07. THE BACK

LOWER EXTREMITIES | UPPER EXTREMITIES

Examination of the Back

The back is examined before a full-length mirror, using a hand mirror or double mirror for viewing backwards. Exami­nation is made of any deformity, tenderness or limitation of motion. The normal back, viewed from behind, forms a straight line, while from the side, it has a graceful wave to it. The vertebrae are not tender, and their tips can be felt from the prominent seventh vertebra at the base of the neck down to the pelvis. The back's ability to move freely, tends to freeze with age, but we can expect a comfortable degree of easy motion in all directions from the average fifty year old back.

Deformity

1. View the spinal column from directly behind,  using a mirror. A curvature to one side is called a scoliosis.
2. View the spinal column from the side. A hunch-back deformity is called kyphosis, and a sway-back deformity is called lordosis.

Tenderness

1. Thump or press upon the bony column and on the bones of the pelvis. Tenderness or pain in various positions may indicate arthritis.
2. Press firmly on the soft muscular attachments to each side of the vertebral column. Tenderness along the soft sides of the backbone, can mean strain or sprain.

Limitation of Motion

1. From a standing position, bend well forward, backward and to each side. Back pain suggests either arthritis, ligament strain or disk trouble.
2. Sit firmly erect with arms folded and bend forward, backward and to each side. Soreness probably means arthritis in the backbone.
3. If the above preceding motion produces no back pain, repeat forward, backward and sideways bending, now in the standing position. Soreness of the soft tissues on standing but not on sitting, is probably due to deformity.
4. In the reclining position, raise each leg straight up in the air with the knee straight. Pain of one leg in this maneuver may mean slipped disk or sciatica difficulties.

Back Difficulties

Arthritis of the Spine. Arthritis of the back is often a serious problem after the age of fifty years. It is caused mainly by wear­ing down of the surfaces of the spine, and by nature's attempts to repair them. Unfortunately, the wearing down is mostly in the centers of these joints, while the repair process is around the edges. Eventually, the spinal joints become calcified and x-rays then show not the clean, block upon block appearance of youth, but rather the thistle upon thistle appearance of osteoarthritis in the later ages.

The spine, dominated by severe arthritis, eventually becomes shrunken, hunched, and finally fused into an inflexible "poker" spine. Pinched nerves and irritated surrounding ligaments, con­tribute to the painful stiffness which is often felt as chest and leg pain. This condition disables many people who are other­wise in sound health.

The wearing down process would not occur in our backs if we relieved the spine of weight bearing, by walking on all fours like

animals, but since a change back to this type of walking does not seem likely, we look to other methods of relief for this condition.

Hormone therapy is one effective method of treating this difficulty, and is based on the observation that continued sexual function of the testicle and ovary seems to prevent spinal wear and tear for some obscure reason. Intelligent medical therapy is usually successful in relieving arthritis of the back and should be sought in preference to mysterious or overly enthusiastic fad remedies, which contribute mostly as methods of self-hypnosis. Many more people would be confined to their wheel chairs to­day, completely or nearly completely disabled, if it were not for the reliable means of relief now available.

Scoliosis Deformity. Curvature of the spine to the side is the most common of all back deformities. Often it has existed since childhood from unrecognized polio or other bone diseases such as tuberculosis, whereas later in life it may well be the result of working habits. This is because heavy work by right handed people tends to lower the right shoulder slightly, and produce a slight spine curvature to the left. Nearly a third of all people have such deformity and are not even aware of it. It should be stated that a mild deviation from the perfect back cannot be considered as a real deformity, but obvious wide variations from the normal may cause considerable back trouble. Most often these difficulties can be relieved by correct medical therapy, and such treatment should be sought, if for no other reason than ordinary comfort.

Kyphosis Deformity. Hunch-back deformity, acquired in the early years, is frequently caused by childhood bone disease or just poor posture. Acquired later in life, hunch-back is caused by arthritis of the wearing-out type. It is very common in later years, it gets worse as time goes on and it is very difficult to cor­rect. Frequently chest, abdominal and extremity pain comes with kyphosis when nerves are pinched by the wearing out and collapsing vertebrae.

Lordosis Deformity. Sway-back, or "tired horse" deformity ac­companies hip joints which cannot straighten out properly and force the back to arch sharply for an erect position. This is

—  SPINAL CHORD

Fig. 133. A Slipped disk, between the vertebrae, frequently pinches against the spinal cord. Symptoms of back and leg pain frequently are made worse by coughing, sneezing and straining. Removal of protruded portion of disk by operative means usually means complete lasting relief.

caused by ligaments about the hip joints, shortened by polio, by infection or by accidents, which prevent straightening of the otherwise normal hip. The resulting "walking horse" posture does not often start after fifty years, as it is usually a hold-over from youth. It rarely causes trouble.

Slipped Disk, Ruptured Disk, Ruptured Nucleus Pulposis, Sciatica. A ruptured or slipped disk between the vertebrae, causes pain in the back and then down one or both legs. It is considered a back difficulty, but results in leg pain, called scia­tica, more than 75 percent of the time.

Each disk between the vertebrae is liquid in its center and firm about its periphery. When forced together, the liquid center of the disk may burst its way out through a rent in its rim, usually directly backward. The bursting putty-like sub­stance presses against the spinal cord and nerves to create pain in our backs, and lower legs. When we cough, sneeze or exert ourselves, the pressure pushes the disk substance harder against the spinal nerve to cause immediate pain in the legs. If this is continued over a long period, the nerve itself becomes sore and sensitive, so that it cannot stretch in walking as it normally should, and the sciatica sufferer must find relief by walking on his toes with knees slightly bent. This relaxes the sciatic nerve; and permits walking with less pain. Sometimes a disk may create severe back pain without pressure on any leg nerves, and walk­ing is no problem.

Most disk troubles occur in the lower part of the back. They do not endanger life and often heal with lengthy horizontal bed rest. When they produce pain which disables a person for too long a period, surgical removal of the ruptured disk can effect complete and welcome relief. The gratifying results from these operations makes those who have already had them the cham­pions of this type of surgery.

Strains and Sprains. A back strain is an injury caused by over­stretching or over-working the ligaments and muscles beyond their normal limits. A sprain, however, denotes actual tearing of muscles or ligaments within the back. Thus, back pain on one side, due to bumpy beds, too much gardening, or unusual exer­cise, most often means back strain and is a common occurrence often relieved by warm baths. But following an automobile acci­dent or a fall downstairs, actual bleeding within the muscles implies that some tissue most certainly has been torn apart and that a sprain has been suffered. However, after these very severe accidents, we most often have a combination of injuries besides a strain, including fractures, dislocations, lacerations and fre­quently considerable bleeding. Such difficulties obviously re­quire the services of the physician.

Fracture. Fractures of any of the vertebrae are difficult prob­lems frequently following trauma  such  as automobile  acci-

dents or serious falls. Not all back fractures are serious, but after any severe trauma, examination of the back, possibly with the help of x-ray, will enable the physician to determine whether or not a fracture exists.

Backaches

The most common complaint of the back is backache, and the most frequent cause of backache after the age of forty-five or fifty is degenerative or wearing down type of arthritis. This very common difficulty is made worse by cold damp weather or un­usual activity. It usually improves somewhat with rest, but gives rise to pain and limitation of motion after too much activity. Degenerative arthritis is most noticeable, in bending forward, backward or sideways, while in a sitting position. These motions bring out the fact that the backache is in the spine itself, and after fifty years of age, back trouble of this description is most often arthritis.

All during our lives, the wearing down processes are pitted against the reparative processes of the body, as nature constantly strives to rebuild anything damaged or worn. Youth can absorb considerable wear and tear, and expect to recuperate with ease, but in later life, we heal slower and cannot tolerate trauma as we did in the younger years. Following an accident backaches which might follow, are generally related to the severity and ex­tent of the injury. For example, after a severe automobile acci­dent, pain might be coming from bones, joints, cartilaginous disks, ligaments or muscles, any of which might be severely in­jured, but in less severe injury of the back, possibly from sleep­ing on a floor or very hard bed, the backache would most likely be due to temporary muscle spasm in the back.

Trauma, of course, can be imposed upon a spinal column which already has other diseases. Thus, the mild arthritic begins to have backache after the mildest trauma and after fifty years of age, it is painfully true that trauma of some sort usually pre­cedes most backache. It is unfortunate that the back should be so singled out to suffer not only from arthritic disease, but also to suffer in so great a way from mild incidents.

Sometimes back pain radiates down into the back of the leg, and is called sciatica pain. It can be caused in the back by pres­sure on nerves to the legs, from an injury to a vertebral disk, the vertebrae itself, or to adjoining ligaments. This pain is greatly aggravated by coughing, sneezing or straining, and depending upon its cause, may be temporary or permanent. Anything re­sembling permanent sciatic leg difficulty should be presented to the physician if relief is desired.

Periodic back pain in the same location, under the same cir­cumstances, and at approximately the same time each day, very likely is caused by a back deformity which exists in about thirty percent of us, though we are not aware of it. Deformity back­ache is usually due to too much strain on one set of muscles and not enough on another. An example is shortness of one leg, an unnoticed deformity that often causes strain in the back region during certain motions and activities. Back pain due to a de­formity, is most noticeable when standing and attempting to bend forward, backward or sideways.

Considerable skill is necessary to properly evaluate the de­formity and to decide accurately whether or not any form of treatment is necessary. Although deformity prevents the spine from maintaining an erect alignment and causes chronic strain, any resulting backache varies considerably from person to per­son.

Posture change due to slouching, a poor bed or possibly poor health, forces upon the spinal column a mechanical strain which may eventually result in a backache. Uncomfortable beds are a widespread cause of this difficulty and many people can recall later that back trouble originated at a time when a change was made from one bed to another.

Another very common back strain results from the obese ab­domen. The spinal column can be greatly strained in supporting an excess of unbalanced weight and the obese individual is usually aware of his chronic backache. This of course, can be greatly relieved by losing the excess weight and regaining good posture.

In nearly one-fourth of all backaches, the main cause of trou­ble cannot be determined. Some backs may be found to have some arthritis, possibly a mild curvature and probably the wear and tear to which all of us are subjected. A few ailing backs do not respond to treatment for any or all of these difficulties, while another back with the same difficulty of even greater degree has no backache at all. It is also true that some of these backaches may have causes which are discovered only after long periods of time have elapsed. For instance, a spine may occasionally be­come a target for diseases in other parts of the body, an example of which is cancer within the back-bone that has come through the blood stream from a distant cancer elsewhere in the body. Such disease, however, is usually suspected and discovered long before the backache begins.

On rare occasions the abdominal organs, especially the female organs, are thought to cause the backaches. At other times, men­tal problems and, occasionally, obscure fevers are at fault. Even diabetes and, at times, sheer nervous tension, has been found associated with an occasional backache.

Backache pain of an undetermined cause requires further study. All backaches have a definite cause, but, unfortunately, in some cases circumstances do not allow the detailed study neces­sary for diagnosis. It is well to understand that the back, like other parts of the body, is undergoing a degenerative process toward old age. Its diseases and affliction are multiple and can occur more than one at a time. It is also very true that the strong back is sought out by the strong mind to accomplish the world's work.

THE LOWER EXTREMITIES

Examination of the Lower Extremities

The lower extremities are examined unclothed, standing, and in all positions of functions, with the aid of enough light and the support of a table.

1. Stand on the leg to be tested and bend forward horizontally, putting the other leg straight out behind. Reversing this action, bend backward with the free leg straight out forward.  Pain and limited motion in the hip indicates probably arthritis within the joint, or rheumatism around the joint.
2. Examine motion of the knee. Cup both hands over one knee in a sitting position, then lift and swing the leg and foot back and forth as far as possible. A grating sensation or limited motion of the knee probably indicates arthritis.
3. Examine the ankle motion. Bend the ankle in all directions as far as possible. Painful motion or soreness about this joint, means probable arthritis.
4. Examine blood circulation in the foot. Feel the pulse at the dorsal artery located just beside the highest bone on the top

Fig. 135. The extremities have no glands or body-serving structure with­in them. They serve the body in its external needs, and are capable of fantastic abilities, as well as many diseases.

of the foot. A strong pulse in this artery indicates good circulation in the legs; its absence may mean circulatory difficulty. Observe also any swelling of the lower leg, ankle and foot which "pits" on deep finger pressure. This can be a sign of heart or kidney disease.

1. Examine the veins of the legs. Lie down with the feet elevated for several minutes and observe the disappearance of nearly all veins. Quickly stand erect and see if the veins fill rapidly into enlarged tortuous knots. Varicose veins will fill rapidly on standing, but normal veins fill slowly, taking about a full minute or more. Examine the skin just above the inner ankle joint for any long standing sore or ulcer, usually the result of varicose veins.
2. Examine the skin sensation of the legs and feet. Run the fingertips lightly over the legs and feet and note any areas of numbness, burning, heat, coldness or pain. Unusual or improper sensations often point to nerve disease in the leg or elsewhere in the body.
3. Standing with the heels flat and the knees locked, bend over and attempt to touch the floor. Soreness in the back of the thighs that travels downward into the calves may mean sciatica.
4. Sit on a table with the legs hanging down. Tap quickly just below the knee cap with a book edge, and note the presence or absence of the kicking reflex in the leg. It is absent in some forms of thyroid disease, pernicious anemia and nerve disease. It is normally absent in very few people.
5. Examine the foot and note any growth or thickening enlargements at the toe joints, side and soles of the foot. These conditions are corns, callouses, bunions or planter warts.

Lower Extremity Difficulties

Arthritis. In the years before fifty, joint arthritis is likely to be an inflammatory disease known as rheumatoid arthritis char­acterized by pain, stiffness and swelling of the joints, with red­ness and increased heat in the overlying skin.

It is seen usually between the ages of fifteen and forty, and affects women three times as often as men. This form of arthritis most often attacks the knees, elbows, ankles and shoulders.

After fifty years of age, arthritis or joint pain is nearly always due to a mechanical degeneration of the joint itself. This is a disease of the later years; it is not infectious and most often affects the finger joints and weight-bearing joints, as the back, hip and knee. Degenerative arthritis is a continuous disease, but its pain is usually not intense and is somewhat relieved with resting.

In degenerative arthritis as the years wear on and the joints wear out, particles of the joint structure break off and create a crunching sensation during motion. These particles can lock a joint momentarily in one position, especially the knee joints. As

Fig. 136. The ankle joint must carry the entire body weight with each step. It is often a victim of in­flammatory rheumatoid arthritis and obesity which punishes the helpless ankle joint with every step.

the joints break down further, especially the fingers, a gnarled twisting produces the typical arthritic hand of old age.

There is no complete cure for degenerative arthritis. Rest, application of heat and pain-relieving drugs have long been the most successful aids in lightening this disabling burden, carried by so many. The effect of damp weather, on nearly all types of arthritis, is well known the world over, but exactly what causes

Fig. 137. Knee joint difficulties in senior years result from youthful in­juries and because the joint actually wears out. Usually, they are not se­verely painful unless forced to carry the sin of obesity.

increased pain in damp seasons remains unknown. Many ar-thritics, however, have experienced considerable relief after moving to areas of a dry climate.

Another unanswered question is why joints wear out in some folks and not in others? The still unknown reason seems to be related to the strength and durability of each individual's body tissues, although over-weight, and exceptional activities without doubt, help wear out the joints. There will probably always remain an inequality of suffering among people with arthritic problems.

The physician's accurate diagnosis, elimination of contribut­ing causes, proper diet and the administration of pain-relieving drugs can do much for the senior age individual with an ar­thritic problem.

Gout. Gout, nearly always found in the male sex, is a disease of later years which differs markedly from arthritis. It is the result of too much uric acid in the blood, and nearly always at-

Fig. 138. Gout is a disease of men, usually in their senior years. Caused by an excessively high level of uric acid in the bloodstream, it generally affects the joint of the great toe. It is readily pre­vented through diet and certain medications.

tacks just one joint, usually, the great toe. Beginning suddenly, the joint grows very red and swollen, and becomes very painful for about a week to ten days. The attack will subside, but will recur again and again, if left untreated.

Gout is easily recognized by the physician, and can be con­firmed by simple blood tests. Usually it is easily prevented through the proper diet, which eliminates elements classed as purines. These foods include wines, certain fish, meats prepared from lamb and whole grain raw cereal.

The physician's identification of these offending food ele­ments in gout, and their elimination from the diet, gives most satisfactory results in relief from further gout difficulties.

Rheumatism. Rheumatism, also known as lumbago, myositis and myalgia, unlike arthritis does not affect the joints, but con­cerns itself primarily with the muscles and ligaments. It may occur anywhere in the body except the joints, and is commonly found in the neck, back, shoulders, arms and legs. It is often thought to be a cold in the muscles.

The exact cause of rheumatism is not clear; however, over-

Fig. 139. Rheumatism concerns the muscles and ligaments, not the joints. Often called a cold in the muscle, it possibly is caused by infection and is influenced by weather conditions.

work and muscular strain are very much associated with this difficulty. Chilling, wet weather and body infections, also have the ability to initiate rheumatism attacks.

A diagnosis of rheumatism is often hard for the physician to make, because of other associated and similar diseases. For this reason the physician's examination is important in this disease. An investigation of possible infection throughout the body must be made along with a search for physical faults possibly creating muscular strain. Education regarding dampness and coldness is also necessary as a preventive measure. The physician's attention to these many details often effectively alleviates or prevents the difficulties of rheumatism so common to those past the age of fifty years.

Sciatica. Sciatica is a soreness of the sciatic nerve, with sharp shooting pain and soreness along the nerve distribution in the hip, the back of the thigh and down into the leg. Usually, these pains are not constant but are produced suddenly and painfully by movements which stretch the nerve itself. These movements are straightening the knee, flexing the hip, or bending the ankle upward.

Because sciatic pain frequently is due to compression of the nerve within the spine, actions which suddenly increase this pressure on the nerve also produce the leg pain. So, coughing, sneezing, straining at bowel movement, and lifting heavy ob­jects often bring down the lash of sciatic pains.

In diagnosing sciatic pain, the physician always considers the possibility of a slipped disk injury between the vertebrae, which is a common cause of sciatica, along with arthritis of the spinal column.

After a diagnosis of sciatica has been made by the physician, surgical removal of an injured disk of the spine, or correction of spinal deformity may be indicated. Treatment for arthritis, or treatment of the sciatic nerve itself are also possibilities.

Absent Knee Jerk Reflexes. Tapping the tendon of the hang­ing leg just below the knee cap should cause the leg to kick for­ward slightly. This happens because the tap slightly stretches the thigh muscles, which respond automatically with a quick con­traction. This response is called the knee jerk reflex and is usu­ally present under all circumstances.

Absence of the knee jerk reflex frequently indicates diseases such as pernicious anemia, thyroid disease, or disease of the spinal cord or brain itself. Only on rare occasions are knee jerks absolutely absent in healthy individuals.

Circulatory Difficulties in the Leg. Diminished blood circula­tion of the lower extremities causes several difficulties which are widespread after the age of fifty. Mostly the result of arterio­sclerosis, which is comparable to the rusting and obstruction of a metal pipe, the arteries to the legs become obstructed and are then unable to carry enough blood into the lower extremities for all activities.

Intermittent claudication is the name of a pain felt in the calf muscle when it is forced to work without sufficient blood supply.

While these muscles can do light work effectively on poor blood supply, they cry out with pain when not supplied with enough blood for heavy duty and hard work. Since intermittent claudi-

cation is also sometimes caused by a temporary spasm of the leg arteries, things which increase blood vessel spasm such as to­bacco, are withheld in this disease.

Gangrene, seen in severe and far-advanced arteriosclerotic blocking in the arteries of the legs, usually results only after many years of circulation difficulty. It most often begins in the toes, and is an incurable disease which demands an amputation of the leg high enough to reach an adequate blood supply. It is very important to a person with severe arteriosclerosis to avoid even slight accidents or infection in the foot.

Diabetics, in later years, are greatly burdened with the pros­pect of gangrene of the toes. Diabetes not only fans the fires of arteriosclerosis, which reduces circulation, but also invites infec­tion about the toes. It is a well-known fact that poor circulation plus added infection greatly magnify the possibility of gangrene in diabetics.

The physician's treatment of circulatory difficulties, especially in the lower extremities, involves the regulation or cure of systemic disease such as diabetes, the elimination of blood vessel irritating factors such as tobacco, the avoidance of extremes of heat, cold and trauma, and the close attention to gentle but thorough cleanliness for the avoidance of infection about the toes or foot.

Varicose Veins. Abnormally dilated, stretched and distorted veins of the lower extremity, called varicose veins, are a penalty put on the human race for standing upright. In some people leg veins can't even be seen, but others less fortunate, have varicose veins on the legs and thighs that look like massive, grape-like

Fig. 141. Varicose veins are abnormally large, stretched veins, most often seen in the legs. The blood actually flows downward in them. Treatment now is very satisfactory, both surgically and otherwise, and should be done before complications develop. Bleeding, ulcer formation and blood clot formation can make varicose veins a very difficult problem.

knots which will bleed heavily if cut or torn. They are the result of inherited tendencies, or possibly from occupations which de­mand long standing, and from pregnancy. The final cause is the weight of the blood forcing weaker vein walls to stretch and expand. There are valves in normal veins permitting the blood to move only toward the heart, but in varicose veins, these over­stretched valves do not work and blood actually flows backward, down toward the feet. We can make these veins disappear tem­porarily by lying down and holding the legs upward, so that gravity drains blood out of the veins instead of driving it back­wards.

The treatment of varicose veins consists of closing up these dilated blood channels. This is done by removing the veins in a
 surgical operation, or injecting them with irritating chemicals which cause them to grow solidly together. These treatments are very successful when done by a physician who has had experi­ence in the treatment of varicose veins.

An unwelcome complication of varicose veins, is the varicose ulcer, due to poor blood circulation in the skin just about the inner ankle. The backward blood flow in varicose veins, dams back the circulation of fresh blood, and the result is a brown pigmented, tight and shiny skin which finally breaks down to form the typical varicose ulcer. These ulcers, of course, exist only while the varicose veins exist.

Corns. A thickened, hardened growth of skin over a bony projection submitted to continually repeated pressures is called a corn. The most common sites for corns are the toe joints, be­cause of pressure from shoes. If the pressure is removed, the corn cannot long exist, and here lies the cure of corns—the discarding of shoes which are too tight or ill-fitting.

The sacrifice of the feet for the style of the moment should be abolished by law.

Calluses. A thickening and hardening of the skin over a broad, non-pointed structure such as the ball of the foot, is a callus. It differs from its cousin, the corn, by not having a sharp bony projection, such as a joint, beneath it. The pressure causing the callus is more distributed to form a wider area of thickened and hardened skin. It often looks like a widely spread-out corn.

The relief of calluses, the same as in corns, demands relief of pressure against the calloused area. Removing the pressure al­lows a softening of the calloused skin, followed by its eventual flaking off in a large scab of dead skin.

Bunions. Continual, intermittent pressure, especially about the feet, frequently stimulates not only a thickening of skin, but also a growth of underlying bone. This bony growth is seen most often at the ball of the foot as a deformity of the base of the great toe. As the deformity becomes enlarged and more exposed, there is greater pressure and trauma on the bone, which of course, stimulates even greater growth and discomfort. Bunions sometimes reach outlandish sizes.

Relief of the pressure that caused the bunion, allows relief for the callus overlying the bunion, but removal of the underlying

Figs. 142, 143. Bunions are bone growths on the feet, resulting from long and continuous pressure, rubbing or trauma. They become very painful but can be treated with minor surgery.

bone growth is also necessary for a long-lasting bunion cure.

Temporary relief from most foot difficulties comes with the simple warm water foot bath, but this is obviously no permanent relief of bunions, calluses or corns. The biggest cause of these annoying conditions is still ill-fitting shoes, so most of our fifty year foot troubles would disappear if only we gave our feet the benefit of properly fitting shoes.

Ingrown Toenail. In later years the toenails may become hardened, thickened, and sometimes very irregular. This, how­ever, does not constitute an ingrown toenail. The ingrown process occurs only after the nail has been trimmed back too far, and then grows forward against the skin in front of it. The nail grows into this skin much as a needle would, and the pene­tration of skin in a contaminated region like the toe, often results in a painful infection, accompanied by pus formation and bleeding.

Ingrown toenails can be prevented by allowing the end of the toenail to grow beyond the end of the toe. Once a toenail has been cut too short, and it starts growing into the skin in front of it, the nail must be mechanically elevated from the skin, by cotton packing or other measures. These relief measures are undertaken frequently in an infected area, and should be attempted only by physicians or foot specialists trained in the treatment of ingrown toenails.

Hip Fractures. One of the unfortunate calamities of later years is fracture of the hip, incurred through accidental falls. The

Fig. 144. The broken hip is the most feared fracture of later years. This is because of the brittleness of the bone and the fact that most falls are onto the hip area.

Fig. 145. Surgical repair of a broken hip is effective with the use of a "nail" pinning the bone to­gether across the fracture line. This is a most satisfactory treatment in an otherwise very difficult fracture.

hip can be broken at any age, but is more liable to occur during later years when the bones become weaker. Youthful bones are tough and strong; they bend slightly and are hard to break. In age, however, the bones acquire a glass-like brittleness and shatter easily. The hip joint's outer position makes it absorb considerable punishment in falls, and is therefore, a likely spot for a fracture. A broken bone at this site of course, means the entire leg is useless, since its sole body support must come through the hip joint itself.

Hip fractures can be nearly painless if the broken bones are rammed together and held impacted in a correct position. How­ever, the usual broken hip renders the patient entirely helpless, because the bones are separated and there is severe pain in any kind of motion.

Treatment of a fractured hip, as in any fracture, requires the broken bones to be put together and held in place. There are several ways of doing this, but the most desired method today is nailing the bone fragments together. To do this, a special nail is driven down the inside of the bone through the bone marrow and through the line of fracture, threading the bone fragments together. This treatment has allowed many patients considerable relief of pain with early leg motion, and quicker return to nor­mal activity. It must, of course, be undertaken by a physician with experience in repairing fractures.

THE UPPER EXTREMITIES

Examination of the Upper Extremities

Examination of the shoulders, arms, forearms and hands re­quires that the upper extremities and chest be unclothed, and that an adequate, stationary mirror and light be used.

1. Examine the movements of the hands and fingers. Note the joints with soreness or limited motion in flexing and extending the finger joints and wrist joints. Observe also any joint swelling or deformity about the finger joints, frequently indicating degenerative arthritis.
2. Examine the elbow motion. Observe any painful inability to straighten the elbows completely, or to completely twist the wrists. Such inabilities again point to possibilities of arthritis.
3. Examine the movement of the shoulder. In a standing position slowly raise the straightened arm outward from the thigh to the horizontal position. Swing the arms forward to join in front and then backwards as far as possible. Note any pain in the shoulder joints during this action, as a probable finding of arthritis or bursitis.
4. Observe the degree of steadiness of the hands. Note especially any tremor of the fingers when held in a relaxed position, and also in a stiffened spread-out position. Tremors of the hands and fingers may mean neurological diseases, such as Parkinsonism.
5. Examine the reflexes present in the hands. Place each hand in cold running water for a few minutes, then withdraw it and observe any severe continuous blanching of the skin, with a long delay in return of color to the hands. Severe blanching may indicate Raynaud's Disease. Now determine the strength of the grip in each hand by squeezing the opposite wrist in turn. A great discrepancy of strength between the right and left grip could be a first indication of
   neurological disease.
6. Examine the hand for infection. Squeeze the palms and the back of the hands for painful swelling or redness of the skin in this region, or in the web of the thumb. These are the sites for serious hand-palm infection.
7. Examine the fingernails for infection. Observe any infected boil-like areas alongside the fingernail with any redness, swelling or pain in the fingers. Possible infections in the fingertips and about the nails are felons or nail infections.

Fig. 146. Arthritis in the hands and fingers may produce the gnarled and weakened appear­ance so typical of long-standing rheumatoid arthritis extending into later years of life.

Difficulties of the Upper Extremities

Arthritis. Arthritis in the upper extremity after the age of fifty years is very common. Rheumatoid arthritis, with its gnarled deformity of the fingers often extends into the years beyond fifty to effect painful, deformed and weakened hands. A wearing out of the joints, however,  termed degenerative ar­thritis, is more common in later years. Occasionally the degen-

Fig. 147. Arthritis of the elbow involving the revolving motion of the forearm may be due to overactivity in younger years, such as swinging a tennis racquet.

erative type and the more painful rheumatoid arthritis, exist in combination to produce a very debilitating disease.

Arthritis of the elbow, more frequent in younger years and known as "tennis elbow," appears in later years as inability to twist the wrist completely without pain in the elbow. It is neither as painful nor as disabling as in other joints.

Shoulder joint arthritis often results from infection in the body, plus the general wear and tear of the years; trouble in the shoulder joint is fairly common.

Because joints of the upper extremities are not weight-bearing joints, relief from arthritis in these joints is easier to find through simple means such as rest, than in the lower extremities.

As in arthritis of other areas, such as the lower extremities and spine, a complete cure of degenerative arthritis in later years is impossible. There is also great variation in the degree of disability it produces in different people, but considerable relief, through the physician's help, can be expected in three out of four such cases.

Bursitis. Bursitis refers to painful irritation of the bursa which overlays the shoulder joint. The bursa overlies the joint like a deflated balloon and allows the skin free motion over the joint structure. Irritation within the bursa is commonly seen after injury to the shoulder joint area; the formation of calcium plaques tend to prolong the irritation. These factors tend to prevent complete and permanent relief of pain in this area. There are also bursa in many other sections of the body, but

Fig. 148. Shoulder joint pain includes arthritis, bursitis, calcification and injuries of joints. A most purposeful joint, disease here can be very disabling. Correct examination and diagnosis are effective in pointing out effective treatment for most cases.

they are best known for their shoulder region location, where they cause ninety percent of their difficulties.

Bursitis is definitely a difficulty of later years. It has long been treated by heat, rest and pain relief through medication and now by calcium dissolving and anti-inflammatory drugs within the bursae itself. Cortisone preparations have become a very effective treatment for bursitis, and x-rays not only reveal the calcium deposits in the bursa, but frequently are also effective for their anti-inflammatory effect. The physician's care can be relied upon to obtain relief for the majority of patients afflicted with bursitis.

Tremors of the Hands and Fingers. Tremors in the fingers and hands may designate various diseases. They are present in some forms of thyroid disease, and frequently in excessive nerv­ousness. In later years however, the most common hand and finger tremor, sometimes called "pill rolling disease," is Parkinsonism, or Paralysis Agitans, a neurological disease thought to be caused by arteriosclerosis within the brain and spinal cord. The difficulty may progress for ten or twenty years, but, fortu­nately, is usually painless, and though cure of the tremor is usually not possible, there are drugs in use which reduce the tremor considerably.

There are also some surgical procedures which are sometimes advised for the treatment of this disease which have been suc­cessful in some cases. Happily the physician's treatment can be relied upon for improvement of this disease in nearly all cases.

Raynaud's Disease. This disease is a sudden reduction of blood circulation in the hands which brings about a blanched almost white-appearing hand which can be extremely painful. The condition is brought on by exposure to cold, such as cold water or cold weather, and is seen most often in women at younger ages, but often extends far beyond the fifty year mark.

Care of Raynaud's disease requires the therapy of certain drugs, and occasionally surgery, for extreme cases.

Palm-Hand Infection. Infections deep within the palm, or under the thumb are very serious. They are usually started by perforating injuries from needles, pins and other sharp objects. About a day after the perforating injury, the palm becomes thickened, hot and painful and red streaks are often seen ascend­ing the arm as a danger signal that infection is spreading.

These deep palm infections can be extremely serious and should be treated without delay. The physician might start anti­biotic therapy, hot, wet dressings, or might recommend an im­mediate incision and drainage of the infection.

Finger and Nail Infection. Infection around the nail border, called a paronychia, often develops from a hangnail or small cut on the finger tip. It might present a boil-like appearance along one side of the nail, or occasionally spread around the entire nail, and undermine it with pus.

Prevention of nail infections means reasonable hand protec-

Fig. 151. Finger infections about the nail, or deep in the finger portion, may ascend into the hand and arm. They should always be attended early to afford relief from pain as well as spread of infection.

tion, prevention of digging or pulling at hangnails and the in­telligent cleaning and covering of small, unimportant cuts on the fingers. Once a paronychia is started, the physician usually recommends warm water soaking, and avoidance of all possible trauma to the infected site. With the appearance of a boil-like head, with obvious pus underneath, a sterile incision and drain­age is in order, but the possibility of a spreading infection in this region demands that no one but the physician perform this operation. The pain, almost always present, is usually bad enough to encourage the patient to visit the physician.

Infection in the pad of the finger tips, looking like a deep-seated boil is caused by pin sticks and other perforating injuries about the ends of the fingers. They are called felons and are excruciatingly painful, very disabling, and serious.

Treatment of a felon infection demands surgical incision and drainage of the pus from its enclosed casing within the finger­tip. They occasionally respond to the physician's conservative treatment of antibiotics and warm water soaking, but neglect of such an infection, or crude attempts at home operation, often result in serious life long damage to the finger or entire hand.