meant: (a) faulty position which remains uncorrected in utero (congenital traumatism);

(b) Cicatricial contraction of the muscles in whose line of contraction the deformity exists (acquired traumatism), induced by inflammation following wounds, etc.

What is the treatment, in general, of club-foot?

In young patients restoration to the normal position is best brought about by manipulation and application of proper apparatus. In older patients or in whom the parts are rigid, tenotomy of the contracted tendons may be necessary, or even an open operation whereby all tendons and ligaments opposing reduction are cut; or even resection of bones may be advisable. Plaster-of-Paris bandage is the after-treatment of such cases.

What are hammer-toe and hallux valgus?

The former is a condition of extreme flexion of the second phalanx and extension of the first of one or more of the smaller toes. Tenotomy. or excision of the joint or amputation is the

treatment.

Hallux valgus is extreme abduction of the great toe at the metatarso-phalangeal joint. Excision of the joint or osteotomy of the metatarsal bone, with subsequent straightening of the toe and application of a plaster-of-Paris bandage, is the treatment.

What are the principal deformities of the spinal column?

Lateral curvature, or skoliosis; curvature forward (concavity looking backward), or lordosis; curvature backward (convexity looking backward), or kyphosis. The last two occur in the lumbar region as a rule, and are rather rare except as complicating some other process, as rickets, acromegalia, Pott's disease, etc. Skoliosis, on the other hand, is very common as a primary affection, and begins in youth. The general health is not necessarily affected, nor is there any inflammation of the vertebræ. The column is simply weak and bends laterally in various ways. The intervertebral disks are compressed, and there is rotation of the bodies of the vertebræ on one another, so that their anterior surfaces look toward the convexity, while the spines of the vertebræ look toward the concavity of the curve.

What are the causes?

Muscular or nervous weakness or habitual faulty position, or the

deformity may be secondary to some definite disease of the vertebræ, of the back muscles, or of the central nervous system.

What is the treatment?

Uncomplicated primary skoliosis is treated by systematic massage and exercise of the muscles, both passive and active, all under careful supervision. Diet and general hygiene are also important.

Discuss excision of joints.

There are various ways of performing "arthrectomy," or excision of a joint, even for one joint. For the knee, a flap of skin and fat should be raised U-shaped, the lowest part on a level with the tubercle of the tibia and each extremity reaching to the corresponding tuberosity of the femur. The quadriceps extensor is then cut through and the joint opened above the patella, which is turned down and removed. Extreme flexion is now made, and a slice sawed off from the femur and tibia, whose raw surfaces are now approximated by straightening the limb and held in position by silver-wire sutures or steel nails. The wound is closed and the limb enveloped in plaster of Paris for eight weeks. The result, of course, is a perfectly stiff limb from the hip to the ankle.

For the other joints the best average incision is the long straight posterior one, through which the joint is opened and the bony surfaces removed.

INJURIES AND DISEASES OF TENDONS

BURSE AND MUSCLES.

What are the causes and symptoms of rupture of tendons and muscles?

Sudden strain, violence, powerful muscular contraction as in tetanus. Rupture of a muscle or tendon is accompanied by a sharp pain, disability, ecchymosis, and a groove or depression at the site of rupture.

What is the treatment?

Rest and approximation of the edges. In severe cases open the tissue above the rupture and suture the torn structure; put the limb in an immovable splint.

What is the treatment of incised and lacerated wounds involving tendons and muscles?

The parts should be placed in a position to relax the muscles and the divided tendons and muscles sutured. In suturing tendons the proximal end should be overstretched, so as to bring the ends together. Tendon that has retracted into its sheath should be pulled down or the sheath opened. If the upper end of a torn tendon cannot be found, the lower end should be united to a neighboring tendon or muscle.

What are the causes of dislocations of tendons and muscles?

Sudden strains brought to bear on a tendon passing around a bony prominence, as the long head of the biceps of the arm or the peroneal tendons.

What is the treatment?

Reduction by relaxation of the muscle and a fixation dressing. In obstinate cases fixation by sutures, or even tenotomy, may be called for.

What are the causes of teno-synovitis, or inflammation of the tendon sheaths?

Wounds, traumatism, or it may complicate rheumatism, syphilis, or gonorrhoea.

What are the symptoms of fibrinous teno-synovitis?

Pain, disability, swelling, and a peculiar crepitation on palpation and motion of the affected tendons. This is the most common form of the acute non-specific varieties. (See under cellulitis.)

Describe the treatment of teno-synovitis.

Rest, warmth, and pressure; hence apply cotton and immobilize.

Describe tubercular teno-synovitis.

The lesions are precisely the same as in tubercular synovitis (which see). It should be treated by incision or removal if only a mass of tubercle tissue exists.

What is a thecal cyst or ganglion?

It is form of cystic tumor found in connection with the tendons about the wrist or ankle. The symptoms are much like those of chronic bursitis. They occur most frequently as tense elastic

globular swellings. They are protrusions of the synovial linings of the tendon sheaths or of the joints.

What is the treatment?

Subcutaneous rupture by pressure or subcutaneous puncture with

a tenotome.

What forms of inflammation are found in connection with the bursæ ?

The varieties of bursitis are the same as those of synovitis. What are the causes of bursitis?

Acute bursitis is caused by injury. Chronic bursitis occurs as a result of long-continued pressure and irritation.

What are the symptoms?

The symptoms of acute bursitis are those of acute inflammation, with swelling and distension of the sac with effused fluid. Suppuration may supervene, with involvement of the surrounding cellular tissue.

Chronic bursitis is more common than the acute form and is attended with less pain; the sac becomes distended and thickened, forming a fluctuating tumor. The formation of a bursal tumor over the metatarso-phalangeal joint of the great toe is known as a "bunion"; over the patella, as "house-maid's knee."

What is the treatment?

In the acute form rest, elevation, and cooling lotions. In the subacute forms a blister is advisable. If suppuration occurs, free incision, evacuation, and drainage is called for.

The chronic form should be treated by counter-irritation and elastic pressure; in obstinate cases aspiration, followed by the injection of carbolic-acid solution or a solution of iodine. Opening the sac and packing with antiseptic gauze, or excision of the sac is sometimes required.

INJURIES AND DISEASES OF THE CIRCULATORY SYSTEM.

What is the surgical treatment of pericardial effusion when attended with dangerous symptoms of heart failure ?

Aspiration of the pericardial sac. The needle should be inserted

in the fifth intercostal space, just above the sixth rib, two to two and a quarter inches to the left of the median line of the sternum. Complicating pulmonary effusion should be aspirated first.

What is hemorrhage?

HEMORRHAGE.

The escape of blood from the blood-vessels; it may be spontaneous or traumatic. When the blood does not appear on the surface, but escapes into the adjoining connecting tissue, the term extravasation or subcutaneous hemorrhage, or hæmatoma, is used.

What are the anatomical varieties of hemorrhage ?

1. Arterial hemorrhage, when the blood comes from an artery; the flow is rapid and in spurts synchronous with each beat of the heart. The color is bright red, except in partial or complete asphyxia.

2. Venous hemorrhage (from a vein) occurs as a steady even spurt of dark-colored blood, and is not affected by the heart's action.

3. Capillary or parenchymatous hemorrhage occurs as a steady oozing, and the blood is less red in color than that from an artery.

What are the clinical varieties of hemorrhage?

1. Primary, when the hemorrhage follows immediately after the receipt of an injury;

2. Intermediary, not occurring till after the reaction from shock, and happening before the lapse of twenty-four hours.

3. Secondary, occurring between the end of the first day and the complete cicatrization of the wound. It may be due to the sloughing of a contused vessel, to traumatism, atheroma, or septic processes. Constitutional conditions, as hæmatophilia, pyæmia, septicemia, chronic renal or hepatic diseases, may interfere with nature's reparative processes and retard the cicatrization of a wounded vessel, so that hemorrhage supervenes.

What is hæmatophilia ?

In some persons a constitutional tendency or hemorrhagic diathesis exists, so that a profuse, uncontrollable hemorrhage may result from the most trifling lesion, or the hemorrhage may even be spontaneous.