lower fragment, which is so frequently present. You will know when this has been done by the inner side of the patella, the internal malleolus, and the inner side of the great toe being in the same line. Further, you should not, as a rule, rest satisfied as long as any irregularity can be felt on drawing your finger down the crest of the tibia, or as long as any marked difference is apparent on comparing the fractured with the sound leg. If any difficulty is experienced, give chloroform, and, if necessary, cut the tendo-Achillis. Having reduced the fracture, secure the foot and leg on a splint. Whatever form of the various splints for the purpose is adopted, take care: 1, that the foot is at right angle to the leg; 2, that the ball of the toes and the heel touch the foot-piece of the splint; 3, that the foot is square with the foot-piece; and 4, that the back of

FIG. 134.

ARNOLD & SONS LONDON

Fracture Apparatus for the Bones of Leg.

the heel is kept from contact with the splint by a small pad placed under the tendo-Achillis just above the heel. The iron splint and cradle, shown in Fig. 134, is almost invariably employed at St. Bartholomew's Hospital for ordinary fractures of the tibia and fibula. In applying the splint, which should reach as high as the junction of the middle with the lower third of the thigh, and should be well padded and shaped to the limb, the foot is first secured to the foot-piece by strapping and a bandage. The surgeon having then assured himself that the fracture is in good position, secures the splint by a broad strip of strapping, and a figure-of-eight bandage over the knee. The splint is next swung in the cradle, as shown in the figure, and side splints are then applied and secured by webbing straps. In the

case of fracture of both bones, the apparatus is generally kept on for a month; in the case of the fibula or tibia alone, for two to three weeks. The leg is then placed in a plaster-of-Paris, a gum and chalk, or a silicate of soda bandage. The above apparatus is also generally used in Pott's fracture. Where, however, there is much difficulty in keeping the bones in good position, the leg is laid on its outer side, with the knee semi-flexed to

Cline's Splints for Pott's Fracture.-A. Outer Splint; B. Inner Splint.

relax the gastrocnemius, and secured in Cline's splints, Fig. 135, the tendo-Achillis being divided, if found necessary. At times Dupuytren's splint (Fig. 136) may be better adapted to the particular case. This splint consists of a straight splint notched at its lower end. It is placed on the inner side of the limb, and should reach from the tuberosity of the tibia to three or four

FIG. 136.

inches below the foot. A wedge-shaped pad, with its base below, and not extending beyond the internal malleolus, should line the splint. The splint is bandaged on from above downward, and the leg having been thus secured, the foot is then brought over to the splint by making figure-of-eight turns over the ankle and foot and through the notches at the lower end of the splint. The bandage should not pass over the external

malleolus or the seat of fracture. The great objection to the use of this splint is, that having no foot-piece, the foot is not kept at a right angle to the leg.

THE TARSUS.-Fractures of the bones of the tarsus are for the most part the result of great violence, and are rare. The only one calling for passing notice is fracture of the os calcis, which may occur from a fall on the heel, passage of a wheel over the foot, or violent contraction of the calf-muscles. Crepitus and, when the line of fracture is behind the interosseous ligament, some drawing up of the posterior fragment by the tendo-Achillis, are the chief signs. But where there is much swelling and bruising of the soft parts, the fracture, as is the case in fractures of the astragalus and of the other tarsal bones, may be very difficult to diagnose. Rest, with the foot and leg on a splint, in such a position as to relax the calf-muscles where there is much displacement, and an ice-bag to subdue inflammation, are the points to be attended to with regard to treatment. When the case is seen early, and there is but little swelling, a plaster-ofParis splint or bandage may be advantageously used.

THE METATARSAL BONES AND PHALANGES of the toes may be fractured by direct violence. No special description, however, of these fractures is necessary.

SECTION VI.

DISEASES OF REGIONS.

DISEASES OF THE SCALP AND SKULL.

ERYSIPELAS OF THE SCALP is very common, and may occur idiopathically, or as the result of a wound. In the so-called idiopathic cases, however, it is probable that there is some scratch or abrasion through which the specific micrococcus gains admission. The inflammation spreads with great rapidity, but is accompanied with very little redness and swelling, on account of the tenseness of the parts. It is apt to be attended with headache, drowsiness, or delirium, consequent upon the hyperæmia extending to the pia mater. See Erysipelas, p. 124.

CELLULITIS of the scalp is usually due to a wound, and is described under Injuries of the Head.

ABSCESS may occur above the aponeurosis, between the aponeurosis and the pericranium, or beneath the pericranium. It is generally the result of an injury, but may be due to the breaking down of gummata, disease of the bones, etc. It is further referred to under Injuries of the Head.

RODENT ULCER, and EPITHELIOMA OF THE SCALP, require no special mention.

SEBACEOUS CYSTS are very common on the scalp, where they are at times hereditary. They are frequently multiple, and as they increase in size, the hair covering them falls off, and they appear as bare, rounded tumors. The signs, secondary changes, diagnosis, and treatment of these cysts have been given at p. 80. All that here need be repeated is that the mass of granulations which sometimes protrudes from the walls of these cysts (fungating ulcer of the scalp) closely resembles epithelioma, from which, however, it may generally be distinguished by the absence of induration and glandular enlargement, and by the history of a sebaceous cyst having been previously present. Congenital or dermoid cysts are described at p. 83.

NÆVI are also common on the scalp. When large, and situated over the anterior fontanelle, they should be dealt with cautiously, lest the membranes of the brain be injured, and meningitis result.

CARIES AND NECROSIS of the bones of the cranium are not uncommon. They are generally the result of syphilitic perios

titis, or injury, or very rarely struma or fevers. The external table is the most often affected, but whether the external or the internal table is involved, the disease seldom extends beyond the diploë, as the two tables have a distinct blood supply. At times, however, complete perforation of the skull occurs. Caries and necrosis in this situation are apt to be followed by septic or infective inflammation of the diploë, and its consequences; by suppuration between the bone and dura mater; by meningitis and abscess of the brain; or by thickening of the dura mater, resulting in persistent headache, or even epilepsy. When the skull is completely perforated, the hole is not filled up by bone; and when necrosis occurs the sequestrum is not invaginated. Treatment. Beyond keeping the parts aseptic, providing free exit for the discharges, and removing loose sequestra, little, as a rule, is required. Should pus collect between the bone and dura mater, it must be let out by the trephine; and a portion of necrosed inner table may also require the trephine for its removal. Appropriate constitutional remedies for syphilis or struma may of course also be necessary.

EXOSTOSES of the skull are described under Diseases of Bone, p. 197.

MENINGOCELE AND ENCEPHALOCELE are rare congenital tumors, formed by a protrusion of the membranes of the brain through an unossified part of the skull. They are believed to be dependent upon hydrocephalus, the excess of fluid in the sub-arachnoid space or in the ventricles of the brain leading respectively to a protrusion of the membranes alone (meningocele), or of the brain also (encephalocele). In the latter instance, the dilated ventricle may extend into the protruding portion of brain, a condition further distinguished as hydrencephalocele. The protrusion is most common in the occipital region, just behind the foramen magnum, between the four centres from which this part of the bone is ossified; next, at the root of the nose, between the frontal and nasal bones; but it may occur in any situation in the course of the sutures and even project into the nasal fossæ or pharynx. Symptoms.-In the occipital region these tumors are generally pedunculated and of large size-sometimes nearly as large as the child's head; at the root of the nose they are usually small and sessile. The skin covering them is generally normal. They swell up when the child cries, and can be completely or partially reduced on pressure, the reduction producing convulsions or other brain symptoms. When they contain fluid only, they are soft, fluctuating, translucent, and completely reducible on pressure; but they rarely pulsate, and are generally pedunculated. When they contain brain-matter they are doughy,