140. 141. 142. FIG. 129. Poroplastic Collars for Spinal Disease 130. Taylor's Brace as modified for use in Cervical Spinal Disease 131. Incision for Costo-transversectomy 132. Removal of the Transverse Processes in Costo-transversectomy 133. Exposure of the Abscess in Costo-transversectomy Method of applying Pressure to a Hæmatoma of the Scalp 138. The Sub-pericranial Hæmatoma 139. Forceps for Hæmostasis in Operations upon the Scalp 335 144. Incision for the Removal of a Dermoid at the outer angle of the Orbit 336 145. Method of removing a depressed fragment of the Skull in a Depressed The Bursting' Theory of Fractures of the Skull exemplified in a Tennis- 346 350 151. 'Bursting' Fractures of the Skull 351 152. 153. Removal of the Diploë in Acute Osteo-myelitis of the Skull 359 365 372 158. Middle Meningeal Hæmorrhage 155. Head-support for Operations upon the Brain 156. The Relations of the Middle Meningeal Artery to the Sutures of the Skull 157. Exposure of both branches of the Middle Meningeal Artery 159. Cushing's Clips for the Middle Meningeal Artery 374 375 376 377 378 160. Incision of the Dura Mater for Sub-dural Hæmorrhage 162. Drainage of the Sub-arachnoid Space in the Cerebellar Region 163. Myringotome 164. Diagram to show the Directions in which Infection may spread from the Middle Ear 165. The complete Post-aural operation upon the Mastoid Antrum 390 395 166. Stacke's Antral Protector 396 167. Formation of Conchal Flaps after complete Post-aural operation upon the Mastoid 397 168. Exposure of the Lateral Sinus after complete Mastoid operation 169. Exposure of the Internal Jugular Vein 399 400 170. Exposure of the upper Surface of the Petrous Bone for Sub-dural Abscess 171. Horsley's Dura Mater Separator 172. Drainage of the Sub-arachnoid Space in the Cerebellar Region 174. 404 180. FIG. 178. Decalcified Bone Tubes arranged for Drainage of the Lateral Ventricles 179. Method of Drainage employed for Internal Hydrocephalus PAGE 419 The Relations of the various Cranial Sutures, Cerebral Convolutions, and 420 426 183. Chiene's method of locating the Fissure of Rolando 184. Position of the patient in operations upon the Cerebrum 186. Cushing's Tourniquet applied to the Scalp 185. Position of the patient in operations upon the Cerebellum. 187. A Method of forming an Osteo-plastic flap in operations upon the Brain The Osteo-plastic flap turned down. 192. Horsley's Brain Knife Cushing's Temporal Decompression (First stage) 194. Cushing's Temporal Decompression (Second stage) 195. Cushing's Temporal Decompression (Third stage) 196. Cushing's Temporal Decompression (Final stage) 197. Occipital Decompression (First stage) 198. Occipital Decompression (Final stage) 435 Whalebone Introducer and Metal Guard for Gigli's Saw in operations upon Lake's Nasal Splint 203. Hollow Vulcanite Nasal Plug 204. Walsham's Splint for Fracture of the Nasal Bones 457 457 457 210. 211. 205. Mason's Method of supporting the Bridge of the Nose after Fracture 208. Incision for the removal of the Submental Lymphatic Glands Lateral View of the Skull showing the landmarks for the injection of 212. The Skull viewed from below to show the course of the needle used to 214. Exposure of the Inferior Dental Nerve from inside the Mouth 215. Ganglion 217. Opening the Skull and raising the Dura Mater in removal of the Gasserian 216. Exposure of the Skull in the operation for removal of the Gasserian Ganglion 480 481 482 483 484 221. 222. Restoration of the Lower Lip by means of Rectilinear Incisions Restoration of the Lower Lip by means of Curved Incisions 223. Restoration of the Lower Lip by Incisions over the Masseters 486 490 492 492 225. Operation for Restoration of part of the Upper Lip 494 495 228. 229. Plastic Operation on the Mouth when there is no Anchylosis of the Jaws 230. 231. 232. Esmarch's Operation for Complete Anchylosis of the Jaw Plastic Operation for considerable loss of tissue with Anchylosis of the 499 233. 234. Flap Operation for Ectropion of the Lower Eyelid 504 505 236. 237. 235. Restoration of the Bridge of the Nose Syme's Operation for restoration of the soft parts of the Nose 238. Formation of a new Columella in Rhinoplasty 507 508 510 511 239. 242. The Italian or Tagliacotian Method of Rhinoplasty 240. Operation for Simple Hare-lip without widening of the Nostril 241. Operation for Simple Hare-lip with widening of the Nostril Mirault's Operation for Hare-lip 512 512 516 517 243. Modified Mirault's Operation . 244. Nélaton's Operation 517 519 245. V-shaped Incision in the Septum for projecting Pre-maxilla 519 246. Method of Lengthening the Columella in Hare-lip Operations 247. Operation for Double Hare-lip 255. Detaching the Soft from the Hard Palate in Staphyloraphy Curved Scissors for dividing the attachment of the Soft to the Hard 527 528 529 257. Passing the Sutures in Staphyloraphy 530 260. Davies-Colley's Operation for Cleft Palate 258. The Double-loop Method of passing the Sutures in Staphyloraphy 259. Staphyloraphy completed 531 531 532 263. Lane's method of closing irregular Gaps in the Soft Palate 264. Brophy's Needles for Cleft Palate Operations 265. Brophy's Operation (Passing the silk sutures) 261. Lane's Needles and Needle-holder for Cleft Palate Operations 262. Lane's Operation for Cleft Palate 535 536 536 537 538 266. Brophy's Operation (Inserting and twisting the wire sutures) 267. Operation for outstanding Auricle The Drainage Tube in position for the repair of a Salivary Fistula 553 553 557 DIVISION I. THE SURGICAL AFFECTIONS OF JOINTS. SECTION I.-INJURIES OF JOINTS. CHAPTER I. DISLOCATIONS: GENERAL CONSIDERATIONS. DEFINITION.-In a dislocation there is partial or complete displacement of the ends of the bones which constitute the joint, so that the articular surfaces no longer maintain their relative positions. In a complete dislocation the normal positions of the articular surfaces are altered so that the end of one bone overrides the other; this is most common in the ball-and-socket joints, but it may occur in almost any joint in the body. In a partial dislocation, on the other hand, there is only an incomplete displacement-usually lateral-without any overriding; this is most common in hinge-joints-such as the elbow or the knee. CLASSIFICATION.-Dislocations may be classified, according to their cause, into the three following groups : Traumatic dislocations, in which a healthy joint is dislocated as the result of violence. Under this heading will also come recurring dislocations, which are commonest in the shoulder and thumb. They are due to extensive injury to the capsule of the joint, followed by imperfect repair, and also, in the case of the shoulder-joint, to an imperfectly formed head of the humerus which does not fit the glenoid cavity. Pathological dislocations, or those resulting from disease. The chief factor in the production of this form is disease in the joint capsule and ligaments, which give way and allow displacement of the ends of the bones; examples of this are seen in tuberculous disease, osteo-arthritis, Charcot's disease, and arthritis after specific fevers-such as typhoid. Congenital dislocations, which are due either to malformation, to displacement in utero, or to violence at or immediately before birth. We shall here deal only with traumatic dislocations; the others are discussed elsewhere. CAUSES.-Exciting.-A dislocation may be caused by (a) indirect violence, as when a fall upon the hand results in dislocation of the humerus ; (b) direct violence, as when a blow on the point of the shoulder dislocates the clavicle; (c) traction, as when the head of the radius is dislocated. in lifting a child by the hand; or (d) muscular contraction, as in dislocation. of the humerus in throwing a ball or playing single-stick. Predisposing. In addition there are various predisposing causes. For example: (a) The nature of the joint. Joints such as the shoulder, in which the articular surfaces are held in apposition mainly by muscular action, the ligaments being lax, are, from their anatomical conformation, more liable to dislocation than well-fitting joints like the elbow. (b) The age of the patient. Dislocation is most common in the young adult. In children, a joint injury is most likely to cause a separation of the epiphysis, while in the old, the bones are more brittle, and fracture is more common than dislocation. (c) The condition of the muscles which surround the joint. If these be wasted from disuse or disease, or if they be taken by surprise, dislocation may be caused by a force that would otherwise do no injury either to bone or joint. TREATMENT.-The treatment of a dislocation may be considered according as it is simple, compound, or of long standing. Any dislocation may be complicated by a fracture in its immediate vicinity or at some distance from it, by severe damage to vessels or nerves near the joint, by pressure on nerves, leading to paralysis, and, in long-standing cases, by adhesion of vessels, nerves, and other tissues to the dislocated articular surfaces. The treatment of these complications will also need consideration. TREATMENT OF SIMPLE TRAUMATIC DISLOCATIONS. The treatment of a simple dislocation must fulfil three requirements: (1) restoration of the displaced articular surfaces to their normal positions ; (2) prevention of recurrence of the dislocation; and (3) preservation of the functions of the joint. REDUCTION OF THE DISLOCATION.-The chief obstacles to reduction of a dislocation are : (a) Muscular contraction. The muscles around the joint are usually spasmodically contracted as a result of the laceration of the ligaments and the presence of the articular ends of the bones in a new position. It is most important to overcome this spasmodic contraction and this may be effected either by giving a general anesthetic, or by overcoming |