would appear to be hereditaiy. In infants the kyphotic curve is most marked in the lower dorsal reijion, where several of the spinous processes often appear pre- ternaturally prominent. In boys and giils and in old people the curve chiefly aflects the upper dorsal region, producing the round shoulders with which all are familiar. The point of chief interest is to distinguish between the comparatively harmless kyphotic curve and angular curvature depending upon caries of the vertebrae. In children and adults it is usually easy, but in rickety infants the surgeon is unable to apply the usual tests for caries, such as the behaviour of the spine in stooping or rising from the recumbent position in walking, jumping, etc.; and he is, moreover, liable to be misled by the acute tenderness and evident pain on handling that often occurs in rickets. If the infant is placed horizontally with its face downwards across the nurse's knees, and gently extended by the arms and legs, the rickety curve disappears or may become ])os- teriorly concave, whilst the back may be more flexible than natural in its whole extent. In caries, on the other hand, the curvature remains, or is even increased, and the spine is rigid ; the infant is, moreover, evidently uneasy in this position, and tries to resist the exten- sion of the back by muscular action and drawing up of the legs. Other indications of rickets will also probably be present. Treatment. — In the infant perfect recumbency should be enjoined, and such dietetic and hygienic measures taken as to restore the muscular tone, with appropriate remedies when there is evidence of rickets. w— 21 338 Manual of Surgery. Local support to the back in the form of a moulded leather or poro-plastic jacket is recommended by high authorities. But I prefer trusting, as a rule, to recumbency. In growing lads and girls slouching habits should be corrected, and a system of muscular exercises instituted, combined, when there is debility, with periods of recumbency and attention to the gene- ral health, A sjjinal brace should also be worn for a few hours daily. In the confirmed kyphotic curve of old age treatment is of little avail. Club Hand. Several rare deformities of the hand, depending upon a contracted condition of the muscles or malformation or absence of some of the bones of the fore-arm and hand, have been included under this term, on the supposition that they were analogous to club foot. The most common of these de- formities, perhaps, is that in which the radius and one or more of the bones of the carpus and the thumb are ubsent, the hand being fixed in the position of flexion and abduction. Space will not permit of a further account of these conditions, nor is this much to be re- gretted as they can have little or no interest for the practical surgeon. Talipes or Club Foot. irive principal forms of club foot are described, talipes equinus, calccineus, varus, valgus, and cavus. These forms of club foot may be variously combined, and are then spoken of as equino- varus, equino- valgus, calcaneo-valgus, etc. Causes* — Club foot may be congenital or acquired. "Various theories have been advanced to account for the congenital form. The chief of these are : (1) That it is due to a spastic muscular contraction consequent Talipes. 339 upon some lesion of the nervous system, the bones being drawn into their abnormal position by the con- traction of the muscles, and there fixed by adaptive shortening of the muscles and ligaments. No alteration, however, has as yet been discovered, either in the brain or spinal cord, to account for this so-called spastic contraction. (2) That it is due to malposition of the foetus in utero, the bones being merely maintained in their faulty position by the adaptive shortening of the muscles and ligaments, and not dra^Ti there by any active contraction of the muscles. (3) That it is due to a structural alteration in the form of the bones them- selves. An alteration in the shape of tJie astragalus in congenital varus no doubt exists, but it appears as likely to be the result of the malformation as the cause of it. The congenital form, moreover, may occur in several members of the same family, and often appears to be hereditary. The causes of acquired club foot are numerous. Of these, infantile paralysis is one of the most common, the deformity being then in part due to the drawing of the bones into the faulty position by the contraction of the muscles antagonistic to those paralysed, and in part to the superincumbent weight of the body tending more and more to increase the faulty position. The less common causes will be referred to under the heads of the different varieties. The symptoms of club foot can better be discussed under each variety. A few general remarks here on treatuieiit, ho-v^- ever, will prevent repetition when describing that appropriate to each. The general indications are, first to restore the deformed foot to the natural position, and then to retain it there until it shows no tendency to relapse and the functions of the joints and muscles have been, as far as possible, regained. For the first indication both operative and mechanical treatment 34© Manual of Surgery, may be necessary ; for the second, mechanical siipporta and physiological after-treatment should be employed. The oj^erative treatment will, in by far the greater number of cases, be merely a subcutaneous division of certain tendons ; but in inveterate cases, where tenotomy and all other means have failed, some form of osteotomy of the tarsus becomes necessary. Tenotomy is indicated where there is much rigidity, and the foot cannot be restored by manii^ula- tion to its natural position. Its object is to perma- nently lengthen the contracted tendon by the insertion of a piece of new material. This new material is formed from a small cell exudation, which, when the tendon is divided, is poured out from the divided ends, and is ultimately converted into fibrous tissue which can- not be distinguished by the naked eye from the rest of the tendon. Thus, from a quarter of an inch to an inch and a half, or even more, of new tendon may be produced according to the rapidity of the rate of extension afterwards employed. The tendon having been made tense by an assistant, the tenotome should be passed beneath it with its blade parallel to it. The tendon should now be relaxed whilst the edge of the tenotome is turned towards it, and then again made tense to facilitate its division, which is effected by cut- ting outwards towards the skin. The assistant should relax, the surgeon cease to cut, the moment the resist- ance of the tendon is felt to be overcome, so as not to pierce the skin and render the puncture an open wound. On removing the tenotome a dossil of oiled lint should be placed over the puncture and secured by a piece of strapping and a bandage, care being taken to prevent the entrance of air lest suppuration should ensue, and the tendon adhere to its sheath or fail to unite. It is usual to place the part in the deformed position on a splint or in some form of Scarpa's shoe, till the puncture has healed, before beginning mechanical extension. Many, Talipes^ 341 however, place the foot at once in its natural position in plaster of Paris ; but in so doing a risk is i-un of the tendon not uniting, or of the uniting tissue remain- ing weak. Whilst using plaster of Paris, I place the foot in a slightly improved position only, so that the ends of the tendon are not sufficiently separated to endanger their union. Tarsotomy. — Various operations having for their object the removal of certain bones or portions of bones from the tarsus, so as at once to restore the normal shape of the foot, have from time to time been practised. Of these may be mentioned Davy's operation, or the removal of a wedge-shaped piece of bone from the tarsus, and Lund's operation of excision of the astra- galus. These operations have been followed yA\h excellent results, but it cannot be too strongly urged that they should only be undertaken in inveterate cases, and not until all milder measures have failed. Mechanical treatment aims at brincnns the foot slowly into its natural position by overcoming the resistance of the contracted muscles and ligaments ; or, where tenotomy has been previously done, by so regu- lating the amount of new tendon formed that the same result is obtained. The apparatus, perhaps, in most general use is some kind of Scarpa's shoe. This, in its simplest form, consists of a leather slipper, united to a leg iron and calf piece, and provided, opposite the ankle, with a joint which can be moved in the direc- tion of flexion and extension by a cog-wheel, so that it can be made to correspond to the shape of the deformed foot. In this position it is strapped on, and then by a daily turn of the cog-wheel the foot is gradually brought into its natural position. But as equally good, if not better, results may be obtained by plaster of Paris, which, moreover, is much cheaper, I have of late treated all the suitable cases in the Ortho- paedic Department at St Bartholomew's Hospital in 342 Manual of Surgery. this way. If plaster of Paris is used, it should be ap- plied once or twice a week, according to the ligamen- tous resistance and the amount of new tendon it is wished to produce. A cotton wool bandage should on each occasion be placed under the plaster. The mechanical supj^orts for maintaining the foot in the improved position will be described under each form of talipes. Physiological after-treatment aims at restoring the proper movements of the joints and the functional activity of the muscles. It consists in active and pas- sive exercises, shampooing, faradisation, hot and cold bathings, and last, but not least, the education of the child in the proper use of the foot in its restored position. Of course, in paralytic cases, where the muscles have undergone fatty change, the same good result cannot be expected, and in such a mechanical apparatus may have to be worn for life. Talipes Equinus. In this form of club foot the heel is drawn up by the tendo Achillis, and the anterior part of the foot, in consequence, depressed. There is neither inversion nor eversion ; when such occurs, the deformity is spoken of as equino-varus, or equino- valgus. Like other forms of talipes, equinus may be congenital or acquired. The congenital form is ex- tremely rare ; tlie causes of the acquired may be enumerated as : (1) Contraction of the muscles of the calf, due to (a) infentile paralysis of the anterior muscles ; (h) extension of the foot for long periods, as from the weight of the bed clothes where the limb is confined on a splint. (2) Disease in or about the ankle joint. (3) Contraction of cicatrices following burns and wounds. Moi'biy suppuration, necrosis of the femur, and other complications. MM. Kobin and Collin have invented instruments for making Delore's operation more pre- cise, which then goes by the name of ostcoclasy. After any of these operations the limb should be Fig.Sl.— 1, Roevofe's diapliysLil operation ; 2, Mace wen's operation; 3, O^stou's ope- ration ; \, Eceves's condy- lar operation. Bow- Legs. 361 placed in a btraiglit position on a long splint or in Bavarian plaster splints for a month, and subsequently for another six weeks in ordinary plaster bandages, till consolielation has occurred. Bow-Legs. ijieiiu vartiiii, or bow-legs, is a deformity in which, when the malleoli are placed in contact with the knees fully extended and the patelhie looking dii'ectly forwards, the knees, instead of being in contact, are separated from each other by a variable intervaL As in knock-knee, both legs, or one leg only, may be aliected, or there may be genu varum on one side and valgum on the other. It is frequently associated with a bowing outwards of the shaft of the tibi?e, just below the upper epiphysis, or at their lower thirds, and sometimes with a bowing of the femora tis well. The symptoms are self-evident, and what has been said of the cause, pathology, and treatment of genu valgum will nearly apply to genu varum, if external be substituted for internal in the phraseology. Where tlie tibia and fibula are much curved, and the bones have become consolidated in the deformed position, either subcutaneous Imear osteotomy or the removal of a wedge-shaped piece from the tibia, with fracture of the fibula, may also be required. Deformities of Great Toe. Hallux valgniis and hallux varus are terms applied to a deformed and partiallv dislocated great toe. In Judlux valgus, the great toe at the metatarso- phalangeal joint is abducted and partially dislocated from the metatarsal bone, and crosses in extreme cases either over or under the second and even the next toe. The deformity is generally attributed to wearing too short or narrow-toed boots, but long-standing gout and rheumatism are thought by some to have some share 362 Manual of Surgery. in its production. The little toe is often dislocated inwards at the same tini'^, whilst the other toes are drawn up claw-like to make room for the great and little toes below them. In long-standing cases the external lateral ligament becomes shortened, and the head of the metatarsal bone distorted and thickened by absorption and the deposition of new bone around ; whilst in consequence of the continued chafing and pressure of the boot, the skin over it becomes callous, and a bursa is generally produced. This bursa is very apt to become inflamed, and is then known as a bunion; or it may suppurate and produce an intractable ulcer ; or should it communicate with the joint, this also may be attacked, leading to caries and necrosis of the bones, or to ankylosis. In old people such an ulcer may become a starting point of senile gangrene. IWeatment. — Slight cases are readily remedied by weari]ig properly shaped boots and by avoiding too long standing and over-walking. The boot should have low heels, and square toes, be sti-aight along the inner edge and sufficiently long and wide to allow plenty of room for the toes to resume their normal position. In severer cases some form of apparatus for drawing the toe into its normal position nnist bo employed. Thus a chamois leather cap may be Avorn over the toe, from which a piece of elastic weighing passes along the inner side of the foot, and is fixed round the heel by bands of adliesive plaster ; or a steel sole plate having partitions of a soft material for separating tlie toes may be worn in the boot, or a wedge may be fitted to such a plate to keep the great toe from its neighbour. At night a light shoe, [uovided with a bunion spring, may be worn. " This s[)ring has an oval opening over the bunion to avoid direct pressure on the aOcjctod joint, and the too is gradually everted by a small strap passing round it, fixed to the end of the spring. " Hammer Toe. 363 The bursa should be protected by soap plaister, and when enlarged and painful pamted with tincture of iodine, or rubbed wuth biniodide of mercury ointment. Should it suppurate a free incision should be made and a poultice applied. The ulcer met with in this situ- ation usually requires a stimulating treatment ; but when the opening is small and the skin undermined, it should be laid freely open and the redundant skin cut away. In some cases amj^utation of the toe may be necessary. llcilliix Icarus is very much less common than valgus. In it the great toe is partially displaced inwards and carried away from the other toes, instead of towards them as in valgus. It may occur in talipes equino-varus, in knock-knee, in sor.ie para- lytic aliections, from contraction of the abductor pollicis, etc. Should it continue after removal of the cause, a properly shaped boot must be worn to keep the toe in place, but tenotomy of the abductor pollicis may be required. IlaiiiiBier toes, — This term is applied to a con- dition of the toes in which the first phalanx is extended and the second and ungual flexed, so that the toes present a claw-like appearance. It is generally present, as has been stated, in talipes equinus and cavus, and in hallux valgus, but may be met with as an independent all'ection from wearing too short boots. It is then generally limited to the second or third toe, over the dorsal surface of which corns commonly form. Tenotomy of the extensor tendons, and even ampu- tation of the first phalanx, may be necessary. (.S'e« also Talipes cavus.) Siipcriiunicrary tligitsare frequently associated with other deformities as webbed fingers or toes, double hands or feet, club foot, etc. They appear to be hereditary, and often occur in several members of the same family. There may be simply an increase 364 Manual of Surgery. in the number of fingers or toes, the extra digits being either of normal size, or, as is more frequent, shorter and smaller. But the most common abnormality is a shrunken and malformed little finger or thumb, at- tached excrescence-like by a pedicle, often consisting merely of skin, though sometimes containing a slip of tendon. An extra toe often causes no inconvenience, and need not be interfered with, but a supernumerary finger should, as a rule, be amputated at an early period. As it may articulate with the metacarpal bone by a joint common to it and the normal finger, it is better to saw through the phalanx close to the articu- lar surface rather than to disarticulate. Cong'euital liyi>crtroi>liy. — This rare condition is generally limited to one or more digits, but it may affect the whole of one or more limbs. It may involve all the tissues of the affected part, or be limited to the bone or to the skin and subcutaneous tissue. Some- times it takes the form of a distinct excrescence con- sisting of subcutaneous tissue and fat. The removal of the affected part, where this is practicable, is gene- rally indicated. Dcflcieiicy of bones. — Almost every bone in the body has been found in part or wholly deficient. Amonij the most common of such de- ficiencies may be mentioned absence of the radius with part of the carpus and one or more fingers in the upper extremity, and of the tibia, with deficiency of some of the tarsal bones, and bones of the toes in the lower. Little can be done in the form of surgical treatment, but in the case of the lower extremity some form of leg iron may be found that will aid the patient in walking. i^'S VIT. DISEASES OF THE HEAD. FllEDElUCK TkKVKS Ki-ysipelas <>f the scalp is common, and tlie bulk of the examples of the idiopathic form of the disease are in this situation. The inflammation spreads with unusual rapidity, but owing to the tense- ness of the scalp, redness is but very little marked, and swelling is inconsiderable. Certain cerebral symptoms are common (headache, vertigo, drowsiness or restlessness, delirium), and depend usually upon hyperaemia of the pia mater. Owing to the possibility of cerebral complications the prognosis in erysipelas of the scalp is a little more grave than that of erysipelas elsewhere. The form of the disease most often met with is that known as the "cutaneous." Cellulitis, or ditTiisc plBleg^moii of tlic scalp, refers to a spreading inflammation, commonly erysipelatous, that involves the loose layer of connec- tive tissue between the aponeurosis of the occipito- frontalis and the pericranium. It is usually due to a wound opening up that layer of tissue, but may depend also upon deep ulceration, or upon suppura- tion following fracture, etc. There is a deep rapidly spreading swelling. The parts are hot, tender, ])ainful, and brawny. Fluctuation ajjpears at certain points. The constitutional symp- toms of suppurative fever are marked. In time the whole scalp may be lifted up, and may be found rest- ing upon a stratum of pus. If the matter escapes spontaneously it usually finds a vent in the temporal or mastoid regions. Sloughs of the connective tissue are discliarged ; necrosis may follow. The inflammation may extend to the meninges. 366 Manual of Surgery, or thrombosis of the cerebral sinuses may follow. The case may end in fatal pyaemia. In favourable cases prolonged suppuration usually supervenes. Treatment. — The head should be shaved and free incisions made as soon as suppuration is suspected. These incisions should be made at the most dependent spots possible, as near to the attachments of the apo- neurosis as the swelling extends, and out of the way of the scalp arteries. The whole scalp should be poulticed with wood wool poultices, and all the inci- sions be freely drained. The ordinary constitutional treatment must be carried out. When the more acute symptoms have subsided, the head may be compressed by means of a Martin's elastic bandage, so as to prevent spreading or bagging of the pus. All sloughs should be removed as soon as they are free ; and the drainage tubes retained until the discharge has become insignificant. Abscess of the scalp may be met with in three situations: 1. In the scalp proper, above the aponeurosis. 2. \\\ the lax tissue beneath the aponeu- rosis. 3. Beneath the pericranium. Abscesses in the first and third situations are circumscribed, but those beneath the aponeurosis are generally difl'nse. Scalp abscesses may follow contusions, ecchymoses, wounds, fractures, the breaking down of scrofulous or syphilitic deposits, and bone affections. They all de- mand an early iucision, but, apart from this, call for no special treatment. Tumours of the Scalp. IIaeiiiatoiiia.^.vCollections of blood (like ab- scesses) may be met with in three situations : 1. In the substance of the scalp (these are small and circumscribed). 2. In the lax tissue beneath the aponeurosis (those hfematomata may be very exten- sive, and may involve nearly the whole of the Hmmatoma of Scalp. 367 vault, being limited onl} by tlie utt;icliiiients of the a]wneiirosis). 3. Beneath the pericranimn. The first two named follow simple contusions, and de- mand no special consideration. The last named are usually spoken of as ccphal-hcematomata, and pi-e.sont some points of interest. They are met with in the newly born, depend upon some injury received during birth, are more common in males than in females, and are usually situated on the parietal bone, especially that of the right side. They usually appear within forty-eight hours of birth, and form soft, elastic, fluctuating, and painless tumours of variable size. They are always precisely limited by the pericranium, and therefore never extend beyond a suture. In a few days the centre of the swelling feels soft, and around its margin is noticed a tolerably hard ring. The latter is probably due to partial coagulation, and in old cases may be replaced by a harder ring of ill- formed bone. The prognosis is favourable, the swel- ling disappearing in from fifteen days to two months. The condition calls for no treatment. Sebaceous cysts are peculiarly common on the scalp. They are apt to be nudtiple and may attain great size. They form roundish tumours with very distinct walls. They are movable, possessed of faint fluctua- tion, and cannot be separated from the skin. When of large size the hair that co\ers them atrophies, and the tumour becomes bare. They are of very slow growth, may remain stationary for an indefinite time, are painless, and contain altered sebaceous matter and epideiinal debris. Many present a black point upon their sunnnits. They are apt to suppurate if in- jured. When suppuration occurs the skin in time gives way, the sebaceous matter protrudes, and granulations spiing up from the exposed sac wall. In this way a I'ungating vascular mass (the follicular or fun(jating 368 Manual of Surgery. iilcer of iJifi, scalp) may he produced, which closely re- sembles epithelioma. From this disease, however, it may be separated by the history of the case, by the previous existence of a sebaceous cyst, by the absence of any infiltration at the margins of the sore, and of any enlargement of lymphatic glands. The only mode of treating so])aceous cysts is by excision. Con^oiaital <1ci*isioi«l cysts resemble the seba- ceous cyst in most points. They are, however, small, seldom exceeding a diameter of two-tliirds of an inch, are of very slow growth, are congenital, and contain in addition to sebaceous matter, as a rule, a number of fine hairs. They are most common at the outer angle of the orbit, and always have deep connections with the pericranium. They may lie in actual depres- sions in the cranial bones. They should be excised when possil)le, but those about the orbit have often such deep connections as to render complete excision impossible or inadvisable. Iffoi'iis. — These strange excrescences are developed from the interior of a sel)aceous cyst that has been opened up by rupture or inflammation. They are formed of sebaceous matter that has become dry and horny from exposure. As fresh matter is constantly being produced by the cyst wall at its base the horn grows. Some have attained the length of six or eight inches. They can be best treated by carefully excising their bases, including the whole of the remains of the sebaceous cyst. Pacliytlcriiiatocclo. — This remarkable affection is also known as elephantiasis, and as hypertrophy of the scalp. It consists of an immense over-growth of the scalp tissues. The tumour formed consists mainly of connective tissue, and hangs down as a huge pendu- lous tumour, tliat is often lobulated, is flabby to the touch, is painless, and covered by normal skin (Fig. 82). The tumour may cover the eyes and even drag ui)on Pne uma tocel l . 369 the moutli. It is innocent, and causes distress only by its bulk. In some cases it is congenital, in otlieivs it appears at puberty or in young adults. It is most common about the temporjil or parietal regions. Some benefit may attend the use of long continued Fig. 82. — Pachydermatocele. pressure, but if this fails excision offers the only alternative treatment. Piiciiiiiatoecle. — This name is given to a tumour containing air ; the collection is bcnea.th the pericranium. Pneu- matocele is usually met with over the mastoid process ; one case has been described as existing over the frontal sinus. The mastoid cells or frontal sinus have become per- forated, and air finds its way under the pericranium from the middle ear in the one case, and from the nose in the other. The perforation may be due to accident, to caries sicca, or to atrophy of the Ttony walls of the cells or sinus. The tumour is small, round, painless, and tympanitic. By jiressure it may be made to dis- appear. Its progress is exceedingly slow, and it usually produces no trouble. It should be treated simply by the pressure of a carefully applied pad. In addition to thrf;e special tumours, the following are also to be met with in the scalj^ : Na^vi ; cirsoid, racemose, and arterio- venous aneurisms ; arterial varix ; sarcomata ; fatty, fibrous, and papillomatous growths. The three last named are very rare. These tumours, differing in no essential respect from like growths found elsewhere, demand no especial notice. Nsevi and arterial angeiomata are more common on the Y— 21 37© Manual of Surgery. head than in any other part of the body. The first named are most often met with about the anterior fontanel le, the orbit, and the temple, and the latter in connection with the temporal, posterior auricular, and occipital arteries. Affections of the Skull, I?lA'B«Biia;:occlc ; CBB<;€'|»lisEloccle, liy<1mice- l»lialo«'X'lo. — These terms are .'ipplied to certain tumours that consist essentially of a protrusion of some part of the cranial contents through an aperture in the skull. They are all congenital. When the tumour contains a protrusion of the meninges only, the term meningocele is used ; when a protrusion of brain, the term encepha- loccle ; and when the mass is formed by a portion of brain, greatly distended with lluid from a dropsical ventricle, it leceives the name of hydrencephalocele. Of these three tumours the last named is the most couimon, while the pure meningocele is the most rare. These protrusions depend upon congenital defects in the development of the skull, whereby gaps are left in the cranial bones. Situation. — The most common site is the occipital region, where the gap is found about the middle line of the occipital bone, and wlience it may extend to the foramen magnum or the posterior fontanelle. The site next in fre([uency is the root of the nose, the protrusion leaving the skull between the cribriform plate and the frontal bone, and appearing externally between the frontal and nasal boncis. Tumours in this site are usually much smaller than those on the occi- put, and being very often covered by red and vascular skin, liave been mistaken for luevi. The I'arest situa- tion is at some j^oint (usually at a siil.ure ]in(i) abtmt the sides or base of the skvdl. Tumours developed in the latter situation have projected into the orbit, the mouLh, and the pharynx. Meningocele, 371 Symjjtonis. — These protrusions appear as roundish elastic tumours, covered usually by normal skin, which may, however, be greatly tliinned and also ex- coriated. They usually have a pulsation synchronous with the heai't, and may be reduced more or less by pressure, such reduction being often followed by brain sym})toms (headache, vomiting, convulsions, stupor, etc.). They are often pedunculated and pendulous. The hole in the skull can usually be made out. On forcible expiration the tumour as a rule becomes more tense or increases in size. If the mass be small the skull will be normal in outline ; if large, the child will be micro- cephalic. The separate symptoms and the features in the differential diamosis are exhibited in the followintj table. Size aud Surface. Pedicle. Fluctuation. Meningocels . ENCEPirAT.OCELE Hydbencepualocele, Small. Surface smooth. Small. Surface smooth. Often large aud peudulous. Sui"- face ofteu in-e- gular or lobed. As a rule pe- dunculated. Wide ba.se. Earely peduu- culated. As a ride pe- dunculated. Most distinct. Absent. Distinct. Ti-auslucency. Pulsation. Reducibility. M;eningk)cele . Ekcephalocele Hydkencephalocele. Perfect. Opaque. T r a u s'l u c e n t ouly at most dcpeudeut or most promi- ueut parts. Earely present. Distinct. Raroly present. Always redu- cible. Reducible, but not completely. Irreducible. 372 Manual of Surgery. Prognosis. — The majority of the subjects of these dt^foi'inities die within a short period of birtli. In hydrencephiilocele the prognosis is absolutely bad ; in meningocele it is the least hopeless. In most cases the tumour increases, and in time bursts, causing death from collapse, convulsions, or acute meningitis. It may, however, i-emain stationary, and the patient may attain adult life. In the case of meningocele, the bony gap may become so narrow that the cavity of the tumour is cut oft' from the cranial cavity, and a sponta- neous cure follows. Treatment — Tlie mass should be simply protected. Operative interference is only justifiable under one condition, viz. when rupture of the tumour is threatening. 1. Empty the sac with a capillary trocar, and repeat the tapjnngs as the sac refills. This has resulted in cure. If, however, the sac re-lill in a shorter time after each tapping, and the fluid )>ecome dull, injections of iodhie may be used (tr. iodi. one part, water two parts) ; this measure has, however, met with little success. As an alternative the excision of the sac under antiseptic precautions may be entertained. 2. Encephalocele, Repeated tappings (if there be fluid in the sac), followed by pressure by means of an elastic bandage, may be employed. 3, Hydrencephalocele is not adapted for any operative interference. Caries and necrosis.— Caries of the skull is less connnon than necrosis, and may be due to injury, to syphilis, or to scrofula. It is most often met with on HycU'eiicephaloccle. Meningocele A^ECROSIS OF THE Sh'ULL. 373 the extornal table, bnt may commence in the inner table or the cli2)loe. The l)ones usually involved are, in order of frequency, the frontal, the mastoid, and the occipital. The disease may be very extensive, and in any form the cranial vault may be perforated. This perforation may occur at many spots, especially in the sy])hilitic form, and through the holes so formed the pulsations of the brain may be recognised. In such cases tlio dura mater is thickened by inflammatory deposit. The pathology and general symptoms of the affection do not differ from those of caries elsewhere. The gravity of the disease depends to a great extent upon certain special complicatiojis. These are pysemia from suppurative phlebitis of the diploic veins, thrombosis of the cerebral sinuses, collections of pus between the dura mater and the bone, meningitis of the convexity, and, in rare cases, abscess of tlie brain. Treatment. — Treat the constitutional condition. Evacuate all collections of pus j keep the parts clean. If the caries be sj^reading, a cautious use of tlie gouge may be advised. If pus be pent up either in the substance of the bone or beneath the dura mater, the application of the trephine is called for. In many cases, also, of early spreading caries, the trephine, not necessarily applied through the whole thickness of the skull, may arrest the disease. Necrosis may follow contusions, lacerations of the scalp, fractures, burns, and extravasations of blood beneath the pericranium or the dura mater, or it may follow the eruptive fevers, or depend upon scrofula or tertiary sy})hilis. The last named cause is the most common of all. In the idiopathic forms the frontal and pnrietal bones are most often involved. The whole thickness of the bone may necrose, but more usually the disease 374 Manual of Surgery. involves only the outer table. In very rare cases it has involved only the inner table. The necrosis is usually limited, but it may be very extensive, and in some recorded cases nearly the whole of the vault of the skull has been lost by necrosis in the process of years. The mode of separation of the sequestrum is the same as that observed in necrosis elsewhere {see Art. II., page 124), and the only pathological feature special to skull necrosis is the absence of any new bone for- mation. The sequestrum is not retained or invaginated by new bone, and the gaps left in the cranium after the separation of the sequestra are filled up by fibrous tissue only. The special complications that may attend caries may attend necrosis. Treatment. — Give free exit to all discharges. Superficial necrosis may be practically left to itself, or the process of exfoliation may 1)e aided by the use of strong sulphuric acid. Remove all loose sequestra. If the dead piece be too large for convenient removal, it may be trej)hined and removed in segments. The trephine may also be used when pus collects between the dura mater and the bone. Tiiiiioiirs of tlie skull. Ostcoinata. — Those bony tumours that grow from the outer table of the skull are called exostoses, those springing from the diplon or inner table enostoscs. Some are spongy or cancellous in structure, but the majority have the structure of ivory exostoses. These tumours are often multijile, sometimes symmetrical, and are most commonly found in connection with the frontal bone, and next in frequency with the mastoid and occipital bones. They are usually iiTegular and bossy ; they are of slow growth, and only cause trouble when they coui press the brain (enostoses) or grow into the orbit or nose. P]xostoses in the latter sites may necrose en masse. In the great majority of cases these tumoui'S Fungus of the Dura Mater. 375 call for no opo.rativc interference, and arc indeed affected Ly none. In very rare instances the following grotvths have been met with in tlie skull. Hydatid cysts ; angeio- mata ; sarcomata growing from the pericranium or the diploe. These tumours are usually of the spindle- celled variety, and are more often secondary than primary. If growing from the diploe they ex- pand the outer table, and for a time form tumours with thin bony shcdls. They are beyond treat- ment. Carcinoma of the skull is met with, Imt always as a secondary affection. Fiiiig:iis of the dura mator. — This term is applied to a sai'comatous tumour growing from tlie dura mater (and in very rare instances from the j)ia mater or arachnoid) that has penetrated the cranium, and has appeared under the scalp. The growths may be primary or secondary. The former are the less common and are single, the latter are due to metastasis and are often multiple. This form of sarcoma is rare, since the majority of the sarcomata of the dura mater do not perforate. Symptoms. — In most cases no symptoms precede the appearance of the external tumour. In other cases there are cerebral symptoms (headache, neuralgia, vertigo, vomiting, convulsions, etc.). As the tumour makes its way through the bone, a soft spot of thinned bone may perhaps be felt at the vertex, which crackles on pressure. This thin bone gives way, and the sarcoma protrudes as a small flat firm tumour that pulsates and can be reduced on pressure ; on reduction the hole in the skull may be made out. The mass soon grows, and, s})reading beyond the hole, becomes more prominent and softer, and at the same time irreducible and no longer pulsating. If the patient lives long enough the mass may fungate through the 376 Manual of Surgery. Bcah) tissues. Sarcomata crowinc: from the Ijone are harder, are never recUicibk-, and never jmlsate. The affection is rapidly fatal, and is beyond the reach of any but palliative treatment. Hypciti'opliy of the <»kiill. — 1. Some few cases oi simple hypertrophy have been noted. The subjects have usually been advanced in life. The hypertrophy has involved the entire skull evenly, or has been limited to some portion of it. The cau.se of the condition is unknown. 2. Osteo-porosis. — This term is applied to certain large thick skulls with obliterated sutures, the bones of which on section appear uniform and finely porous like white brick. The general shape of the skull is, as a rule, not altered, but the component bones may be four or live times their normal thickness. Tliis change is more or less entirely limited to the vault of the skull. In some eases this peculiar hypertrophy has been associated with osteo-malacia, and in other instances with osteitis deformans. In the latter affection, however, the bones are usually quite dense on section, and the dimensions of the skull are greatly increased in all its diameters. {See Art. 11., page 120.) 3. In leontiasis ossium the skull is thickened and deformed by the growth of irregular bossy masses of rough and porous bone. These masses may be very large, are often symmetrical, and produce great deformity. The frontal, parietal, and malar bones are most often affected, the orbits and nasal fosss^e may be encroaclied upon, and certain cf the cranial foramina closed. It appears usually at or before ])uberty, and is of un- known origin. Pressure symptoms of various kinds may arise. No form of hypertrophy of the skull is amenable to any but palliative treatment. Cliroiiie liytU-oceplialiis.— This tenn is ap- plied to a disease of young children characterised H\ PROCEF/fA L US. 377 by cort.iin accumulations of fluid within the cranial cavity. The fluid may 1)0 within the ventricles (inter- nal hydrocephalus), or in the subdural space (external hydrocephalus). Internal hydrocephalus is the usual form. The ventricles are enormously distended, the ganglia flat- tened out, the convolutions unfolded, and the brain matter very greatly thinned. In severe ca.ses the Fig. 84.— Chronic Hytlrocepliihis. covering of brain matter may not be more than half to a quarter of an inch thick over the most distended parts of tlie ventricle. Tlie head enlai-ges, the bones are separated, and the fontanelles and sutures become of considerable width. The orbital plate of the fron- tal is thrust down, and the cavity of the orbit becomes greatly narrowed. The zygomatic fossre are tilled up, the scalp is full and tense, and covered by prominent veins. Fluctuation may be detected in the gaps be- tween the bones. External hydrocephalus cannot be detected from the internal form except in this, that there is in the present 378 Manual of Surgery. variety no displacement downwards of the orbital plate of the frontal bone. The prognosis is bad. Tlie great majority die of exhaustion, or of coma, or convulsions, or even acute cerebral mischief The cases where the child has grown up to adult life or even survived a few years are quite rare. Treatment. — With the general treatment of the disease the present article has no concern. The local treatment proposed in certain cases consists (1) in the use of pressure, and (2) in paracentesis. 1. Pressure may be applied by means of strapping or an elastic bandage. It is merely a palliative measure that may do good in some cases, while in others it excites cerebral symptoms, and cannot be borne. 2. Paracentesis has met with so little success that the operation is now seldom practised. It has afforded tem]iorary relief in a few instances, and has appeared to clieck the disease when progressing rapidly. A very fine trocar is entered at the coronal suture, about one inch from the anterior fontanelle, and is pushed downwards and backwards ; only a small quantity of fluid is drawn oft' at a time. The use of iodine injections in hydrocephalus has been only attended by unsatisfactory results. Remove a of cerelM'nl titmoiirs. — This pro- cedure has been, so far, adopted in one case only. Tlie surgeon was Mr. Godlee ; the physician in charge of the"^ case. Dr. Hughes Bennet.* The patient was a man, aged 25. His chief symptoms were agonising headache, vomiting, optic neuritis, and paralysis of the left upper limb. There were no external evidences of tumour. Dr. Bennet diagnosed a tumour of the cortex, at the niiddj.e third of the fissure of Rolando, and at this * Med.-Chir. Trans., 1882. Cerebral Tumours. 379 spot a glioma the size of a walnut was discovered at tlie operation. The opening in the skull was made by three trephine holes, each with a diameter of one inch. The growth was removed by means of Yolk- man's scoop. Bleeding was arrested by the cautery. The procedure was conducted under Listerian pre- cautions. The operation did not affect the patient's intelligence, and led to no special disturbance. His symptoms were for a while much improved. Un- fortunately the wound became septic, a hernia cerebri formed, and the patient died at the end of four weeks of meningitis. But for this surgical accident there is every reason to suppose that the case would have resulted in complete cure. 3 So VUL INJURIES OF THE HEAD. Anthony II. Corley. Injuries op the Scalp. Injuries of tlie scalp, tliougli always of im- portance, yet frequently become of secondary interest, in consequence of being accompanied by some lesion of tlie skull or its contents. Whilst subject to the same classification as injuries of other regions, the peculiar anatomical structure in which they occur often gives scalp wounds a character of their own. Notwithstanding the frequency and triviality of " cut heads," there is generally a disposition to over-rate their gravity, first, because of their possible compli- cation with deeper injuries ; and secondly, because of an old and deeply-rooted belief that they are more likely to be followed l)y erysipelas and allied diseases than arc wounds of other regions. They may be divided thus : A. Contusions. B. Wounds. The latter may be subdivided into (1) incised, (2) contused, (3) lacerated, (4) punctured, (5) poisoned, (G) gun-shot, and (7) " fiap " wounds, these last being usually a combination of contused and lacerated injuries, worthy of particular mention. Before entering upon a description of these lesions, it may be well to glance at the anatomical arramjrmcnts which confer special characters on some of these injuries. The scalp is a complex structure tightly covering, but movable upon, the cranium. Its principal com- ponents are : the skin with its appendages, and tlie occipito-frontalis muscle with its intervening tendon, the epicranial aponeurosis. Of great importance, from Injuries of the Scalp. 381 a surgical point of view, are two planes of con- nective tissue, one between the skin and subjacent ai)oneurosis, and the second separating the aponeu- rosis from the pericranium. The first or exterior layer of connective tissue is of a dense, fibrous cha- racter, containing in its substance the blood-vessels and nerves ; whilst, as the muscle is to glide freely over the cranial vault, the layer beneath it is of a loose character, readily torn and sparingly supplied with blood. Removal of the scalp, for whatever purpose, is effected by tearing through this in- ferior layer, and is a process very readily performed. Pus formed within the supeiiicial plane most com- monly constitutes an abscess, and blood in the same position a circumscribed tumour, but when either is found in the deeper connective tissue layer it forms a diffuse swelling, tending to project in tlie direction of the eyelids or ears. Tlie fact, too, that the copious blood and nerve supply of the scalp lies in the subcutaneous connective tissue, explains the well-known axiom that practi- cally the scalp never sloughs ; for, though it is true that a portion of it may be destroyed by direct injury or pressure, yet the mortification is limited to the part immediately involved. In the case of the scalp, deep-seated suj^puration is powerless to destroy the vitality of the superficial parts, wl-.ose blood- vessels the pus can neither strangle nor destroy. The lymphatic vessels of the scalp are numerous, and seem specially prone to propagate the results of irrita- tion of their peripheral ends to the glands in the neck. A. Coiitusioiis of tlic scalp may be divided into those special to now-born children and those found at all other periods of life. The former are the direct result of injury during parturition. Amongst them the ordinary scalp tumour or caput succeda7ieu7nj found in most cases of head 382 Manual of Surgery, presentation, can scarcely be reckoned as a morbid condition, inasmuch as it is caused by mei'e local con- gestion and cedema due to mechanical obstruction of the venous trunks by the contracted os uteri. When, however, the constriction has been more considerable or has lasted longer, some of the dilated blood-vessels may be ruptured and an extravasation take place, in which case a more serious condition results, and a tumour is formed which has received the name of cephal-ha3matoma. {See Article on Diseases of the Head.) The other contusiones iieonatorum are localised and small, and are produced by direct violence, either from matei'ual structures or from obstetric instruments. These contusions vary in intensity and eifects ; slight ones tend to rapid resolution, but a greater degree of pressure may result in ulceration or sloughing. The natural vitality of the infantile structures usually influence even those conditions, and frequently the morbid action terminates in healing, but sometimes more severe consequences ensue, such as shock, localised spasm, or paralysis. Contusions at other periods of life vary in extent from the slightest subcutaneous ecchymosis to the formation of a bloody tumour, and when they occur in the supra-orbital region they may present special and important local complications. The simple contusion requires no special descrip- tion, nor does it call for any special treatment. The traumatic bloody tumour of the scalp, how- ever, requires a special description, and it is not always possible to say, with certainty, into which plane of connective tissue the blood is extra vasated. Though usually, when the tumour is large, the extravasation is under the epicranial aponeurosis ; in many cases its presence is complicated by a fracture of the skull, when it may lie, possibly, under the pericranium. Cephal-Hmma TOM a . 383 The cause of the tumour is usually a severe injury, such as a blow of a heavy instrument, or a fall on the head from a height. A soft fluctuating tumour is in these cases readily felt, yielding to pressure at its centre, but giving the feeling of having a hard and sometimes api^arently sharp margin, a distinction ^vhich results from the fact that the central portion contains tluid, and the circumference coag\dated, blood. The diagnosis between such an extravasation and a depressed fracture of the skull is easily laid down, but not always so easily made ; and instances are not infrequent in which surgeons of great experience have been doubtful or even mistaken in their judgment. These doubts arise from the fact that the centre of the tumour is sometimes so soft, and the hard margin so sharply deiined, that the sensation it conveys to the touch strongly suggests a fracture with depression, es- pecially as the cause of the injury may have been of such a nature as to produce depression. But then, the sur- geon is to remember that, in the case of a fracture, the finger, when palpating the margin, passes at once from the level of the surrounding surface into the depression, whereas, in the case of bloody tumour, the finger first passes up the elevated margin of the coagulated blood before it dips into the central, yielding, fluid portion ; and, if pressure enough be made, the tip of the finger, displacing the blood, feels at length the resistance of the subjacent bone. In reference to this last test, it must be remembered that its use would not be jus- tifiable if any reasonable grounds existed for thinking that the case was one of depressed fracture, as such pressure might then be highly injurious. It may be pleaded in justification of doubts, or nus takes in the diagnosis of the two conditions, that extravasation and fracture may co-exist. As regards treatment, the part must be as little disturbed as possible, and absorption must be aided 3^4 Manual of Surgery. by discutient lotions. The extravasation will probably be absorbed in time. No incision is necessary unless suppuration be imminent or have ah'cady occurred, when any delay in opening and evacuating the tumour is fraught Avith e^■il consequences. Injuries imjilicating the supra-orbital reii'e!^iflrei'eiitiatioii of tlic vai'ii'tic«>) of coiii- preission. — As has been seen, the causes of com- l)ression vary, and it is important to differentiate these. If the symptoms of compression exist from the beginning, however those symptoms may be obscured ])y the signs of concussion, it may be sus- pected that depressed fracture, foreign body, or some serious brain lesion exists, and if the history of Ficr. 87. -Compression of the Brain due to extensive Extra vixsation of Blood. (After Hiitcliiusou.) Compression. 413 tlie case, or the apparent cause of the condition, such as a fall on the head, be accompanied by the signs of compression, we are safe in assuming the presence of a depressed fracture or a foreign body ; whilst if the signs of concussion disappear, and those of compression gradually supervene, after the lapse of a period from one to forty-eight hours after the injury, extra vasated blood is probably the cause. Such cases as the following are not uncommon, and they may some- times involve the surgeon in unmerited blame : A man is thrown from a vehicle on his head and is brought to the nearest surgery or hospital in a state of concussion. He recovers more or less quickly, and insists on proceeding home- wards, contrary to the urgent ad\ice of the surgeon. Perhaps he hastens reaction by taking stimulants, and in some hours afterwards he becomes drowsy, stupid, and falls fi-om his seat. Complete insensibility and all the other signs of compression supervene, and death closes the scene. What is the explanation ? The middle meningeal or other vessel had been ruptured at the time of the accident, and during the collapse state of concussion, when the heart's action was more or less in abeyance, a clot formed at the seat of injury, which stemmed the tide of extravasation. But with the establish- ment of reaction (perhaps too. vigorous) the clot had been swept away, and the cerebral ha-morrhage proceeded un- checked, either between the bone and dura mater, or upon the surface, or within the substance of the brain itself, and that haemorrhage produced the fatal coma. Compression by serum or lymph may be suspected if the symptoms arise in the early stages of encephalitis or meningitis, and in these cases it is fortunate that diagnosis is not so important, as there can be no surgical interference, and a reliance on the general remedies can alone be inculcated. At a later period, when inflammation, in whatever structure it may originate, has produced suppuration, a condition which is indicated by rigors, by the presence of Pott's puffy tumour (an appearance so rare that many experienced surgeons have never seen 414 Manual of Surgery. it), or by the state of the bo2ie if it be bare, the existence of the effused pus may be diagnosed, and its probable position should be considered. It may have been formed between the skull-cap and the dura mater, as when the puffy tumour is present, or where the bone is manifestly dead ; or it may be diffused upon the surface of the brain, or circumscribed betw-een adherent membranes, or in the subarachnoid spaces, or in the brain substance itself. Our knowledge of the modern topographical anatomy of the brain may lead us in doubtful cases to suspect a pressure limited to a particular spot. In such cases operations may be attempted with hope, as they have been performed with success. It must be remembered that compression may exist to a considerable extent, especially when slowly induced by the gradual formation of matter, or the slow growth of a tumour, and that, nevertheless, few of the symptoms described as belonging to compression will be manifested, or they only mark the termination of the case. On the other hand, it may occur that though all the symptoms are present, a post-mortem examination gives very negative proof of the existence of any appreciable compressing cause. It is in cases where coma is not so marked or per- sistent, where limited primary spasms or paralyses are present, where aphasia, or the implication of certain groups of muscles point to an irritation, such as that which a localised compression may produce, that operative interference is most hopeful, and, although these symptoms may be almost altogether absent, yet the existence of an obvdous cause, such as in. punc- tured fracture, or foreign body, will at once suggest operation, and encourage hope of success. With regard to peripheral inseated inflammatory mischief, and enjoin the necessity of absolute rest. When the meningitis (" pachymeningitis," as it has been termed) has involved nervous elements, cord or nerve roots, other signs and symptoms help to make the diagnosis certain. We now find, in varying pro- portion and degree, interference with motion and sensation in the regions supplied by individual nerves, wasting of muscles, peripheral pains and other evi- dences of nerve disturbance. Treatmerd is in such cases far from satisfactory. Counter-irritation should be used, either by repeated blisters to the spine, or by seton ; and the persistent administration of mercury and iodide of potassium should not be withheld, even in cases where no syphilitic element is present. Intraspinal hseuioi-iiia^c is a yet rarer result 456 Manual of Surgery. than the foregoing of any violent twist or wrench of the spme, and is due to some vessel giving way with- in the sj)inal canal. The quantity of extravasated blood may be very large, and give rise to symptoms which are dependent on pressure upon the spinal cord. Paralysis may be com})lete of all tlie parts below the blood level, which, as it rises in the canal, may speedily cause death from interference with respiration. Intraspinal htemorrhage may also result from falls on the buttock, or from severe blows on the spine ; but from any cause it is extremely rare unless accom- ])anied with other injuries to the spinal column, such as fracture-dislocation. Symptoms. — It maybe difficult to say whether the sym2:>toms are really due to haemorrhage or to some more immediate damage to the cord ; but in the latter case the })araplegia is commonly instantaneous, while from hajmorrliage the symptoms may begin to show themselves only after lapse of time, or they may steadily increase as the blood is being poured out in the canal. Should the Ijlood be small in quantity and low down in the canal, there may be few symptoms, and there is hope of its complete absorption and of ultimate recovery ; but there is also a risk of inflammatory mischief, and the development of symptoms which are due either to tlie pressure of unabsorbed clot, or of subacute meningitis. Treatment. — Ice must be applied to the spine, whilst the patient is kept at perfect rest on his face, and ergot or gallic acid should be administered. In the later stages we must follow the same line of treat- ment as in subacute meningitis. It is, however, but little amenable to treatment, both in its actual progress and in the after-consequences which may ensue. A very rare result of violent and extreme bend of the spine is hajmorrhage into the substance of the cox'd Fractures of the Spine. 457 itself, with such symptoms as must necessarily follow its partial or complete destruction at the seat of lesion. Fractures and Dislocations. Injuries of this nature are most commonly caused hy indii'ect \T.olence, whereby the spinal column has been bent beyond the limits of its elasticity and the strength of the ligaments which hold its segments together. Parts of the spine, however, as of the verte- bral arches, may be broken by the direct violence of a severe blow. Thus, one or more spinous processes may be detached, and the diagnosis is made by the mobility and crepitus which can be easily elicited. When the line of fracture is more deeply seated, and runs through the laminae or pedicles, for instance, these usual signs may be more obscure. Any such deep- seated fracture entails the additional risk of bein» associated with intraspinal haemorrhage, and of in- flammation arising in close proximity to the spinal canal. The precaution, therefore, should never be neglected, after all severe blows on the spine itself, of acting as if fracture had unquestionably occurred, and keeping both the patient and the parts at absolute rest, so that repair may take place with a minimum of inflammatory action. Persistent pain in the region of one or more vertebrae increased by manipulation, and pain or hypersesthesia in the periphery of one or more nerves emanatincr from the neicjhbourhood of the injury, should excite the suspicion of fracture. Should paraplegic or other sjTuptoms of nerve disturb- ance be met with soon or late as the result of a severe blow on the spme, the symptoms are probably due to intraspinal haemorrhage or to the pressure of intlammatory lymph. It is not common for tlie spinal cord itself to be aflected in such accidents, although it has sometimes been found contused when the blow 458 Manual of Surgery. has been caused by a bullet or shell striking the spine with the momentum of a great velocity. Fracture-dislocation.— In fractures and dis- locations from indirect violence the cord is almost in- variably injured, crushed by the displaced vertebra, or torn by tlie sudden and excessive stretching or bend. Amongst this class of injuries, the commonest by far are those in which fracture and dislocation are combined ; but the exact nature of the lesion depends more upon the region in which it occurs than upon the mode of accident. The smallness of the cervical vertebrae, their horizontal position, and the extreme flexibility of this region, render uncomplicated dislocation most frequent in the neck, although examples of it have been met with lower down. Below the neck, however, the " broken back " is usually a " fracture-dislocation," from the fact that a greater violence is necessary to cause the injury, and that the vertebrae are not so readily separated from each other. Thus, of 394 cases collected by Ashhurst, 124 were pure dislocations, and of these 104 occurred in the cervical, 17 in the dorsal, and 3 in the lumbar region. These facts have an im- portant bearing on prognosis and treatment, for in cases of pure dislocation the cord is somewhat less likely to be irreparably crashed, or, at any rate, lace- rated, such injuries as it receives being, perhaps, from simple pressure alone. If, therefore, we can succeed in reducing the displacement in the rare cases where the displacement has not undergone spontaneous re- duction, the cord may be thereby liberated, the para- lysis from pressure on it may disappear, and the risk of destructive inflammation spreading in its substance may be lessened. And although the etf"orts to reduce a displacement lower than the neck, where probably fracture and dislocation are combined, ax'e not so likely Fractures of the Spine. 459 to be successful, it may be well to make the effort, that the cord may have a better chance of repair, should it happen that it has not been crushed to pnlp by the displaced vertebrae. Signs.— In every region deformity is a sign of displacement ; but in the neck, in addition to in- creased mobility, and the existence of a gap Ijetween spinous processes, there may be distinct projection in the pharynx, and the patient may experience difficulty in swallowing. Lea\'ing, then, for a time, the nature of the injuries in special regions, and acknowledging that there may be infinite variety of lesion in different parts, there are cer- tain characteristics more or less common to all cases where the "back" has been "bi^oken" by indirect violence or inordi- nate bend. The intervertebral substance is more or less torn and separated from the bone, and the vertebra, which is the upper one at the site of disloca- tion, rides forward on that w^hich is below it, and carries with it all the parts above, never being separated at the same time from both its fellows. Moreover, one or both of the articular processes may be dislocated, and a line of fracture may or may not lun through any part of the vei-tebral arch. Ligaments are more or less injured, lacerated, or completely ruptured, and in the lower part of the column, in the lower dorsal region, for example, where fracture-dislocation is most common, it is not unusual to find that, in the extreme forward bendi]ig of the spine, a portion of the body of the vertebra immediately below the point of separation is Fig. 93. — Fracture-Disloca- tion of tiie Spiue. 460 ATanual of Surcekv. broken off obliquely from above downwards and for wards (Fig. 93). The deformity thus induced may be permanent and irreducible ; but in the upper parts of the spine, where the segments are small, it is by no means uncommon for the dislocated parts to return to their natural positions instantly after the accident. Whether the dislocation has been momentary or remains permanent, the cord is crushed at the moment of the accident. Injury to the cord is, then, the source of chiefest danger in all cases of broken back, for inflamma- tion is prone to spread from the seat of lesion, and gradually \n.\ olve the centres of respiration, and cause death by asphyxia. The higher the lesion, therefore, the sooner is death imminent from spreading myelitis, and if we can liberate the cord by the reduc- tion of displacement, we may perhaps remove one cause, at any rate, of continuing injury to it, and give thereby some better chance of life. Of no case, however, is it possible to think hopefully. We are in the presence of an injury which is almost inevitably fatal sooner or later, and the best we can do is, by good nursing, to make life comfortable and free from suffering as long as it lasts. The proposal made to trephine the spine, so as to relieve the cord from pressure, has met with no success, and has made no footing in surgery. Trephining the sj)ine has no analogy whatever to trephining the skull. Syanptoinis» due to injury of the cord. — Pa- raplcg'isi., or j^aralysis of motion and sensation? is commonly complete, and is of aJl parts below the seat of lesion. It may, however, be of lesser extent, and incomplete, and often motion is more affected than sensation. The limit of cutaneous insensibility is usually well defined, and may be mapped out with accurate precision, and the boundary between sensibility and insensibility may sometimes be Fractures of the Spine. 461 hypersestlietic, a phenomenon probably due to the nerve trunks being involved in inflammation, and so irritated at the site of lesion. As myelitis spreads up the cord, so the line of insensibility gradually rises higher. When there is no deformity the seat of lesion has to be determined by the level of the paralysis ; and then it must be borne in mind that the nerve cords run with a gradually increasing obliquity downwards in the spinal canal ; that in the cervical i-egion, with the exception of the eighth, the nerves are named from the vertebra above wliicli they issue, while below this region they are named from the vertebra below which they come out of the column. A nerve, in fact, comes oif from the cord considerably higher than its name might imply. The cord, moreover, is most commonly injured at or about the lowest part of the displacement, that is, at the part where the upper or dislocated vertebra rides forward on the vertebra below it. Speaking broadly, the higher the lesion the greater is the immediate danger, while above the origin of the phrenics, which issue above the fourth cervical ver- tebra, death is usually instantaneous unless the cord has not been entirely destroyed. When the fracture-dislocation is below the second lumbar vertebra the paralysis may be very irregular in its distribution, or there may be none at all, because the cords of the cauda equina are less liable to in- jury than the spinal marrow itself. In any region the cord may be only partially crushed, and recovery is then more likely to ensue, with more or less of permanent paralysis. In the upper dorsal region paralysis may seriously interfere with thoracic breathing, which, according to the level of the lesion, will be more and more embarrassed, until there is nothing 462 Manual of Surgery. left but diaphragmatic respiration. The diagnosis of this kind of breathing is not difficult. The chest walls are not motionless, as might have been expected, but they sink from atmospheric pres- sure when the diaphragm descends, and rise some- what suddenly again to their previous position when the diaphragm is once more relaxed. The chest cavity is tlierefore made small by collapse of the thoracic walls just when descent of the diai>hragm is compelling the entry of air ; extra work is thus thrown on the diaphragm, and the breathing becomes more and more laboured, for hypostatic congestion of the lungs soon arises. The alse nasi work vigorously, the patient is obliged to breathe through his mouth, and his distress is added to by dryness of the throat and tongue. Paralysis of the bladder is usually complete in all cases of fracture-dislocation when complete paraplegia indicates the severity of the cord lesion. Ketention of urine is commonly the first symptom of it, and when the bladder has become full the urine runs over and dribbles away. In the course of a few days, perhaps, and more especially after injury to the Cauda equina alone, the bladder may regain a certain amount of tone. The normal act of micturition is probably under the control of special centres in the cord, reaching from the level of the second to that of the fifth sacral nerves, some centres being con- nected with the sphincter vesicje, others with the detrusor urinse ; and although in paralysis after in- juries the action of both these muscles is commonly annihilated, it is conceivable that one may be affected while the other remains intact. Thus, for example, the bladder itself might be paralysed while the sphincter remained normal, and the reflex act whereby the sphincter relaxes in micturition being abolished, the bladder might fill until it burst. Fractures of the Spine. 463 It is often impossiLle to say what is the jjre- cise nature of the paralysis, and the state of the bladder must therefore from the first engage the surgeon's attention. A serious matter in these cases is the fact that the nrine frequently becomes alkaline and purulent, and presents all those features which, together, are characteristic of cystitis. This change in the urine may appear in the course of a few days, and is probably due, in some measure, to the outbreak of lesions iu some part of the urinary tract, kidney, ureter, or bladder, of the nature of those " trophic " lesions which have yet to be sjwken of under the name of bed-sores, and to the urine being contaminated with the products of sloughing inflammation. Cystitis and its symptoms may arise even when no catheter has been used, so that the view which attri- butes it to the introduction of septic matter into the bladder is not always tenable. In some cases it is doubt- less due to the bladder being imperfectly emptied. It is a most difficult thing for some persons to empty their bladders, or even to micturate at all, in the recumbent posture, and cystitis of a mild degree may arise from this cause even in persons who have no real paralysis. Cystitis may become a source of danger by setting up or aggravating inflammation in the urinary passages, and in chronic cases may cause death by exhaustion or by the formation of *' surgical kidney." The treatment does not differ from that which is suitable for cystitis in other cases, and no catheter should be used which is not scrupulously clean. Paralysis of the bowel. — Closely allied in its physiological nature to the act of micturition is that of defsecation, which also may be variously affected after fracture-dislocations. The immediate effects de- pend, to a large extent, on the contents of the rcctn:n 464 Manual of Surgery, at the time of the accident. If full, involuntary evacuation will soon take place ; while if empty, defsecation may not be until tlie rectum has become full. Hence the involuntary act of defsecation takes place only every now and then. Constipation is very common. Continuous " incontinence " is, mdeed, very rare unless the motions are extremely loose. Occasional involuntary evacuation is the usual rule ; but sometimes the patient acquires the power of tell- ing when his rectum is becoming loaded, and the baneful consequences of involuntary and unexpected discharge may be thus avoided. When the cord lesion is high up, additional dis- tress may be caused by tympanitis, collection of flatus being favoured by arrest or diminution of the natural peristalsis of the intestines. This, also, not only adds to the constipation, but may even inter- fere with the already embarrassed respiration, and call for relief by the use of enemata containing some antispasmodic, such as asafcetida or turpentine. The tympanitis may also be relieved by the passage of a long tube into the sigmoid flexure. Aspiration of the gut in such cases is not devoid of risk. Priapism, from vascular turgescence of the penis, is a common result of injuries of the cord, and is due, in all probability, either to passive distension of vessels from vaso-motor palsy, or to irritation of special centres, the exact seat of which has not been determined. The state of semi-erection is most marked during clie few days which follow the accident, while at a later period it may only be induced by some local irritation, such as passing a catheter. Most commonly met with after cervical and dor.sal injuries, it has in rare instances been seen after fracture-dislocation still lower down. Its im|)ort is uncertain, and it is neither influenced by nor demands treatment Bed-sores in Spinal Injuries. 465 Disturbances of temperature are sometimes very striking in cases of fracture - dislocation, especially when the cord injury is in the cervical region. When the fall incidental to collapse has passed away, there follows in some instances a very high range, the thermometer rising to 107°, 108°, or even 110° Fahr. The cause of this hyperpyrexia is by no means clear, but from recent physiological observations, which have been strikingly confirmed by the results of cei-tain injuries or lesions, it seems probable that the heat production which ordinarily goes on in the body tissues is no longer restrained by supposed true calorific centres, having their seat in the cerebral cortex of each hemisphere near the fissui^e of Rolando, and having crossed action. A lesion may cut ofi" this inhibitory action of one or both centres ; and it is obvious that this result is most likely to ensue when the injury is high up, as in the cervical region when the cord is wholly crushed, and when a larger area of the thermo - genetic tissues is thus severed from the inhibitory centres in the brain (Hale White) Sometimes, also, in cases of cervical injury, the pulse becomes extremely slow, deliberate, and full. The precise seat of the lesions causing these phenomena has yet to be determined. Of far greater importance is the occurrence of bed-sores, to the prevention of which the surgeon must devote his earliest care. In all probability there are two kinds of bed - sores. Some appear at points of pressure alone, such as tlie sacrum and great trochanters, and originate only after pressure has been long continued or unrelieved. They do not difier from pressure sores in other cases, but it is more difiicult to prevent them, because the paralysed and hel})less }>atient cannot gain relief l)y voluntary change of postux'e. The tendency to their E E— 21 466 Manual of Surgery. formation may, however, be largely diminished by placing the patient at the earliest moment on a water or spring bed ; and by the use of ring cushions, stuffed with horse-hair or cotton wool, we may ensure that such pressure as is unavoidable may be widely diffused instead of bearing on one small point. The skin, moreover, may be protected with plaister, or hardened by bathing it with spirit lotion, and all contact with urine or faeces must be prevented. Bed-sores of the other variety run a more rapid and violent course, and cause extensive destruction of tissue. These also are found most commonly at sites of pressure, but not invariably so, and they may have a destructive rapidity which seems out of all proportion to any pressure which can have been exerted. Sometimes they appear within a day or two of the accident ; and from all their characteristics it seems highly probable til at they are really the result, directly or indirectly, of some " trophic " disturbance, either due to inflam- mation of the cord, or through the intermediate influence of a peripheral neuritis which has arisen as the result, in some as yet unexplained manner, of the myelitis. To such bed-sores the name " decubitus acutus^' and ^^ decubitus ominosus" has been given, and more recently that of " neurojiathic eschars^ While ever of gravest import, it sometimes happens that the destructive process is arrested, the sloughs become detached, and healing may ensue. In both kinds of sores the detachment of slough may be hastened by linseed or charcoal poultices, and when granulations have been formed the ulcer may be dressed with stimulant ointment or lotion, pressure being as much as })Ossible avoided. Altci'ation in tlie reflexes is a common se- quence of fracture-dislocation, and the phenomena vary according to the site of the cord lesion. When situated in the dorso-lumbar region, the knee jerk, Fractures of Cervical Spine. 467 for exarn))le, may be abolished and may remain so ; but it often happens in the course of a few days, as myelitis sets in, that the reflexes become exaggerated, and a sensory stimulus, such as tickling the feet, or the movement of the bed clothes, may, unknown to the patient, cause spasmodic movements of the legs, which are most distressing and interfere with perfect rest. The character of the reflexes, both superficial and deep, may give, in both recent and chronic cases, most valuable information as to the site and extent of the cord lesion. The reader must refer to special works on nerve diseases for fuller knowledge on this subject. The injuries of special regions now demand our consideration. Fracture-dislocation in tlie cervical re- gion. — Separations between occiput and atlas are most uncommon, for the range of movement between them is limited, and the ligaments are strong. The most frequent injury in this part, from falls upon the head whereby the upper spine is violently bent, is separation of the atlas and axis, the flrst vertebra riding forwards on the second, and causing instant death from crush of the cord against the odontoid process (Fig. 94). The odontoid is itself sometimes broken 05", and one or both of the check or other ligaments give way ; but notwithstanding that death is usually instantaneous, there have been cases where the odontoid has be- come anchylosed in a new position, and recovery has taken place with permanent narrowing of the spinal canal. Separations between the second and third vertebrae are usually associated with fracture. Below the third cervical we enter the region where pure dislocations are more common from falls upon the head and neck. Symptoms. — The cord is usually crushed iu 468 Manual of Surgery. its entire thickness, and life is rarely prolonged for more than two or three days, thoracic respiration Ijeing annulled, and diaphragmatic alone left. The phrenics come out above the fourth vertebra, and may escape injury even when the separation is at this level ; but myelitis will speedily put an end to the integrity of their centres. Below this point, as far as the second dorsal, it is necessary to remember the origin of the cords of the brachial plexus, and the distribution of its branches, in making a diagnosis as to the exact seat of lesion, and that the de- scending branches of the cervical plexus may allow of perfect cutaneous sensibility in parts much below the level of the destruction of the cord. In partial lesions, when the anterior cornua are alone involved, movements may be paralysed according to physiological rather than anatomical connections. Extension, for example, may be paralysed, while flexion remains intact, because the correlated muscles, which cause a particular action of a limb, are grouped together in the spinal ganglionic cells. Injuries to the cord in the lower cervical and upper dorsal region may cause jKtrahjtic myosis, in which the pupils are unable to dilate l)ecause of palsy of the dilator fibres of the iris supplied by the sympathetic, which has an intimate connection with this, the " oculo-pupillary " region of the cord. The myosis is most marked when unilateral, but in any case it is necessary to examine the eyes both in liglit and shade in order to recoiJrnise it. Fij?. 94. — Fracture-Dislocation of the Upper Cervical Spine. Fractures of Dorsal Spine. 4^9 Fracfiii'e-clislocutioii in the dorsal and lumbal* reg^ious. — From tlie second dorsal vertebra do^vn wards, fracture-dislocations are far more common than dislocations alone, and, as a rule, the cord is irre- parably damaged. In fractures below the eleventh dor- sal the prognosis is more favouralile, for the size and strength of the vertebrae in this region render complete dislocation more difficult, and the cord escapes total destruction. Below the second lumbar the cords of the cauda equina are less liable to injury than the spinal cord itself. Paralysis may from the first be incomplete, and there may be considerable return of motion and sensation, and of control over bowel and bladder. Cystitis and bed-sores are the chief risks to which the patient is exposed. Deformity is likely to be permanent, and when repair is taking place the application of a Sayre's jacket may give comfort by ensuring rest and fixation of the spine. Injury to the sacro-coccyg:eal joint. — The sacro-coccygeal joint may become the seat of disease from injury, and any movement of it, as in def aecation, or in excessive action of the gluteus maximus, which has attachment to the coccyx, may give rise to pain. There may also be local heat and swelling. These symptoms and signs are of impoi-tance in diagnosis, because " coccygodynia," or neuralgic pain, is a not uncommon affection, especially amongst neurotic women. Rest is essential in the one case ; it probably has little influence in the other, and attention should be rather directed to the pelvic \dscera, uterus, and ovaries. Unilateral dislocations of the spine are not uncommon in the neck, from violent bend or even extreme rotation. Here two articu- lar processes are separated from each other, and 470 Manual of Surgery. the inferior comes to ride in front of the superior, the head is turned and fixed towards the opposite side, local deformity may be felt if the neck is thin, and either by some impairment of motion and sensation, or by pain and tingling in the periphery, there may be evidence that the nerve which issues from the spine at the site of injury is being irritated by stretching or pressure. Reduction should be effected at once by extension of the neck so as to disengage the processes, and turning the head into its right position. Rest must be enforced for some time afterwards, and the prognosis is favourable unless there be fracture also, or the cord has been itself damaged. Concussion of the Spinal Cord. This term ou^ht to be restricted to those cases in which an injury has been inflicted on the cord from blows upon the spine, similar and analogous to the effects produced on the brain by blows on the skull. In the case of the head it is well recognised that severe concussion blows upon it may cause contusion of the brain substance both near the site of the blow and at opposite parts from contre-coiqy, and in addition certain effects which are commonly those of collaj)se from the shock or concussion of the whole brain mass. Although brain and spinal cord are merely different parts of one system, their physical suiToundings are yet so different that that which is a common injury in the case of tlie brain is extremely rare in the case of the spinal cord. There are, indeed, very few cases on recoixl in which it is possible to say that the cord has been locally injured, stunned, or contused by con- cussion only ; and careful examination of many which have been so recorded sliows that sufficient attention has not been paid to the effects of direct contusion from displaced vertebrae, of hiemorrhage around the Concussion of Spine. 471 cord, or of hsemorrliafje into and laceration of its sub- stance from violent sudden Lend. Given, however, a case in whicli the cord lias been locally concussed or contused, the resultant symptoms are the same as are met with from local injury due to other causes ; and they would doubtless be the same if the injury mei-ely consisted in local stunning, for a time, that is, until the effects of the concussion or stunning had j)assed away. Nevertheless, it is extremely doubtful whether this latter condition ever follows local injury. Railway sjnne. — It has been thought by some that the severe nervous disturbances which are seen after railway collisions are due to concussion of the spinal cord, but there is no evidence that the spinal cord is any more affected than are other organs of the body by the severe shock of such accidents ; and although it is conceivable that prolonged func- tional disturbance thus originated may end in struc- tural degeneration, such a result is very very rare, and occurs perhaps in those only who, by various causes, are predisposed to the outbreak of nerve disease. It must not be forgotten that concussion of the brain is often caused in railway accidents, and many of the after- symptoms of neurasthenia are rather due thereto than to injury to other parts of the nervous system. It has indeed been suggested that the term " railway brain" is more appropriate than "railway spme." Concussion injuries of the cord, much more analo- gous to concussion iujuries of the brain, are some- times met with in connection with gun-shot wound, where the great momentum of a bullet upon the spine may cause contusion of the cord without opening the sj)inal canal. The term also is applicable to cases where many minute lesions, giving rise to immediate paralytic symptoms, have been caused by a fall from a height flat upon the back. 47? XL INJURIES AND DISEASES OF THE NECK. Victor Horsley. L Wounds and Contusions of the Neck. A. Contusions. — A Llow directly on the neck will in all cases cause a certain amount of ecchymosis, i.e. extravasation of blood. So long as this is superficial to the deep fascia it is of no importance, pro\T.ded the skin is unbroken. It frequently extends in the loose subcutaneous tissue almost to the middle line posteriorly, and in front may reach below the clavicles on to the chest. If, on the other hand, the extravasation is beneath the deep fascia in the loose connective tissue surrounding the large vessels and nerves, then it will, by pressing on the same, cause symptoms sometimes of an alarming character. As for direct injury to the deep cervical structures from a blow, we may note an accident which is not an organic lesion, but a disturbance of function which may end fatally, namely, spasm of the glottis. As a result of contusion the larynx may be frac- tured or the oesophagus ruptured. The arteries may be damaged so as to produce a traumatic aneurism, and injury of a vein may lead to the formation of a blood cyst. Injury of the sympathetic nerve, if suffi- cient only to irritate it, will cause dilatation of the pupil and protrusion of the eye-ball, while if it is paralysed then the pupil will be dilated, the eye-ball retracted, and the secretion of sweat on that side of the head and neck interfered with. B. IrVounds. — Simple uncomplicated wounds of the neck must be treated on general principles, and Wounds of Neck. 473 may be expected to heal by the first intention if tlie parts are kept perfectly at rest. For this purpose the patient's head and neck should be fixed by being placed between sand-bags covered with a thin pillow, or a light splint of guttapercha may be fitted to the shoulders and nape of the neck, so that the head cannot turn. After ligature of large vessels this pre- caution should always be taken. ^Vouiids of special parts. — Punctured wounds, stabs, etc., in the 2?osterior triangle may reach the subclavian vessels, the brachial and cervical plexuses, the spine and spinal cord. If the large vessels are wounded, and the haemor- rhage temporarily arrested by plugging, pressure is to be made on the proximal side of the wound, which must then be laid freely open and the vessel tied with chromic catgut, and the wound dressed antiseptically. If one of the cervical nerves entering the brachial plexus, or one of the cords of the plexus, is divided by a cut, and no restoration of motor power has been attained at the end of five or six weeks, the wound must be reopened and the nerve sutured. If the spinal cord is reached by a knife, bayonet, etc., then the special symptoms of paralysis, etc., will denote the amount of injury (Art. x.), and treatment must be mainly directed to providing very free drainage of the wound, coupled with the liberal use of anti- septics. Wounds in the front of the neck and of the anterior triangle may be here considered together, although in some points, especially in their after effects, the regions differ. (>S'ee Cellulitis of the neck, page 477.) "Wounds of the front of the neck and of the an- terior triangle may injure (1) the air passage ; (2) the food passage ; (3) the large vessels ; (4) the large nerves. The ordinaiy cut throat of the suicide or homicide has always received special notice in surgical text-books, 474 Manual of Surgery. but presents nothing peculiar in itself, unless it be endless variations in the extent of the lesion. Conse- quently, the symptoms attendant on injury of various important structures noted above will be described in detail, vA\h their appropriate treatment, and as such symptoms are very distinct, any corajilicated case of cut throat is merely a combination of some of the above possible accidents. However, it cannot be too often insisted upon as a general fact, applicable to all cases, that the main importance of a wound in the neck does not lie in the immediate symptoms it presents, however urgent, but in the possibility of complications arising in the after-treatment ; for since the former can be met by the ordinary rules of action in surgical emergency, the sequelse (cellulitis, pneu- monia, etc.) really determine the result of the case, and therefore the prognosis too. 1. Wounds of the air jmssage. — The pharynx may be opened by a horizontal cut passing above the hyoid bone through the base of the tongue, or below the hyoid bone in the thyro-hyoid space. Here, if the pharynx be extensively opened, the cut divides the epiglottis more or less completely according to the position it was in at the time. The divided epiglottis has sometimes caused asphyxia by dropping into the glottis, plugging it up, and exciting spasm. In either of these kinds of severe cut-throat about the hyoid bone, air and food will escape through the wound, and the tongue, when thus cut free from the hyoid bone, frequently presses backwards, and i)ro- duces more or less sufibcation ; it must in such a ca.se be drawn forward by a silk loo)) passed through it. After thorough washing out of the part with carbolic solution, the wound in the mucous membrane of the pharynx, where feasible, may b(3 closed by sutures placed entirely in the submucous tissue, the angles of the skin wound apposed by a few horsehair sutures, and Wounds of Neck. 475 free dvaiiiage with a large tube arranged in the middle third of the space. The wound heals always by granulation, as the movement of the parts prevents adequate rest for primary union, and it usually heals quickly if kept very clean by frequent iiTigation. It must be wiped out, not syringed, if the glottis is exposed. The larynx is usually opened by one or several transverse cuts about the lower part of the thyroid carti- lage. While no special symptoms, beyond the usual escape of air, etc., directly accompanies this condition, it is esjiecially liable to be followed by the very dangerous sequel of acute inflammatory cedema of the glottis. The glottis being cut into, usually above the vocal cords, it is exposed to the air, to irritation by blood, etc., and so acute cedema (in which the mucous mem- brane becomes extremely swollen by exudation in- to the loose submucous tissue) being excited, the lumen of the larynx is choked, and the patient rapidly becomes asphyxiated unless a tube is passed into the trachea. For this reason it is advisable to perform tracheotomy whenever the glottis is the seat of the wound, for the rapidity with which cedema glottidis sets in is so extreme as to sometimes kill the patient before the operation can be performed. At the moment when the wound is inflicted there is danger of asphyxia from blood running down between the vocal cords and tilling the air passages ; and a rela- tively small quantity of blood can thus produce fatal asphyxia, unless, of course, the patient is able to cough it up. In addition to oedema glottidis, the complication of emphysema may arise, in which condition the subcutaneous tissues of the neck become infiltrated with air and enormously swollen. Finally, when the vocal cords are injured, or the cricoid cartilage is cut through, the voice is eitlier com- pleLuly abolished or very much weakened and hoai'sc. 476 Manual op Surgery. If the trachea is only opened for a small distance, it will heal readily, as most tracheotomy wounds do. If, however, as rarely happens, it is very severely wounded (it has been seen completely cut across), it should be united with fine catgut sutures, the wound being kept freely open and frequently cleansed. 2. Wounds of the food passage are described in Art. v., vol. iii. Note may here be taken of the risk of septic infection with this complication- Where possible the mucous membrane of the alimentary canal should be closed by sutures. 3. There is no mystery about the symptoms of wound of one of the large vessels. If seen in time the bleeding point should be caught between the thumb and fore-finger of the left hand, one digit (preferably the thumb) being thrust to the bottom of the wound, the other being outside, pressing on the stemo-mastoid muscle. The bleeding being thus absolutely arrested for the moment, the wound should be enlarged up and down for a short distance, the fresh incision dividing the deep fascia. A finger of the right hand can now be brought to exert fii-m pressure directly on the trunk of the bleeding vessel, the wound in which can then be exposed by removing the left hand. It can then be completely closed by catch forceps. If the original wound gape very widely there will be no necessity to enlarge it, but no time is to be wasted in trying to compress the vessels through the intact structures of the neck. The wound in the vessel, now under perfect control, is to be permanently closed by ligature of the trunk above and below it. The wound is then to be disinfected and dressed. 4. Injury of the large nerves has already been alluded to. In concluding the subject of wounds of the neck, Cellulitis of Neck. 477 attention is again drawn to the fact that the majority of oases end fatally because, the wound decomposing, the foul discharge either sets up cellulitis, which spreads down into the mediastinum, or it enters the trachea and sets up septic pneumonia. Every care, therefore, is to be exerted towards thorough cleansing and disinfection of the wound. II. Cellulitis of the Neck. To grasp fully the conditions under which the loose connective tissues of the neck become the seat of cellu- litis the arrangement of the cervical fasciae must be borne in mind. CeSluIitis may be started in any one of the regions of the neck occupied by connective tissue, by several causes, the commonest of which is inflammation of a gland, almost invariably a lymph gland, and more rarely the salivary glands. The lymph glands are liable, of course, to become inflamed by absorption of septic matter from a sore inside the mouth and pharynx, or elsewhere, especially in some acute specific fevers, e.g. scarlet fever, diphtheria, when the swellinor of the neck receives the title of O scarlatinal angina, cynanche maligna, etc., the name simply signifying that the connective tissue around the glands is in a state of acute phlegmonous inflam- mation. Next to acute inflammation of the glands as a cause of cervical cellulitis, comes chronic adenitis, which is usually of tubercular origin, then wounds and injuries of the soft ])arts of the neck, alveolar abscess from carious teeth, and, Anally, specific poisons, which produce the particular form of cer\ical cellulitis known as angina Ludovici (or Ludovigii), and the rare parasitic disease known as actinomycosis. Cervical cellulitis presents itself in various degrcoa of severity, as cellulitis does everywhere. Thus wo may have a simple but acutely developed oedema (acute 4 7^ Manual of Surgery. inflammation) of the connective tissue spaces as occurs sometimes in diphtheria. Or this may be phleg- monous, as in many cases of septic poisoning and scarlet fever, the centre of the phlegmonous mass softening down into an acute abscess. Further than this, the inQammation may be of so virulent a type that the result is gangrenous destruction of the tissues, producing sloughs bathed in a horribly foetid ichorous fluid. As the best example of this latter condition may be detailed the aflfection known as angina Ludovic% or submaxillary cellulitis or angina. The general causes which excite cervical cellulitis have just been mentioned, but it will easily be understood that the condition of submaxillary cellulitis is most usually started by a local spreading inflammation from an abscess round a carious tooth, or from septic in- flammation of the submaxillary gland. Angina Ludovici begins like an acute specific fever, and when not treated runs a very rapid course, ending fatally, sometimes in from five to nine days. It begins with pyrexia, the temperature rising rapidly to 103°, 104°, ushered in by a rigor, accompanied by headache, depression, and loss of appetite. When these symptoms are well declared, there then begins a swelling under the jaw, which is simply due to oedema of the connective tissue. The swelling forces the tongue upwards and backwards so as to form a large unwieldy mass in the mouth. This causes some pain in swallowing, and interferes with the free movement of the jaw and with speech. Fre- quently there is comparatively little pain in this afiec- tion ; but sometimes, if the swelling is developed very rapidly, the pain is severe, until the limiting fascia gives way and allows the pus to infiltrate the surround- ing tissues, when the patient experiences considerable relief. Tf the swelling is incised at this time it will Cellulitis of Neck. 479 be found to be composed of slougliy, but solid, connec- tive tissue, infiltrated with foul gi-eyish-brown sero- pus. The muscles become infiltrated secondarily, and the cellulitis may spread into the anterior mediastinum and even reach the pericardium, the patient dying of exhaustion and septicemia if not relieved. Treatment. — In all cases an incision, from 1 inch to \\ inches long is to be made through the skin and snperficial fat, any vein di- vided being picked up with catch forceps. If the cellulitis is clearly de- fined and local- ised to one or the other spaces of loose cellular tissue in the neck, then it clearly must be under the deep fascia, which is therefore to be divided to the same extent as the skin. A certain amount of serous oedema fluid will ooze into the wound from the cut tissues. A steel director is now to be thrust carefully towards the centre of the swelling, and if foul ichorous matter flow along the groove of the director, a pair of dressing forceps is to be thrust (closed) along the groove to the centre of the abscess, and then withdrawn with the blades moderately sepa- rated so as to dilate the opening. Finally a large drainage tube should be inserted, and the whole Fig. 95.— Incisions for Cellulitis of the Neck. 4 So Manual of Surgery. syringed out with warm carbolic acid solution. The neck should then be wrapped in hot fomentations of boracic lint. The line of incision varies according to the space to be opened (Fig. 95). Thus, in the posterior tri- angle the cuts should be made parallel to the main vessels and nerves, taking care at the fore part not to wound the external jugular vein. To open the spaces in front of the neck in angina Ludovici, the incision must always be made in the middle line, and if necessary a further one may be carried through the centre of the swelling, but this is rarely necessary. The connective tissue space around the carotid, etc., is to be opened as in the operation for ligature of that vessel, namely, parallel to the sterno-mastoid. III. Tumours op the Neck. Tumours of the neck include among their varieties several kinds which are peculiar to the region in- volved, these mostly being congenital in origin. Viewed as a whole they may very justly be divided into two main classes, viz. cystic and solid tumours. Cysts are usually arranged according to their contents, but for clinical purposes are best grouped in the anatomical order of the parts they arise from, and the same method will be employed in treating of the solid tumours. A. Cystic Tumours. 1. Cystic tiiiiioiirs arising: from persis- tence of embryonic structures. — The fissures in the neck, known as visceral clefts in the embryo, sometimes do not close, or only partially, i.e. at both ends and not in the middle, or at one end only. If the first imperfection exists, there may be found a prolongation of the angle of the mouth almost to the Tumours of Necic 481 ear, while at three points between the lower border of the jaw and the thorax it may present itself as a sinus- like cavity, running upwards and backwards from the front of the neck, sometimes only just admitting a probe, and always secreting a little thin mucous fluid. If the ends of such a " congenital fistula " are closed and the centre patent, then there develops a congenital cystic tumour, which may reach a large size and extend deeply (sometimes to the spine), so as to form important connections with the large vessels and nerves. These cysts form rounded, painless swellings, with ex- ceedingly thin walls, and the skin over them non- adherent (Fig. 96). They usually contain a serous fluid, and therefore come under the general appella- tion of ^* hydrocele colli,'' but in some rare instances they are lined by one or more layers of epithelial cells, and contain a fatty material. If it should prove impossible to extir- pate these cysts (after repeated aspiration has been tried), they should be injected with iodine or car- bolic acid. The other common class of congenital cystic tumours are often called dermoid, but it must not be supposed that they always contain examples of all dermal appendages. These dermcrid c}'sts usually are found in the middle line, where the somatic plates fuse together, and they arise no doul)t from small masses of included epiblast. As may readily be ima- gined, they are also found in the sites of the visceral Fig. 96.— Large Congenital Hy- di'ocele of tlie Neck. 482 Manual of Surgery. clefts, but this position is rarer. The commonest seat is between the genio-hyoid muscles, where the tumour presents itself as a rounded swelling in the middle line, just above the hyoid bone. It pushes up the floor of the mouth and the tongue so as to project considerably beneath the buccal mucous membrane These cysts, when they occur on the side of the neck, often form dangerous adhesions to the large vessels. Like the " hydrocele " cysts, these have very thin walls, but unlike them, the dermoid contents always contain a large quantity of yellowish-white fcitty debris (cholesterine, etc.), ^vith epithelial cells. More rarely hair, sebaceous matter, and teeth have been found in them. They must be extirj^ated with special attention to surrounding structures. 2. Cystic ttuuoui's arising^ from the air ami food passages. (a) Cysts containing air may arise in the neck from either the apices of the lungs projecting up under the sterno-mastoid, or from the side (usually) of the trachea {tracheocele). In the first case the cyst is an example of hernia of the lung (Ai*t. i., vol. iii). In the second case, as the result of maldevelop- ment, the parts are not united in the middle line, so that a tracheal fistula is left ; or one or more rings are wanting so as to render a hernia of the mucous membrane of the trachea possible when powerful expi- ratory effects are made, especially if the glottis be closed. (6) The bursa between the hyoid bone and the thyroid cartilage may enlarge and become distended with fluid. It should, if acutely inflamed, be treated with leeches and hot fomentations. It may require aspiration, but I have seen the fluid absorbed in about a month in the case of a young man who refused all treatment. Aspiration is always of service. Tumours of Neck. 483 (c) Cystic tumours may originate in the mucous glands of both trachea and oesophagus ; the secretion being pent up so as to form retention cysts. 3. Cysts arising from the blood-vessels. (a) The commonest blood cystic tumour in the neck is an aneurism (Art. xxvii.,vol. i.). (b) The next commonest, perhaps, is a simple cyst containing blood; the cyst being developed in con- nection with a vein or in an enlarged venous plexus. Another variety of cyst containing blood, more or less altered, however, is the so-called hsemorrhagic cyst, which condition results from rupture of some small vein or veins leading to the formation of a cystic cavity. Asj^iration of this kind of cyst sometimes draws off blood so altered as to present a chocolate- like appearance. (c) The third kind of blood cystic tumour is venous angioma, which develops in the neighbourhood of the vessels, usually in the posterior triangle. Beyond being extremely rare, it does not differ from ordinary venous angioma. The treatment of blood cysts, omitting aneurism, depends on the nature of the cyst. If the latter is in connection with a large vein and is of moderate size, it is to be exposed, and the pedicle or the feeding vessel ligatured. If this is impossible it must be treated like an aneurism, viz. by electrolysis, etc. A hsemorrhagic cyst requires dis- secting out where possible ; if not, it must be scraped and drained. Venous angioma in the neck is always best treated by frequent puncture with the actual cautery at a dull red heat. 4. Cysts arising: from lymph vessels. - Lymph cysts containing a thin serous fluid are probably more common than is generally believed. From their watery contents and the deformity pro- duced they have been named "hygroma colli." They 484 Manual of Surgery. are divisible into two classes, congenital and ac- quired. Congenital hygroma is a very grave affection, the exact origin of which is not very clear. A child is born with a sero-cystic tumour usually over the carotid, the gi'owth steadily increasing and causing death by pressm-e on the oesophagus, trachea, and blood-vessels. If punctured, it is found that the cyst is composed of loculi communicating with one another, and the walls of each firmly adherent to the large vessels and nerves. The treatment should consist in incision and antiseptic drainage. In the adult a lymphatic cyst (acquired hygroma) in the neck is usually a single cavity formed by a fairly thick- walled sac, which is lined by lymphatic endothelium, so that there is little doubt of the nature of the tumour. It should be excised. 5. Simple sebaceous (atheromatous) cysts of the neck are not uncommon, and require no further notice here. 6. Hydatid cysts of the neck.— Very rarely, ?.e, in 0*5 per cent, of all cases of hydatid disease, has the echinococcus been found in cysts of the neck. Treatment should be by incision and drainage. Little has been said of the differential diagnosis between the various cysts described above, because the diacrnosis between the different kinds is rendered sufficiently obvious by the description of each ; but it is important to point out that they may be confounded wdth soft solid tumours, e.g. lipoma, and with abscesses (especially if chronic). In most cases aspiration with an exploratory syringe is harmless if performed anti- septically, and with due caution, while it frequently definitely decides the diagnosis. Tumours of Neck. 485 B. Solid Tumours in the Neck. The following description of the solid tumours is arranged according to the tissues they begin in. 1. Ttimoiirs groTring: from the skin and connective tissues.— The skin itself is occasionally the seat of nsevi, warts, and epithelioma, the latter occurring especially in old cicatrices. These require no special notice. The subcutaneous tissue is very frequently the seat of one of the simple growths, e.g. fibroma and lipoma, which are most common in the posterior triangle. More rarely enchondroma and osteoma have been found springing from the remnants of the visceral arches or so-called cervical ribs. Primary sarcoma has been described growing in the connective tissue, especially in the anterior triangle. Special difficulties in diagnosis can only arise when these tumours are soft and growing deeply in fat subjects. 2. Tumours of the muscles.— These are very rare. There is, however, a definite tumour peculiar to the cervical muscles, especially to the sterno-mastoid, and occurring in new-born children- which must be noticed here. In breech presenta, tions, and in children the subjects of congenital syphilis, there is often noticed after bii'th a steadily increasing swelling about the middle of the sterno-mas- toid muscle, which at the end of a month may inter- fere with swallowing, etc. It is clearly a syphilitic formation at a point damaged by rupture at birth, and is best treated with mercury and external anti- inflammatory remedies. 3. Tumours of the lymph glands.— These glands give rise to by far the largest number of tumours in the neck, so that it is worth while to digress for a moment to recall to mind their normal position. Besides the glandulae concatenatre lyino 4^6 Manual of Sitt^cfry. along the posterior border of the stemo -mastoid muscle, the following are constant sites for lymphatic glands, viz. over the carotid just at its bifurcation ; a few smaller ones being arranged along the carotid sheath upwards and downwards from this point ; over the submaxillary gland just below the body of the jaw; between the genio-hyoid muscles; over the parotid gland in front of tho tragus of the pinna, and, occasionally, beneath the parotid. Lymph glands may give rise to tumours under the following con- ditions : Sim])le hypertrophy sometimes wrongly described as lymphadenoma. The glands simply increase in size and density, the skin is freely movable over them and not reddened; the swelling is painless, as a rule, and non-adherent to surrounding struc- tures. In true lymphadenoma the cervical glands partake of the general numerical enlargement, some- times forming enormous collar-like masses on the sides of the neck. In these cases the glands are often so adherent to one another as to form, practically, a confluent mass. Simple enlargement occurs in young individuals placed under bad hygienic conditions, or over-worked, etc. The treatment consists in local counter-irritation by iodine, interstitial injection of the same, and general constitutional treatment. And if all these means fail, excision of the mass should be performed. {See Art. xxviii., vol. i.) Strumous disease. — Chronic inflammatory changes, in which caseation occurs early, is found in the cervi- cal glands both in children and adults. The condition is described in Art. xix., vol. i., to which reference is directed. Chronic inflammatory and syphilitic enlargement. — ^These require only to be mentioned as causes of tumour in this region, reference for further detail being made to Art. xxii., vol, i Parotiditis. 487 Primary new growths. — The commonest new grow-th commencing in the lymph glands is sarcoma, it may be spindle-celled or round-celled, usually the latter, which is consequently termed lympho- sarcoma. Tliis is excessively malignant, grows with great rapidity, and involves surrounding structures. Scattered glands may be attacked simultaneously. Early excision is the only, but not a promising, treatment. Secondary new growtJis. — Cancer and round- celled sarcoma usually involve the lymph glands secondarily. Cancer, especially epithelioma, invades the glands nearest the original tumour. The enlarge- ment of the gland is usually irregular, painful, and hard. It soon becomes very adherent on the outside to surrounding structures, while it degenerates in the centre so as to form a cavity filled with pul- taceous debris. Early excision is the only treatment. IV. Affectioxs of the Salivary Glaxds. A. Simple infla.iaiuiatiosi of the parotid. — The parotid gland inflames rarely from direct primary causes, but very frequently as a symptom of some acute specific disease. It is so common a feature of mumps as to almost render the terms parotitis and mumps synonymous. It also occurs frequently in pyaemia, and more rarely in scarlet fever, typhus, and small-pox. Acute adenitis of the submaxillary gland is as rare as that of the parotid is common. Parotitis usually presents itself as congestion and oedema of the gland, the acute swelling being painful, and causing movement of the jaw to be very limited. The incubation period of mumps is about three weeks, and after the swelling has developed, and is disap- pearing in one gland, the opposite one becomes affected. Suppurative parotitis only occurs in very debili- tated subjects, and in pyaemia. In the latter affectioB 488 Manual of Surgery. it is lieralded by a severe rigor, and is Tisually found to form a localised swelling, although the phlegmonous infiltration around spreads through the whole gland. Early antiseptic incision is the only treatment, coupled with the general treatment of pyaemia. Gangi-enous parotitis is a very rare affection, in which the inflammation terminates in sloughing of the superjacent skin, with subsequent destruction of the proper gland tissue. Treatment consists in free incision and the application of strong disinfectant solutions. B. Cystic tumours of the parotid. — Occa- sionally the main duct of the gland becomes plugged by a calculus, so that the part behind the obstruction and the gland itself are distended to form a retention cyst. This condition is, however, rare in the parotid. In the sublingual region, salivary retention cysts are more common. Very rarely true cysts (probably arising from the blocking of a secondary duct) have been met with. C. Solid tumours ; adenoma. — Simple tu- mours in the salivary gland, composed of one tissue only, are very exceptional; in almost every case the growth is compound. Growths are common in the parotid, but rare in the submaxillary and sublingual glands. The ordinary non-malignant " parotid tumour " of the older writers is now known to be a fibro-adenoma. The adenomatous tissue is simply a co{)y of the original gland tissue, the lumen of the acini, however, being filled up with cells. Owing to changes in the fibrous stroma of the tumour, it is frequently more correctly termed myxo-adenoma, and from the not infrequent development of cartilage therein, is termed a myxo- chondro-fibro adenoma. These simple parotid tumours grow very slowly, distending and usually rupturing the original capsule Parotid Tumours. 489 of the gland, but forming a new capsule out of the surrounding connective tissue. While growing in the gland they can often be shelled out of this false capsule without wounding the healthy gland tissue. The skin, too, is usually freely movable over the mass. Occa> sionally the socia parotidis is affected alone. Tlie most important points to be borne in mind in connection with parotid tumours are («) the facial nerve, and (6) the vascular supply. {a) The facial nerve running througli the lower end of the i)arotid is liable to the paralysing effects of pressure from a new growth of the kind indicated. But it is more liable to be in- jured in removing the tumour, and the possibility of this accident (sometimes a necessity) should be ex- plained beforehand to the patient. {h) As regards the blood supply, it is also to be remembered that the external carotid artery passes through the deep portion of the gland, but no notice need be taken of hremorrhaore when it IS a question of thoroughly removing a growth, all vessels being secured with forceps as they bleed. The internal maxillary artery, will be found to bleed from both ends so as to require a double ligature. D. Adeiio-sarconia is a gi^owth which affects the submaxillary gland neai-ly as often as the parotid ; it forms a steadily growing tumour (the rate of growth increasing with each recurrence) which becomes ad- herent to neighbouring structures, and invades muscles Fig. 97. — Adenoma of tlie Parotid Gland. 490 Manual of Surgery. and fasciae. By pressure on the branches of the fifth nerve it gives rise to excruciating pain, and penetrates deeply between the jaw and the base of the skull. It sometimes affects the glands secondarily. Free ex- cision must be performed. K Carcinoma of the salivary g^lands is very rare ; scirrhus has been described as most common. An attempt to remove the whole mass may be made if the disease be not too far advanced. Y. Diseases of the Thyroid Body. Up till quite recently an account of the diseases of the thyroid body has been confined to description of goitre and its treatment. There seems good reason now to believe that the thyroi'l gland may undergo active atrophic changes, accompanied by overgrowth of its stroma, so as to produce the fatal disease called myx- oedema; and, moreover, that the condition known as cretinism results from non-development of the gland, and consequently loss of its function. A similar parallel is to be found in the case of Addison's disease, which there is very little reason to doubt is simply due to a loss of the function of the suprarenal bodies. Both in cretinism and in myxcedema the thyroid gland is either atrophied, or the seat of fibro-atrophic disease. The probable function of the thyroid gland, as established by experiments and clinical observation, concerns, in the first place, the control of the mucinoid substances in the tissues of the body, and albuminoid metabolism to some extent ; and^ in the second place, hsemapoiesis, i.e. manufacture of blood corpuscles. 1. Atrophy of the thyroid g^land is followed by the disease called myxoedema^ in which the patient becomes lethargic, the subcutaneous tissues swell from an accumulation of mucus, and produce an appearance like oedema, save that the swelling is resistent (the eye- lids and lips especially being extremely 2>uffy). The Myxcedema. 491 blood becomes very anaemic, there being a loss of red corpuscles and an increase of leucocytes. The super- ficial vessels of the skin are dilated on the cheeks, etc.; and the hair, after getting very thin and fine, falls out rapidly. The speech becomes thick and slow, and the mental obfuscation increases until the patient gra- dually becomes almost imbecile. The temperature is almost always sub- normal, and the urine free from al- bumin, except just towards the end. The general appear- ances are well seen in Fig. 98. This condition has been described at some length, for since I have produced ex- actly the same dis- ease in m or. keys by simply removing the thyroid gland, it is now possible to explain the results obtained by Kocher and others in extirpating goitres. At the same time there is proof that myxcedema is the result of atrophy of the thyroid body. Some hold to the hypothesis that myxcedema is in some way or other an affection of the sympathetic nerve, but on careful examination no primary changes have ever been found in the sym- pathetic, 2. Tiiinoiirs of the tli>Toinax aud tracliea. — Contusions and wounds of the larynx and trachea have already been referred to. There remain then fractures and scalds of those parts for consideration. As cadeina glottidis plays a most important part in de- ciding the nature and treatment of these cases, a few- words may be added to what has already been said at page 475. In the first place it must be noted that oedema of the glottis may come on " idiopathically," i.e. in some cases of Bright's disease. Occurring in middle-aged men, it is not very uncommon to find that the patient is seized with rapidly increasing difficulty of breathing, requiring to be sat up in bed, using all the extra muscles of respiration, and becoming cyanotic. In these cases the mucous membrane of the pharynx and larynx (especially the loose aryteno-epiglottic folds) becomes enormously swollen from rapid transudation of fluid into the submucous tissue, and it is this swelling which blocks up the entrance to the glottis, and so causes dyspncea. If met with early, this so- called idiopathic oedema (exactly the same thing is seen in wasp or bee stings of the back of the throat) can sometimes be got rid of by causing the patient to inhale steam as hot as it can be borne, but it often requires operative interference. Scarification of the aryepiglottic folds, performed by scoring the mucous membrane with a curved probe-pointed bistoury, is sometimes followed by complete relief as the fluid and blood flow out of the cuts. As a rule, however, laryngotomy must be performed; without an an- aesthetic (or with preliminary freezing of the skin) for these cases which are specially liable to fatal syncope which might be induced by chloroform. Scalds of the pharynx and larynx pro- duce the same condition mure lapidly. The boiling 49^ Manual of Surgery, water taken into the moutli from a kettle is not swallowed, but ejected by the violent spasm of the pharynx. However, the scalded membrane instantly becomes violently congested, and oedema sets in. Tracheotomy must be performed if the symptoms of asphyxia rapidly increase, and if hot inhalations have proved useless. Syncope is also common in these cases owing to the acuteness of the asphyxial cou- ditioiL Often, if the child escape the primary evils just described, the pharynx and larynx become the seat of a fibrinous exudative inflammation which has been called croupous since the mucous membrane is covered with a white fibrinous false membrane. Pre- cisely the same condition may arise from a person swallowing strong acids. Fractures of the larynx are very fatal ac- cidents. The thyroid cartilage is usually separated into its two halves, and the hyoid bone is not in- frequently broken at the same time, under which cir- cumstance movement of the tongue becomes very pain- ful, and the voice is so altered as to be unintelligible. Fracture of the larynx may be immediately fatal from dislocation of the vocal cords, and consequent asphyxia from spasm of the glottis. Or, again, if the mucous membrane is torn the person may be choked with blood; evidence of wound of the membrane being afforded by his coughing up bloody mucus. Finally, Oidema glottidis may set in at any time, soon after the accident. Tracheotomy should therefore be per- formed as a prophylactic measure in all cases of bad fracture of the larynx. Treatment should be limited to relieving symptoms, and attempting to fix the fragments together by strapping the neck lightly ; or if the displacement is severe, they should be cut down upon and united with catgut. Foreig^ii bodies in the air passages. — The substances which may find their way into the air Foreign Bodies in Larynx, 497 passages are very various and numerous, but the symptoms produced are so very much alike that a diagnosis, in most cases, is comparatively easy. First, as regards their entry into the air passage, it will not be forgotten that, in order to reach the trachea, a foreign body must pass through the rim a glottidis, the least touch of either side of which naturally ex- cites a severe spasm of the glottis, and, consequently, such a body can get into the trachea only when the glottis is widely open. This happens when a person holding a body loosely in the mouth gives a sudden violent inspiration. The foreign body is then sucked into the air passage. A foreign body may be im- pacted in the larynx above or between the vocal cords, very commonly above, being caught in the mouth of the laryngeal pouches or sacs on either side. Xext, it may be loose in the trachea, and, finally, may drop down into a bronchus, usually the right one, because that is in a more direct line with the axis of the trachea than is the left. The symp- toms of a foreign body in these different regions of the air passage vary, as does also the treatment. Impaction in the larynx. — The presence of a foreign body in the larynx usually causes violent spasm of the sphincter-like muscles of the larynx, so that the patient just after the accident is in imme- diate danger of death from asphyxia ; in fact, the majority of patients die at once if the mass impacted is cylindrical and too large to go through the rima glotti- dis. Such instances are seen in cases where a person has "bolted " large pieces of meat and one has slipped beneath the epiglottis. If, however, the foreign body is thin and flat, albeit very angular and sharp, the patient will probably recover from the first severe spasm of the glottis, and, as air can pass freely. past the body, he will survive the accident, having, how- ever, severe attacks of spasm at intervals, with G G— 21 498 Manual of Surgery. exhausting cough, and expectorating blood-stained mucus. This accident is to be feared, as specially tending to asphyxial syncope from failure of the heart, a very fatal form of fainting. Examination of the larynx with the lar^aigoscope must be made at once, and, if the body is seen at the top of the larynx fixed in the aryepiglottic fold, it should be seized with laryngeal forceps and withdrawn (Fig. 100). If deeply impacted, laryngotomy must be performed, and thyrotomy car- ried upwards for half an inch or so, and the foreign body ex- tracted with as little laceration of the mucous membrane as possible. After thorough cleans- ing of the parts a laryngotomy tube should be kept in for twenty-four to forty -eight hours, until danger of oedema glottidis has passed away. Under certain circumstances, e.g. narrowness of the foreign body, etc., persons may tolerate the pressure of a foreign body in the larynx for months. Foreign body loose in the trachea. — This con- dition of things is perhaps the most trying to a patient, for two reasons. Firstly, the body, being loose, is coughed up against the lower surface of the rima glottidis; this excites powerful spasm of the glottis, with accompanying asphyxial symptoms of greater or less severity. Secondly, the presence of the loose body excites free secretion from the air tubes of a quantity of frothy mucus, which also suffocates the patient. In one instance I saw a plug of tenacious mucus itself produce urgent symp- toms by being driven against the glottis until it was removed by tracheotomy. A patient suffering as Fig. 100.— Fish Bone im- pacted in Larynx. Foreign Bodies in Larynx. 499 above sits propped up, the air entering the chest badly, owing to the filling up of the tubes, so that the face is livid and the respirations very laboured. On auscultation little air will be found to get to the bases of the lungs, and the air tubes will be full of loud mucous rattling rales. Simple acute bronchitis being excluded by the history, tracheotomy must be done at once ; ancl, instead of a tube being inserted, it is best to pass a carbolised silk loop through each side of the tracheal wound, so that it can be drawn open and the escape of a foreign body facilitated, thus avoiding the hindrance necessarily offered, to a large extent, by the presence of a tube. A dilator (Golding Bird's) is also used for the same purpose. The mucus should be aspirated or sucked out of the trachea as soon as the latter is opened. When the air passage is fairly free the patient may be inverted gradually and encouraged to cough ; the body, if loose, will probably then be expelled through the larynx or wound. It is imperative obviously to perform tracheo- tomy when the symptoms of laryngeal spasm are re- curring, but now it must be stated that the operation should always be performed as a prophylactic measure if the diagnosis is clear; and a paroxysmal attack of laryngeal spasm is unmistakable. It should be performed because the expulsion of the body is rendered quite safe, since the patient can breathe in spite of the spasm above. This treatment is strongly supported by statistics, which have con- siderable value in a question like the present. Foreign bodies have been expelled naturally even as long as nine months after the accident, but usually the end of the case is much less favourable. Impaction in a bronchus^ usually the right one. — This condition will be preceded by such symp- toms as have been just described. Special symptoms are : Pain at seat of lodgment, no breath sounds 500 Manual of Surgery. in Inng, whistling rales at seat of impaction, especially if the body is tubular, purulent bronchitis, followed by abscess in the lung very frequently, and more rarely phthisis. An attempt should be made to extract the body by passing down the trachea a wire hook and fine forceps, the patient being fully an- aesthetised. Tumours of the larynx may very well be considered next, since the symptoms they give rise to are practically those of foreign bodies. They are popularly grouped together as polypi. They consist of the following kinds, the commoner being men- tioned first : 1. Fapillovm, or wart, consists of a fibrous framework covered with thin mucous membrane. Laryngeal papillomata are frequently multiple, sometimes sessile, at other times pedunculated (Fig. 101). In children these may grow to a large extent and cause chronic asphyxia, for which tracheotomy has been resorted to in ignorance of the cause. Thyrotomy is the operation to be performed. 2. Fibroma. — A roundish smooth tumour, usually sessile, composed of simple fibrous tissue growing from the submucosa. Fig. 101. — Lai'yngeal Papilloma. Tumours of Larynx. 501 3. Adenoma. — A solid tumour, which begins in the mucous glands and grows in the submucosa. 4. Epithelionw, rather commoner than the last, is like epithelioma elsewhere. The disease sjDreads iintil it destroys the surrounding tissues, sometimes appearing on the surface of the neck as a fungating sore. The ulcer presents the typical raised thick and hard border, with dirty granulation tissue forming the floor. It implicates surrounding tissues, and in- fects the neighbouring lymph glands. 5. Myxoma. — Myxomatous polypi are found sometimes in the larynx. The above tumours grow very slowly, as a rule, and, if high up in the larynx, cause practically no symptoms until of considerable size. As a rule they produce alteration in the voice, coughing, and, in severe cases, attacks of paroxysmal dyspnoea. They are detected, of course, by the laryngoscope, and their early removal effected. This may be done in two ways. Either the growth may be seized with laryngeal forceps, snare, or galvanic cautery (the larynx being partly ana3sthetised with cocaine), and the instrument guided by means of the laryngo- scope ; or the thyroid cartilage must be split and the larynx examined. The former operation is styled endo-laryngeal, and requires no further mention here ; but a few words must now be said on thyrotomy. Thyrotomy. — The patient being anaesthetised, and the shoulders raised and the neck stretched, the anterior border of the thp-oid cartilage and the crico- thyroid membrane are exposed by free incision. All bleeding having been stopped, the crico-thyroid mem- brane is opened for a short distance, and then the thyroid cartilage is split up to the top quarter inch, which is left intact to prevent gliding displacement of the two halves. The two halves being now separated, the interior of the larynx is inspected, and all growths 502 Manual of Surgery. removed. As the mucous membrane is "sery sensitive axid reflex action vigorous, it is best to first paint it with cocaine solution, 10 to 20 per cent. (Parker)^ and then snip off the growths. All bleeding can be arrested by pressure, and then the sides of the thyroid must be stitched toirether with fine catsrut and the wound closed, except opposite the crico-thyroid o[)ening. A light dressing of carbolic gauze should be applied. Excision of the larjiix.— If the new growth is epithelioma, the larjTix must be excised, the operation being performed in the following way : A free incision is made through the superficial struc- tures, and through the deep fascia from the hyoid bone to opposite the third tracheal ring ; the trachea is then laid bare above the isthmus of the thyroid gland (which is drawn downwards), freed from the oesophagus, and finally cut across at the second ring and the open lower end plugged with a tampon tube, through which the anaesthetic can be admini- stered, and which at the same time allows no blood to trickle into the windpipe. The larynx is then freed on each side, the edge of the knife being kept turned towards the part to be removed. In doing this the superior laryngeal arteries will require ligature. The larynx is now separated from the hyoid bone, and finally from the front of the pharynx. The wound .should be mopped out with chloride of zinc (40 gr. to 5j) and dusted with iodoform. The dressing should be a light one of gauze or wool. The patient to be fed by nutrient enemata as long as possible, and then by a tube. When the wound is healed, Gussenbauer's or Foulis's artificial larynx is inserted into the gap so that the patient can talk distinctly. L.ar}Tig:itis Mith especial reference to croup, diphtheria, and the operation of trach- eotomy* — There are several conditiona of the larynx Laryngitis. 503 to be here noted which are usually termed laryngitis, but the pathological state of which is really spe- cific. Bearing this in naind we may enumerate the varieties of laryngitis as, (a) acute laryngitis ; (6) chronic laryngitis ; (c) croupous laryngitis ; \d) diphtheritic laryngitis; (e) tubercular laryngitis ; ( syphilitic laryngitis. (a) Acute laryngitis of a simple character pro duces symptoms like oedema glottidis, for the simple reason that the latter is present, but are not so urgent, since the causation is simpler. Acute laryngitis, started by catarrh, and causing hoarse- ness and loss of voice, is sometimes succeeded by urgent symptoms of dyspnoea, etc. It can usually be controlled by the simple application of hot fomenta- tions (mustard, etc.) to the outside of the neck, coupled with steam and benzoin inhalations, the patient being kept in a warm room, and well fed up. (6) Chronic laryngitis, evidenced by hoarseness and soreness, with hawking up of mucus, etc., is to be treated laryjjgoscopically with astringent lotions applied by a proper brush. (c and d) Croup and diphtheria are regarded by many as degrees of the same disease, viz. a mem- branous intlammation, i. e, an inflammation in which there is exuded on the surface of the mucous membrane a fibrinous exudation which forms a white false membrane. This false membrane may be easily detached in a mild case of croup, or is firmly adherent to a raw bleeding surface in a bad case of diphtheria. Croup very often attacks a child sud- denly, with an incubation period of only a few hours elapsing before the characteristic brassy cough is heard, and dyspnoea follows. Diphtheria as a rule is pre- ceded by some days of malaise, and the throat symptoms often take a good many hours to develop. 504 Manual of Surgery, The inflammation of the mucous membrane, followed by the growth of the membrane, passes upwards into the nose (when it is nearly always fatal) and down- wards into the larynx, forming sometimes a perfect cast of the air passages (Fig. 102). In the latter case it produces the clas- sical signs Q.f laryngeal obstruction. There is one symptom, however, that forms a strong indication for the performance of tracheotomy, and that is the recession of the soft parts about the chest walls when the patient makes efforts at inspiration. When this is marked, tracheotomy is to be per- formed at once. {e and f) Tubercular and syj)hilitic laryiigitis are the names given to tubercular and syphilitic congestion and ulceration of the larynx. The ulcers are in both cases ragged sores, the edges raised, and the floor sloughy. In tubercular disease there is usually chronic cedema, and in syphilis gummatous masses are often seen. Tubercular laryngitis is usually very painful and fatal, and traclieotomy affords but slight relief. As syphilitic ulceration heals, the cicatrices often contract the larynx so much as to necessitate the operation. TrsLclicotonay is one of the most important Fig. 102. — Memb)-anous cast of Trachea aud Bronchi from a case of Diphthci'ia. Lond. Hosp. Museum.) (From Tracheotomy. 505 "emergency" operations, and therefore one always to be done with every precaution and deliberation if tliere is reasonable time. The shoulders are to be raised on a firm small pillow, the neck and head thrown back, the former resting in a hollow in a sand-bag, which fixes it and prevents it rolling from side to side. An assistant, hold- ing his fore-arms on each side of tiie child's head, is ready to open the w^ound with blunt hooks. An incision is then to be made ex- tending from the crico-thyroid membrane to a variable distance above the ster- num. The ante- rior jugular vein being " avoided (Fig. 103), the deep fascia is opened to the same extent as the skin, the de- pressor muscles of the hyoid are then exposed and the fascial septum between them incised, and the muscles held apart by the hooks. The loose connective tissue covering the isthmus of the thyroid is divided, and the isthmus drawn down- wards with a blunt hook, the trachea being exposed then between it and the cricoid cartilage by a few more touches of the knife. A small sharp hook is now stuck into the front surface of the windpipe to steady it while it is opened carefully with the Fig. 103. — Median line of Neck. L. Larynx ; c, cricoid cartilage ; T, trachea ; Th, thy- roid glaud. 5o6 Manual of Surgery. scalpel, the back being towards the thyroid isthmus. Directly it is opened, the sides of the wound in tho trachea must be held apart, and all mucus and false membrane cleared out by feathers, or aspirated by a soft catheter and syringe. When clear, the tube is to be inserted, and tied in. A little carbo- lised vaseline may be rubbed gently on the wound before the tube is put in. Complications. — The operation is usually much more difficult than just described, the patient strug- gling for breath, vessels oozing, etc. Chloroform pre- vents such struggling (but very little is required), serious bleeding is stopped by forceps as the operation proceeds, oozing always ceasing when respiration is re-established. After the operation the tube wants constant attention. The wound may become sloughy, the neck emphysematous, oedematous, or erysipelatous. . Attempts should be made to do without the tube, beginning on the fifth day by stopping the mouth of the tube, and then leaving it out for a few minutes, increasing the interval every day. The operation is of value, not only by relieving the asphyxia, but because it enables the operator to thoroughly clear out the larynx, this being done by passing a feather up from the wound, or passing a string into the mouth and drawing small plugs of antiseptic wool up, as sponges. If the tube and wound tend to dry, so that the discharge blocks it, then the steam kettle must be used to keep the air moist, and at the same time the membrane must be softened with solution of carbonate of soda and glycerine. 5°? XiJ. DISEASES OF THE NOSE AND NASAL CAVITIES. William J Walsham. IVouiids of the nose may be inflicted from without, or from within through the nostrils ; they may merely involve the superficial structures, or they may be complicated by division of the cartilages, or fracture of the bones. {See Art. i., vol. i.) The parts should be thoroughly cleansed, and brought as accurately together as possible with horse- hair sutures, and the wound sealed with collodion. Even where considerable portions of tissue have been detached, immediate union may be hoped for, as the blood supply of the nose, like that of the face generally, is very free, a fact wdiich also explains the liability of wounds of these parts to be followed by swelling or erysij)elas ; but if much tissue has been lost, a plastic operation may be subsequently requrred. When a sharp instrument has been thrust up the nostril, care should be taken that no portion of it is allowed to remain in the wound ; and as in such cases the cranium may have been penetrated and the brain injured, rest sliould be enjoined and the patient watched for any signs of intracranial inflammation. £pistaxis, or bleeding from the nose, is a common attendant on blows or other injuries, and is a promi- nent symptom of certain forms of fracture of the base of the skull and of fibrous and malignant growtlis in the nose or naso-pharynx. It frequently occurs spon- taneously. Thus, in children and young adults it is often due to congestion of the mucous membrane, and is especially common in girls about the age of puberty. In the middle-aged it appears to be due to plethoric 5o8 Manual of Surgery. habit and congestion of the brain and liver. In the old or cachectic it may depend upon a poor condition of the blood, such as occurs in cirrhosis of the liver, granular kidney, heart disease, scurvy, and in some fevers. The blood usually escapes from one or other nostril, but may pass through the posterior nares and the gullet into the stomach, and, being afterwards vomited, may simulate haematemesis, or it may irritate the larynx and be coughed up in a frothy condition and be mistaken for haemoptysis. Some florid blood, however, will generally escape from the nostril at the same time, and can usually be seen trickling down the back of the throat. Treatment. — For an account of the treatment required for the various conditions that may give rise to epistaxis the reader is referred to other portions of this work, or to a treatise on medicine. Here it will suffice to indicate the means that may have to be adopted for arresting the bleeding when this is thought advisable. When the result of a blow or other injury of the nose, or occurring spontaneously in the young, the hajmon-hage generally ceases of its own accord, or may be readily controlled by cold sponging, elevation of the arms_, and other well-known domestic remedies ; whilst in the plethoric, as the result of congestion, it should not be too hastily checked, as it may prevent graver mischief, such as cerebral haemorrhage. In the old and cachectic the arrest of the bleeding is generally indicated, but may be attended with difficulty. Rest, the sucking of ice, an ice bag to the bridge of the nose, cold to the spine, and cold douches, with the internal administration of gallic acid, lead and opium, ergot or perchloride of iron, may be tried. These means failing, it may be necessary to plug the nares. This may be done either with the inflating tampon, or with pledgets of lint or iodoform wool. An inflating tampon is shown in Fig. 104. It consists of an indiarubber tube Epista xjs. 509 with two dilatations upon it, so sized and shaped that when inflated they may accurately fill the anterior and posterior nares respectively. It is passed through the nostril in a flaccid condition by means of a long probe, and the air after inflation prevented from escaping by twisting and clamping the tube. To ])lug the posterior nares with lint or cotton wool, a pledget should be made about the size of the last joint of the thumb, and secured round the middle by a piece of twine which has been preWously passed through the nostril, round the palate, and out of the mouth by means of a Bellocq's sound, or if this is not at hand, by a gum elastic catheter. The plug can be then drawn into the posteiior nares by making trac- tion on the end of the string protruding from the nostril, aided by the fore-flnger behind the palate. I have found, however, that the patient is less inconvenienced by pushing a piece of fine soft rubber tubing along the floor of the nose, and when it presents below the palate, drawing it forwards by the forceps and securing it to the twine already attached to the pledget. Tlie anterior nares may next be plugged by a similar pledget, secured by the thread already hanging out of the nostril. The other end of the string attached to the posterior plug may be fastened loosely to the cheek or allowed to fall backwards into the pharynx, and will be of service in the removal of the plug. Foreign bodies, such as peas, beads, etc., are often pushed up the nostril by children, and, more rarely, hard substances such as cherry-stones and the like have during vomiting entered into the nasal cavities from behind the palate. They may remain in Fig. 104. — Indianibber inflating Tampon for plug^int? the Nares in Epistaxis. (Arnold's Catalogue.) 5IO Manual of Surgery. the nasal passages for some time witliout being dis- covered, but the foetid discharge to which they almost inevitably sooner or later give rise should lead to a suspicion of their presence. They can generally be extracted by the forceps, or by some of the ingenious screws or curettes invented for the purpose ; or they may be freed by the nasal douche sent up one nostril and returned by the other ; but Rouge's operation has sometimes been necessary for their removal. l&liinolitlis, or nose stones, are formed from the deposition of phosphate of lime and mucus upon either a foieign body or hardened secretion. They give rise to much swelling, nasal obstruction, and a foetid discharge. They have been mistaken for osteomata, polypi, or even malignant growths. Re- moval with the forceps, previously crushing if neces- sary, is the proper treatment. Nasal catarrh, rhinitis, and coayza, are terms used to denote inflammation of the mucous membrane of the nose. The disease may be acute or chronic. As acute catarrh, or cold in the head, falls under the domain of the physician rather than that of the surgeon, the chronic form only will be here described. Clironic nasal catarrh is most frequently met with in the young, especially in delicate and strumous children. It may be caused by oft-repeated and ne- glected attacks of acute catarrh, the irritation of noxious dust or vapours, the abuse of spirits and snuff- taking, or the presence of foreign bodies or growths in the nose, or adenoid vegetations in the '^ault of the pharynx. In infants it may be due to congenital syphilis, and is then known as the snuffles ; and in rare instances it has appeared to be the result of gonorrhoeal or leucorrhoeal infection. Several varie- ties of the affection have been described, all of which, however, appear to be merely different stages of the Nasa l Ca ta rrh. 511 same disease. They will be here classed as (1) simple, (2) hypertrojihic, and (3) atroi)hic catarrh. (1) The simple form is characterised by a thin mucous or muco-purulent discharge^ and a con- gested condition of the mucous membrane, but there is neither thickening, incrustation, nor foetor. If neglected it may pass into (2) the hypertrophic form. In this stage of the disease the mucous membrane, especially over the spongy bones, become infilti'ated with inflammatory products, and appears swollen and thickened, and of a deeper red than natural, whilst the glands are stimulated to extra secretion, and pour out a thick muco-purulent discharge. Nasal respiration is obstructed, the voice is altered in tone, the aire nasi are often contracted and thickened, and their mucous surface covered with scabs. Should the catarrh spread to the naso-pharynx, the discharge may be seen streak- big the back of the throat, whence it is continually being hawked up in the form of pellets. Some gran- ular pharyngitis, and perhaps increase of the glandular tissue of the vault, may co-exist, and possibly deafness from the implication of the Eustachian tubes. In severe cases the posterior ends of the inferior spongv bones may become so hypertrophied as to appear in the rhinoscope as two globular, congested tumours, almost blocking up the choanse. This condition of the mucous membrane is well seen in the accompanying illustrations (Figs. 105 and 106). Occasionally within a few months, but more often after several years, the hypertrophic may pass into (3) the atrophic variety. This form, also called dry catarrh, and by some, when attended with foetor, simple ozcena, is apparently due to the shrinking of the inflammatory new formation infiltrating the tissues in the former variety with con- sequent atrophy and more or less destruction of the mucous glands. The nasal cavities appear preter- naturally large, and the spongy bones diminished in 512 Manual of Surgery. Fig. 105.— Hypertrophy of the Mucotia Membrane of the Nose, from a specimen (No. 1762) in the Museum of St. Bar- tholomew's Hospital. In the recent state the posterior end of the inferior spongy bone resembled a vascular tu- mour. size, while the mucous membrane is pale, dry, and shrunken. The discharge, which is viscid, and secreted in deficient quantity, hardens into greenish- yellow crusts. The disease is generally, though not invari- ably, attended with a horrible foetor, due either to the decom- position of the dis- charge beneath the adherent crusts, or to its retention in some of the adjoining cavities into which the catarrh has spread. When foetor is present, as it oc- casionally is during what appears to be the hypertrophic stage, it is probable that atrophy has already set in in some of the deeper recesses. It should be remembered that all three forms of chronic catarrh are unattended with ulceration. Treatment. — Except as the result of congenital syphilis or gonorrhceal in- fection and in the earlier stages, chronic nasal ca- tarrh is a most intractable malady; indeed, when it assumes the atrophic form little except amelioration of the distressing symptom of fcctor must be expected. In all forms the treat- ment should be constitutional and local. In strumous Fig. 106.— Appearances presented by the above on rhinoscopic examination. (After Leff erts. ) A^ASAL Catarrh. 513 subjects cod-liver oil and the syrup of the iodide and phosphate of iron should be persevered in for long periods. In congenital syphilis small doses of grey powder or mercurial inunctions generally act like a charm. Locally, in the simple variety and in milder cases of the hypertrophic, the parts should first be cleansed, either by simply Ijlowing the nose or by the use of some such lotion as that known as Dobell's (acid. carbol. gr. j ; sodii bicarb., sodii biborat. aa gr. ij ; glycerine 5J ; aquam ad Jj). Lotions should not be applied, as is too frequently done, by means of the nasal douche, as in this way the deeper recesses and upper portions of the nasal fossse cannot be reached, and if care is not taken inflammation of the middle ear may be set up. They are better employed in the form of a coarse spray, I'ig- i'"^"- — Nasal Spray !Pro*iiiCGr A x>ozz1g tor either by the anterior or ])0S- anterior xinres ; b, uozzle terior nasal spray producer (Fig. J.^;il^.rSSogue.T- ^^' 107) worked by the double hand balls. When the parts are thoroughly cleansed, as- tringents such as the sulpho-carbolate or iodide of zinc, iodoform, tannic acid, or nitrate of silver may be used in the form of sprays, powders, or gelatine bougies. Where there is great hypertrophy, the thickened tissue should be destroyed by nitric or glacial acetic acid, or by the galvanic cautery. In using the cautery, Shurley's sjjeculum (Fig. 10^) will be found useful for protecting the septum. When the posterior ends of the inferior spongy bones are much enlarged they may sometimes be advantageously removed by Jarvis' snare, or by tlie galvanic ecraseur. A deflected septum should be straightened, and adenoid growths in the vault ot the pharynx should be extirpated. H H— 21 5H Manual of Surgery. Where the catarrli falls chiefly on the naso-pharynx {retro-nasal catarrh), the local remedies should be applied from behind the palate, by substituting the posterior for the anterior nozzle in the various spray producers, etc., whilst cubebs, which appear to exert a special action on the glands of the naso-pharynx, should be given internally. In the atrophic form little can be done beyond cleansing and disinfecting the nasal chambers by means of lotions of carbolic or boracic acid, or Condy's fluid, and the like. Stimu- lation of the mucous membrane by the local insuflSation of the sanguinaria galanga, as recommended by Ilobin- son, and the continued use of Gottstein's nasal tampons, with cubebs internally, may Fig. 308.-shnriey's Nasal prove of temporary benefit. Speciilum, for protecting OzaPllSl (to Stink) IS a S'Ia^SIcSoS term which has been used very loosely by authors. By some it is applied to all diseases of the nose attended by a foetid discharge, whilst by others it has been restricted to the fcetid form of atrophic catarrh. It is better, therefore, to regard it as a symptom and not as a disease j)er se. It is generally present in the follow- ing affections : (1) Atrophic nasal catarrh; (2) syphi- litic, lupoid, and tuberculous ulceration ; (3) caries and necrosis ; (4) some forms of new growths in the nose and naso-pharynx ; (5) certain diseases of the antrum and other air sinuses ; and (6) foreign bodies and rhinoliths. Ulceration in the nasal cavities is generally of a syphilitic, more rarely of a lupoid, and very rarely of a tuberculous nature. Syphilitic ulceration usually occurs in the later stages of syphilis, and is due to the breaking down of gummata in the mucous mem- brane or beneath the periosteum. It frequenth leads N'asal Caries. 515 to necrosis and caries of the bones and cartilages, per- foration of the septum and sinking in of the nose. Lupoid ulceration is preceded, as elsewhere, by lupoid tubercles ; it is most common on the anterior and lower part of the septum, and just within the alae of the nose, and not infrequently leads to a small perfor- ation. Both forms are attended with a muco-purulent and foetid discharge. Treatment. — In the syphilitic form iodide of potassium in full doses should be given, the parts cleansed with antiseptic sprays, and dead bone, if de- tected, removed when loose. In lupoid ulceration the surface should be scraped with a Yolkmann's spoon or destroyed with caustic or the galvano-cautery, and cod-liver oil and arsenic should be given internally. Caries or necrosis of the cartilages or bones forming the nasal cavities is generally the result of syphilis, but it may be due to struma, lupus, or rodent ulcer, or may follow an injury or long impaction of a foreign body. The bone disease may be secondary to ulceration of the mucous membrane or to the breaking down of gummous material in j^eriostitis or perichon- dritis. The septum and the spongy bones are the most frequently affected, but caries of the roof of the nose is not infrequent. When the septum is extensively involved the bridge of the nose may fall in ; but it is re- markable how much of it may be lost in adults without any marked external deformity. A foetid discharge, foul- smelling breath, depression of the bridge of the nose, a history, perhaps, of a former injury or of dead bone having come away, and concomitant signs of syphilis or struma, such as perforation of the palate and loss of the uvula, are suspicious of diseased bone, but the diagnosis can only be made certain by striking it with a probe. Though usually in this way readily detected, a prolonged search with the patient under chloroform may be required, and Rouge's operation has had to be 5i6 Manual of Sc/kgerf. resorted to before it could be found. If the surgeon has a small index finger this may be easily passed through the nostril^ and with the finger of the other hand behind the palate a very thorough exploration can be made. Treatment. — The dead bone, as soon as loose, should be removed, the parts in the meantime being kept as sweet and clean as possible by antiseptic sprays. Removal can usually be readily effected through the nostril, but where this is not possible Rouge's operation may be done. Tumours or ue^v g^i'owths in the nasafl cavities are usually spoken of as polypi, of which three forms are generally described : the gelatinous, the fibrous, and the malignant. Oelatiuous or mucous polypi are by far the most common. They occur as soft, gelatinous, semitrans- lucent bodies of a pale yellow or pinkish colour, and of a globular, pyriform, or ovoid shape, but appearing opaque and shrunken when preserved in spirit. They maybe pedunculated or sessile, and are generally mul- tiple, one or two being frequently larger than the rest. They grow from the mucous membrane, and have the mi- nute structure of the myxomata,and are usually covered with ciliated epithelium. It has generally been taught that they most frequently arise from the superior and middle turbinated bones, but, from the recent observations of Zuckerkaudl, it is probable that they generally have a deeper origin in some of the remote recesses of the nose and neighbouring cavities. Rarely they spring from the roof, and very exceptionally from the septum. They have been attributed to neglected chronic catarrh, and by Dr. Woakes are believed to depend upon a chronic inflammatory condition of the muco-periosteum lining the turbinated bones and tells of the ethmoid, attended by necrosis of the osseous crabeculae ; but their etiology is at the best obscure. Nasal Polypi. 517 Symptoms. — The chief of these are a feeling of obstruction in the nose, increased in damp weather from swelling of the polypus, and in some cases amounting to complete occlusion, the so-called nasal tone of voice, and a mucous, but not, as a rule, offen- sive, discharge. Amongst other symptoms that may be met with may be mentioned frontal headache, deaf- ness, and loss of smell ; whilst recently certain forms of cough, asthma, and epilepsy have been attributed to reflex irritation set up by the presence of polypi Diagnosis. — On looking into the nostril they can generally be seen, and may be distinguished from hypertrophy of the mucous membrane over the spongy bones, for which they are most likely to be mistaken, by the characters already enumerated, and by the light or dark red appearance of the latter. But when high up or far back the speculum or rhinoscope may be necessary to detect them. Treatment. — They can generally be removed by the polypus forceps ; but the use of the galvano- cautery is preferable, as with this there is less pain and little or no haemorrhage ; pain, moreover, may be prevented by the application of cocaine. ^Yhen the polypus projects in the naso-pharynx, it can be removed from behind the palate either with the forceps or with the galvano-cautery. Tannic acid used as snuff is said to prevent a recurrence, but the author has not found it of much service. Fibrous pol>'pi rarely arise from the interior of the nose. They more frequently originate in the naso- pharynx from the basilar process of the occipital or body of the sphenoid, or in the cavity of the antrum, and only secondarily invade the nose as they grow larger. When arising in either of the first two situations they are generally designated tiaso-pharyngeal polypi. They spring from the periosteum, and consist chiefly of fibrous tissue, in which spindle-shaped cells are not 5t8 Manual of Surgery. infrequently found. They are covered by a very vascular mucous membrane, and contain numerous large thin-walled blood-vessels, which give to them in places almost a cavernous structure. At first gene- rally broadly pedunculated and confined to one side of the naso-pharynx, as they increase in size they assume a very irregular shape, invading the nasal cavi- ties and the rest of the naso-pharynx, perhaps push- ing forward or projecting below the palate, or penetrating into the orbit or spheno-maxillary fossa, or even protruding externally through the cheek or into the interior of the cranium. Syni'pto'ms. — At first these may be slight, but sooner or later there will be obstruction of one or both nostrils, attended by a mucous and often foul- smelling discharge, repeated attacks of haemorrhage, and perhaps deafness or trouble in breathing and swallowing ; whilst later, as the bones are invaded and displaced, the face assumes the characteristic appearance known as "frog-face." They are most common in young adult life, and, if not removed, may produce fatal exhaustion from the repeated haemor- rhages, though in some instances they have undergone atrophy as the patient grew older. They may be known by their firmness, smoothness, dark red colour, and proneness to bleed on examination. The diagnosis is readily effected by the aid of the rhinoscope or the finger passed behind the soft palate, while at times they may be seen with or without the speculum on looking into the nostril. Treatment. — Kemoval by the galvano-cautery, the wire being passed through the nares and directed over the base of the growth by the finger behind the soft palate, the base being afterwards destroyed by Lincoln's electrode, is, perhaps, the best treatment when the poly- pus is of moderate size. If too large to admit of this, an attempt may be made to reduce it within removable Nasal Polypi. 519 limits by electrolysis ; or, this not being considered advisable, an exposure of the growth must first be obtained in one of the following ways, and its re- moval then accomplished either by the galvano- cautery or ecraseur. If chiefly confined to the naso- pharynx, exposure is best obtained by splitting the soft palate, and if more room is still required, by chiselling away part of the hard palate as well (Nelaton's method) ; or, when chiefly invading the nasal cavities, by turning back the ala of the nose after splitting the upper lip in the middle line, or even removing the superior maxillary bone. Rouge's operation of turning up the upper lip and cartihiginous portion of the nose, and Langenbeck's method of resecting the maxillary bone, have each their advocates, but I have not found exposure by the former so good as that by turning back the ala after splitting the lip, and the resection of the maxillary bone is cer- tainly attended with greater risks than its mere removal. Maligrnaiit polypi may have either a sarcomatous or carcinomatous structure, and may arise in the nasal cavities, naso-pharynx, or antrum. The symptoms attending them are similar to those of the fibrous variety already described ; but they grow more quickly, infiltrate as well as invade surrounding parts, and sooner or later involve neio^hbourinor irlands. A microscopical examination of a small portion will reveal its exact structure. Early and complete removal, when there is a fair prospect of being able to get away the whole gro"S7th, is the treatment that should generally be adopted. Adenoid vcg:ctatioii8 consist of sessile, pedun- culated, or fringe-like growths, due to hypertrophy of the adenoid tissue, so abundant in the vault of the pharynx and in the region of the choanse. They are most common in childhood, and are of more fi*equent 520 Manual of Surgery. occurrence in northern Europe than in this country. They have been attributed to cold and damp, the exan- themata, etc., but their etiology is obscure. Symptoms. — Obstructed breathing in infants, and in older children deafness, are usually the symptoms that first attract attention. The voice has a peculiar tone, described by Meyer as of a "dead" character. The countenance has a vacant expression from the breathing, in consequence of the nasal obstruction, being carried on through the half-open mouth, whilst nasal catarrh, granular pharyn- gitis, enlargement of the tonsils, and purulent otitis, are not infrequently present. The diagnosis can be readily made by passing the finger behind the palate, and by the aid of the rhino- scope. To the finger they feel soft, yielding, irregular, pulpy, and velvety, like a bag of earthworms as Meyer puts it ; whilst in the mirror they appear as irregular, pink or reddish, sessile or pedunculated, fringe-like masses, partially obscuring the posterior nares. Bleeding commonly attends the examination. Treatment. — Though they have a tendency to atrophy as the patient gets older, removal is generally called for, as they may lead to permanent deafness. This in slight cases may be effected by the application of solid nitrate of silver or astringent solutions. The softer varieties may be scraped oflf with the finger nail, whilst the larger and firmer may perhaps best be removed by Loewenberg's forceps, guided by the mirror or finger. Those near the Eustachian tube require careful management lest the tube be injured, and may most conveniently be destroyed by Meyer's ring knife, which is passed through the nose, or by a small galvano-cautery guided by the mirror with the patient under chloroform and the soft palate tied up. €oiig:eiiital deformities of the nose are rare and of little surgical interest. Tbe only one to which Lipoma Nasi. 521 reference need be made here is occlusion of the nostrils. An incision, where this is merely mem- branous, will generally suffice, but in some cases a plastic operation will be necessary. Diseases of the exterior of the nose. — The affections to which the external parts of the nose are most liable are : lupus, rodent ulcer, epithelioma, acne rosacea, and lipoma nasi These, with the exception of the last named, present, when attacking the nose, ■» no special features, and the reader is referred for a description of them to Arts. v. and xxiv.,vol. i. Lipoma nasi is a hypertrophy of the sebaceous follicles and surrounding skin and subcutaneous tissue, not, as the name seems to imply, of the fatty tissue. It has been ascribed to exposure and alcoholism, and is most common after middle age. The tip and alse of the nose are chiefly affected, being transformed into irregular, lobulated, prominent, or pendulous masses, on which the apertures of the hypertrophied glands are seen as pit-like depressions. Occasionally pale, they are perhaps more often of a purplish-red colour, and traversed by dilated capillaries. Treatment. — The masses should be shaved off with a sharp scalpel, care being taken not to penetrate the cartilages. The improvement, when the parts have cicatrised, is veiy marked. Atfections of the septum. — Blood tumours are occasionally met with as the result of fracture of the sej)tum or other injury. The blood is extra vasated between the cartilage and the soft tissues, causing a circumscribed, fluctuating swelling, of t€n on both sides of the septum, which may readily be distinguished from abscess by its appearing immediately after the injury and by the absence of inflammation. The blood, as a rule, is slowly absorbed, but may break down into pus. In the latter circumstance only should an incision be made into the swelling. 522 AfANUAL OF SUKGERV. Abscess may occur after an injury, breaking down of a blood tumour or gumma, and sometimes without any evident cause. The signs of inflammation and fluctuation serve to distinguish abscesses from other tumours. They should be opened early. Cartilaginous and osseous tumours forming out- growths from the septum and projecting into the nostril are sometimes met with. The absence of a depression on the opposite side distinguishes them from deviation of the septum. They may be removed either by the knife, saw, or dental engine. Deviatio7i of the septum to one or other side may occur as the result of a blow or fall upon the nose, or as a congenital ''''■dXMenS'rs!^IZ:'"V^l malformation. It appears noid's Catalogue.) as a swelling projecting into and more or less ob- structing one of the nasal cavities, and may readily be distinguished from a polypus, for which it has some- times been mistaken, by the presence of a correspond- ing depression on the opposite side. It is generally attended with some lateral deviation, and perhaps depression in the case of injury of the lateral cartilages or even of the nasal bones. The inferior turbinated body on the side corresponding to the concavity is often much hypertrophied. The symptoms commonly complained of are obstructed nasal respiration, altered tone of voice, and a continual chronic catarrh ; whilst sometimes frontal headache, giddiness, and certain other distressing symptoms referable to nasal obstruc- tion are present. Treatment. — The septum may generally be forcibly straightened. I have found the forceps shown in the woodcut, which are a modification of Adams', best for the purpose, the large bows below the blades protecting tlie columnella. The straightened septum Deviations of Nasal Septum. 523 should then be kept in position l)y retentive apparatus ; the hollow plugs made for me by Messrs. Arnold will be found useful for this purpose. In some cases portions of the prominent septum may be advan- tageously excised. Deviated carti- lages should be rectified at the same time, and even where the bones have been displaced they may be straightened even after Fij?. 110.— Walsliam's Mask for making Pressure on crooked Nose. (Arnold's Catalogue. ) many years. Great force, however, is often necessary, and the forceps must be carefully padded to prevent injury to the soft parts. In these severe cases I have found the Fig. 110 of service, as in its use a fixed point is gained to bear on the displaced parts. mask shown in 524 XIII. DISEASES OF THE EAR. George P. Field. Specific Aiiictions of the auditory ap- paratus. — The perception of sound is commonly due to motion of the chain of ossicles connecting the tympanic membrane with the internal ear, the intra- labyrinthine fluid of which, being set in vibration, occasions disturbance of the processes of the organ of IrLCus StapGSv Mailleiis Malleus TlLCUS \ Stapes Fig. 111.— The Auditory Ossicles Fig. 112.- -The Auditory Ossicles viewed from within the Tyin- viewed from within the Ex- pauum (enlarged). ternal Meatus (enlarged). The dotted line indicates the position of the drum-head. Corti and of the cochlear and ampullar air cells, with concussion of the otoliths contained in the endolymph of the utricle and saccule. The differentiation of sonorous impulses is presumably rendered possible by their passage through the whole length of the peri- lymph to affect the endolymph. Sounds not con- veyed by the ossicles may travel to the membrane of the fenestra rotunda across the middle ear, or more directly, and seemingly to the cochlea and ampullae, through the bony labyrinth or the skull. Of the ossicles, the stapes is that most essential, serving, in common with the membrane of the fenestra Examination of the Ear. 525 ovalis, to (lam back the fluid of the internal ear. Of the labyrinth, biology indicates the vestibule to be fundamentally the most important part. Intensity of sound appears to be interpreted by the vestibular nerve, and difference in tone by the organ of Corti, Cyon's view, that the semicircular canals are the peri- pheral organs of the sense of space, seems probable. The Eustachian tube serves (1) to maintain equality of atmospheric pressure on the tympanic Fig. 113.— Brunton's Otoscope in use. membrane; (2)' to drain off excess of mucus; and (3) to prevent echo by affording passage for son- orous undulations from the middle ear. The inner end is generally considered to be opened only at the conclusion of deglutition. Examiuatioii and treatment of patients. — In children, the external auditory canal, it must be remembered, differs from that of adults in being less in its vertical than in its horizontal diameter. Of otoscopes, Brunton's is that most universally service- able (Fig. 113) ; but usually a concave mirror, with a forehead strap for use if required, and an ordinary silver ear speculum, sujfice. 526 Manual of Surgery, A liealthy drum-liead appears of a delicate blue- grey colour, and through it is seen the handle of the malleus running downwards and backwards, with the apex of the white spot at its extremity. To test a patients hearing power, bring the watch or other sound-producer gradually to the ears, and make a note of the distance at which it is first audible. Conversational tests must be applied so as to preclude lip-reading. It should be borne in mind that the relative audibility of different sounds may vary with the patient's condition. The tuning fork applied to the forehead distinguishes betwixt mere obstruction to the passage of sound reaching the meatus and defect in the auditory nerve {i.e. betwixt impairment of the sound-conducting and the sound- perceiving capacity of the ear), its vibrations in the former case being by reverberation considerably in- tensified, although the ear may be totally insensitive to aerial sound waves. Diminished audibility of bone- conducted sounds may be due to (1) senile changes in the auditory nerve, or (2) to acute otitis. Whispering, in which diminution in the vowel sounds renders the consonants the more easily dis- tinguishable, is usually better heard by the deaf than ordinary speech. Increase in the apparent perception of high musical tones is said to indicate greater though limited tension of the drum-head, or breach of its substance, admitting the easy passage of short sound waves to the labyrinth. The audiV)ility of high sounds is best arrived at with the aid of Konig's rods, or Galton's whistle. Paracentesis Willisii, or improvement in the hearing of some deaf persons during noise, is compatible with very different conditions of the drum, and may be due to an exaltation by the noise of the impaired functions of the auditory nerve, without the creation of corresponding auditory impulses. Another and perhajjs more probable explanation is, that the Diseases of External Meatus. 527 improvement in a noise is consequent on the extra shaking of ossicles which have become fixed from some catarrhal inflammation. Diseases of the external meatus of the car. — Impacted wax in the ear can usually be re- moved bj gentle syringing with water at 100° F. ; in some instances it should be previously softened by the installation of warm solution of bicarbonate of soda (gr. x ad Jj), which is especially useful in exam- ples of keratosis obturans (over-accumulation in the meatus of epithelial laminae). Abnormal dryness of the external meatus may be indicatory of disease of the internal ear. Fluidity and offensiveness of cerumen in children, if not cor- rected, are apt to lead to catarrhal inflammation or worse results. With patients complaining oi foreign bodies in the meatus, it is well to ascertain, by means of the specu- lum, that there is actually anything foreign to be removed. Avoid, where possible, instrumental inter- ference, to which complete inaction may be preferable. Careful syringing along the roof of the meatus, the auricle being drawn upwards and backwards, is generally all that is required, the patient, if necessary, being placed on his side or back. But this treatment should not be adopted if the foreign body has occa- sioned much swelling of the soft parts ; in this case the inflammation should be relieved by leeching freely in front of the tragus. The offending substance may sometimes be removed by affixing it with glue or coaguline to a piece of linen or a brush, or by the use of adhesive plaister on a string. If it is swollen by absorption of moisture, the use of glycerin may be effectual. In some cases an anaesthetic is necessary. Epileptiform convulsions or symptoms like those of Meniere's disease sometimes result from irritation caused by foreign bodies in the meatus. 528 Manual of Surgery, For hoih in the meatus, poultices (not admissible in other instances of aural inflammation), glycerine applications to relieve pain, and lancing and subse- quent treatment with boracic acid, should be resorted to. Defective house-drainage is said to be the cause of abscesses in the ear. Insects or their larvae in the auditory canal can be destroyed by warm oil or chloroform vapour, and then removed by syringe or forceps. Aspergillus, the fungus most usually met with in the ear, follows on eczema or other inflammation aflfecting the epidermis. Its growth is fostered by a damp, ill-ventilated atmosphere. With the symptoms characteristic of inspissated cerumen, it causes dull pain. It is best combated by frequent applications of solution of lead acetate, chlorinated lime, or of potas- sium permanganate, or by chlorine, bromine, and iodine water, or applications of alcoholic 2 to 4 per cent, solution of salicylic acid. Narrowing of tlie meatus from chronic inflamma- tion indicates recourse to constitutional remedies, and locally the application of strong solution of silver nitrate, or of ointment of ung. hydrarg. nit, and ung. zinci (1 to 8). The insertion of a series of lubricated short imperforate drainage tubes may at times be use- ful. Erysipelas, molluscous or sebaceous tumours, and various other causes of stenosis must, of necessity, receive specific treatment. Otorrhagia (bleeding from the external auditory meatus) usually results from polypus, or it may be due to injury to the base of the skull or to the internal carotids, the membrana tympani, or the walls of the meatus. It may occur also in purpura, yellow fever, and malignant small-pox, in acute aural catarrh, in Bright's disease, in the condition known as otitis haemorrhagica, and in suppression of the menses. " Ear cough" due to irritation of the external Diseases of Auricle. 529 auditory meatus or of the outer layer of the drum- head, is regarded as a reflex result of aflfection of a branch of the pneumogastric su])plyiiig the same. Diminution in the calibre of the external auditory canal from diffuse thickening of its bony walls may be treated by the insertion of small ivory bougies. The commonest bony outgrowths, or exostoses, in the meatus originate usually in inflammation of the middle ear, are of rapid growth, and mostly pedunculated. Being of the nature of spongy osteomata, they can be removed by tlie ecraseur. In minute structure they resemble newly-formed bone. The majority of the multiple out- growths, which are commonest in the wealthy classes, are more com- pact, and histologically comparable with syphilitic nodes on the cranial flat bones. True ivory exostoses, or hyi^erostoses, are still denser in structure, and of rarer occurrence ; are painless, and usually bilateral ; and are the effect neither of active inflammatory changes nor of con- genital tendency, but apparently of a chronic irritation of the meatus, such as is producible (as the author flrst pointed out) by constant sea-bathing. For their removal, drilling with Matthewson's dental engine has proved the most effective measure. During the opera- tion a steel guard is needed to protect neighbouring structures. Diseases of the auricle and associated parts* — Malformations may be due to defective or excessive developmental actiWty in the tissues bound- ing the first post-oral cleft, in the minute folds of which dermoid cysts in the external meatus probably Fig. 114, — Multiple Exostoses bounding a Triangular Open- ing. originate. I 1-21 530 Manual of Surgery. Among other affections of the auricle are warts, chalk stones in the upper part of the helix in gouty . persons, epithelioma, keloid growths, and cicatrices caused by ear-ring punctures, traumatic and idiopathic otha^inatomata^ or blood tumours, herpes, erysipelas (usually chronic), and syphilitic eruptions. Idiopathic othceniatomata usually occur in the insane, and are pathognomonic of disease of the base of the brain. In eczema of the auricle it is important to ascertain that topical applica- tions are not being rendered use- less by uncured otorrhoea. Con- tagious impetigo of the auricle requires, first, removal of scabs, and then destruction of pus by carbolic lotion and mercurial oint- ment. Chilblain is best treated by warmth and spirit liniment, and pruritus by soothing lotions and ointments containing opium, creasote, hydrocyanic acid, and mercurials. Ichthyosis of the auricle is alleviated by the con- tinued application of glycerine. For lupus erythema- tosus treat by early inunction with cod-liver oil, followed by scarification and general tonics, Syphilis, either secondary or tertiary, has been observed to affect the ear (probably both the middle ear and labyrinth), by bringing on (1) changes in the drum-head ; and (2) deafness, which is usually painless and unilateral, is rapid in onset, and is like that produced by obstruction in the meatus, so that by bone conduc- tion a tuning fork is better heard in the affected ear. Again, syphilis attacking the labyrinth or auditory nerve may cause deafness, commonly absolute, of one or both ears, the healthy ear alone being then sensitive to bone-conducted sound. Syphilitic tliroat disease Fig, 115. — Othaema- toma. A UR A L Ca TARR H. 531 V- is a not uncommon ori^rin of acute aural catarrh. Nervous deafness from hereditary syphilis generally comes on between the ages of 10 and 16, together with chronic interstitial keratitis, and is much more common in girls than boys. UndouVjtedly the best treat- ment is the administration of grey powder ; but the prognosis is un- favourable. Aural catarrh. — Acute aural catarrhal inflammation, usually uni- lateral and the result of catching a cold, is characterised by increased vascularity of the drum-head, and by continuous intense pain preceding the discharge, as also by pain on eructa- tion or forcible expiration, and in children notably by intolerance of rest of the head on the side aflected. Convulsions are an occasional compli- cation. Fomentation by instillation of warm water, mild purgation, the careful use of Politzer's bacj to favour escape of pent-up pus from the Eustachian tube, and also leeching in front of the tragus, are the usually efficacious modes of treatment. Simple acute non-suppurative catarrh rarely causes perforation of the drum-head.' It may originate in inflammation of that structure only (myringitis). Foul air and also over-doses of quinine have both been known to produce aural catarrh. In cases of chronic catarrh attention should be given especially to the promotion of the general health by the use of warm clothing, by the administration of cod-liver oil, and F"g. 116. — Polit- zer's Basr, with Nasal Pad. 532 Ma.yual of Surgery also by the application of astringents to the throat and of iodine over the mastoid process ; inflation of the tympanum with Politzer's bag, or with simply a piece of rub] er tubing in the case of children, may often prove of great value. Folitzerisation, commonly practised at the moment of swallowing, may be promoted also by the pronunciation of certain syllables (as " buck "), or by puffing out the cheeks. The diagnostic or auscultation tube, one end of which is placed in the patient's, the other in the surgeon's ear, enables the observer, by the sound, gurgling or whistling, at tlie moment of politzerisation to ascertain the existence of fluid in the tym2:)anum or of a perforation in the drum- head. Excision of the tonsils and prolonged treatment of the naso-pharynx may be necessary in cases of deafness from con- tinued closure of the Eustachian tube, one evil result of which is to cause in- ward bulging of the drum-head from exhaustion of the tympanic air. In aural catarrh unbenefited by politzerisation, the Eustachian catheter must, except with children, be employed. To those who are unaccustomed to the instrument, the following method of using it will be found serviceable. It should be passed along the floor of the nares to the posterior wall of the pharynx, with- drawn, and turned inwards to hook round the vomer, and then semirotated downwards till the point is directed outwards and slightly upwards, when it enters the mouth of the Eustachian tube. The intro- duction of air or fluids into the tube is best effected Fig. 117.— The Eustachian Catheter. Deafness. 533 through a piece of indiarubber piling connected with the injector or indiarubber bag, which is suspended from the operator's coat, and is compressed with the right hand while the left steadies the catheter. Variable hearing is a pretty sure sign of defective action of the Its intermittent and progressive sure Eustachian tube. Fig. 118. — The Eustachian Catheter in position. dilatation by bougies introduced through a catheter has been successfully practised by Meniere and others. In chronic non-suppurative inflammation of the middle ear, vapours of ammonium chloride are recom- mended in a catarrhal and simjjle or iodised aqueous vapour in a dry condition of the mucous membrane ; but injection of astringent and slightly stimulating fluids is often useful. Daily massage over the mastoid region is recom- mended by Eitelberg for acute and subacute middle- ear catarrh. Where the cause of deafness is due, not to 534 Manual of Surgery. deficiency of atmospheric pressure but to thickening of the mucous lining of the middle ear, or to adhe- sions within the tympanum, the local effect of solution of potassium iodide (gr. x ad ^j) is beneficial ; and, similarly, weak solution of iodine, copper sulphate, potash, silver nitrate, or of chloral hydrate may be very efficacious, as well as the internal administration of potassium iodide and mercury perchloride, these last particularly in strumous patients. The severance of adhesions is sometimes to be efiected by the use of a pneumatic tractor. Bing, of Vienna, states that words spoken into the Eustachian catheter are not heard if the stapes is fixed, fixation of the malleus and incus alone not preventing their audibility. Adenoid vegetations in the pharynx may be the source of deafness by closing the mouth of a healthy Eustachian tube, or by so blocking the nares that swal- lo\ving occasions rarefaction of the tympanic air. These growths may be removed very easily with instruments^ or even with the finger nail. Serous effusions in the tympanum are commonly absorbed after politzerisation. Where catheterisation does not avail for syiinging out the t}Tnpanum, punc- ture of the drum-head may be of value. This should be efiected in the lower portion, before or behind the handle of the malleus. The tympanum can then be evacuated by infiation, or by the use of a Siegle's speculum. Paracentesis is required also when, in acute suppurative aural inflammation (a possible sequela of scarlet fever, typhoid, typhus, diphtheria, and other diseases), pus pent up in the tympanum fails to burst through the membrana tympani, or to escape through the Eustachian tube, and so causes the drum-head to bulge outwards. Spontaneous per- foration is otherwise a probable event ; but in some cases the accumulated pus rapidly produces fatal meningitis or cerebral abscess. Otorrhcea. 535 Otoriii€Da, or discharge of the pus from the middle ear, is not necessarily ushered in by acute otitis, being e.g. a common symptom in struma. For treatment, the main indications are restoration of the general health, thorough cleansing of the ear, and frequent syringing with warm water, and afterwards the ap- plication of lotions containing zinc salts, carbolic acid, or rectified spirits. These various astringents should be changed occasionally. Counter-irritation behind the ears, and the insufflation of powdered alum, iodoform, or boracic or salicylic acid, and repeated ap- plications of boroglyceride, may be very useful. The origin of inflammation in an atmosphere contaminated with sewer gas must be guarded against. The intro- duction into the tympanum of a medicated fluid poured into the meatus may, when a very small perforation in the drum-head exists, be simply efiected by Val- salva's method of closing the mouth and nostrils, and blowing, the bubble of air then conveyed by the Eustachian tube being replaced, as it passes out through the drum-head, by a drop or so of the fluid. Neglected otorrhcea may become chronic, and may cause polypus, thickening of the drum-head, de- struction of the ossicles, and caries of the mastoid, or even facial paralysis, haemorrhage from the carotid artery, inflammation of the brain, epilepsy, or by the formation of thrombi in the lateral sinus or the jugu- lar, pysemic lobular pneumonia. Ali'ectioiis of the membrana tynipani. — Traumatic slits or cuts in the membrana as a rule heal readily, and the tendency in cases of direct injury generally is towards recovery. Perforations from disease, however, are apt to become permanent, if otorrhcea be not arrested, and the health of the middle ear restored. A perforation is not incompatible with fair audition, its position and the state of the ossicles having considerable influence. Deafness owing to a 536 Manual of Surgery. perforation or to separation of the ossicles is some- times greatly benetited by the pressure or support afforded by an artificial membrane or a plug of cotton wool, which may be suitably combined. Dr. 0. W. Tangeman has recorded a case of double perforation successfully treated by skin grafting. Mammilliform perforations may be effectually treated by instillation of rectified spirit, as shown by Professor Zaufal. Disease of tlie mastoid process is character- ised by deep-seated local pain and signs of inflamraa* tion. Early and thorough incision over it down to the bone, followed by free leeching, repeated washing with antiseptic and astringent lotions, and treatment of the general health should invariably be resorted to. Should these measures fail, in order to obviate the dangers of retention of pus, trephining about a quarter of an inch behind the meatus and a little below the level of its upper wall, or the removal of carious bone by knife or probe is necessary. Polypi of the ear, generally due to catarrh there- from, are composed of tissue which is either (1) soft and granular ; (2) mucous ; (3) fibrous ; (4) hyaline or gelatiniform or myxomatous, the last being the rarest. Their common seat is the tympanum. Granulation tissue in the ear, if not amenable to the treatment for aural catarrh, or to the instillation of rectified spirit, or touching with perchloride of iron, may require removal by scraping. For the larger polypi excision with a snare such as Wilde's, and subsequent cauterisation of the root with saturated solution of nitrate of silver with chloracetic or chromic acid, and removal of the cause, comprise appropriate treatment. Mucous polypi may be shrunk or, if small, obliterated by re2:)eated instillation of rectified spirit. Abscesses of the brain due to ear disease are usually single, and situate in the whit'^^ matter MENf'kRE\'^ D/SFASK. 537 of the hinder part of the middle lobe, the posterior lobe, or the cerebellum. Pain in the ear, if not the result of a recog- nisable affection of the meatus, points either to simple catarrh, or to more or less acute, and hence dangerous, otitis interna. Pain caused by an affection of the ear may not, however, be distinctly referable to that organ. Conversely, aural neuralgia may be caused by dental caries or by general malarial poisoning. Disease of the internal ear, i.e. of the labyrinth and its contained structures, rarely primary, is secondarily of either traumatic or constitutional origin. Traumatic causes are repeated concussive shocks, injuries to the brain, or local lacerations, and eflfusion of blood or serum ; and the constitutional include developmental defects, exposure to cold, rheumatic degeneration, middle ear affections, fevers, mumps, syphilis, meningitis, and sometimes tabes dorsalis. Lesion of the internal auditory apparatus is distinguished by deficient perception of both 3ranially and aerially conducted vibrations ; the patient suffers from true nervous deafness. Nervous deafness dependent on hypersemia of the labyrinth is at once relieved by leeching and blistering behind the ears. Meniere's disease is by some authors under- stood to be simply haemorrhage into the semicircular canals ; by others it has been more comprehensively defined as an abnormal nervous irritation in the semi- circular canals, or inflammation in these or the middle ear, causing vertigo. Its vital or medullary symptoms {e.g. faintness, perspiration, iiTegularity of pulse) have been held due to affection of the cochlear nerve, and its locomotor or cerebellar symptoms (vertigo with or without reeling) to affection of the semicircular canals. In cases regarded as typical the giddiness is usually preceded by a feeling of vertical rotation, and is accompanied by tliat of foiward and backward 538 Manual of Surgery. movement about a transverse axis. Subjective auditory sensations are common. The attacks tend to merge into an habitual vertiginous state. Counter- irritation behind the ears, large doses of potassium bromide, and also quinine and ammonium chloride, are useful in many instances. As vertigo may be pro- duced in a variety of ear lesions, the discovery and treatment of the cause must be aimed at. Electricity in aui'al disease.— The induced electrical current has been successfully employed in several cases of intratympanic disease ; and stimula- tion of the ear muscles by the continuous current is sometimes beneficial. Tinnitus aurium, or persistent subjective sound in the ears, when not ascribable to sympathetic or to cerebral stimulation of the auditory nerve, would appear to be usually the result of abnormal pressure upon the labyrinthine nerve fibres, which again is generally due to some afiection of the drum-head. It may be dependent on spasm of the tensor tympani and stapedius, or on the existence of free fluid in the tympanum, and may occur also as a symptom in various disturbances of the circulation, in debility, alcoholism, exophthalmos, and other conditions. For its alleviation have been employed medicinally pilocarpine injections, zinc valerianate, digitalis, arnica, ammonium chloride, quinine and morphia combined, and hydrobromic acid, and locally chloroform vapour and warm glycerine and laudanum for the meatus, strychnine solution injected through the Eustachian catheter, the air douche, faradisation, and section of the posterior fold of the membrane. Autophony, or the hearing of one's own voice in the head, a symptom in sundry aural afiections, appears to result from defective mechanical action of the membrana or the ossicles. Deaf mutism, or deaf-dumbness, afifects on Deaf Mutism, 539 an average one person in some 1550, and males more than females. It is congenital or acquired, according as produced by causes arising before birth (consanguinity, heredity, syphilis, inebriety, e.g.^ or after birth (as fevers, scrofula, catarrhal inflammation, and falls and blows). It is rare that the immediate parents of deaf mutes are deaf and dumb. For the acquisition of speech by deaf mutes the German or pure oral method is that best adapted, the pupil learning both by personal practice and by ocular demonstration (lip-reading) the mechanism of speech. Instmineiital aids in deafness. — Of the various instruments for the improvement of hearing by reflection of sound a hollow cone is the simplest and most eflScient. Small globose or conical resonatora may be of great benefit. Hearing through the teeth may be rendered possible by the use of the audiphone or one of its numerous modifications. 540 XIV. DISEASES OF THE EYE. E. Marcus Gunn. Diseases of the Eyelids. Anatomically the eyelid is a complex structure, and its diseased conditions are corresjDondingly varied in character ; its skin and cutaneous glands, conjunctival mucous membrane, muscles, Meibomian glands, tarsal "cartilage," and eyelashes, with their follicles and sebaceous glands, are all liable to be affected. Again, the position of the lid is such that any departure from the healthy condition readily causes discomfort. Paralysis of the muscles and affections of the con- junctiva of the lid will be more appropriately con- sidered later. Blepharitis. — The edges of the lids are specially prone to disease, and principally to a chronic form of inflammation known as marginal blepharitis. In the more severe forms of this affection the palpebral border is dusky-red, swollen, and covered with hard, dark yellow crusts. On removing these latter a moist surface is exposed, often with ulceration or small yellow pustules round the insertion of eyelashes ; sometimes there is eczema of the neighbouring skin. If neglected, the ulcers may damage or even destroy the cilia follicles, leading to badly developed, misplaced lashes {trichiasis), or to more or less complete absence of them. Sometimes we get ectropion from hyper- trophy of the conjunctiva, and epiphora from eversion of, or other interference with, the puncture. In the milder forms there is hypersecretion from the seba- ceous glands, leading to the formation of small, yellowish-white crusts, on removing which we find Stye. 541 the underlying surface somewhat reddened but not ulcerated. Sometimes we have mere redness of the edges of the lids, especially in persons with delicate skin and light complexion, often asse)ciated with some error of refraction and consequent straining of the eyes. This condition is also liable to be caused by external irritation, as exposure to dust or cold. The more severe cases usually occur in strumous children, and frequently date from an attack of measles. Treatment. — In all cases we must attend to the general condition of the patient, syrup of the iodide of iron or other chalybeate being frequently indicated. External irritants and over-use of the eyes are to be avoided, and glasses ordered if necessary. Locally, our treatment must be directed principally to re- moving the crusts and preventing their re-formation. Warm alkaline lotions {e.g. 10 gr of biborate of soda to the ounce of water) are to be used several times daily, the softened crusts then picked ofF, and dilute nitrate of mercury ointment (1 part to 7 of vaseline) applied to the roots of the lashes. In very severe cases all the affected lashes should be pulled out and the excoriated surface of the lid touched with a strong solution of nitrate of silver (20 gr. to the ounce). When the lashes have been destroyed and the lids everted (lippitudo) we cannot hope to restore a healthy condition, but cleanliness, astringent lotions, and slitting the everted canaliculi will cause much im- provement. The crab-louse occasionally takes up its abode on the edge of the lids, and its eggs are then found dis- posed along the sides of the lashes like little dark beads. At a superficial glance the condition might be mistaken for blepharitis, or dirt on the lashes. The use of a mild mercurial ointment, such as that men- tioned above, will soon kill the pediculi. ITordeoliim, or stye, is a circumscribed hard 542 Manual of Surgery. swelling at the outer edge of the margin of the lid, due to a suppurative inflammation of one of the seba- ceous glands at the roots of the lashes. There is con- siderable pain at first, and marked swelling from infiltration of the adjacent loose tissue of the lid. The most severe cases are of the nature of boils ; in these the pain is very acute, and there is often considerable chemosis of the conjunctiva. Treatment. — In an early stage, touching the part with nitrate of silver, pulling out the corresponding eyelash, and using lead lotion, often cut short the inflammation. Later on, warm applications are useful in soothing the pain and in hastening the suppurative process. When pus has formed it should be evacuated. General treatment is often indicated by the condition of the patient, mild purgatives, iron, and nitro-hydro- chloric acid being frequently serviceable. Some young adults are particularly subject to styes occurring in successive crops, and the local treatment of most service in such cases is the use of an eye douche, with lead lotion. Styes are sometimes associated with an error of refraction, which should be corrected by the necessary glasses. At other times they are dependent on some defect in the general health, or on local irritation, as from blepharitis. Distichiasis and tricUiasis are terms used to signify difierent forms of displacement of the eyelashes produced by disease. In the former condition they are disposed in a more or less complete double row, while in the latter they are obliquely placed and often stunted ; in both afiections some of the displaced lashes rub against the cornea and thus set up irritation, sometimes leading to pannus and even ulceration. The usual causes of trichiasis are blepharitis and trachoma. Treatment. — Temporary relief can always be afforded by epilation of the misplaced lashes. The Entropion. 543 more radical operations consist either in destroying the cilia at fault or in giving them a new position. If there be only one or two lashes actually rubbing on the cornea, we may destroy their follicles by electro- ' lysis. In more severe cases we may remove all the offending lashes and their bulbs by judicious excision of part of the lid margin. The number of methods that have been devised with the object of transplanting the misplaced lashes outwards, suggests the unsatisfac- tory nature of the results usually obtained. For an account of these operations the reader must be referred to special text-books on ophthalmic surgeiy. Ankylo-blepharon, or union of the edges of the upper and lower lids, may be congenital, but generally arises from injuries (wounds or bums) or from ulcera- tion. It is rarely complete. Division of the adhesions with scissors, and attention for a few days so as to prevent reunion, will generally effect a cure. Entropion, or inversion of the lid margin, may affect either the upper or lower eyelid, but its nature usually differs in the two cases. It always causes much discomfort from the rubbing of the lashes against the cornea. Entropion of the lower lid generally occurs in old people, and is then due to a spastic contraction of the palpebral fibres of the orbicularis muscle in association with loose senile tissues. It may be relieved by excision of a strip of skin and orbicularis along the whole length of the lid, a little below its margin ; sutures may or may not be employed. We also occasionally get a spasmodic entropion of the lower lid from the prolonged use of bandages, as after cataract extraction. Generally, repeatedly brushing a little collodion outside the lid, a little below the lashes, is sufficient to relieve it, and in any case it soon disappears on discontinuing the use of the bandage. Entropion of the upper lid is usually organic, due to a cicatricial contraction of the 54-1 Manual of Surgery. conjunctiva and inversion of the tarsus from burns or old trachoma. Relief can be obtained by radical removal of all the lashes, or by cutting or grooving the " cartilage " as in Burow's and Streatfeild's operations. Ectropion, or eversion of the lid margin, may be caused by chronic marginal blepharitis, or by relaxed tissues in old age, or, again, by cicatricial contraction (as from burns or wounds, or from abscesses in caries near the orbital margin) ; or it may be due to a rapid hypertrophy of conjunctiva, as sometimes occurs in purulent ophthalmia. The lower lid is most frequently affected. This condition often produces much de- formity, the conjunctiva is usually inflamed, and the eversion of the puncta causes the tears to flow over the cheek. Treatment. — In the non- cicatricial cases we can {a) remove a horizontal strip of the everted conjunctiva and trust to the subsequent contraction drawing the lid into position ; or (6) we may shorten the lid by remo'dng a V-shaped piece of its entire thickness and bringing the edges together with sutures or a hare-lip pin. Cicatricial ectropion may affect either lid, and is often only partial. The remedial operation necessary must therefore be determined by the particular case, but the method most frequently useful in ectropion of the lower lid is that known as the V-Y operation. Blepharospasm is a spasmodic contraction of the orbicularis muscle, usually a reflex result of irritation of the fifth nerve. It may occur from a foreign body in the eye, a phlyctenule, etc., or from caries of the teeth. In other cases there is pain or pressure over the supra-orbital or other branch of the fifth, while occasionally it is met with in weak hysterical subjects without any evident local cause. The treatment must be determined b^ the cause. Ptosj6. 545 In cases dependent on ocular conditions any foreign body present must be removed, and in phlyctenules great relief is afforded by the use of cocaine and atropine. Counter-irritation by blister or seton, and the cold face-douche are also often of great service. In severe cases that do not yield to other treatment eanthoplasty is useful, the external canthus being divided with scissors, and the adjacent conjunctiva united by suture with the apex of the incision. Ptosis, or drooping of the upper eyelid, may be mechanical, congenital, or paralytic. The latter form will be considered later. Ptosis may be said to be mechanical when it occurs in association -wdth a shrunken globe or empty socket ; or, again, in trachoma, where it is due to relaxation of the upper conjunctival fold and increased difficulty of elevation of the lid from its gi-eater weight. The congenital form is often unilateral and varies in degree. It is said to be due to imperfect development of the levator muscle. In these latter cases the appearance may be improved by the removal of an oval piece of skin from the upper lid, so as to cause the shortening desired ; but care must be taken not to leave the cornea permanently exposed by removing too much. Certain other congenital anomalies are to be met with in the eyelids, and may be mentioned here. Coloboma appears as a wedge-shaped fissure, and is usually in the upper lid. The treatment consists in paring the edges and uniting them with sutures. In very rare cases the lids are completely absent. £picaiithus consists in a fold of skin passing from the side of the nose to the inner end of the eyebrow «ind concealing the inner canthus. It commonly dis- ftppeai-s as the bridge of the nose is developed ; but should it not do so the defoiTnity may be removed by excising a vertical elliptical fold of skin from the upper part of the nose. J J— 21 54^ Manual of Surgery ChalaxJon, or Meiboiisian cyst, generally appears as a hard, round, painless tumour in the substance of the lid, about the size of a split pea, and its position is recognised on everting the lid by a greyish semitranslucent patch in an area of increased conjunctival vascularity. It is due partly to an hypertro})hy of the Meibomian gland, partly to retention of its secretion and a chronic inflammation of the surrounding tissues. Occasionally it inflames acutely, and may then point cutaneously. Where })0ssible it is always best to open it by a crucial con- junctival incision and remove all the contents with a scoop. They often occur in crops, and, like styes, are especially frequent in young adults. The other tumours which are not infrequently found on the eyelid are milium, molluscum contagiosum, xanthelasma, and naevus. Their character and appropriate treatment are the same as when they occur in other situations, and do not demand further description here. In this region we may also get congenital dermoid tumours, warts, fatty tumours, and more rarely sarcoma and epithelioma. The eye- lid is a favourite situation for rodent ulcer, while not infrequently we also find here primary and tertiaiy syphilitic sores and lupus. Diseases of the Lacrymal Apparatus. The lacrymal gland is rarely acutely inflamed. We then find localised symptoms of inflammation, the pain often very severe, and pus generally soon forms. It should be evacuated by early incision, as fistula may be the result when the pus is allowed to find its own way out. Chronic inflammation of tlic lacrymal g^land is more commonly met with, and is recognised by a circumscribed hard swelling in the upper outer pai't of the orbit, the enlargement being visible in HPIPHORA. 547 this part of the conjunctival fornix on everting the upper lid. We sbould try to produce absorption by local application of iodine or mercurial ointments. If pus forms it is to be evacuated as in acute cases. Very rarely we get a blueish translucent swelling in the same position, viz. up and out, a retention cyst in connection with the gland ducts (dacryops). A small seton placed and tied loosely in the anterior wall of the cyst, and allowed to ulcerate through, is a good method of treating this affection. The tiiinoiu's most liable to occur in the gland itself are cysts and sarcomata. "When necessary the gland can be extirpated through an incision at the outer orbital margin above. Epiphora. — In by far the greater number of cases of lacrymal disorder the drainage of the teai-s is defec- tive, in consequence of which they run over the cheek, and we get the condition known as epiphora, stilli- cidium lacrimarum^ or " watery eye." In such cases it is well always systematically to examine each part of the ch-ainage system in the natural order of the passages from above downwards. Eii'st, then_, one of the pw?icfa may be at fault, (a) from disj^tlacement, as in ectropion ; or (h) it may be obstructed by the presence of a foreign bo^Iy, e.g. an eyelash; or, again, (c) the puncta may be narrowed, sometimes even quite occluded, as a congenital mal- formation or as the result of old inflammation. Kext, the canaliculus may be obstructed by a chalky concretion or by a fungoid growth (leptothrix) ; or, again, its calibre may be narrowed, either from swelling of its mucous membrane, as in chronic blepharitis, or from cicatricial contraction, the lesult of a former inflammation. The most common posi- tion of stricture is just at its entrance into the sac. The sac is subject to a chronic form of blen- orrhcea and to acute inflammation. The former 548 Manual of Surgery. condition is generally either the result of extension of inflammation from the conjunctiva or from the Schneideiian membrane, or it begins as a simjjle dis- tension of the sac^ due to stricture of the nasal duct below. The increased secretion of mucus from its thickened walls sc-on bulges the sac, and we find a swelling at the inner canthus which can generally be dispei-sed by pressure {mucocele). The contents can thus usually be forced backwards through the canaliculi, and are either clear, or turbid from admixture of pus. Acute dacryocystitis, or lacrymal abscess, is generally the result of suppuration of a mucocele. There is brawny swelling and redness of all the adjacent part of the face, often extending to the bridge of the nose and half across the cheek ; but its most prominent part corresponds to the position of the sac, where the shining red skin seems ready to burst. There is much pain, and considerable general disturbance. If left to itself the pus finds its way through the skin over the sac, but often burrows for a considerable distance before doing so, thus leaving a large ragged sore ; the cicatrix left is always a source of deformity, and often we get a troublesome fistula in addition. Sti'icture of the nasal duct may affect any part of it, but most commonly occurs just below the sac. It may be caused by a uniform cii'cumscribed, or by a valvular swelling of the mucous membrane, by fibrous contraction of the submucous tissue, or by bony outgrowths. The etiology of the affection is obscure, but some cases can be traced to a syphilitic or stmmous periostitis, or necrosis, and others to an pxtension of inflammation from the nasal mucoua membrane. Treatment* — Foreign bodies in the puncta or canaliculi must be removed, the latter being slit up if necessary. A narrowed i^unctiiia may be dilated by Conjunctivitis. 549 a fine conical sound, or enlarged by incision. In epiphora from ectropion the canaliculus should be slit along its entire length, and the same treatment must be followed in stricture of the canaliculus. In all cases of mucocele and stricture of the nasal duct the upper or lower canaliculus is to be divided with a Weber's knife, and a probe passed. The probing should be repeated in a few days, and the interval gradually increased to a week or month as the case improves. The probe used should be fairly large if it will pass without force, a convenient size being No. 5 or 6, of the bulbous-ended kind known as Couper's. Washing out the sac and duct with boracic acid lotion is also useful, and a weak astringent should be ordered for the conjunctiva. In cases of laciymal abscess, when still possible, the canaliculus should be slit and the knife passed down the duct so as to divide the anterior wall of the sac. Warm lead lotion is a ijood application afterwards. If the case be far advanced and pus already pointing, an incision should be made into the sac ^\T.th a Beer's knife, and warm ap- plications used ; when the swelling has somewhat sub- sided the canaliculus is to be slit and the duct probed. Diseases op the Conjtjxctiva. The conjunctiva is subject to inflammation of different forms and of varied degrees of severity, to all of which the term '^ o^jhthalmia " is often applied. While usually the whole membrane participates, cer- tain kinds of conjunctivitis are localised, at least at first. Simple catarrhal conjunctivitis* — Symp- toms. The whole conjunctiva is much congested, often showing patches of ecchymosis ; there is considerable mucc-purulent discharge. The lids are somewhat swollen, soft, and discoloured, and on first waking from sleep theu* edges are glued together. Occasion- ally in children an easily detached, sharply limited 55© Manual of Surgery. membrane is formed on the palpebral conjunctiva, to be carefully distinguislied from that found in the diphtheritic form. The disease runs its course in from eight to fourteen days, and nearly always attacks both eyes. Corneal affections are rare. The patient complains of a burning, gritty sensation, aggravated at night and on exposure to light. Causes. — It is exceedingly contagious, and is very a])t to spread when once introduced into a household or school. It is liable to occur at all seasons of the year, but is especially common in early summer and late autumn. Its etiology is obscure; sometimes it seems traceable to a sudden change of temperature, as on cominof into an overheated room from the cold outer air. The treatment consists in using a cold astringent lotion (3 gTains of alum or 1 gi'ain of sulphate of zinc to 1 oz. of water) several times daily, and in applying vaseline to the edges of the lids at bed time, so as to prevent gumming. Purulent op!ttl«a!niia (conjunctival blenor- rhoea). — At first the subjective symjjtoms are like those in the catarrhal form (sensations of burning and grittiness), but soon there is generally severe pain in and over the eye, becoming less as the discharge be- comes more profuse. The lids are swollen, red, and tense, the upper being also much elongated, so that in severe cases it cannot be fully everted nor the eye fully exposed. The entire conjunctiva, both pal- pebral and ocular, is much swollen and injected, the latter being frequently chemosed so as to project over the corneal margin. The secretion is at first watery, soon becomes opaque and whey-like, and is finally thick, yellow, and purulent. Course and complications. — The discharge lessens spontaneously in the course of a few weeks, and there is not much tendency to connective tissue develop- ment. The palpebral conjunctiva often remains for GONORRHCEAL OPHTHALMIA. 55 I some time greatly thickened, and its surface covered with closely ])laced prominent granulations. Except in the most severe cases, the swelling and conjunctival injection disappear, and the secretion ceases in about three weeks under treatment, and the lids gradually recover their original smooth mucous lining. Where the chemosis is extreme we are apt to get corneal complications from strangulation of the marginal corneal vessels. Sometimes there is a slight diffuse liaze of tlie entire cornea, but this is not so danger- ous as a localised purulent infiltration. The latter ulcerates and often leads to perforation, and sometimes to subsequent panophthalmitis. Indeed, from the nature of the discharge, any loss of corneal epithelium is highly dangerous, and we must be exceedingly care- ful to avoid causing an abrasion in our efforts to evert the lids, and in our use of the brush or mitigated stick. Pathologically, we find in the acute stage great hypersemia of the conjunctiva, witli increase of its epithelium and hypertrophy of papilke. Lymphoid cells occur diffusely both in and beneath the epithelium. Causes. — Purulent ophthalmia results in some persons (as in subjects of chronic tracljoma) from the contagion of an ordinary catarrhal conjunctivitis, but the two best marked forms of the affection are gonor- rhoeal ophthalmia and ophthalmia neonatorum. (ct) Ooiiorrhceal oplitlialiiBhi, is due to inocula- tion with discharge from another similar case, or from a urethral gonorrhoea. The i)atients are generally young male adults. One eye only is affected at first, but the other runs great risk of infection. The symptoms are usually severe, and the condition is always a grave one, requiring every attention. Treatment. — If one eye has escaped infection until the patient comes under observation our first aim is to protect this sound eye elliciently. This can be done by putting a pad of dry boracic acid wool over 552 Manual of Surgery. the closed lids, and covering its entire surface and sealing its edges with collodion. This must be re- moved at least once a day for purposes of examination and cleansing, and a fresh pad is to be carefully re- applied. A more convenient method of protection is by the use of Buller's shield, consisting of a watch- glass inserted between two squares of indiarubber plaister, each of which has a large round hole in its centre so that the watch-glass remains uncovered except just round its edge. The double square thus prepared should be of such a size that when applied the watch- glass is opposite the eye, the upper edge of the square just above the eyebrow, the inner along the nasal bridge, the lower at least one inch below the edge of the lower lid, and the outer beyond the external orbital margin. All these edges, except the lower part of the outer, are then fixed securely in position with strips of strong adhesive plaister ; through the watch-glass the eye can be kept under observation, and the patient can see to feed himself, etc.* The patient should be put to bed, an iced astringent lotion (four grains of alum or one grain of sulphate of zinc to the ounce of water) kept constantly applied over the lids of the inflamed eye, and a solution of chloride of zinc (two grains to the ounce) dropped into the eye three to six times a day, the frequency varying accord- ing to the amount and thickness of the discharge. The eye is also to be washed frequently with a cold astringent lotion, and as soon as the discharge becomes thick the everted lids should be painted once daily with a solution of nitrate of silver (twenty grains to the ounce). If the lids are very tense and painful, two or three leeches to the temple are beneficial. Sometimes it is impossible to evert the upper lid thoroughly : we must then cut through the external * It is well to have these prepared beforehand and ready for use when required. Ophthalmia Neonatorum. 553 canthus with scissoi's, the direction of the wound being a continuation of the curve of the outer end of the lower lid. If the secretion collects much under the lids, the conjunctival sac should be syringed out with cold water two or three times daily ; vaseline applied to the edges of the lids prevents gumming during sleep. On the appearance of localised corneal haze, with or without ulceration, the iced astringent compress must be discontinued, cold or even hot poppy lotion being used in its stead, and solution of sulphate of eserine (two grains to the ounce) dropped into the eye six times daily. The brushing of the lids should be continued, but we must be very careful in everting them, lest we cause rupture of the affected corneal tissue. The chloride of zinc drops may be discon- tinued, or a weaker solution employed, but they do not cause much irritation even in cases of deep ulceration. Slitting the conjunctiva radially with scissors when greatly chemosed is to be recommended, as it relieves the tendency to strangulation. The patient should get good diet, with tonics when considered necessary, and any urethral discharge must be treated locally. A mercurial purge should be given if the bowels are constipated at first. When the conjunctival discharge has nearly ceased the lids may only be brushed once every second or third day, and this treatment gradually discontinued. (6) Oplitlialmia neonatorum. — This is pro- bably always caused by inoculation with leucorrhoeal or gonorrhoeal discharge during the passage of the head through the vagina. It is usually first observed about three days after birth, and v^aries much in severity in different cases according to the character of the infecting secretion, but is seldom so severe as the gonorrhoeal ophthalmia of adults. Treatmenit. — Both eyes are generally affected, but if one has hitherto escaped and the other be severely 554 Manual of Surgery. inflamed, a protective of cotton wool may be ap- plied as directed above. The afiected eye is to be bathed frequently with cold astringents (alum or sulphate of zinc), the conjunctival sac thoroughly syringed out several times daily, and vaseline applied to the edges of the lids. If there is much discharge, chloride of zinc drops should be used four times a day, and in all cases, except the very mildest, the lids are to be brushed daily by tlie surgeon with solution of nitrate of silver. Periplieral ulcers of the cornea should be treated with eserine, as has been recom- mended in gonorrhoeal ophthalmia, but in central ulceration atropine is preferable. Much attention has been recently drawn to the necessity of prophy- lactic measures for the prevention of this disease. It is recommended that the vagina be carefully disin- fected before the birth, and that the face and eyes of the newly-born child be thoroughly cleansed with some simple antiseptic solution. Oraiiiilar oplitlialsiaia or traclioiiia. — - Symptoms. The form of this disease most commonly met with in this country is a chronic one, charac- terised by thickening and vascularity of the conjunc- tiva, and by the presence of round, semitranslucent, pale prominences on the inner surface of the lids. From their resemblance to small grains of boiled sago these prominences are often called "the sago grain granulations." At first they occur principally on the lower retro-tarsal fold of conjunctiva, s})reading gradually to the same position above, and finally affecting the entire lid surface. The ocular conjunc- tiva often participates in the vascularity, and small granulations may even occur in it. We often get vascularity and cloudiness of the upper part of the cornea (pannus), the vessels here lying immediately beneath the ejiithelium ; this condition sometimes extends over the entire cornea. Ulcers are also apt Trachoma. 555 to form on the cornea, especially -when there are in- verted lashes. There is no tendency to spontaneous cure, and a long continuance of the chronic changes generally leads to entropion, trichiasis, and often corneal mischief as just mentioned. Apart from direct infection by the secretion from another such case, the chief causes seem to be prolonged exposure to a damp atmosphere and bad ventilation, children being most apt to suffer. Certain races, e.g. the Irish and Jews, seem s})ecially liable to it. Pathology. — The granulations consist principally of lymph cells superficially, with more and more con- nective tissue towards the base. As the cells are gradually transformed into connective tissue, so we get finally a cicatrix at the seat of the granulation. The submucous tissue and tarsus are likewise at first infiltrated with lymph cells, so that here, too, we ultimately get connective tissue contractions, the " car- tilage " also undergoing fatty degeneration. Pannus is said to be mainly due to the irritation produced by the granulations of the upper lid constantly rubbing against the corneal surface on every lid movement, but possibly a more correct explanation would be that the general conjunctival infiltration with lymph cells extends hither, and, on becoming organised, forms new vascular tissue. In the acute form of the disease the local appear- ances are those of a severe conjunctivitis, with de- velopment of the characteristic gi-anulations, but often without much purulent dLscliarge. Such an attack may lead to the chronic form of trachoma, but some- times it is self-curative from the very violence of the inflammation destroying the granulations. Cases of chronic trachoma are liable to severe acute ophthalmia from comparatively slight exciting causes, antl the discharge from all such cases is highly infective, often communicating the same foiTu of disease. 556 Manual of Surgery. Treatment. — In acute trachoma we should first use mild lotions {e.g. boracic acid 10 gr. to the ounce of water), but, if there be much purulent discharge later, we must brush the lids with solution of nitrate of silver. Chronic granulations are best treated by touching the everted lids mth the mitigated nitrate of silver stick (1 of nitrate of silver and 2 of nitrate of potash), and then washing them with water. This should be repeated t^^4ce a week, or oftener, according to the severity of the case, and a mild astringent lotion used frequently by the patient. Single granu- lations may be destroyed by the actual cautery. The corneal ulcers, entropion, or trichiasis, demand the treatment proper for these affections ; if there be photophoVjia, dark glasses are useful. The ordinary partial (upper) pannus usually disappears as the condi- tion of tlie lids improves. Severe total pannus is much relieved by the excision of a strip of conjunctiva and subconjunctival tissue of about two lines in breadth from immediately round the cornea (peri- otomy). Benefit is also sometimes obtained in suitable cases by inoculation with pus from a mild case of ophthalmia neonatorum. Recently an infusion of jequirity seeds has been used, the purulent ophthalmia so produced often giving good results.* Diphtheritic ophthalmia is a very serious disease, happily rare in this country. Symptoms. — At first the conjunctiva in its entire thickness is in- filtrated with a firm fibrinous exudation, rendering the lid hard and stiff, and patches of the mucous sur- face are smooth, firm, and of a light grey colour. The existence of the exudation leads to pressure on the vessels, and the conjunctiva is found pale and almost * About 45 grains of the decorticised seeds are macerated for twenty-four hours in half-a-pint of cold water, and a little of the fresh infusion applied to the conjunctiva twice daily for two or three days. Diphtheritic Ophthalmia. 557 bloodless on tearing away a piece of the superficial layer. The nutrition of the cornea is necessarily greatly interfered with, and sloughing often occurs. When this stage has lasted about a week, the infiltra- tion breaks down, and we get a free purulent discharge with red prominent granulations. Finally, we may get symblepharon from loss of large patches of con- junctiva and resulting cicatricial changes. Causes. — It often occurs in epidemic form, chiefly in spring and autumn^ and usually attacks young chil- dren from two to six years old. It may be communi- cated by direct transplantation of membrane, but in predisposed individuals a purulent ophthalmia may take on this type. It is more frequently a precursor of, than secondary to, general diphtheria. Treatment. — Protect the sound eye by a pad of wool as previously described. In the first stage we must avoid using strong astringents, especially nitrate of silver, and trust to mild lotions {e.g. boracic acid or quinine) and atropine drops. Both ice and hot fomentations have been recommended by different surgeons. Scarifying the conjunctiva and applying a weak yellow oxide of mercury ointment have also proved useful. The patient's strength must be sup- ported by nutritious food. Besides the above-mentioned more severe and definite forms of conjunctivitis we frequently get slight cases due to the patient's occupation or sur- roundings. Thus dust of all kinds, smoke, or irritat- ing vapours are apt to cause a chronic form of con- junctivitis, and not infrequently it is associated with some error of refraction. In the former ci\ses sul- phate of zinc lotion (one-half to two grains to the ounce of water) should be used and the cause removed as much as possible, glasses being ordered where required. Sometimes on everting the lids we find small, gritty, calcareous particles projecting from the 558 Manual of Surgery, saccules of some of the Meibomian glands : these should be picked out with the point of a broad needle. Old people often have a troublesome conjunctivitis in the lower lids, commonly associated with slight ectro- pion ; much relief is obtained from lightly touching the inflamed surface once daily with sulphate of copper. Instillation of atropine sometimes produces severe irritation of both surfaces of the lids, and in such cases if a mydriatic must be used, daturine or duboisine is generally much less irritant. Eserine also frequently produces a chronic conjunctivitis when used for some time. This unpleasant effect may often be avoided, in the case of all these applications, by dis- solving the salt in a strong solution of boracic acid and adding about one per cent, of hydrochlorate of cocaine. Subcoiijunctival eccSijTiioses may occur dur- ing straining, as in whooping cough, or spontaneously without apparent cause. They undergo gradual ab- sorption, and are of no local importance. Xerophtlialmois is a term applied to a condition of the conjunctiva "where its surface is dry and lustre- less. Sometimes it exists with almost complete obli- teration of both upper and lower culs-de-sac, and may then be due to old diphtheritic ophthalmia or lime- burns, or possibly to a succession of attacks of pemphi- gus. Sometimes the patch is only epithelial, and confined to an area near the outer and inner corneal margins. This form occasionally occurs in schools or other public institutions, and is associated with night-blindness and scurvy. Treatment. — The epithelial cases are to be treated through tlie general health ; good diet with vegetables, fresh air, etc., being most important. The parenchy- matous forms can only be treated with palliatives, a lotion containing milk, glycerine, and bicarbonate of soda relieving the symptoms somewhat. Pterygium. 559 Syiiiblcpliaron, or adhesion of the palpebral and ocular conjunctiva, is usually the result of burns with lime or hot metal. When its extent is such as to obscure vision or limit ocular movement, an operation may be tried for its relief. When partial and narrow, it will be sufficient to strangulate it by a tight liga- ture. Those of larger size are to be carefully dis- sected off the eye-ball, and the resulting gap filled in as well as possible by flaps of neighbouring conjunc- tiva, or by a piece of transplanted mucous membrane from the lip. Pteryjfiiiin is a triangular, vascular patch of thickened conjunctiva, its apex usually encroaching on the cornea from the inner or outer side. The gi'owth is generally commenced by an adhesion of con- junctiva to a marginal corneal ulcer. If thought necessary, its apex may be detached from the cornea with a scalpel, the tumour dissected up to near its base, and then transplanted into a gap prepared for it below the cornea. Lupus sometimes occurs on the palpebral con- junctiva_, and is then usually associated with lupus of the skin or mouth. The aftected patch of conjunctly -a is very vascular, and is covered with small, soft, dark- red nodular outgi-owths. Scraping with a sharp spoon is the best treatment. A Pinguecula is a small yellowish thickening of conjunctiva near the outer or inner edge of the cornea, common in old people ; it contains no fat as the name would imply. It is of no importance, but may be snipped off if desired. The other tumours of the conjunctiva (dermoid, cystic, malignant, fatty) are comparatively rare, and the reader must be referred to some of the larger text- books on eye diseases for their description. 560 Manual of Surgery. Phlyctexular Affections of the Eye. These affections are much most frequently met with in young people between the ages of three and twelve years, and usually in association with the strumous constitution. The attacks tend to recur during early life, such repetition being easily induced by any slight irritation of the eye. Varieties and symptoms. — Either the ocular conjunctiva or cornea may be the seat of the phlyc- tenule. When situated on the conjunctiva quite away from the cornea, it appears at first as a papule or pustule about two mm. in diameter, surrounded by a localised patch of injection ; this soon breaks down, and we have a flat whitish ulcer. There may be one or several such pustules, but they seldom cause much photophobia, pain, or lacrymation, and are gene- rally soon amenable to treatment. Sometimes, how- ever, especially when near the corneal margin, the ulcer formed may run on to the cornea, and travel towards, or even across, its centre. In such cases the ulcer advances slowly in the form of a small infil- trated crescent with its convexity forwards, and with a vascular leash run- ning to its concavity over its recent track from the original starting point (Fig. 119). There is gene- rally much blepharospasm during the attack. Very rarely a marginal pustule, instead of .spreading super- ficially, leads to a perforating ulcer at the corneal edge. Phlyctenules at, or just within, the margin are usually small in size and multiple. Sometimes the entire corneal border all round is slightly swollen and Fig. 119- -Vascular phlyctenular Ulcer of Cornea. (After Travers.) Phlyctexulm, t6i vascular, with minute phlyctenular elevations like fine sand-grains : the conjunctiva generally is usually in- jected in this form. More commonly, at one or more points of the corneal margin, we find a vascular eleva- tion, with greyish summit, about the size of a turnip seed. In all such cases there is generally considerable pho- tophobia^ and there are often short relapses during treatment, but ultimately they as a rule do welL Occasionally, however, such phlyctenules cause trouble- some ulceration, but not so commonly as those which are located quite within the corneal edge, and appear first as prominent greyish opacities about the size of a small pin's head. In these latter the blepharospasm, pain, and lacrj^mation are usually severe. Treatment. — In the case of conjunctival pustules, and in other forms without photophoVjia or deep corneal ulceration, the dilute yellow oxide of mercury ointment (8 grains to the oimce of vaseline) is the most suitable local remedy. A small piece of this salve should be laid within the lower lid once or twice daily, the upper lid then gently rubbed over the eye-ball for a few minutes (with the finger placed on its skin surface), and the eye bathed with lukewarm water half an hour later, if irritation continues. Finely-iwwdered calomel dusted into the eye once daily may be substituted for the ointment. ^Yhere there is photophobia the patient should wear a large shade or goggles over both eyes, and ati-opine oint- ment (2 grains to the oTince of vaseline), or a mixture of equal parts of this and the dilute yellow oxide of mercury ointment, according to the severity of the symptcmis, should be applied twice daily. In the vascular travellinij ulcer the same local treatment is good, combined with a seton in the temple. Division of the leash of vessels at the corneal eam is generally in and around the eye, but sometimes may be also referred to the distribution of the fifth nerve in the face and temple, as where there is associated iritis. The photophobia is really, more properly speaking, a reflex blepharospasm, and, like the lacry- mation, is due to ii-ritation of the sensory fifth nerve branches in the cornea. These latter symptoms are usually most severe in young patients and where the corneal afiection is superficial. The impairment of vision varies directly with the density of the haze produced, and its more or less central position. Locally we get congestion and loss of corneal trans- parency. Not infrequently we have iritis also, and even where this does not exist the pupil is often Kera tit is. 563 small, probably a " congestion miosis." The nature of the loss of transparency differs according to the corneal layer involved and the character of the Fig. 120.— Vascular Supply of the Eye-baU. a. Long posterior ciliary artery ; h. vena vorticosa; c, chorio-capillaris ; d, epis- cleral brancbes ; e. recurrent cboroidal artery ; /, vessels of ciliary i>roces.«es; g, anterior ciliary arteries and veins; h, ix)sterior conjunctival vessels; i, anterior conjunctival vessels ; k, marginal looivplexus of cornea ; /, canal of Scbleium ; m, vessels of iris. (After Leber. Diagrammatic.) inflammation. "When the anterior ejHthelium is affected the surface looks steamy and finely pitted. Chronic interstitial inflammation .cdves rise to an 564 Manual of Surgery. oj>aJescent haze, the anterior epithelium soraetimes remaining sound. A yellow opacity results from the presence of pus between the layers. Minute round ■white dots on the posterior surface are found in in- flammation of the posterior epithelium (keratitis punctata). The congestion may be deep, appearing simply as a pink or lilac circumcomeal zone, e.g. in an early stage of keratitis, in many cases of corneal nicer, etc., and due to injection of the episcleral branch^ of the anterior ciliary arteries. Or we have a salmon-coloured patch over part of the cornea from formation of new vessels in its true stroma, as in int-erstitial keratitis. Again, we may get a superficial vascular mound encroaching on the cnraeal edge at one or two spots, or all round, as in many cases of peripheral ulcer, and es-pecially in miliary phlyctenules, and due to injection of the marginal loop-plexus (Fig. 120). Pannus we have already mentioned when speak- ing of trachoma ; the new vessels under the epithe- lium are in connection with the conjunctival vessels. Pannus may also, less commonly, result from tri- chiasis, entropion, phlyctenular keratitis, chronic blenorrhosa, and may occur during the healing process in corneal ulcers. Sometimes we also get considerable conjunctival injection in association with keratitis. Causes. — Local injury, malnutrition (local or general), and constitutional diseasa It may likewise occur as part of a more general ocular inflammation. As examples of corneal inflammation produced by local injury, we have ulcei^ation from a foreign body or abrasion, and snppui-ative interstitial kei'atitis after cataract extraction. As forms resulting from local maJnidrition we may instance the severe keratitis met with in ]>urulent and diphtheritic ophthalmia, where infilti-ation of the conjunctiva and subconjunctival tissue has led to strangulation of Keratitis. 565 vessels round the corneal margin ; also possibly the ulceration often found in cases of herpes frontalis. General malnutrition, as a result of over-lactation, insufficient food, etc., is responsible for many cases of. ulceration, and for the keratomalakia met with occasionally in puny, ill-thriven infants. The best marked constitutional types of com^al inflammation are the interstitial keratitis of congenital syphilitics and the phlyctenular of strumous children. In sym- pathetic oplithalniitis, relapsing cyclitis, etc., the corneal affection is /^r??-^ of a more geyieral ocular inflammation. The treatment will be considered more par- ticularly later ; but we may say here that hot fomen- tations are nearly always indicated, and that atropine is good except where we have increased tension. Results. — There is always more or less opacity, which may or may not ultimately clear up. Super- ficial nebulpe and parenchymatous opacity from chronic interstitial keratitis are most likely to disappear, especially if the patient be young. Sometimes we get a staphylomatous bulging, as after perforating ulcer ; in other cases the cornea flattens and shrinks after extensive loss of its substance. Varieties of keratitis. — 1. lleers of the cornea either commence wdtli a loss of ei>itlielium, or are formed by the breaking doNVTi of a circumscribed infiltration. If much purulent infiltration remains at the base and edges of the ulcer the healing process is generally less rapid and the tendency to perforation greater ; some clear ulcers, however, heal very slowly. In purulent ulceration^ or in cases of corneal ulcer complicated with iritis, we may get a deposit of pus in the lowest part of the anterior chamber {Jiypopyon). If this be quite fluid, its upper boundary shows a level surface, its plane altering fairly readily according to the position of the patient's head. If it be thick, 566 Manual of Surgery. consisting of puro-lymph, the upper surface is more or less convex upwards, and it moves slowly and partially (if at all) on changes in position. The pus in hypopya may be derived from the cornea or iris ; if from the cornea it may result from suppuration of its posterior epithelium, or may come from an abscess that has either burst through the posterior surface or that has gravitated interstitially and has filtered into the chamber through natural sj)aces, such as those of the ligament\im pectinatum iridis. To the gravitated de- posit remaining between the corneal lamellae the term onyx is applied. If the ulcer passes quite through the parenchymatous tissue the posterior elastic lamina bulges into the gap, constituting a hernia comese. On perforation occurring, the aqueous escapes, the pupil contracts, and the iris and lens lie against the posterior surface of the cornea, the iris often even prolapsing through the aperture ; in such cases we occasionally get purulent inflammation of the iris, choroid, and vitreous, and ultimate loss of the eye. During the process of healing of a deep ulcer, superficial vessels are formed on the cornea running from the limbus, and the base of the ulcer loses its yellow colour. As a final result we get a clear facet, a nebula, or a more or less dense leucoma (permanent if from a deep ulcer); where perforation occurred we usually have an anterior synechia. Forms mid treatment. — Many distinct types of corneal ulcer "^ occur, but for practical i:)urposes we may (with one exception, to be considered later) divide them into sui^erjicial and deej)^ central and 'peripheral^ clear and infiltrated. Chronic clear superficial ulcers require local stimulation, as with the dilute oxide of mercury ointment or powdered calomel. Infiltrated ulcers are best treated with hot fomentations, applied * For description and treatment of phlyctenular vdcers, see page 660. Keratitis. 5C7 every hour or so for 10 to 20 minutes at a time, and used as hot as can be tolerated ; in the interval the eye should be covered with a firm pad of cotton wool. If the ulcer be central or painful, belladonna fomentation (3J of extract to the pint of water), or hot boracic acid lotion will be suitable, and atropine drops (4 gr. to the ounce) instilled four to six times daily. When in the periphery of the cornea, and especially where the tension of the globe is increased, the ulcer is best treated with eserine droi)S (2 to 4 gr. to the ounce), and hot boracic acid or poppy fomentation. In the case of deep ulcers with much purulent infiltra- tion it is well, first of all, to scrape the base of the ulcer with a small sharp-edged spoon, so as to remove all the broken down corneal tissue, and afterwards to fill the cavity with powdered boracic acid ; the hot fomentations and atropine or eserine drops should then be used. If the ulcer have all but perforated, and there be no hypopyon, we should prick the projecting posterior layer with a sharp needle. Whenever liypo- pyon accompanies purulent ulcer or corneal abscess, the most generally successful treatment consists in cutting right through the cornea with a narrow linear knife, the slit extending quite across the inflamed area and just into the sound tissue at each side ; on completing the section the aqueous escapes and generally carries with it all, or some, of the hypopyon. Not infrequently a thick piece of puro-lymph sticks in the wound and can be easily withdrawn with forceps. The exceptional form of ulcer above alluded to as demanding separate consideration is the serpiginous (ulcus serpens). It generally begins as a small, oval or round, superficial loss of substance, with slight j)pacity, usually near the centre of the cornea. At one or more points along its margin we find a white, cheesy-looking, crescentic infiltration. The ulcer spreads in the direction of the infiltrated crescents, 568 Manual of Surgery. and may thus creep over the entire corneal surface, cicatrising at some places while extending at others, while it also often tends to affect the deeper layers. The symptoms are frequently severe, i.e. well-marked congestion and great pain. It is apt to become com- plicated with iritis and hypopyon, and sometimes per- foration takes place. Persons advanced in years, and subjects of chronic dacryo-cystitis are liable to get this foi-m of ulcer, often from a mere corneal abrasion. A fungoid growth (aspergillus) is said to be the active local cause of tlie ulceration. In an early stage the treatment should consist in hot fomentations fre- quently, atro})ine four times a day, and powdered iodoform dusted over the cornea twice daily. Some surgeons recommend touching the infiltrated edge with the actual or galvano-cautery. If perforation occur, atropine or eserine should be used according to its position, so as to prevent prolapse of irLs as far as possible. In severe pain leeches to the temple re- lieve temporarily; but if it returns, and particularly if there is increased tension or hypopyon, corneal section is advisable. {See page 567.) If the hypopyon returns and the tension keeps high, iridectomy should be performed. In all forms of corneal ulcer, but especially where there is photophobia, the eyes should be shaded from light. In every case the general health of the patient must be inquired into, and the diet and exercise regulated according to the indications. Tonics are often useful, quinine seeming to be so specially in purulent ulceration and abscess with hypopyon. Lead lotion should never be used where there is a corneal abrasion, as we are apt to get an opaque, white, sharply margined, insoluble opacity as the result. This lead deposit can be removed piecemeal with care, by means of a Beei's knife inserted below the edge of the flake. Kera titis. 569 2. Abscess of tlie cornea.— We get one or more circumscriLed yellow, purulent infiltrations in the corneal substance, with circumcorneal injection and often with severe subjective symptoms. Their occurrence is often connected with a low state of health, as from over-lactation or after an exanthem; sometimes they are found with granular lids or puru- lent conjunctivitis. The abscess tends to burst anteriorly and form an ulcer ; exceptionally it opens posteriorly. In all cases, except where there is trachoma or other form of conjunctivitLs, the treat- ment should consist of hot fomentations and atropine. When of considerable size, say 2 mm. in diameter, and in all cases complicated by hypopyon, paracentesis through the floor of the abscess is indicated. When conjunctivitis is present cold applications are best, with atropine, and appropriate treatment of the palpebral conjunctiva. 3. Keratitis punctata is the term usually applied to cases where numerous round, opaque, whitish dots are found on Descemet's membrane, generally disposed in the form of a triangle on the lower part of the cornea with its apex central. There is nearly always iritis, and it is particularly common in sympathetic ophthalmitis. Sometimes in young (?) strumous adults it occurs without ai)parently any iritis, i.e. without discoloration, contraction of pu[>il, or posterior synechias ; this form is often associated with a deep anterior chamber and increased tension, and the iritis present is not plastic. The condition just described is called Descemet'itis by some, the term punctate keratitis being restricted to cases where w^hitish punctate infiltrations occur in t^he posterior part of the corneal stroma. Treatment. — Hot fomentations and atropine are useful locally, the latter not increasing tension here. The cases are usually very tedious. The patient must 570 Manual of Surgery. wear a shade or dark goggles, and have constitutional or other treatment according to the j^i'obable cause of the local affection. 4. Diffuse interstitial keratitis begins in tlie centre or near the edge of the cornea as an area of slight opacity ; in the course of a few weeks it spreads gradually over the entire cornea, denser at Fig. 121. — Thickening of Cornea and formation of Vessels in its Stroma in Interstitial Keratitis. Subconjunctival tissue thickened. (After Nettleship.) some parts than at others. We find usually a patchy light red (^'salmon-coloured ") vascularity, commencing at the periphery and extending inwards towards the centre of the cornea (Fig. 121). There is circumcorneal congestion and a varying degree of photophobia ; iritis frequently occurs. The attack lasts on an average from six to twelve months, and is almost always bi- lateral, but commonly with an interval of a few weeks between its onset in the two eyes. It generally occurs during second dentition, but it may exception- ally be met with in early childhood or as late as middle life. The infiltration is very rarely purulent, but in some cases it is exceedingly severe, causing corneal Kera Tins. 571 shrinking. As a rule the opacity clears up wonder- f\illy, the patient ultimately getting very good vision. In the great ma^jority of cases we get a definite history of inherited syphilis, and very commonly we find other signs of the disease in the patient, e.g. the character- istic pegged or notched teeth, scarring at the angles of the month, deafness, etc. Treatment. — Locally, atropine drops ; if there be pain, hot fomentations and leeches to the temples. Internally, a mild course of mercury is advisable, with iron if there be anaemia ; a pill (or powder) containing hydrargy- rum cum creta, ferrum redactum aa gr. j, may Ije given three or four times daily, the effect on the gums being carefully watched. Conical cornea usually begins shortly after puberty, and increases very gradually, sometimes becoming stationary spontaneously. It is most common in females. The apex of the cone corresponds to a point a little below the centre of the cornea, and it often becomes nebulous in advanced cases. The condition is best recog- nised on looking at the cornea sideways, but a prominent cone is easily seen in any position, and gives a glistening appearance, as if there were a tear in the eye (Fig. 122). The myopic astigmatism pro- duced is irregular, and cannot be corrected by an ordinary glass, but vision may often be improved by wearing a disc with slit aperture, the exposed corneal meridian being corrected with its appropriate concave lens. When the cone is sharp-pointed or nebulous, removing a wedge-shaped piece, including the apex, produces the best result. Fig. 122. — Conicnl Cornea. (After Mackenzie.) 572 Manual of Surgery, Tumours of the cornea are very rare as primary growths, and it is generally only affected in its super- ficial layei-s. Dermoid tumour, epithelioma, and sar- coma are the most frequent in occurrence. Injuries. — Foreign bodies on or in the cornea are to be removed with a spud or bent needle ; after this operation^ and in cases of simple abrasion, the eye should be bandaged until the epithelium is restored. Cocaine is very» serviceable where foreign bodies have to be picked out, the only disadvantage from its use in such cases being that it renders the cornea abnor- mally flaccid. Ordinary cleanly cut corneal wounds usually heal quickly. Where 'prolapse of iris has occurred, and the case is quite recent, we may try the effect of eserine, or atropine with cocaine, according to its position (the mydriatic where central, eserine where peripheral), so as to induce its retraction within the chamber ; we should never use a spatula to push back the prolapsed iris. If the prolapse be of more than a few hours' standing it is best to seize it with iris forceps, pull it free, if possible, from the edges of the wound, and snip it off internal to the constricted portion. If it has existed too long to be freed in this manner, we must cut it off level with the cornea, or we may enlarge the original wound and remove a larger piece of iris, inclu<]ing its sphincter edge. In burns from lime, hot metals,, etc., our prognosis should be guarded, as the cornea may remain fairly clear for some days after the injury, and yet the result prove ultimately unfavourable. In recent cases any remain- ing fragment of metal or other solid must be removed, and in the case of burns with acids or alkalies the conjunctival sac is to be thoroughly washed out with a mild solution of opposite reaction. Ice compresses should be applied in all cases of severe recent injury, and in corneal bums a drop of atropine and of castor oil are to be put inside the lid, thrice daily. When Iritis. 573 keratitis results, hot fomentations, etc., must be used as recommended above. Diseases op the Iris. Iritis. — The subjective symptoms of acute iritis are pain, photophobia, lacrymation, and imjjairment of vision. The amount of 'pain varies much in different cases and at different times ; it \s> usually worst at night and during an early stage of the attack, and is most apt to be severe in the arthritic and the traumatic varieties. The first symptom of iritis is often an itching sensation down the side of the nose, and tlie pain is referred not only to the eye, but also frequently to the supra-orbital, temporal, and other branches of the fifth nerve. The 'photophobia and lacrymation are seldom so severe as in corneal affections, and are worst at an early stage of an acute attack. The impairment of vision is generally due to the opacity of the media (cornea, aqueous, pupillary area of anterior capsule, or rarely vitreous) ; some- times also to hypersemia of the optic disc and retina. The local symptoms are circumcomeal congestion, discoloration of iris and loss of its lustre, narrowness of l^upil, slowness of pupillary reaction, and posterior synechite. The circumcomeal congestion occurs as a lilac-coloured zone, about two to four mm. wide ; sometimes the anterior and posterior conjunctival vessels are also congested. Discoloration. — A blue or grey ^ris becomes greenish, and a brown becomes dark reddish-brown; occasionally the change of colour is only partial. The discoloration, loss of lustre, narrow pupil, and sluggish action to light and mydriatics are all due to congestion, with efiusion of lymph and serum into its substance. A large amount of solid exudation into the iris often occurs in syphilitic iritis, sometimes appearing as distinct yellow or rust- col 011 red nodules on its anterior surface. Sometimes we get opacities in the aqueous humour from pus or 574 Manual of Surgery. blood corpuscles ; their presence in suspension assists in producing an apparent discoloration of iris. When they form a deposit in the anterior chamber we get hypopyon or hyphsema. A large hypopyon is usually found in cases of iritis secondary to keratitis or purulent choroiditis. Hyph^ema is commonly the result of wound of the iris, but sometimes occurs from R blow, or during whooping cough. Occasionally we get a round grey gelatinous mass in the anterior cham- ber from coagulation of the exudation, looking some- what like a dislocated lens. Posterior syne- chice are the result of an exudation of lymph on the posterior sur- face of the ii'is, gum- ming it to the anterior lens capsule ; they usually occur at the pupillary edge. They become readily visible on using atropine, the pupil dilating between the synechia, which now appear as pointed projections from the edge of the iris (Fig. 123). If no apparent change in the pupil take place on using atropine, the pupillary edge is adherent all round {excluded pupil), or the entire posterior surface of the iris is adherent {total posterior synechia). When much lymph is exuded it may cover the entire pupil, forming, when organised, a more or less dense whitish TCi&mhvd^rvQ {occluded pupil). In non- plastic inflammation no posterior synechiae are formed. Not infrequently we get a punctate precipitate on Descemet's membrane, a secondary keratitis punctata. {See page 568.) Tlie most convenient classification of iritis is an etiological one, and we shall therefore consider at the same time its .X'^^^ Fig. 123.— Posterior SynechisB, result of Iritis. the iFfTis. 575 Causes and varieties, — Iritis may arise from local injury or from constitutional disease ; it may also be secondary to other inflammation in the same eye, or sympathetic from wound of the opposite eye. Traumatic iritis is not only caused by injuries of the iris itself, but may follow any penetrating wound of the eye-ball, particularly in old people and where the lens has been wounded. Slighter forms of it often follow cataract extraction ; sometimes after this operation the iritis is severe, and may be suppurative where there is purulent infiltration of the corneal wound. Occasionally superficial corneal wounds and direct blows on the eye are followed by iritis. The constitutional causes of iritis are syphilis, rheumatism, gout, and possibly struma. Syphilitic iritis is acute, and usually symmetrical ; it occurs in the secondary stage of the disease, either acquired or congenital. There is often much efi^usion of lymph, and occasionally vascular nodules of it project from the sur- face of the iris near the pupillary edge; when large, these may suppurate and cause hypopyon. Rheumatic iritis is recurrent, and both eyes usually sufter, but seldom both at once. The interval between the relapses may be many months. There is rarely much lymph efiused, but the congestion and pain are often very severe. It sometimes accompanies gonorrhceal rheu- matism. Gouty iritis resembles the rheumatic in its being recurrent, and in its affecting one eye at a time. It is sometimes very chronic and insidious, leading slowly to much contraction of pupil and impairment of vision without severe pain. Struma is said to be the cause of some cases of slight iritis, with keratitis punctata, occurring in young adults. Secondary iritis may result from continuity of sti^uc- ture in inflammations of the cornea (j)articularly when complicated with hypopyon), ciliary region, or choroid. 576 Manual of Surgery. Sympathetic iritis and its peculiar symptoms will be considered later. Results of iritis. — The adhesions are often persistent, but if due to freshly effused lymph they will nearly always, sooner or later, yield to atropine, often, however, leaving permanent dark spots of uveal pigment on the anterior surface of the lens capsule. When complete exclusion of the pupil occurs the body of the iris becomes bulged forward by the aqueous fluid between it and the lens capsule, so that the anterior chamber is shallow, except just over the pupil ; in such a condition we are liable to get secondary glaucoma. In old-standing cases of chronic iritis with numerous posterior synechise, secondary cata- ractous changes often occur in the lens. When the pupil is occluded vision is always much interfered with, particularly, of course, if the membrane be dense, and in such cases also secondary glaucoma may follow. Treatment. — Perfect rest of the eyes and the ase of a shade or dark goggles must be insisted on till the attack has quite passed off. Locally, atropine drops (4 gr. to the ounce), one to be instilled from four to eight times daily, according to the severity of the attack ; they are useful in often breaking down synechise already formed, and in preventing the formation of new adhesions, and they also diminish congestion and relieve pain. If the latter be very severe, two or three leeches should be applied to the temple, and the eye bathed frequently with hot belladonna lotion. A dry pad of cotton wool is to be worn over the eye and removed only when neces- sary for local applications. In syphilitic cases mercury in some form should be given to slight salivation, and continued cautiously till acute symptoms disappear. Salicylate of soda is worthy of trial in arthritic cases. Tlie diet must be carefully regulated. In iNyURIES OF THE IrIS. 577 severe recurrent iritis that does not yield to ordinary treatment, an iridectomy is sometimes followed by excellent results. In cases of recent iujury where iritis is dreaded, ice compress continuously applied over the closed lids for twenty -four hours is valuable as a prophylactic measure. On the very first onset of the symptoms of iritis two or three leeches to the temple will often cut short the attack. Iridodoueisis, or tremulous iris, is generally due to loss of its posterior support from luxation or absence of the lens, or from fluidity of the vitreous. Sometimes the iris quivers slightly in a healthy eye, especially in myopia. Iiijurleis of the iris. — (1) Foreign bodies which have penetrated the cornea and become fixed in the iris must be removed, along with the portion of iris implicated, by iridectomy. (2) Iridodialysis {coredialysis), or separation of the iris from its ciliary attachment, sometimes results from a blow on the eye, and is usually accompanied by hyphaema (Fig. 124). "When recent, the treatment should consist in ice compresses for twenty-four hours, followed by warm fomentations so as to favour removal of the blood clot. Tiinioiirs of the iris may be solid or cystic. The solid tumours are tubercular, syphilitic, or sarcoma- tous. Where there is reason to suspect them to be tubercular or sarcomatous the affected piece of iris and the growth should be removed ; if this cannot be done effectually, the globe should be excised. In syphilitic cases specific treatment must be adopted. C yds are L L— 21 Fis 124.— Coredialysis following a blow. (After Wardrop.) 578 Manual of Surge r v. generally the result of injury, and should be removed, as they are liable to lead to secondary glaucoma. Coug^euital auoiiialies. — Colohoma usually occurs below, or down and in, appearing as a gap in the iris like that left by an iridectomy. It is due to im- perfect closure of the foetal choroidal cleft. Iridercemia (absence of iris) is a rare condition, often associated with microphthalmos or other congenital ocular defect. Persistent 'pupillary membrane is usually only repre- sented by traces, which appear as thin bands of iris tissue attached to the anterior surface of the iris, but not to the lens capsule. Diseases of the Sclerotic and Ciliary Region. Episcleritis appears as a swollen, congested, discoloured patch of considerable size in the ciliary region, the unaffected part of the globe usually re- maining of normal colour. It is really a circum- scribed inflammation of the sclerotic with effusion into the subconjunctival tissue over it, and congestion both of the deeper and of the conjunctival vessels. The colour is usually rusty or purplish-red. As a rule, the subjective symptoms are slight, but sometimes the pain is severe, and there is generally much tender- ness on pressure over the affected part. It is most apt to begin in the outer ciliary region, but relapses are usual, fresh spots being attacked until often the entire ciliary area has suffered. It rarely occurs in both eyes at once, but the second eye is often attacked later. Its course is slow, the swelling reaching its height in two to three weeks, and then undergoing slow absorption ; the middle of the formerly inflamed patch generally remains dusky. It is much most common in adults. Causes. — One form, rather more sharply limited than the usual one, is due to tertiary syphilis. In other cases rheumatism and anaemia seem to be predisposing causes ; menstrual CvcLiTis. 579 disturbances are frequently associated with it in women. Treatment. — Rest, warm bathing, dilute yellow oxide of mercury ointment with atropine (with massage), and blisters to the temple are most service- able. The medicinal treatment must be regulated by the history and condition of each individual case. Sclero-kerato-iritis (relapsing cycUtis, anterior sclero-choroiditis) is the name applied to a disease in which a somewhat similar scleral swellinsf to that just described occurs, but here associated with peri- pheral corneal opacity and iritis. The swelling is slight, diffuse, and of a deep violet colour, occurring in one or more large patches, coming quite up to the corneal border. The subjective symptoms are usually severe. It is extremely tedious, and relapses are frequent, causing more and more corneal haze, and thinning, staining, and bulging of the ciliary region. It is most common in women about middle life, and is often associated with a family history of struma, or, according to some, of arthritic disease. The treatment is much the same as in the last affec- tion, atropine being especially indicated here, and the use of dark glasses. 5lercury with cod-liver oil and iron are useful. It is extremely intractable, and, when practicable, change to a warm, dry climate is advisable. Cyclitis is rare as a primary affection, and would be recognised by deep circumcomeal injection, with tenderness on pressure on this region, and by opacities in the anterior part of the vitreous without visible iritis. The tension is often much reduced, but later on the eye may become glaucomatous from ultimate implication of the iris and posterior synechise. A chronic relapsing form of the affection, associated with irido-choroiditis and keratitis punctata, is occasionally met with in young people, and often with a history of inherited gout. In the less severe cases a good 580 Manual of Surgery. result is generally obtained, the best treatment being rest, dark glasses, and atropine ; and internally iron and quinine, with a mild mercurial course. In trauuiatic cyclitis marked pain is an early symptom, along with the other signs mentioned above. Tlie rest of the uveal tract (iris and choroid) are soon aftected, and this form of inflammation is often a fore- runner of sympathetic inflammation of the other eye. Sometimes the inflammation becomes purulent in type {panophthahnitis), and in such cases the liability to sympathetic disease seems decidedly less than in the plastic form, though the early excision generally practised in panophthalmitis may possibly account for this difference. Wounds of the sclerotic. — There is generally simultaneous wound of some part of the uveal tract, and often of the retina, with loss of vitreous. Often we find haemorrhage into the anterior chamber, or vitreous, or both. If the wound be quite behind the ciliary region, i.e. quite a quarter of an inch from the corneal margin, and recent, we should apply an ice compress, and trust to its healing. If it gape much, one or two fine stitches may be inserted, but care should be taken not to embrace the deeper layers of sclera in our suture, as then the choroid will almost certainly be included, and an irritable eye with uveitis may be left. When a foreign body is embedded in the anterior, but post-ciliary, part of the sclerotic, it must be re- moved, the wound being enlarged for this purpose if necessary. Where the ciliary region is deeply wounded stitches should never be used, and it is really safer in all such cases to excise the eye-ball at once. If the lens have escaped injury, however, and the case be quite recent, ice compress may be apjjlied and the eye watched, and excision deferred till there be evident signs of cyclitis or marked sympathetic irritation. Uii|>(ure of the sclerotic is not an uncommon Sympathetic Irritation. 581 result of a direct blow on the eye, usually occurring a little outside, and concentric with, the corneal margin. The rent is generallyiarge and involves all the tunics, we then may get escape of the lens and part of the vitreous, there is blood in both aqueous and vitreous chambei-s, the eye is soft, and vision is greatly reduced. The conjunctiva is the tunic most likely to remain unrup- tured, and then the lens may pass through the scleral rent and remain under the conjunctiva as a round, translucent tumour. In very severe cases of rupture immediate excision is best. In less severe cases, and especially when the conjunctiva has escaped untorn, we should apply ice compress and wait till the absorp- tion of blood enables us to judge of the probable future usefulness of the eye. If it be decided to retain it, a subconjunctival dislocation of lens should be left until the scleral rent has healed, when it can easily be removed. Primary tumours of the sclerotic are exceed- ingly rare ; sarcoma and fibroma have been observed. It is often secondarily affected in the case of morbid growths of the choroid or retina. Sympathetic Affections of the Eye. The condition most liable to excite sympathetic disease is a plastic inflammation of the uveal tract (iris, ciliary region, choroid), usually the result of a wound involving the ciliary region. The eye injured or first inflamed is called the " exciting," the other the "sympathising" eye. Sympathetic irritation. — The common symp- toms are lacrymation, photophobia, and occasionally dimness of vision in the sympathising eye. It flushes on exposure to a bright light, especially if the exciting eye be also exposed or otherwise irritated. Some- times pain is felt in the forehead or shooting across the root of the nose. The occasional dimness is 582 Manual of Surgery, usually mainly due to a relaxation of the ciliary muscle rendering accommodation impossible, or some- times possibly to a condition of spasm rendering dis- tant objects indistinct. In such cases the pupil will be found to react well to light, but to be in a constant state of oscillation. Sometimes there seems to be a true temporary blindness, the nature of which is doubtful. Treatment. — If the exciting eye be lost or mani- festly a dangerous one, it must be excised without delay. If, however, it be uninflamed, its vision good, and the wound not such as is likely to lead to sympathetic inflammation, the patient should be kept at rest, dark goggles worn, and the condition watched for a few days. If the irritation persist or increase, it is advisable to excise, but even after excision the symptoms may not cease for a considerable time. Syiiipatlietic iiillaiiiinatioii ueually sets in a month or two after the injury, but it may appear as early as two weeks, or may be delayed for many years. It always attacks both eyes, but not necessarily with like severity. One of the earliest and most constant signs is the occurrence of keratitis punctata. In severe cases the iiitic adhesions are rapidly formed, extensive and firm, and the iris itself is much thickened, with numerous large blood-vessels visible on its dulled surface. Eventually we get occluded pupil, increased tension, and secondary cataract. In the worst cases ciliary staphylomata form, and the globe finally shrinks. In the milder cases no synechise are formed, or they give way readily to atropine. Treatment is too frequently of little avail after sympathetic ophthalmitis has begun. The exciting eye, if quite blind or practically useless, must be excised at once. If there be any hope of useful vision in it, however, it should be retained, as its removal wiU now do little or no good to the other, and it may Cataract. 583 eventually be the better eye of the two. The sym- pathising eye, and the exciting eye if retained, must be covered with a black bandage and treated with atropine, leeching or blistering to the temple, and perfect rest in a dark room. In moderately severe cases, when the eye has become perfectly quiet (always at least a year after the beginning of the inflamma- tion), an operation may restore some vision. Our great aim, however, must be to prevent this form of inflammation by early excision of lost dangerous eyes, whether blind from injury, or from past inflammation in which the iris or ciliary region has participated. We have already mentioned cases of injury where excision is advisable. {See also page 580.) Diseases of the Lens. Cataract, or opacity of the crystalline lens, may occur at any age, and may be partial or complete. An opacity in this situation looks white or light grey by reflected light (e.g. on focal illumination), and black by transmitted light, as when the eye is illuminated by the ophthalmoscopic mirror. Cataract is said to be prima7'i/ when it arises apparently independently of any other ocular inflammation, and secondary when it follows some local disease. The former is nearly always symmetrical, the latter may or may not be so. In advanced life a greyish reflex is always obtained from the pupil in consequence of the normal lenticular changes, and this is sometimes mistaken for cataract, but transmitted light shows no loss of transparency. Varieties and diag^nosis. — Senile cataract is the most common form, and seldom occurs before fifty years of age. It may begin in the nucleus or cortex. Nuclear cataract appears as a central amber-coloured haze. The cortical variety generally at first presents the appearance of strite, often only visible after dilating the pupiL These striae gradually increase in 5S4 Manual of Surgery. number and breadth, the nucleus gets hazy, and ulti- mately the whole lens becomes opaque {mature cataract). Occasionally we simply find numerous minute dots of opacity in the cortex, best seen by direct ophthalmo- scopic examination with a strong convex lens behind the mirror ; such cataracts are exceedingly slow in progress. The time necessary for maturity varies in different individuals, but the average time taken by the usual senile cataract is from two to four years from the first observed impairment of vision. In a cataract just ripe for removal, the opacity is found on oblique illumination to be quite up to the anterior capsule, or on a level ^vith the pupillary edge of the iris, and the lens has frequently a spermaceti-like lustre. It is always symmetrical, but one eye is generally in advance of the other. If not extracted it usually undergoes further degenerative changes, often becoming hard and calcareous ; sometimes the cortex liquefies, while the nucleus remains hard [Morgagnian cataract). Lamellar catarojct is either congenital or forms in early infantile life, and is generally associated with the occurrence of convulsions. The permanent teeth, especially the incisors, canines, and first molars, often show deficiency of enamel in patients with this affec- tion. The opacity is seldom very dense, and affects an intermediate zone of the lens, the nucleus and peri- phery remaining clear. On dilating the pupil artifi- cially we find that the margin of the lens is clear, and that there is also a layer of transparent lens substance anterior to the opaque area. The opacity itself is round, with occasionally sharp opaque spicules project- ing radially from its margin. Its size varies in different cases, but is nearly always similar in the two eyes of the same patient, and shows little or no tendency to increase. Congenital cataract may present different forms of opacity, but it usually involves the whole lens, and is Cataract. 585 almost always symmetrical in the two eyes. There is frequently nystagmus. Pyramidal cataract is always the result of ocular inflammation in early life, and usually of perforating corneal ulcer from ophthalmia neonatorum. It appears as a small, sharply defined, dense white opacity at tlie anterior pole of the lens, sometimes projecting forwards towards the cornea in the form of a small pyramid with its base slightly embedded in the lens substance. Once developed it does not increase in size. Posterior polar cataract, as the name implies, is an opacity at the middle of the posterior surface of the lens. It is not sharply limited, but usually thins out irregularly from a denser centre ; it is not stationary. By focal illumination it is generally of a yellowish colour. It is often due to disease of the vitreous dependent on choroidal inflammation. Diabetic cataract is usually cortical at first, and when mature presents much the appearance of an ordinary senile cataract, but with the spermaceti lustre very distinct. The age of the patient often leads us to suspect glycosuria in such cases. When occurring early in life the diabetic form is soft, instead of being hard like the senile cataract, and reaches maturity very quickly, often in a few months from its first detection. Subjective symptoins.— There is visual failure where the opacity is at or near the axis of the lens. As the cataract spreads and becomes denser, the sight fails more and more, until the patient, with his back to the light, can barely count fingers at a few inches, or only distinguish the hand moving before his eye. Many subjects of cataract, especially where the nucleus is principally afiected, see best in a dull light, as the large pupil then allows the rays to pass through the clearer peripheral parts of the lens. Caiisos — The manner of production of an ordinary 586 Manual of Surgery. primary cataract is not understood. It is often found associated with general senile changes, with arterial disease, gout, and especially with glycosuria. When cataract results from some local disease, such as choroiditis, old iritis, glaucoma, detached retina, intra-ocular tumour, etc., it is called "secondary," and is then frequently uniocular. Traumatic cataract will be considered later. TreatHient.— We can often improve vision con- siderably in the early stages of senile cataract by keep- ing the pupil under the influence of a weak mydriatic* In some slight cases of lamellar cataract no operation is necessary, the patient seeing sufficiently well for all practical purposes. Before attempting any operation we should examine the condition of the eye and of the patient carefully. Thus, if the eye be perfectly blind, it is needless to remove the cataract. Again, if the projection be bad, if there be traces of old iritis, if the cornea be nebulous, or if the patient be suflfering from glycosuria or other form of malnutrition, the prognosis must be guarded accordingly, and special care taken in the operation and in the after-treatment. To test the projection, light is thrown into the eye by the ophthalmoscopic mirror from different points of the visual area ; if the patient can always indicate truly the direction from which it comes, his projection is good. If there be lacrymal obstruction or conjunc- tivitis, operation must be deferred till the condition is cured. The oi:)erative treatment indicated varies according to the consistence of the cataract; or, which is practically the same thing, the age of the patient. Under thirty-five years of age the cataract is always soft, and the best means of removing it are : (1) discis- eion, the lens being needled and allowed gradually to become absorbed in the aqueous; and (2) removal by * Atrop. sulpbat. gr. i ; zinci sulph. gr. ^ ; aq. destill. ^j. One di-op eveiy second day. Cataract. 587 auction or curette, generally after a previous breaking up of the lens substance by needling. After any such operation, ice compress must be applied for twenty- four hours, and the eye kept under atropine until all redness has disappeared. In the case of hard cataract, (after thirty-five years of age) the lens should be extracted entire. The modified Graefe incision with a long narrow knife is that usually now adopted, the puncture and counter-puncture being made at the apparent sclero-corneal junction, about the level of the upper border of the undilated pupil, and the centre of the incision coming just within the apparent upper corneal margin. An iridectomy is then performed (if not done as a preliminary step at least six weeks pre- viously), the anterior capsule opened freely, and the opaque lens extracted through the corneal wound by pressing with a curette against the lower part of the cornea. All cortical matter must be carefully removed. After the operation both eyes are covered with dry cotton wool and an appropriate bandage, the patient being kept in a darkened room, and the eyes bathed gently every morning and evening for the first week. On the earliest symptoms of iritis leeches must bo applied to the temple, and atropine drops put into the eye. Should the edges of the wound become infiltrated with pus, hot fomentations are advisable, and eserine drops six times daily, or powdered iodoform dusted into the eye twice daily. Should panophthalmitis occur, it is better to excise the eye early, as thus much needless pain is avoided. A bandage should be used over the eye even in favourable cases for at least a fortnight, and both eyes carefully shaded from light. After a couple of months the eye may be tested for glasses, +10D being about the average lens required for distance, and -}-14D for close work. Should the distant vision be unsatisfactory, the pupil must be examined by focal illumination, as fi-equently an 5SS Manual of Surcerv. opaque membrane is found covering it. If present this membrane must be torn through with one or two needles, so as to leave a clear aperture corresponding to the centre of the cornea. After this secondary- operation ice and atropine must be used, and the eyes kept shaded until all irritation and injection subside. For all cataract operations cocaine is most serviceable, but it must be remembered in performing iridectomy under its influence that it does not fully deaden the sensibility of the iris."*" Injuries. — (1) Traumatic cataract is the result of any injury by which the lens capsule is opened. It may follow a penetrating wound of the globe, or may simply be due to a direct blow rupturing the lens capsule. In recent cases ice compress and atropine drops must be used, A small piece of metal is some- times embedded in the lens, and may be removed by the electro-mamet. Should the lens swell so as to produce increased tension, it must be removed by curette or suction. In young patients the cataract sometimes undergoes slow spontaneous absorption, as after the operation of discision. If severe iritis supervene, in cases due to punctured wound, early excision is advisable, as the eye will never be a service- able one, and is very likely to set up sympathetic inflammation. (2) Dislocation of the lens is occasion- ally the result of a direct blow on the eye-ball. It is generally still enclosed in its capsule, and is commonly displaced downwards, its upper edge being still visible through the dilated pupil. It ultimately often becomes cataractous, and sometimes causes glaucoma. Occasionally the dislocated lens lies in the anterior chamber. From either situation it may be removed * Solutions of all alkaloids used after any perforating wound of the eye-ball should be freshly prepared, as the fungoid growths which Boon form in them seem sometimes to have a most prejudicial effect. Optic Neuritis. 589 by the spoon through a large peripheral corneal inci- sion, but the operation is one of great delicacy and liable to be accompanied by much loss of vitreous. Coug^enital abnormalities.— Con^e/iz^a^ cata- ract has been already alluded to. Occasionally we find partial congenital dislocation of the lens, usually in both eyes. Appropriate glasses ai-e often serviceable in such cases. Diseases of the Optic Nerve. Developmentally and structurally the optic nerve is unlike ordinary cerebro-spinal nerves, and is to be regarded as a direct prolongation of the brain. It is peculiarly liable to suffer in affections of the central nervous system, in certain general diseases, and in some forms of chronic poisoning. Inflammatioii of tiie optic nerve.— P«^Ao- logy. The intra-ocular end of the hqyvq {^^ papiVa") is the part most commonly inflamed, and to this con- dition the term '■^ papillitis " is conveniently applied. When the inflammation first attacks the nerve trunk behind the eye-ball, we speak of it as a ^^post-ocular neuritis,'^ The expression, ^^ optic neuritis,^' should be retained as a general term for inflammation of any part of the nerve. Optic neuritis may be acute or chronic, may occur at any point in the course of the nerve, may affect the whole thickness or only a part of it, and may or may not lead to permanent atrojjhy. Where the periphery of the nerve is mainly involved, we call the condition ^^ perineuritis ; ^^ where the in- flammation attacks the central part of the nerve we speak of it as " axial neuritis." Usually both nerves are affected, though not necessarily to the same de- gree nor consentaneously ; unilateral optic neuritis is generally dependent on a local cause, such as orbital cellulitis. In the early stage of a papillitis, the con- nective tissue is unaffected j and if the inflammation 590 Manual of Surgery. proceed no further, we may finally get a healthy disc and retention of normal vision. Usually, however, we ultimately get interstitial changes. Symptoms. — There is usually no ocular pain, and there may not even be loss of sight for some time. In exceptional cases, indeed, papillitis may run its course and disappear again without there being any impairment of vision, but usually sight fails gradually. The manner of the failure varies according to the kind of the neuritis. In ordinary papillitis we have a pro- gressive loss of central vision along with a peripheral diminution of the visual field. In some cases of post- ocular neuritis, in the axial form for example, we have the central vision alone first impaired, the peripheral field remaining perfect ; in such cases the loss of colour vision is characteristic, the power of distinguishing red and green, in a small central area, being often lost at the very commencement of the affection. Ophthalmoscopic appearances. — We must exercise much caution in diagnosing positively the slighter departures from the normal vascularity of the papilla, and we must invariably examine both eyes. In simple passive congestion of the papilla, it is redder than normal, and the veins are somewhat dilated, but there is no swelling, and though its margin is wanting in definition, it is not actually obscured. Between such a condition and a fully developed papillitis or " choked disc," there are many gradations, which may siraply be stages in the development of a high degree of papillitis, or any one of them may be the final condi- tion where the inflammation is of less severity. In advanced papillitis the changes are unmistakable ; we find swelling of the papilla, with obscuration of its margin, loss of translucency, increased vascularity, and obliteration of the physiological cupping. Numerous straight vessels radiate from it on every Optic Neuritis. 591 side, coursing over its obscured edge, and small haemor- rhages often occur on or near it. The veins are dis- tended, dark and tortuous, and the arteries usually some- what narrowed ; both sets of vessels, but especially the arteries, are often hidden on or near the disc. Smooth, opaque, whitish spots occur on the papilla or on the surface of the adjacent retina, concealing completely what they cover, and there are often large areas of cloudiness in the retina. As the papillitis subsides, the redness and swelling diminish, and the disc margin again comes into view. The disc is first opaque and " woolly " looking, but gradually becomes smoother, and is ultimately (stage of atrophy) of a white colour, with concealment of the lamina cribrosa ; around it there is often a pale zone from changes in the retinal pigment ; the vessels are all much narrowed, and are often bordered by opaque white lines. Causes. — {a) A large majority of cases:of papillitis are due to intracranial disease ; e.g. tumours, menin- gitis, cerebral abscess, internal hydrocephalus, aneu- rism of internal carotid. Injuries to the head may cause optic neuritis either through meningitis, efiiision of blood (within the skull or within the nerve sheath), hernia cerebri, or possibly through a laceration of the brain. {h) We are liable to get optic neuritis (usually one- sided) in many orbital affections ; e.g. tumours, cellu- litis, periostitis, etc. In the case of orbital tumour there is generally protrusion of the eye-ball. (c) Papillitis has been observed in association with acute myelitis, and in cases of injury to, and caries of, the cervical spine. (d) In general diseases, e.g. progressive pernicious ana3mia and Bright's disease, but in cases of the latter we usually have a characteristic retinitis in addition. Acqvvi'ed syphilis may cause optic neuritis either through meningitis or from a gummatous growth, 592 Manual of Surgery. which latter may be within the skull, or at the optic foramen, or on the nerve trunk, the neuritis being generally one-sided when in either of the two last situations. In diabetes mellitus we get an axial neuritis, and probably the same limited inflammation is caused by chronic poisoning by lead, alcohol, tobacco, and bisulphide of carbon (e) Sometimes optic neuritis is simply an extension of inflammation from a neighbouring ocular tissue. The prog-iiosis must always be guarded as to the flnal condition of vision, and depends more on the cause than on the intensity of the papillitis obse>red. It is relatively more favourable where the cause is removable or amenable to remedies. We may have a papillitis with good vision, leading ultimately to complete atrophy and blindness, while again we may have a papillitis with the barest perception of light, followed by almost perfect recovery. Ti'eatnfieiit. — Where not contra-indicated, mer- cury and iodide of potassium should be employed as a matter of routine, the latter being given in full doses. Perfect rest must be insisted upon, and the cause i» to be treated by appropriate remedies when possible, or to be removed altogether in the case of exposure to poisons. Locally, dry or wet cupping, or blisters to the temple, may be tried, and ice to the forehead has been recommended in an early stage. Atrophy of the optic nerve. — Pathology. In all cases of atrophy the nerve is ultimately affected in its entire length. In all true cases the nervous ele- ments are involved, and there is a corresponding loss of function. In the post-neuritic atrophic process the nerve fibres finally either break down and are re- moved, or undergo grey degeneration ; in the former case the diameter of the nerve is much reduced from contraction of the hypertrophied fibrous tissue. In nmple atrophy there is seldom much increase of Atrophy of Optic Nerve. 593 connective tissue, but the nerve fibres lose their me- dullary sheath by a process of granular fatty degenera- tion, while the axis cylinders are usually retained, but converted into fine indistinct fibrils ; there is conse- quently little change in the size of the nerve. This " grey degeneration," as it is termed, may be difftise, affecting the whole nerve uniformly, or insular and varying much in extent in different sections. In most cases of atrophy both nerves are affected, though one may be considerably in advance of the other. Causes. — All cases may be divided broadly into hijiammatory and non-inflammatory or simple. (1) Those due to inflammation are traceable either to a papillitis, a post-ocular neuritis, or an inflammation of the choroid or retina. (2) Simple atrophy may be primary or secondary. In the primary form we get visible atrophic changes occurring consentaneously with gradual failure of vision, often in association with disease of the central nervous system (locomotor ataxy, etc.). The more immediate cause of this form seems to be severe bodily fatigue, anxiety, exhausting brain work, sexual excess, etc. In the secondary form of atrophy the loss of vision precedes the visible atro- phic changes. This occurs in all cases where inter- rupted conductivity in one part of the nerve leads to subsequent atrophy in the remainder, as where the nerve has been cut across, or torn through, or pressed upon (by tumours, foreign bodies, etc.), or has had its blood supply interrupted (as from embolism). Syphilis may induce either a post-inflammatory atrophy or a secondary one (as from pressure of a gumma), and a specific history is also common in cases of simple grey degeneration. Symptoms. — The failure of vision in post-neu- ritic cases has been already described. {See page 590.) In atrophy from choroiditis and retinitis the failure is usually gradual, central vision often remaining fairly M M— 21 594 Manual of Surgery. acute while the rest of the field has become amblyopia In the secondary form of simple atrophy vision often fails suddenly. In primary atrophy the loss of vision is slow and continuous, there being both central failure and contraction of field. Affection of the colour sense is almost constant, green being generally first confused, while later perception fails for red, blue, and lastly yellow. The pupils are generally wide in post^papillitic atrophy, small in spinal cases, and often of medium size in other forms. Ophthalmoscopic appearances. — The colour of the atrophied disc is white, grey, or of a blueish or greenish tint. The disc is often excavated quite up to the margin all round, but never deeply, and the slope is gradual. The lamina cribrosa may or may not be visible. The edge of the disc is usually well defined. The central blood-vessels are in some cases much diminished in size, in others only slightly if at all. In the post-papillitic form the disc margin is often irregular-looking from loss of pigment due to choroido-retinal changes ; the central vessels are re- duced in size, and frequeutly bordered by opaque white lines ; the excavation is absent or slight, and the lamina cribrosa is invisible. In atrophy from choroido-retinal disease the disc has usually a peculiar opaque, yellowish-red, "waxy" look, and the retinal vessels are greatly diminished in size, and sometimes in number. In the partial atrophy from axial neur- itis the pallor is confined to the temporal half of the disc. The prognosis is always unfavourable, but is relatively less so where the cause is removable or may pass away spontaneously. In some of the posi- papillitic cases considerable improvement takes place if the sclerosing process do not lead to much pressure on such nerve fibres as have escaped destruction by the inflammation. In marked contraction of the visual Injuries of Optic Nerve. 595 field, and in cases of long-standing amblyopia, little Of no improvement is to be expected. In cases of primary atrophy, almost complete blindness generally occurs in from one to three years. Treatment. — Where the atrophy is dependent on some general condition or toxic influence, the treatment must be regulated accordingly. Nervine tonics, such as strychnia, are said to be occasionally useful. Where the atrophic process has not gone too far, the continuous current is sometimes beneficial. One pole should be applied over the closed eyelids and the other over the supra-orbital nerve, the current being broken frequently and the poles transposed. The smallest number of cells which will give the physiological light-flash on making and breaking the circuit should be employed ; the whole sitting should last about five minutes, and be repeated daily for at least a month. If no improvement take place during this time, either in central acuity or in visual field, galvanism may be abandoned as useless. If any marked benefit result, the current should continue to be employed at longer and longer intervals, as the condition may indicate. The patient is quite capable of carrying out the treatment for himself after having once been properly instructed, lujiu'ies. — The optic nerve may be injured by a blow, stab, gun-shot wound or fracture of the sphenoid bone. A severe blow on the side of the eye-ball may cause rupture of the nerve ■ at its entrance into the globe. A stab or thrust into the orbit may cut or tear the nerve, or cause an extravasation of blood within its sheath, or may sever the central vessels outside its tinink. A foreign body penetrating deeply may produce fracture of the orbital walls or of the clinoid process of the sphenoid bone, thus leading to injury of the nerve. Gun-shot wounds may implicate either the orbital or intracranial part of the nerve, 596 Manual of Surgery. and pellets or metallic fragments may penetrate the globe and become embedded in the papilla. Fracture of the base of the skull sometimes causes injury to the nerve at the optic foramen, or behind it if the clinoid process be displaced. Any severe injury to the nerve usually occasions sudden complete blindness of the corresponding eye. If the solution of continuity be incomplete, or if the nerve be simply bruised, we may get partial or complete restoration of vision, but secondary changes often occur leading to ultimate atrophy. The opiithalmoscopic appearances differ according to the nature of the injury. If the central artery be divided the changes are like those met with in embolism of this vessel. In other cases the disc remains normal in aspect until the atrophic process reaches it, when it gradually assumes the appearance of an ordinary secondary atrophy with normal vessels. The treatment of the recent injury must be based on general surgical principles. Later on, if the continuity of the nerve has been preserved, galvanism may be of some service. Tumours. — The intra-ocular end of the nerve may be affected secondarily in sarcoma of the choroid or in retinal glioma. The most common form of tumour proper to the nerve trunk is the myxo- sarcoma. It leads to proptosis, papillitis or simple atrophy, and early blindness ; the ocular movements are usually good, and there is little or no pain. The intracranial part of the nerves and the cbiasma are especially liable to gummata, and the chiasma may also be the seat of a deposit of cheesy tubercle. Diseases op the Retina. With the exception of its blood-vessels and its pigment epithelium, the retina is almost perfectly transparent, and consequently practically invisible Retinal Hemorrhages. 597 ophthalmoscopically. Its diseased conditions may therefore be recognised by a loss of its transparency, or by changes in its circulation or in its pigment layer. Its transparency may be lost over a small or large area from haemorrhages, deposits of pigment, cedema, exudations, or fatty changes. HsBiiiori'hag'es may occur at any part of the fundus, and may be single or multiple, small or large. When recent they present a bright red appearance, but become darker with time, and undergo slow ab- sorption. If large, they may either burst into the vitreous or cause detachment of the retina. When in the nerve fibre layer they present a striated or " flame-shaped " appearance, and when in the deeper layers they are round or irregular. They interfere with vision according to their size and position, those at the yellow spot causing necessarily much impair- ment. Causes. — They may accompany inflammation of the retina or optic nerve, but are more frequently dependent on general conditions, or on retinal disease consequent on general conditions. They are generally due to rupture of vessels, as from increased intra- vascular pressure (e.g. in cases of contusion of the eye-ball, optic neuritis with much constriction of veins, violent effort, or high arterial tension), or from sudden diminution of the vitreous support (following wound of the globe), or from weakness of a degener- ated vascular wall. Diapedesis may possibly occasion visible haemorrhages in cases where there is an altered condition of the blood, e.g. in diabetes, severe antemia, leucocythsemia, purpura, pysemia, etc. They are also commonly found in association with the hsemorrhagic diathesis. The treatment must be mainly determined by the patient's general condition, but local application of ice may be employed in recent cases. 598 Manual of Surgery. Retinitis is usually tlie result of some general disease, and the classification of its forms usually adopted is a clinical one. Syniptonis. — The loss of vision, both temporary and permanent, varies much in different cases. Oph- tlialmoscopically we find loss of retinal transparency, venous dilatation, and a tendency to the occurrence of haemorrhages and white patches. The treatment depends mainly upon the patient's general condition. Complete rest must be ordered, and all strong light cut off by wearing dark neutral tint glasses. Counter-irritants and leeches to the temple are sometimes advisable. Tarieties. — 1. HcBmorrhagic retinitis occurs in association with disease or disorders of the circulatory system, and usually affects one eye only. The haemor- rhages are small and numerous. 2. Albuminuric retinitis is most commonly asso- ciated with chronic kidney disease, especially the con- tracting form, but is also frequently found in the albuminuria of pregnancy. There are numerous light- coloured, soft-edged patches in the retina ; minute, opaque, very white dots or striae at the yellow spot, arranged in the form of an asterisk, with its centre at the fovea ; and generally papillitis and haemorrhages. These changes may subside if the renal affection im- proves, those at the macula, however, lasting for a long time. In the cases associated with ])regnancy we may get perfect vision restored with a normal fundus. 3. Syphilitic retinitis usually comes late in the secondary stage, about the end of the first year or later. The ophthalmoscopic changes are generally slight : the larirer veins distended and dark, and the disc outline blurred. Very commonly there are nu- merous dust-like opacities in the vitreous. The visua 1 failui-e is considerable, and the attack lasts for months, Retinitis, 599 but the result is generally favourable. The treatment must be energetically anti-syphilitic, mercury being the remedy chiefly to be relied on. In leucocythaemia, and more rarely in diabetes, retinitis may also occur. Retinitis pig-nientosa is a term used for a disease where a certain group of symptoms and definite course are usually found in association with pigmen- tary changes in the retina. The disease is symmetrical and chronic, usually beginning in early life and ter- minating in blindness soon after middle age. Niglit blindness is the earliest and most characteristic symp- tom. There is soon loss of visual field, the central area remaining longest. Ophth. : We find a yellowish- red, " waxy " atrophy of the disc, nan-owed retinal vessels, and much pigment in the retina, black masses, shaped somewhat like bone-corpuscles, lying superficial to the retinal vessels. Galvanism is the only form of treat- 'nient of any avail ; it sometimes causes improvement both in field and in central acuity.* Thrombosis may occur in the central artery or vein, but neither form merits separate description here. We may get embolism in the central artery or in one of its branches. It is rarely bilateral, and is more common on the left side ; the usual cause is cardiac disease. In a case of complete plugging, the leading symptom is sudden blindness of one eye. Ophth. : The disc is pale, with slightly blurred edges. There is a diflPuse haze of retina, best marked in the region of the macula ; corresponding to the fovea centralis is a bright red spot. The arteries near the disc are often reduced to mere white threads. The OTi\ J treatm €71 1 that has proved sometimes bene- ficial is massage of the eye-ball, probably best perfonned by alternate prolonged, modei'ately firm, pressure over the globe and sudden removal of this pressure. In retinal detaeliment the retina proper is • For its manner of employment see page 595. 6oo Manual of Surgery. separated from its pigment epithelium, and a serous fluid usually occupies the interval. The fluid may be effused primarily as a haemorrhage, or as a serous exudation in connection with inflammation or tumour of the choroid. The common reason of detachment, however, is some alteration in the vitreous, either a mere diminution of its support to the retina, or cou- traction of connective tisssue formations within it dragging the retina away from its normal position. Retinal detachment often occurs in cases of progres- sive myopia. On illuminating the eye, with the mirror held at twelve to eighteen inches' distance from it, we find that some part of the fundus gives a blueish- grey or whitish reflex instead of the normal red seen elsewhere. This discoloured detached portion is usually folded and tremulous, and on its surface the retinal vessels run as distinct, slender, dark, tortuous lines. In a recent shallow detachment we find no such diflference in colour, but its vessels have the characters just mentioned. We should always note the extent, mobility, depth, and degree of folding of the detachment ; we are thus in a position to decide as to the probable nature of the displacing agent. Symptoms. — There is frequently a history of sudden impairment of vision. Generally the detach- ment gradually extends until there is finally complete, or almost complete, blindness. Treatment. — Rest in the recumbent position in a dimly lighted room, with a pressure bandage over the eye, is advisable in recent cases. Puncture of the sclerotic at the site of the displacement, so as to per- mit the subretinal fluid to escape, is recommended, and this certainly sometimes improves vision con- siderably for a time. Olionia of the retina is essentially a disease of early life. It commences ir.sidiously, without inflammation, grows rapidly, and if left to itself soon Chor o id it is. 6o I leads to the death of the child, spreading both cen- trally and peripherally. Diagnosis. — The attention of the parents is gener- ally first aroused by seeing a whitish reflex from behind the pupil. By this time there are often signs of second- ary glaucoma, and the eye is sometimes tender. By focal illumination we see a yellowish-white, rounded or lobulated, solid-lookmg mass in the vitreous, with blood-vessels and often small hsemorrhas^es on its surface. The vessels are distinguished from those found on a detached retina by their irregular dis- tribution, different mode of branching, greater breadth, and somewhat brighter colour. The treatment is early removal of the affected globe, with as much nerve as we can conveniently get. If the other orbital contents are affected, wdiile the nerve at the point of section appears healthy, it is advisable to thoroughly clean out the orbit and then destroy the surface with chloride of zinc paste. When the tumour has attained a large size it is often prudent to leave it alone, simply giving opiates, if necessary, to relieve pain and induce sleep. Coug^enital abiioriiiality. — Opaque nerve fibres usually occur as a brilliantly white patch, narrower at the end next the papilla, with which it is nearly always continuous. Its broader peripheral end has a teased out, bi-ush-like appearance from sepa- ration of the fibres. The affected fibres are generally above or below the disc, concecUing the large blood- vessels more or less. We get a blind spot correspond- ing to the extent of the opaque area. Diseases of the Choroid. Choroiditis. — From the absence of subjective symptoms of inflammation, its occurrence is usually diagnosed from vitreous changes, or from subsequent choroidal atrophy seen ophthalmoscopically as white, 6o2 - Manual of Surgery. yellow, or black spots or patches. These latter vary in size from mere fine points to areas much larger than the disc, and their form is round or irregular. They may occur only at the macula, at the equator, or over the entire fundus. One of the best marked clinical varieties is choroiditis disseminata^ in which the atrophic spots are generally round, white, and bor- dered by a ring of black pigment ; they occur scattered over the fundus, but principally towards the perii)hery. This variety is usually symmetrical, and in association with syphilis. Causes. — Syphilis, myopia, senile degeneration. When seen in an early stage or while the sight is still failing, the treatment should consist in rest, and anti syphilitic remedies when indicated. Purulent choroiditis leads to secondary infil- tration of the vitreous, recognised by a yellow reflex. It is often an early stage of panophthalmitis, and always leads to wasting of the globe. Causes. — Injury, septic emboli (as in puerperal fever a^nd pyaemia). A less acute form is met with in epidemic cerebro-spinal meningitis, tuberculosis, etc., leading to a whitish reflex from the vitreous and partial jDhthisis bulbi (pseudo-glioma). Treatment. — In traumatic panophthalmitis, early excision. Posterior staphyloma.— A certain amount of it is often merely a stationary congenital peculiarity, usually found with myopia, and exceptionally with emmetropia and hypermetropia. It generally occurs as a whitish crescent at the outer edge of the disc, with sharp, even boundaries and a dark border. Another form is progressive, and associated with high degrees of myopia ; here the boundaries are less marked and frequently indented, the pigment border is interrupted, and there are often other distmct patches of choroidal disease in its vicinity. Rupture of Choroid, 603 Tubercle of the choroid is generally found in the neighbourhood of the macula and papilla, and usually in both eyes. Ophth. : Yellowish - white, round, somewhat raised spots, varying much in size. Cause. — Usually miliary tuberculosis in young subjects. Rupture of the choroid, from a direct blow on the eye-ball, generally occurs near the posterior pole of the globe in the form of a crescent, with its con- cavity towards the disc. Opldli. : The lissure is white or yellowish white ; when fresh, haemorrhages are often found at or near it, but later we get a black pigmented border. Colobonia is a congenital defect at the lower part of the choroid, the result of imperfect closure of the foetal cleft. It is generally of large size, often extending from the disc to the periphery. Ophth. : We find an uneven surface of exposed sclerotic Avitli tortuous vessels on its surface, and often surrounded by black pigment. Coloboma of the iris frequently accompanies it. Tuiuours.— J/e/ano^ic sarcoma is much the most common form ; it generally occurs at or past middle life, and especially in eyes damaged by injury or disease. Usually the patient is first seen in a com- paratively late stage, with the retina largely detached, the eye glaucomatous, and the lens often cataractous. A positive diagnosis is then difficult, and we must rely chiefly upon the history. Whenever we have reason to suspect its presence, we should excise at once. If the nerve at the point of section be afiected, and still more if the tumour have perforated the outer coats of the eye-ball, all the contents of the orbit must be removed, and chloride of zinc paste applied. 6o4 Manual of Surgery. Diseases op the Vitreous. Opacities in the vitreous are generally due to inflammatory afiections of this structure, occurring secondarily to disease of the ciliary body, choroid, retina, or optic nerve. They are common in cases of high myopia. They may also be the result of haemor- rhages (from rupture of retinal or choroidal vessels), or of degeneration, especially senile. Occasionally we get cholesterin crystals in a fluid vitreous, appearing as a sparkling golden shower on movements of the eye {syiichysis scintillans). All vitreous opacities are best examined with a plane or slightly concave mirror held at twelve to eighteen inches from the patient's eye. On his turning his eye smartly upwards^ downwards, or laterally we detect the opacities against the red background as dark webs or dots which are still in motion after the eye has come to rest. By their rapidity and extent of movement we can judge of the consistence of the vitreous. Sometimes the opacities are very minute, like small dust particles difi'used throughout the vitreous, e.g. in specific choroiditis ; these are well seen by using a strong convex lens ( 4- 18D) behind our mirror held close to the patient's eye so as to focus them accurately. Symptoms. — He generally complains of seeing bbck specks floating about, and sometimes, especially where the opacities are large and central or diff*use, vision is much reduced. Treatment. — Heurteloup's leech to the temple, along with the remedies appropriate to the exciting cause. The dust-like opacities associated with specific disease usually disappear under a mild mercurial course. Suppurative hyalitis occurs from injury or from a purulent choroiditis. We get a yellowish reflex from the j)urulent deposit, the tension is reduced, and Gla ucoma. 605 there is generally iritis. The prognosis is unfavour- able, the eye being usually lost. Foreign bodies in the vitreous.— If the eye have sufiered irreparable damage, and vision be much aflfected, early excision is best. Where the lens and ciliary region have escaped, and there is no evidence of iritis or choroiditis, we may try to remove the foreign body. If it be of steel or iron, the electro- magnet is exceedingly useful for this purpose. If it be of other metal, or of glass, etc., it will be found extremely difficult to effect its removal, unless placed well forward in the equatorial region. If evident inflammation of any part of the uveal tract occur the eye should be excised. Cysticercus is sometimes found in the vitreous, but it is very rare in this country. Persistent hyaloid artery occasionally is met with, appearing as an opaque cord running forward from a branch of the central artery on the disc. Glaucoma. "We have already mentioned the occurrence of secondary glaucoma in several ocular affections ; we have now to consider the primary form of the disease. Symptoms and mechanism.— Primary glau- coma consists mainly in an increased tension of the eye-ball due to excess of fluid within the vitreous chamber, and is most apt to occur when the sclerotic is unyielding and thick, as in old hypermetropic eyes.* * In examining tension the patient stands facing us with head erect, and looks down towards his feet. We now place one finger of each hand on the upper lid of the eye to be examined, as near the upper orbital margin as possible, and press the globe lightly down- wards. Each finger is used alternately simply to steady the globe, and to estimate the resistance offered to light pressure when steadied by the other finger. The tension of the two eyes should always be compared. The student should thoroughly acquaint himself with the average tension of the normal eye, so that he may have a mental standard with which to compare alterations in disease. 6o6 Manual of Surgery. This excess of fluid is partly due to increased secretion and intra-ocular vascular congestion, partly to diminished escape. Continued high tension in the vitreous chamber will mechanically aflfect every part of its enclosing walls. The soft ciliary body soon yields to it, and we get rapid failure of accommoda- tion (shown by increase of presbyopia), often a valu- able early symptom of the disease. The ciliary nerves are also affected by the pressure, and this result as- s'sfcs in diminishing the accommodation, besides lead- ing to dilatation and inactivity of the pupil, and to corneal anaesthesia. A sudden access of tension inter- feres with the circulation in the choroidal vessels, and we consequently get congestion of the perforating and other branches of the anterior ciliary veins outside the globe. The lens is pushed forward by the pressure behind, and the anterior chamber rendered shallow in consequence. The peripheral part of the iris is also pressed forward, and often becomes adherent to the inner surface of the cornea. The optic nerve and lamina cribrosa, being of less resisting power than the sclerotic, ultimately yield, leading to cupping and atrophy of the disc. The intra-ocular tension being as great as, or even greater than, that in the central retinal artery except during systole, we get arterial pulsation evoked by gentle finger pressure on the globe, or occurring spontaneously. From the impeded blood supply, and the pressure on nerve fibres, there is loss of function, the nasal field being first affected. Other symptoms of glaucoma are steaminess of the cornea and pain, and the patient often sees coloured halos round a flame. The pain varies greatly in different cases, being sometimes absent, and sometimes very severe, referred to the eye, occiput, and back par- ticularly, and often then associated with sickness and vomiting. Course. — Glaucoma is distinctly a progressive Gla ucoma. 607 disease, leading to blindness, but the rate of its progress and the severity of its symptoms are liable to much variation in different cases, and often in the same case at diflferent times. In consequence of this variability, different forms of the affection are described as acute, subacute, and chronic. In the acute form the symp- toms appear suddenly, and are very severe, the con- gestion and pain being especially marked, and the tension very high. Vision fails rapidly, and is generally abolished in a week or so if the acute symp- toms continue, and sometimes even in a few hours {G. fuhninans). lu chronic, or simple glaucoma there is no congestion and seldom pain ; the tension is never very high, and all the other symptoms are propor- tionately modified and the progress gradual, lasting for months or years before causing total blindness. The subacute form is intermediate in severity, and is the most common in occurrence, frequently, indeed, ap- pearing intermittently in an otherwise chronic case. There are considerable congestion and pain, and the vision fails rapidly ; such an attack, if continuous, leads to complete blindness in a few weeks. Glaucoma usually attacks both eyes, though not necessarily in the same form, and often with a long interval. The second eye is especially liable to an attack immediately after an operation {e.g. iridectomy or excision) on the one first affected. Oeiieral cauiscs. — It seldom occurs before forty- five years of age, and is most common in women and in hypermetropic eyes. Grief, anxiety, overwork, or the local use of atropine, are apt to bring on an acute attack in those otherwise predisposed. Its subjects are often gouty. The different theories as to the patho- logical origin of glaucoma cannot be discassed here. The fundamental aim of all such theories is either to explain a hypersecretion of the intra-ocular fluids, or to account for their abnormal retention within the globe. 6o8 Manual of Surgery. T'reatment.— Iridectomy gives much the most satisfactory results, and often affords permanent relie£ The incision should be made well behind the apparent corneal margin, and the excised piece of iris removed well up to its ciliary attachment. This operation is particularly indicated in all acute and subacute cases, and should be performed at the earliest possible op- portunity. When a painful glaucomatous eye is per- manently blind, iridectomy may be done for relief of pain, but enucleation is usually preferable in such cases. In true chronic glaucoma treatment is often of no avail, but even here iridectomy is always worth trying, as it is more likely than anything else to give relief. Some surgeons prefer sclerotomy in this form of the disease, the operation consisting practically in a large incision through the anterior part of the scle- rotic, without iridectomy. Userine is often service- able by keeping the tension temporarily diminished in the more acute cases, when for some reason iridectomy must be deferred. It may also be used in chronic forms as a preliminary to, or instead of, operation.* Eserine should always be employed as a prophylactic agent for the one eye when the other requires opera- tion for increased tension ; in such a case it is suffi- cient to use it just before, and for two or three days subsequent to the operation. In all cases of glaucoma rest must be insisted upon, errors in diet avoided, and causes of mental excitement, as far as possible, re- moved. Atropine and similar mydriatics must never be used where a predisposition to glaucoma exists^ still less when the disease is actually present. • In glaucoma I have found a solution containing eserine and cocaine serviceable, the latter (by its stimulant action on the sym- pathetic nerves) presumably preventing the internal vascular con- gestion usually caused by eserine. Such dilatation of pupil as cocaine would naturally cause, is readily overcome by very weak eserine. R Cocain. hydrochlor. gr. v ; eser. sulphat. gr. j ; aq. destUl. 3j. One drop four to six times daily. Errors of Refractiox. 609 Errors of Refraction and Accommodation. The eye sees by virtue of the rays of light which have passed through its pupil and reached its retina. For the formation of defined images, it is necessary that the rays coming from an object be accurately focussed on the outer segments of the rod and cone layer ; the normal or eynmetropic eye, with relaxed accommodation, is such that parallel rays are so fo- cussed. In myopia the retina is placed too far back, so that ]:iarallel rays come to a focus in front of it, and the resulting retinal image is consequently ill-defined. In hijpei'metropia, on the contrary, the antero-posterior measurement of the eye is too short, so that the rays have not yet come to their focus when they reach the sentient retina, and a blurred image is again the re- sult. The rays coming from every point of an object are divergent, but when such object is situated at several feet distance from the eye, those passing through the pupil may, for all practical pvir- Ijoses, be considered parallel. It is usual to place our test object at six metres (or twenty feet) in testing the refraction of the eye at rest. To be accurately seen by the average eye, an object must be of such a size that it subtends an angle of five minutes, the apex of the angle being situated near the i)osterior pole of the lens, where the rays coming from all eccentric points of the object cross the principal axis. The test types usually employed (Snel- len's) are made on this principle, and we express the visual acuity (V) by a fraction, the numerator corresponding to the distance (in metres or feet) between the patient's eye and the test, the denomi- nator being the distance at which the type ought to be distin- guished by the normal eye. Thus, with normal vision, V = § (or |§), but if the smallest type read at six metres is that which ought to be distinguished at twelve or at sixty metres, V = ^% or ^ ; i.e. = ^ or ^th of normal vision. Each eye must always be tested separately. We cannot here consider the subject of optics further than to remind the student that an ordinary convex or + lens renders divergent rays less divergent, parallel, or convergent, according to the amount of the divergence of the original rays and the strength of the lens. Kays already parallel it brings to a focus at a dis- tance varying inversely with the curvature of the lens. By in- creasing the curvature of a lens, therefore, we augment its etfect NN— 21 6io Manual of Surgery. on divergent rajs, ami render its focussing distance for parallel rays shorter. An ordinary concave or — lens increases the diver- gence of already divergent rays, and makes pai'allel rays diverge as if coming from a point in front of the lens ; the inteival between this point (or virtiuil focus) and the lens is the focal distance of the lens in question. A lens, whose focal distance is one metre, is called one dioptre (1 d), and is the unit of the metric system now ■generally adopted ; a lens of two dioptres (2 d) is, therefore, twice the strength, or one-half the focal distance. Enimetropia (^E) and presbyopia [Pr). — Were it not for the power of accommodation, the normal eye would be incapable of seeing near objects dis- tinctly, as the rays would be too divergent. By the action of the ciliary muscle, however, the curvature of the crystalline lens can be increased, so that rays of very considerable divergence can be brought to a focus on the retina. This temporary increase in cur- vature (or accommodation) is dependent on the elas- ticity of the lens substance, and diminishes with age. Whenever it has failed so much that objects must be placed at nine inches or more from the eye so as to be clearly seen, the condition of presbyopia is said to exist, and the increased curvature required must be artificially supplied by suitable convex glasses. Pres- byopic glasses of Id are necessary in the emmetropic eye at about 45 years of age, and they require to be increased by about Id for each five years of life up to the age of 60, and afterwards by 0'5d for each subsequent five years. Hypermetropia. — Although all objects must ap- pear indistinct to thehypermetrope with relaxed accom- modation, he is able to see distinctly by an effort of his ciliary muscle provided he be still young and the hypermetropia not very large in amount. Some such effort is necessary even for distant objects, but a greater is required for all near vision. In as far as convergence and accommodation are naturally consen- taneous acts, such a hypermetrope is apt to develop a convergent concomitant squint, and a continuance of Myopia. 6 i i the accommodative effort leads to fatigue, supra- orbital headache, and occasional blurriiiir of imairoy from failure to maintain the accommodation neces- sary. The glass suitable for such an eye is a convex one, of such a strength that jjarallel rays will, by its aid, be focussed on the retina without the use of accommodation. To overcome all action of the ciliary muscle in young people it is necessary to use atropine, but the full correction found under its use should not be ordered, a glass of 1 D less than this being most suitable. The hypermetrope should wear his glasses constantly. Myopia.— For distinct vision the object must be comparatively near the eye, so that the rays coming from it and passing through the pu[)il have such a divergence that they will be focussed on the retina. Distant objects can only be rendered distinct by the aid of a concave lens, and the weakest that will give this result must be the one ordered. Should there be insufficiency of the internal recti, prisms with their bases inwards are often very serviceable for near work. Astig^iiiati^ni. — In regular astigmatism one meridian of the eye is of less refractive power than any other, and at right angles to this is the meridian of greatest refraction. If one meridian be emmetropic while the opposite is myopic or hypermetropic, we have respectively simple myopic or simple hypermetropic astigmatism. If both such meridians be unequally myopic the condition is called compound myopic astigmatism ; if both be unequally hypermetropic we have compound hypermetropic astigmatism. Again, if one meridian be hypermetropic, while that at right angles to it is myopic, the case is one of mixed astig- matism. The consequence of astigmatism is that no object is seen with perfect distinctness, but any straight line will be comparatively well defined if at a Buitable didance from the eye. The correcting glass 6i2 Manual of Surgery. required is a cylindrical one (-f or — ), witli a spherical in addition where the astigmatism is com- pound or mixed. Affections of Ocular Muscles. Convergent strabismus of a concomitant nature has already been mentioned when considering hypermetropia. It usually first appears in early child- hood, and may only be periodic, or worse during strong accommodative efforts, but sometimes it is constant in presence and in degree. If both eyes see equally well, it is often alternating, affecting sometimes one, some- times the other eye. In the constant form, diplopia is generally avoided by a mental suppression of the image from the squinting eye, which latter conse- quently becomes defective. Occasionally the squint disappears spontaneously after some years. Treatment. — The glasses required for the hyper- metropia are usually sufficient to prevent a concomi- tant squint if given sufficiently early. When the squint persists, however, after using glasses for some time, one internal rectus should be divided, and if this be insufficient the other eye may also be operated on some weeks later. Divergent strabismus not infrequently occurs in myopia from insufficiency of the internal recti ; here, again, diplopia seldom exists when the squint is constant. The treatment consists in giving the requi- site glasses and dividing one or both external recti. Divergent strabismus also often afJects an eye whose vision is defective, as from corneal opacities. Ocular paralysis. — Paralysis of the nerves supplying the extra-ocular muscles leads to strabismus, and to di[»l.opia, whicli latter is always more trouble- some when the strabismus is slight, i.e. when the double images appear close together. The false image is always displaced in the direction in which the Stka bjsmus. 6 1 3 affected muscle would act were it not paralysed. The strabismus is due to the unopposed action of the sound muscles. Such a paralysis is usually uni-ocular. The whole of the third nerve is seldom equally affected, one or more branches generally suffering more than the others. Very rarely we get all the extra-ocular muscles paralysed {ophtludmoplegia externa) in both eyes. Paralysis of the intra-ocular muscles. — The iris (sphincter and dilator) and the ciliary muscle may be affected separately or together. In third nerve par- alysis the sphinctor iridis and ciliary muscle are usually both affected. Paralysis of all three intra-ocular muscles (ojihthalmoplegia interna)!^ occasionally found. Causes. — Syphilis is a frequent source of these affections, either by a periostitis (at the base of the skull or at the sphenoidal fissure) or by gummata somewhere in the course of the nerves or at cerebral centres. Other causes are meningitis, orbital or intra- cranial tumours and fracture of the skull. Some cases are said to be rheumatic in origin. Paralysis of the ciliary muscles (cycloplegia) is not uncommon after diphtheria. In an early stage of tabes dorsalis, tem- porary localised extra-ocular paralyses are sometimes observed, and in a later stage of this affection we get a form of iridoplegia in which the pupils do not re- act to light, but still contract on convergence of the eyes. Treatment. — Where syphilis is a possible cause •we should give a course of mercury and iodide of potassium. Galvanism may also be employed. In stillation of a weak solution of eserine {h or 1 gr. to the ounce) is useful in post-diphtheritic cycloplegia. In some incurable cases the diplopia may be prevented by the use of prismatic glasses, and the pupil may be restored to its normal size and the ciliary muscle stimulated by a solution of eserine of an appropriate strength, accordinor to the effect desired. N X*— 2] 6i4 Manual of Surgery. Nystag^iiiu^, or involuntary oscillation of tlie eye-ball, may be vertical, horizontal, or rotatory. It is generally due to congenital or early infantile defect of vision, and usually affects both eyes. It is also occa- sionally found in coal miners, pro'l3ably from the com- bined influence of insufficient light and of a constantly strained unnatural position of the eyes when at work. This latter form may be cured by change of employment, but ordinary nystagmus does not yield to treatment. Diseases of the Orbit. Periostitis usully affects the orbital margin, and is most common in sti'umous children ; sometimes it IS due to injury or syphilis. Symptoms. — Dull pain, circumscribed swelling with redness, and much tenderness to finger pressure. At first the swelling is hard, but it usually softens later on the foiTaation of pus, and on puncture bare bone may be detected by the probe. If the disease be deep in the orbit, the general symptoms are more severe, and the eye-ball is pushed forward or displaced laterally. Course. — As a rule such cases do well, but some- times deeply seated periostitis or caries may cause optic atrophy, or even endanger life by the inflamma- tion spreading to the meninges or causing venous thrombosis. Treatment. — Poulticing or hot fomentations. Earlv evacuation of pus. Constitutional treatment as indicated. Orbital cellulitis. — Symjjtoms. — Proptosis and impaired movements of globe, conjunctival chemosis, redness and swelling of lids ; severe localised pain and general fever. On pus forming, we find a circum- scril)ed, fluctuating, conjunctival bulging. Sometimes we get optic neuritis, or even purulent choroiditis, and still more rarely we may have pyaemia or purulent meningitis. Diseases of the Orbit. 615 Causes. — WouuJs, spreading of inflammation from a neighbouring cutaneous erysipelas or from caries. Sometimes it is metastatic, as in splenic fever, glanders, or pyaemia. Treatment. — As of last affection. Tumours in this situation usually cause prop- tosis and impairment of ocular movements, and often lead to papillitis or optic atrophy. Both orbits are rarely affected. The i^imary tumours are cystic (dermoid, cysticercus), sarcomatous, bony (ivory exos- tosis), and vascular. In the vascular variety we usually get a bruit heard over the orbit and adjacent part of the skull, and often visible pulsation. The secondary tumours arise in the globe itself or in the neighbouring parts. Many of the vascular tumours here are intracranial in origin, the most common being arterio-venous aneurism from rupture of the internal carotid into the cavernous sinus, generally caused by fracture of the base of the skull. Treatment. — Cysts may be evacuated by free incision (after needle puncture so as to eliminate the remote possibility of its being an encephalocele). Exostoses, when not attached to the thin upper wall, and wlien their base is narrow, may be removed. Malignant tumours slioukl be removed early along with the eye-ball and all the orbital contents, and chloride of zinc paste then applied. In many vascular tumours ligature of the common carotid is advisable ; digital compression may be tried as a preliminary. INDEX TO VOLUME II. Abscess, Iliac, 43 >, 43*^ , Lumbar, 436, 438 of bone, 101, 104, 107, 112 , Psoas, 436 Acetabulum, Fracture through, 61 Acromion, Fracture of, 38 Amputation in joint disease, 269, 295 Aneurism of bone, 144 Angina Ludovici, 477 Ankle, Dislocation of, 201 joint, Strumous disease of, 302 Ankylo-blepbaron, 543 Arthritis, 235 , Acute, of infants, 238, 239 Astigmatism, 611 Astragalus, Dislocation of, 205 , Fracture of, 92 Atrophy of bone, 130, 136 Auditory meatus, Atiections of, 527 , Foreign bodies in, 527 Aural catarrh, 531 polypi, 536 Auricle, Diseases of, 536 Back, Injuries of, 447 , Sprains of, 449 Bfed-sores in spinal injuries, 465 Bladder in spinal injuries, 462 Blephantis, 540 Blepharospasm, 544 Bone, Abscess of, 101, 104, 107, 112 , Atrophy of, 130, 136 , Contusions of, 27 , Cysts of, 148 , Diseases of, 93 ■ , Exfoliation of, 124 , Fibrous tumours of, 148 , Hypertrophy of, 128, 137 , Inflflmmation of, 93 , Pulsative tumours of, 143 Bone, Sarcoma of, 140, 141 , Sclerosis of, 101, 104, 110 , Scrofula of, 13 L , Syphilis of, 134.J136 , Tubercle of, 131 ■ ■, Tumours of, 140 , Wounds of, 26 Bow legs, 361 Bowel in spinal injuries, 463 Brain, Compression of, 401, 409 410, 412 , Concussion of, 401, 402, 410 , Contusion of, 4C7 -, Inflammation of, 406, 4 16 , Irritation of, 404 , Laceration of, 401, 409 , Topography of, 423 Bronchocele, 491 Bryant's triangle, 65 Bursae, Diseases of, 319, 321 Bursitis, 319 Callus, 18 Caries, 101, 104 f ungo?a, 107 necrotica, 107 of nose, 515 of skull, 372 sicca, 106 Carpus, Fracture of, 59 Cataract, 683 , Causes of, 585 , Treatment o% 586 , Varieties of, 583 Cephalhsematomata, 367 Cerebral tumours, Eemoval of 378 Chalazion, 546 Choroid, Diseases of, 601 Choroiditis, 601 Ciliary region, Diseases of, 579 Clavicle, Dislocation of, 167, 171 , Fracture of, 32 , Separation of epiphysis of, 35 Index. 617 Cline's splint, 88 Chib foot, 338 hand, 338 Coccyx, Fracture of, 62 Colles' fracture, 53 Coloboma, 545, 578, 603 Compression of braiu, 401, -109, 41(1, 412 Concussion of brain, 401, 402, 410 of spinal cord, 470 Conjunctiva, Diseases of, 549 Conjunctivitis, 549 Contusions of joints, 149 Cornea, Abscess of, 569 , Conical, 571 , Diseases of, 562 , Injuries of, 572 , Ulcers of, 565 Coryza, 510 Cranial nerves, Injuries of, 418 Cranio-tabes, 137 Cranium, Contusions of, 391 Croft's splint, 10 Croup, 503 Cut-tkroat, 473 Cyclitis, 579 Cyphosis, 336, 445 Cysts of bone, 148 of neck, 480 Deaf mutism, 538 Deafness, 633, 539 Dermoid cysts of sculp, 3 58 Digits, Deformities of, 363 Diphtheria, 503 Dislocations, 158 , Causes of, 159 , Complications of, 160 , Special. (See indixidi.al joints and bones.) , Symptoms of, 160 , Treatment of, 161 unreduced, 163 Distichiasis, 542 Dupuytren's contraction, 318 fracture, b7, 202 splint, 90 Dura mater. Fungus of, 375 Ear, Diseases of, 524 Ectropion, 544 Elbow, Dislocation of, 180 joint, Disease of, 273 Emmetropia, 610 Encephalitis, 416 Encephalocele, 370 Enchondroma, 147 Ivndosteitis, 114 Eutropiou, &43 Epicanthus, 545 Epiphora, 547 Epiphysitis, 117, 119, 238 Epistaxis, 507 Eustachian catheter, 533 Excision of joints, 263, 293 Exostosis, 145 Eye, Diseases of, 540 Fasciae, Conti-action of, 318 , Injuries of, 317 Fat embolism, 15 Femur, Dislocation of, 186 , Fracture of, 63 , Separation of epiphyses of, 69, 71, 77 Fibrous tumours of bone, 148 Fibula, Dislocation of, 2ul , Fracture of, 86 Flat foot, 352 Follicular ulcer of scalp, 367 Foot, Dislocation of, 201 Fractures, 1 , Causes of, 3 , Complications of, 13 , Compound, 1, 11 , Delayed union of, 22 , General treatment of, 7 , Greenstick, 1 , Intra-uterine, 5 , Non-union of, 23 of skull, 398 , Repair of, 18 , Special. (See individual bones.) , Symptoms of, 5 , Union of, with deformity, 25 , Varieties of, 1 Fragilitas ossium, 130 Fungus of dura mater, 375 Ganglion, 315 Genu valgum, 356 varum, 361 Glaucoma, 605 , Causes of, 607 , Course of, 006 , Symptoms of, 605 , Treatment of, 608 Goitre, 491 Gronorrhoeal synovitis, 229 Gout, 219 Hallux valgus, 361 varus, 361, 363 Hammer toes, 36.3 Head, Diseases of, 365 , Injuries of. 3S0 6i8 Manual of Surgery. Hereditary syi)Lilis, Boue dis- eases of, 136 Hernia cerebri, 419 Hip, Disease of, 277 , Dislocation of, 186 Hodgen's splint, 76 Hordeolum, 541 Horns, 368 Humerus, Dislocation of, Vi'l , Fracture of, 41 Hyalitis, 604 Hydrencephalocele, 370 Hydrocele of neck, 481 Hydrocephalus. 376 Hydrops articuli, 232 Hypermetropia, 610 Hypertrophy of bone, 128, 137 Internal ear, Diseases of, 537 Iris, Diseases of, 573 , Injuries of, 577 , Tumours of, 577 Iritis, 573 , Eesults of, 576 , Varieties of, 575 Jaw, Dislocation of, 165 , Fracture of, 28 Joints, Contusions of, 119 , Diseases of, 210 , Dislocation of, 158 , , Causes of, 159 , , Comj)licatio*.is of, KJO , , Symptoms of, 160 , Injuries of, 149 , Sprains of, 150 , Tumours of, 260 , Woiinds of, 152 Keratitis, 562 , Interstitial, 570 punctata, 569 Knee, Dislocations of, 197 joint, Disease of, 297 Knock knee, 356 Kyphosis, 336, 445 Laceration of brain, 401, 409 Lacrymal abscess, 548 apparatus. Affections of, 547 , Bone, fracture of, 27 gland, Affections of, 546 Laryngitis, 502 Larynx, Affections of, 495 , Excision of, 502 , Foreign bodies in, 496 , Fractures of, 495, 496 , Iiifliimmation of, 502 • , Scalds of, 495 Larynx, Tumours of, 500 , Wounds of, 474 Lateral curvature of spine, 327 Lens, Diseases of, 583 , Injuries of, 588 Leontiasis ossea, 129 Lids, Affections of, 540 Lipoma nasi, 521 Listou's splint, 74 Loose bodies in joints, 250 Lordosis, 336 Macintyre's splint, 75 Malacosteon, 138 Malar bone, Fracture of, 28 Marrow, Inflammation of, 114 Mastoid process. Diseases of, 536 Medullitis, 114 Membrana tymi^ani, Affections of, 535 Meniere's disease, 537 Meningitis, 416, 454 Meningocele, 370 Metacarpvis, Fracture of, 59 Metatarsus, Dislocation of, 209 , Fracture of, 92 Mollities ossium, 138 Morbus coxae, 279 IMumps, 487 Muscles, Atrophy of, 3<>6 , Hypertrophy of, 306 , Inflammation of. 305 , Ossification of, 310 , Rupture of, 304 , Tumours of, 310 , Woimds of, 301- IMyeloid sarcoma, 141 Myopia, 611 Myxcedema, 491 Nasal bones, Fracture of, 27 catarrh, 510 cavities. Tumours of, 516 duct, Strict'ires of, 548 polypi, 516 Neck, Cellulitis of, 477 , Contusions of, 472 , Diseases of, 472 , Iij juries of, 472 , Tumours of, 480, 485 , Wounds of, 472 Necrosis, 120 , Acute, 98, 115 of nasal bones, 515 of skuU, 373 , Phosphorus, ?28 , Quiet, 127 N^laton's line, &5 Nerves, Cranial, Injuries of, 418 Index. 619 Nodes, P6, 133, 134, 137 Nose, Atiectious of septum of, 521 , Deformities of, 520 , Diseases of, 507 — — , Foreign bodies iu, 500 , Wounds of, 507 Nystagmus, 614 Ocular muscles, Affections of, 612 , Pnralysis of, 612 Olecranon, Fracture of, 57 Ophthalmia, Diphtheritic, 556 , Gronorrhceal, 551 ^—, Granular, 554 • neonatorum, 553 , Purulent, 550 , Simple, 549 Ophthalmoplegia. 613 Optic neuritis, 589 • nerve. Atrophy of, 592 , Diseases of, 589 , Injuries of, 595 • , TumouTB of, 5.% Orbit, Diseases of. 614 ■ , Periostitis 01, 614 , Tumours of, 615 Orthopaedic surgery, 324 Os calcis. Fracture of, 92 Osteitis, 93, 100, 104 deformans. 129 of skull, 391 Osteo-aneurism, 143 -malacia, 138 myelitis, 114, 115 porosis, 101, 104 sclerosis, 101, 104, 110 Osteoma, 145 Osteophytes, 96, 137 Osteoplastic osteitis, 101, 104, 110 Osteotomy, 359 Othaeujatoma, 530 Otorrhagia, 528 Otorrhoea, 535 Ozaena, 514 Pachydermatocele, 368 Palmar fascia. Contraction of, 318 Papillitis, 587 Paronychia tendinosa, 314 Parotid gland, Inflammation of, 487 . , Tumours of, 488 Parrot's nodes, 137 Patella, Dislocation of, 195 , Fracture of, 78 Pelvis, Fracture of, 60 Pericranium, Injuries of, 390 Periosteal abscess, 95 Periosteal nodes, 96, 133, 134 Periostitis, 94—98 • of skull, 391 Phalanges, Fracture of, 60, 92 Phlyctenular affections of eye, 560 Phosphorus necrosis, 128 Pinguecula, 559 Pneumatocele, 369 Politzerisation, 532 Pott's disease of spine, 432, 445 fracture, 86, 89, 202 Presbyopia, 610 Priapism, 464 Pseudo - hypertrophic paralysisj 308 Psoas abscess, 436 Pterygium, 559 Ptosis, 545 Pulpy degeneration of joints, 249 Quiet necro.-is, 127 Radius and ulna. Fracture of, 5 , Dislocation of, 180, 183 , Fracture of, 52 Railway spine, 452, 471 Rarefying osteitis, 101, 104 Refraction, Errors of, 6<,>9 Repair of fractiu-es, 18 Retina, Detachment of, 509 , Diseases of, 596 , Glioma of, 6aj Retinitis, 598 pigmentosa, 599 . Varieties of, 59S Rhinitis, 510 Rbinolith, 510 Sacro-coccygeal joint. Injuries of, 469 tumours, 431 Sacrum, Fracture of, 62 Salivaiy glan«1s, Aflections of, 487 Sarcoma of bone, 140, 141 Saj-re's jacket, 4U Scalp, Abscess of, 366 , Cellulitis of, 365, 388 , Contusions of, 381 , Erysipelas of, 365 , Hcematoma of, 366, 382 , Inflammation of, 388 , Injuries of, 380 , Tumours of, 366 , Wounds of, 384 Scapula, Fracture of, 38 Sclerosi-*, lol, 104, 110 Sclerotic, Diseases of, 578 Scoliosis, 327 Scrofula of bone, 131 620 Manual of Surgery. Scrofulous diseases of joints, 242 Sebaceous cysls, 367 Semilunar cartilage, Dislocation of, 200, 256 Sequestrotomy, 126 Sequestrum, 124 Shoulder joint. Disease of, 271 Skull, Diseases of, 372 , Fracture of, 893 of base of, 393 of, Varieties of, 395 , Hypertrophy of, 376 , Injiu:ies of, 393 , Osteitis of, 391 , Tumours of, 373 Spina bifida, 427 veutosa, 109 Spinal coid, Concussion of, 470 , Inflammation of, 454 , Injiiries to, 460 Spine, Caries of, 432, 445. , Ciurvatiures of, 327, 335, 336 , Disease of cervical, 442 , Diseases of, 427 , Dislocation of, 457, 4G7, 469 , Fracture of, 457, 467, 469 , Injuries of, 447 , Pott's disease of, 432, 445 , Eailway, 452, 471 , Sprains of, 4i9 Spondylitis deformans, 445 Sprain-fractiu'es, 150 Sprains, 150 Staphyloma, Posterior, 602 Strabismus, 612 Strumous node, 133 Stye, 541 Subastragaloid dislocation, 207 Supracondyloid fracture of hume- rus, 47 Surgical neck of humerus. Frac- tures of, 42 Sutures, Separation of, 400 Symblephxiron, 559 Sympathetic alfections of eye, 581 Synovitis, Acute, 210 , Chronic, 211 , GonorrhcEal, 229 , Gouty, 219 in specific fevers, 229, 231 , Puerperal, 229 , Pyaemic, 227 SjTiovitis, Rheumatic, 215, 217 , Scrofulous, 242 , Syphilitic, 224 Sypbilis of joints, 224 Syphilitic disease of bone, 134, 136 Talipes, 338 calcaneus, 351 cavus, 355 equinus, 342 valgus, 352 varus, S45 Tarsotomy, 341 Tarsus, Fracture of, 92 Tt etb in syphilis, 137 Tendons, Dislocation of, 312 , Injuries of, 311 Teno-syuovitis, 313 Tenotomy, 34J Thumb, Dislocation of, 185 Thyroid body, Affections of, 490 Tibia and fibula, Fracture of, 85 Fracture of, 85 Tinnitus auriutn, 538 Toe, Deformities of, 361 Torticollis, 324 Trachea, Foreign bodies in, 496, 498 , Wounds of, 474 Tracheotomy, 504 Ti'achoma, 554 Trephining, 421 Trichiasis, 542 Tubercle in bone, 131 Tumours of bone, 140, 145 of joints, 260 Ulna, Dislocation of, 180, 182 — — , Fracture of, 57 Vision, Errors of, 609 Vitreous, Diseases of, 604 , Foreign bodies in, 607 , Opacities in, 604 Whitlow, 314 Wounds of joints, 152 Wrist, Disease of, 275 , Dislocation of, 184 Wry neck, 324 Xerophthalmos, 558 PBIXTKD by CA88ELL & COMPANY, LlMITKD, La BELLK SaUTAQK, LON'DOS, E.O lo. 1191 / rreves T7^ V.2 ilES(hsl.stx) RD31T72 1892C.1v. 2 A manual of surqef 2002189313 ^