ful; hence ether should be given to the first stage, nitrous oxid should be administered, or the superficial parts should be frozen by a spray of chlorid of ethyl.

Bursitis is inflammation of a bursa. Acute bursitis arises from strain or from traumatism. The symptoms of acute bursitis are pain, limited swelling, moist crepitus, fluctuation, and discoloration in the anatomical position of a bursa. Bursitis of the retrocalcaneal bursa (Albert's disease) is a painful affection which is often overlooked. Walking causes great pain in the heel. Raising up on the toes is excessively painful. It is usually associated with flat foot. In these cases osteophytes often form within the bursa. Bursitis of the gluteal bursæ produces symptoms resembling those of incipient coxalgia. But in bursitis the symptoms do not remit as in hip disease. There is moderate pain back of the leg and knee which disappears when the patient is at rest; there is marked limp, limitation of motion, and an area of deep fluctuation in the buttock (Brackett).

It is difficult to separate bursitis of any deep bursa from synovitis; indeed, the joint is apt to become secondarily affected. This difficulty is especially vexatious in distinguishing between joint-injury and injury of the bursa beneath the deltoid. Suppuration may take place. Direct force may rupture a bursa. When this accident happens there are pain, marked swelling, a large area of moist crepitus, and later extensive discoloration from blood. Chronic bursitis may follow acute bursitis, or the disease may be chronic from the start. Its symptom is swelling with little or no pain unless acute inflammation arises. Chronic bursitis of the subhyoid bursa is known as Boyer's cyst.

Treatment.-Acute bursitis is treated at first by rest and pressure and with lead-water and laudanum; later with iodin, blue ointment, or ichthyol. If the swelling persists, aspirate. If pus forms, incise, swab out the sac with pure carbolic acid, and pack it with iodoform gauze. A chronic bursitis may get well from the use of pressure, as the application of blue ointment, with treatment of any causative diathesis; but most cases require incision and packing. A ruptured bursa is treated as an acute bursitis. Some cases of retrocalcaneal bursitis get well from rest, but others demand incision and drainage. If osteophytic formation takes place in Albert's Disease remove the bony stalactites with a rongeur forceps or a gouge.

Housemaid's knee is thickening and enlargement of the prepatellar bursa, due to intermittent pressure. In effusion

into the knee-joint the fluid is behind the patella and the bone floats up; in housemaid's knee the fluid is above the bone and the osseous surface can be felt beneath it. "Miners' elbow," which is a condition similar to housemaid's knee, affects the olecranon bursa. "Weavers' bottom" is enlargement of the bursa over the tuberosity of the ischium. A bursa which is simply thickened and enlarged rarely gives rise to annoyance; but when it inflames, as it is apt to do, it causes the ordinary symptoms of bursitis.

Treatment.-Housemaid's knee is treated by incision and packing with iodoform gauze. In enlargement of the bursa beneath the ligamentum patellæ, if rest and blistering fail to cure, aspirate or incise. In enlargement of the bursa below the tendon of the semimembranosus and also in "weavers' bottom" incise and pack.

Bunion.-A bunion is a bursa due to pressure, and it is most commonly found above the metatarsophalangeal articulation of the great toe, but is occasionally seen over the joint of another toe. When the big toe is pushed inward by illfitting boots a bunion forms. When a bunion is not inflamed it may cause but little trouble, but when it is inflamed the bursa enlarges and the parts become hot, tender, and excessively painful. Suppuration may occur and pus may invade the joint, and the bone not unusually becomes diseased.

Treatment. In treating a bunion the patient must wear shoes that are not pointed, that have the inner borders straight, and that have rounded toes (Jacobson).

mild case a bunion-plaster gives comfort. Sayre advises the use of a linen glove over the phalanges, which are to be drawn inward by a piece of elastic webbing one end of which is fastened to the glove and the other end to

a piece of strapping from the heel. A special apparatus may be worn (Fig. 148). In many cases osteotomy of the first phalanx or of the first metatarsal bone is required; in some cases excision of the joint is necessary; in others amputation must be performed. When the bursa is not inflamed, but only thickened, blisters should be employed over it, or there should be applied tincture of iodin, ichthyol, or mercurial ointment. When the bursa inflames, lead-water and laudanum is applied, and intermittent heat by foot-baths gives relief. Suppuration demands immediate incision and antiseptic dressing. If an ulcerated

FIG. 148.-Bigg's

apparatus for bun

ions.

bunion does not heal by antiseptic dressing, stimulate it with silver and dress it with unguent. hydrarg. nitrat. (1 part to 7 of cosmolin). Jacobson recommends skin-grafting for some

cases.

OPERATIONS UPON MUSCLES AND TENDONS.

Tenotomy is the cutting of a tendon. It may be open or subcutaneous, the open operation being preferred in dangerous regions.

Division of the Sterno-cleido-mastoid Muscle for Wry-neck.-Subcutaneous tenotomy has been abandoned. It is not only more unsafe than the open operation, but it never completely divides all of the thickness of the contracted band.

The instruments required consist of a scalpel, dissectingforceps, hemostatic forceps, scissors, needles, ligatures, etc. The patient is placed recumbent, the chin being drawn more toward the opposite side.

A transverse incision is made over the muscle about onefourth of an inch above the clavicle. The superficial parts are divided, the muscle is exposed and sectioned, bleeding is arrested, and the skin is sutured. Avoid the anterior jugular vein, which is underneath the muscle, and also the external jugular, which is close to the outer edge of the muscle. Mikulicz advocates the removal of almost the entire muscle, leaving, however, the upper and posterior portion where the spinal accessory nerve passes. After operation for wry-neck support the head with sand bags until healing occurs, and then inaugurate motions active and passive.

Subcutaneous Tenotomy of the Tendo Achillis.— This operation is performed for club-foot, in which the heel is raised. The tendon is cut about one inch above its point of insertion. The instrument used for the first puncture is a sharp tenotome. The patient lies upon his back "with his body rolled a little toward the affected side" (Treves), the foot being placed upon its outer side on a sand pillow. The surgeon stands to the outside. The tendon is rendered moderately rigid, and the sharp tenotome, with its blade turned upward, is inserted along the anterior border of the tendon until the surgeon's finger feels the knife approaching the outer side. A blunt-pointed tenotome is inserted in place of the sharp instrument. The tendon is drawn into rigidity, and the surgeon turns the blade of his knife toward the

tendon, places his finger over the skin, and saws toward his finger. The tendon gives way with a snap. Treves states that a beginner is apt not to push the knife far enough toward the outside, or he may in the first puncture push the knife through the tendon; in either case the tendon is not completely cut. The little wound, which is covered with a bit of gauze, will be entirely closed in forty-eight hours. In club-foot cases after tenotomy some surgeons at once correct the deformity and immobilize the limb in plaster; some partially correct the deformity and apply plaster for one week, at which time they remove the plaster, correct the deformity further, reapply the plaster, and so on; other surgeons do not attempt correction of the deformity until the cut tendon has begun to unite, when they gradually stretch the new material.

Subcutaneous Tenotomy of the Tendon of the Tibialis Anticus.-The tendon is divided about one and a half inches above its point of insertion. It can be made tense by extending and abducting the foot. The sharppointed tenotome is entered upon the outside of the tendon, and is passed well around it. The blunt-pointed tenotome is used to cut the tense tendon.

Subcutaneous Tenotomy of the Tendons of the Peroneus Longus and Brevis.-These two tendons are cut together back of the external malleolus, and one and a half inches above the tip of the malleolus, so as to avoid the synovial sheath (Treves). The patient lies upon the sound side, the outer aspect of the deformed foot being upward and the inner aspect of the ankle of the deformed side resting upon a sand pillow. The instrument is introduced close to the fibula, and is carried around the loose tendons. A bluntpointed tenotome is now introduced, its edge is turned toward the tendons, and these structures are cut as they are made tense.

Subcutaneous Tenotomy of the Tendon of the Tibialis Posticus.-This tendon is sectioned above the point where its synovial sheath begins; that is, above the internal annular ligament (Treves). The tendon is made tense and the knife is entered above the base of the inner malleolus. The knife is entered just back of the inner edge of the tibia, and is carried around the muscle while it is kept close to the bone. The tendon is sectioned with a blunt knife.

Subcutaneous Fasciotomy of Plantar Fascia.The contracted bands are discovered by motions which

render them tense, and they are divided just in front of the attachment to the os calcis. The sharp knife passes between the skin and fascia at the inner side of the sole of the foot. The fascia is cut from without inward by the blunt-pointed tenotome. It is usually necessary to section the fascia at more than one point.

Tendon-suture and Tendon-lengthening.-The instruments required in these operations are an Esmarch apparatus; curved needles and needle-holder; chromicized gut, kangaroo-tendon, or silk for an ordinary case, silver wire for a suppurating wound. In performing tendon-suture make the part aseptic and bloodless. It is wise to apply a rubber bandage on the proximal side, the bandage being applied centrifugally, forcing the proximal end of the tendon into view (Haegler). If searching for the proximal end of a flexor of the finger, flex the injured finger, and hyperextend the adjoining fingers (Filiget). If this expedient fails, enlarge the incision, or, what is better, make a large flap in the skin. After finding the ends approximate them, being sure the proper ends are brought into contact; stitch them together with a continuous suture or with one of the sutures shown in Fig. 149, A, B, and c. In a suppurating wound

FIG. 149.-Tendon-sutures: A, of Le Fort; FIG. 150.-Anderson's method of tendonB, of Le Dentu; c, of Lejars.

lengthening.

suture by silver wire should be tried, though it usually fails. After suturing, remove the Esmarch apparatus, arrest bleeding, close the wound and dress it antiseptically, relax the parts, and place the limb on a splint. If, after suturing, there is much tension, stitch the cut tendon above the sutures to an adjacent tendon, and apply a splint, the finger which was injured being flexed, the others being extended. If only the distal end of the tendon can be found, graft it upon the nearest tendon with a like anatomical course and function. When a tendon has been sutured begin gentle