Trochee

“ When the femoral head penetrates into the pelvis—the central dislocation of the hip of German writers—the condition simulates a fracture of the neck of the femur, but the trochanteric region is more depressed and the trochanter lies nearer the middle line. The limb is shortened, and movements of the joint are painful and restricted, especially medial rotation. In some cases there is pain along the course of the obturator nerve. ”

“ Fractures of the great trochanter are the effect either of falls on that protuberance, or of the action of bodies striking against it. Oblique or transverse, situated sometimes at its summit, and sometimes at its base, these fractures may be either simple or complicated. They are rendered complicated sometimes by splinters and a swelling, as happens when a ball produces the division, and at other times by a fracture of the neck of the bone, an example of which we find in the Journal of Surgery, in the case of a man seventy years of age, who had been long subject to the itch. ”

“ In tracheotomy, the incision of the tracheal rings can be extended with much less injury than can division of the laryngeal cartilages, when the largeness of the foreign body, its being firmly fixed, or other circumstances, require that the wound be of considerable size. The risk or danger in the one operation is not much greater than in the other. Division of the crico-thyroid membrane and skin is effected by one incision; there is nothing important in the way of the knife. ”

“ Two strong muscles are inserted into the small trochanter by a common tendon, the iliacus internus and psoas magnus. This insertion should remain untouched if the fracture should not extend below the little trochanter. [92] It is not always necessary to injure them, and they will be of great use afterward, if the operation should prove successful. If the neck of the bone be broken through, rotating the thigh as directed may not assist much in dislocating its head. ”

“ If we compare the femur of certain animals with that of man, we see that the corresponding details of form are readily recognisable, but they are slightly modified. Thus, on examining the superior extremity, we find there a head, a neck, a great trochanter, and a lesser; but the neck is usually short and thick, and the great trochanter does not occupy the same level with regard to the articular head of the bone. ”

“ It is tolerably easy to perform, and does not involve any sawing of bones, but the flaps are apt to be cut too short, unless care be taken, from the manner in which the trochlea projects downwards beyond the line of the condyles, so that if the base of an ordinary-shaped flap be made on a level with the condyles, it will prove insufficient to cover the bone. ”

“ Every medical graduate has been taught that there are two kinds of tracheotomy, high and low, the low operation being very difficult, the high operation very easy. When he is suddenly called upon to do an emergency tracheotomy, this erroneous teaching is about all that remains in the dim recesses of his memory; consequently he makes sure of doing the operation high enough, and goes in through the larynx, usually dividing the cricoid cartilage, the only complete ring in the trachea. ”

“ As the foot enlarges the leg atrophies from disuse; so that in the advanced disease an enormously enlarged and misshapen foot, flexed or extended, is attached to an attenuated leg consisting of little more than skin and bone. In some the tibia, or, if the hand is the seat of invasion, the bones of the forearm become involved; in others the disease at first may be confined to a toe, or a finger, or other limited area. In a very few instances the seat of the disease is the knee, thigh, jaw, or neck. ”

“ In the adult we have more room, and the cartilage is often found hard, and unyielding in persons of advanced life, and it is therefore necessary when enlargement is required in the adult, to cut an additional ring or more of the trachea. I continue my incision below the cricoid cartilage, so far as one or more of the rings of the trachea. ”

“ The proximal end or head is evenly rounded and is formed by an epiphysis ossifying from a centre different from that forming the shaft. It articulates with the glenoid cavity. The shaft bears on the flexor surface, at some little distance behind the head, a prominent rounded protuberance, the deltoid ridge. The distal end or trochlea is also formed by an epiphysis and is partially divided by a groove into two convex surfaces; it articulates with the two bones of the fore-arm, the radius and ulna. [264] ”

“ Fibrillation of the cartilage imparts a feeling of roughness when the joint is grasped during flexion and extension, and lipping of the margins of the trochlear surface of the femur may be felt when the joint is flexed; it is also readily seen in skiagrams. When a portion of the “lipping” is broken off, it may give rise to a loose body. In advanced cases with destruction of the cartilages, there may be movement from side to side, with grating of the articular surfaces. ”

“ Locomotion is impossible. There is intense pain and violent sweating at first. Crepitation may in some cases be discerned by rectal examination, with one hand resting over the coxo-femoral (hip) articulation. Fractures of the tuberosities of the upper end of the bone, the great trochanter, may be identified by the deformity, the swelling, the impossibility of rotation, and the dragging of the leg in walking. Fracture of the body is always accompanied with displacement, and as a consequence a shortening of the leg, which is carried forward. ”

“ Croup exceeds by contracting the trachea enough to impede the passing of air to the lungs; diphtheria has more swelling of the tonsils, throat and glands of the neck, but all depend upon the same blood and nerve supply, or a general law of blood beginning with arteries to and from veins, lymphatics, glands and ducts to supply and take away all fluids that are of no farther use to the vital and material support. As all authors have agreed that the brain furnishes the propelling forces to the nerves, it would be proper to inquire how the brain is nourished. ”

“ This done, he returned to the cabin, and he and I “set” Mr. Trufant’s broken leg—and a deuce of a “set” we made of it. I had read “anatomy” in my time, and fancied I knew something of surgery and the general construction of the human frame; but, tossing about as the ship was at that time, the most skillful surgeon could scarcely have done justice to the case.
Only the tibia—that is, the large bone of the leg—was broken, and we applied three splints to it, bound it too tightly, with too much bandage, and fancied we had “reduced the fracture,” in a scientific manner. ”

“ It is obvious that, when the disease has proceeded thus far, the joint must become more or less deformed, and its motions considerably impeded. Accordingly, old men are often seen at work with much rigidity of the joints, particularly of the knee, which is frequently projected inwards, from absorption of the cartilage from the outer condyle of the femur and corresponding part of the tibia, with a thinning and degeneration of the inner-articular cartilage into a tissue resembling the cellular. ”

“ Why does this nerve (n.IV. in Fig. 106, C and D) alone of all the nerves in the body take the peculiar position it always does take? The only suggestion that I know of which sounds reasonable and worth consideration is that put forward by Fürbringer, which is an elaboration of the original suggestion of Hoffmann. Hoffmann suggested in 1889 that the trochlearis nerve represented originally a nerve for a protecting organ of the pineal eye, which became secondarily a motor nerve for the lateral eye as the pineal eye degenerated. ”

“ If the accident consists merely in the formation of a depression in the muscle, in which the summit of the trochanter is fixed, and if there is no fissuring, the muscle and the femur are certainly immobilised, but the limb can be moved to a certain extent, the “mowing” movement is less marked, and there is no well-defined rigid cord along the anterior margin of the muscle. ”

“ A variety of manipulations are to be used by the surgeon, consisting in pushing, pulling, pressing, rotating, and, indeed, whatever movement may be necessary, until the bones are forced into such relative positions that the muscular contraction, operating in just the right directions, pulls the opposite matched ends together in true coaptation—a head into a cavity, an articular eminence into a trochlea, as the case may be. ”

“ When attacking the anterior half of the cartilage, the close contiguity of the joint renders the disease of a more serious nature. It is then that we have acute pain, and with it extreme lameness, for in this position it is more than likely that we have involved either the synovial membrane of the articulation or the tops of the sensitive laminæ. It will be remembered that here the synovial membrane protrudes as a small sac between the antero- and postero-lateral ligaments of the joint. ”

“ The patient often thinks lightly of the condition at the time of the accident, and may only apply for advice some time after on account of the deformity. The head is flexed and the face turned towards the side opposite the dislocation, the attitude closely resembling that of ordinary wry-neck, only it is the opposite sterno-mastoid that is tight. The bony displacement is best recognised by palpating the transverse process of the dislocated vertebra. In the case of the upper vertebræ this is done from the pharynx, in the lower between the sterno-mastoid and the trachea. ”

“ The operation, which is often required in adults, must be carried out upon the lines already described. The enlargement of the thyreoid and cricoid cartilages, the small amount of fat, the small size of the thyreoid isthmus and of the pretracheal vessels after puberty, make the trachea easy to find. Difficulties, however, arise and are determined by the urgency of the case and the nature of the disease. Thus, with inflammation, the neck may be so swollen that the trachea is many inches from the surface; with tumours the trachea may be displaced, or the obstruction may be in the thorax. ”

“ The superficial and deep cervical groups may be uniformly affected, the muscles lifted and wasted, and vessels and trachea surrounded by a solid mass. Sometimes all distinction between the tissues is lost, and the carotids run in the midst of the new growth, which may extend far out beneath the trapezius and down into the chest or over the clavicle on to the outside. When the neck is not primarily affected the groups are more isolated, and can be traced as chains of enlarged glands along the trachea and the carotids continuous with those of the axillæ and mediastinum. ”

“ These dangers constitute shoals and quicksands to the anatomist and surgeon, that has made many a one shudder at their approach. The six or eight vessels to tie, before daring to open the trachea, causes delay dangerous to life, as well as to the success of the operation, and brings into question the propriety of the operation, and sometimes the skill of the physician. In the upper operation, laryngo-tracheotomy, you can enlarge the opening upward whenever necessary, with but little risk, by cutting through the thyroid cartilage. ”

“ According to that measurement, allowing the 20 rings for 21⁄2 inches makes the space taken up by cutting three rings 3–8ths of an inch long in the adult, if no more is divided, and proportionately less in the child. We can readily understand that those operating in this region do as little cutting as possible, and although the operation so far as the outside incision, may begin at the cricoid cartilage, and terminate as at a little distance from the fossa at the top of the sternum. I have no idea that the trachea is often laid open to that extent. ”

“ On probing these, dead bone is felt, which has not yet separated. The right limb is about three inches shorter than the left, is freely movable in any direction without pain. He can raise the knee from the pillow, but cannot lift the heel from the bed; he can, however, turn himself over on to the left side without assistance. The prominence of the crest of the ilium is greatly diminished from loss of bone. The trochanter major is unusually projecting; the natural appearance of the hip-joint is entirely gone. ”

“ If those only are torn which connect the end of the bone to the acromion, there is mere rising of the end. But if—as is often the case when the violence has been great, as in a fall either from a height or with great velocity—the conoid and trapezoid ligaments connecting the tuberosity of the bone with the coracoid process, have given way, then the end of the bone projects, pushes out the deltoid, and gives rise to considerable flattening of the shoulder. ”