apparatus which can easily be removed to permit the use of massage and electricity. In some cases of talipes calcaneus the surgeon may be forced to shorten the tendo Achillis.

Pes planus (flat-foot) is the loss of the arch of the foot, due to ligamentous weakness and to prolonged standing. This condition is productive of much pain on standing. Flat-foot can at once be recognized by wetting the sole of the patient's foot with a colored fluid and causing him to step firmly upon a piece of paper (Fig. 118, A, B).

Treatment. To treat flat-foot deformity. a shoe should be made containing a piece of steel so arranged as to raise the arch of the foot. The patient's general health must also be looked to.

A

B

FIG. 118.-Print of a Normal Foot-sole (A)

and of a Flat Foot-sole

Pes cavus (hollow-foot) is an increase (B) (Albert).

in the arch of the foot, due to contraction

of the peroneus longus muscle or to paralysis of the muscles of the calf. It is the opposite of flat-foot.

Treatment.-A shoe is worn containing a plate of steel in the sole, and pressure is applied over the instep. Tenotomy, cutting of the plantar fascia, or excision of bone may be required.

Hallux valgus or varus, a displacement of the great toe outward or inward, may occur in the young, but it is most frequent in old men; it may be due to rheu

matic gout. In hallux valgus a bunion is apt to form.

FIG. 119.-Ham

Treatment.-An arrangement may be worn to straighten the toe and to protect the bun- mer-toe. ion, osteotomy may be performed upon the metatarsal bone, the joint may be excised, or amputation may be required.

Hammer-toe (Fig. 119) is the flexion of one or more toes at the first interphalangeal joint. Shattuck shows that this

condition is due to contraction of "the plantar fibres of the lateral ligaments of the joint." This disease usually begins in youth. A bunion is apt to form, and the joint may be dislocated. The treatment is excision of the joint or amputation.

XXI. DISEASES AND INJURIES OF NERVES.

1. DISEASES OF NERVES.

Neuritis, or inflammation of a nerve, may be limited or be widely distributed (multiple neuritis). The first-mentioned form will here be considered. The causes of neuritis are traumatism, wounds, over-action of muscles, gout, rheumatism, syphilis, fevers, and alcohol.

Symptoms.-The symptoms of neuritis are as follows: Excessive pain, usually intermittent, in the area of nervedistribution. The pain is worse at night, is aggravated by motion and pressure, and occasionally diffuses to adjacent nerve-areas or awakens sympathetic pains in the opposite side of the body. The nerve is very tender. The area of nerve-distribution feels numb and is often swollen. Early in the case the skin is hyperæsthetic; later it may become anæsthetic. The muscles atrophy and present the reactions of degeneration; that is, the muscles first ceases to respond to rapidly-interrupted, and next to slowly-interrupted, faradic currents; faradic excitability diminishes, but galvanic excitability increases. When, in neuritis, faradism produces no contraction, a slowly-interrupted galvanic current which is so weak that it would produce no movement in the healthy muscles causes marked response in the degenerated muscles. In health the most vigorous contraction is obtained by closing with the pole; in degenerated muscles the most vigorous contraction is obtained by closing with the + pole. 1 American Text-book of Surgery.

When voluntary power returns galvanic excitability declines, but power is often nearly restored before faradic excitability becomes manifest (Buzzard).

Treatment.-The treatment of neuritis consists of rest upon splints, ice-bags early in the case, and hot-water bags. later. Massage and electricity must be used to antagonize degeneration. Deep injections of chloroform may allay pain. Treat the patient's general health, especially any constitutional disease or causative diathesis. In some cases nervestretching is advisable.

Neuralgia is manifested by violent paroxysmal pain in the trajectory of a nerve. This disease belongs chiefly to the physician, except in very bad cases. Neuralgia of stumps and scars belongs to the surgeon, and is due to neuromata, or entanglement of nerve-filaments in a cicatrix. Tic douloureux and other intractable neuralgias may require severe operations.

Treatment of Neuralgia of Stumps.-Excise the scar; find the bulbous end of the nerve and cut it off. In some cases re-amputation is performed. In entanglement of a nerve in a scar, remove a portion of the nerve above the scar.

2. WOUNDS AND INJURIES OF NERVES.

Section of Nerves (as from an incised wound).—In nervesection the entire peripheral portion of the nerve degenerates and ceases structurally to be a nerve in a few weeks, but after many months, or even after years, the nerve again regenerates -with difficulty, if union of the ends has not taken place, with much greater ease if the ends have united. The proximal end only suffers in the portion immediately adjacent to the section; it degenerates, but rapidly regenerates, and a bulb or enlargement composed of fibrous tissue and small nervefibres forms just above the line of section; this bulb adheres to the perineural tissues. Union of a divided nerve is brought

about by the projection of an axis-cylinder from each end and the fusion of these cylinders. The nearer the two ends are to each other, the better is the chance of union.

of a divided nerve.

Symptoms.-Pronounced changes occur in the trajectory The muscles degenerate, atrophy and shorten, and show the reactions of degeneration. When union of the nerve occurs the muscles are restored to a normal condition. If the nerve contains sensory fibres, complete anæsthesia (to touch, pain, and temperature) usually follows its division, but if a part is supplied by another nerve as well as by the divided one, anæsthesia may not be complete. Trophic changes arise in the paralyzed parts. Among these changes are muscular atrophy, glossy skin, cutaneous eruptions, ulcers, dry gangrene, painless felons, falling of the hair, brittleness, furrowing, or casting off of the nails, jointinflammations, and ankylosis. Immediately after nerve-section vaso-motor paralysis comes on, and for a few days the paralyzed part presents a temperature higher than normal. The diagnosis as to which nerve is cut depends upon a study of the distribution of paralysis and anæsthesia.'

Treatment. In all recent cases of nerve-section, suture the ends. If the patient is not seen until long after the accident, incise and apply sutures (secondary sutures); if the nerve cannot be found, extend the incision, find the trunk above and trace it down, and find the trunk below and follow it up. Even after primary suture loss of function is bound to occur for a time. After secondary suture sensation may return in a few days, but it may not return until after a much longer period; in any case muscular function is not restored for months. In partial section of a nerve the ends should be sutured.

Pressure upon nerves may arise from callus, scars, pressure of a dislocated bone or a tumor, or. pressure from an

1 See Bowlby on Injuries of Nerves.

external body. The symptoms may be anæsthetic, paralytic, and trophic. The treatment is as follows: Remove the cause (reduce a dislocated bone, chisel away callus, excise a scar, etc.); then employ massage, douches, and electricity. Contusion of Nerves.-The symptoms of contusion of nerves may be identical with those of section. Sensation or motion, or both, may be lost. The case may get well in a short time, or the nerve may degenerate as after section. The treatment at first is rest, and later electricity, massage, frictions, and the douche.

Punctured Wounds of Nerves.-The symptoms of punctured wounds of nerves may be partly irritative (hyperæsthesia, acute pain, and muscular spasm) and partly paralytic (anesthesia, muscular wasting, and paralysis). The treatment is the same as that for contusion.

3. OPERATIONS UPON NERVES.

Neurorrhaphy, or Nerve-suture.-When a nerve is completely or partially divided by accident, it should be sutured. The instruments required are an Esmarch apparatus, a scalpel, blunt hooks, dissecting-forceps, hæmostatic forceps, curved needles or sewing-needles, a needle-holder, and catgut or kangaroo tendon. In primary

FIG. 120.-Nerve-suture.

suture render the part bloodless and aseptic. Enlarge the incision if necessary. If the ends can readily be approximated, pass two or three sutures through both the nerve and its sheath and tie them (Fig. 120). If the ends cannot be approximated, stretch each end and then suture. Remove the Esmarch band, arrest bleeding, suture the wound, dress antiseptically, and put the part in a relaxed position on a splint. After union of the wound remove the splint and use massage, frictions, electricity, and the douche. The operation in some instances fails,