Manual of Surgery Volume I Part 45

There is no means of arresting the disease, and surgical treatment is restricted to the removal or division of any ma.s.s of bone that interferes with an important movement.

A remarkable feature of this disease is the frequent presence of a deformity of the great toe, which usually takes the form of hallux valgus, the great toe coming to lie beneath the second one; the shortening is usually ascribed to absence of the first phalanx, but it has been shown to depend also on a synostosis and imperfect development of the phalanges. A similar deformity of the thumb is sometimes met with.

Microscopical examination of the muscles shows that, prior to the deposition of lime salts and the formation of bone, there occurs a proliferation of the intra-muscular connective tissue and a gradual replacement and absorption of the muscle fibres. The bone is spongy in character, and its development takes place along similar lines to those observed in ossification from the periosteum.

#Tumours of Muscle.#--With the exception of congenital varieties, such as the rhabdomyoma, tumours of muscle grow from the connective-tissue framework and not from the muscle fibres. Innocent tumours, such as the fibroma, lipoma, angioma, and neuro-fibroma, are rare. Malignant tumours may be primary in the muscle, or may result from extension from adjacent growths--for example, implication of the pectoral muscle in cancer of the breast--or they may be derived from tumours situated elsewhere. The diagnosis of an intra-muscular tumour is made by observing that the swelling is situated beneath the deep fascia, that it becomes firm and fixed when the muscle contracts, and that, when the muscle is relaxed, it becomes softer, and can be moved in the transverse axis of the muscle, but not in its long axis.

Clinical interest attaches to that form of slowly growing fibro-sarcoma--_the recurrent fibroid of Paget_--which is most frequently met with in the muscles of the abdominal wall. A rarer variety is the ossifying chondro-sarcoma, which undergoes ossification to such an extent as to be visible in skiagrams.

In primary sarcoma the treatment consists in removing the muscle. In the limbs, the function of the muscle that is removed may be retained by transplanting an adjacent muscle in its place.

_Hydatid cysts_ of muscle resemble those developing in other tissues.

DISEASES OF TENDON SHEATHS

Tendon sheaths have the same structure and function as the synovial membranes of joints, and are liable to the same diseases. Apart from the tendon sheaths displayed in anatomical dissections, there is a loose peritendinous and perimuscular cellular tissue which is subject to the same pathological conditions as the tendon sheaths proper.

#Teno-synovitis.#--The toxic or infective agent is conveyed to the tendon sheaths through the blood-stream, as in the gouty, gonorrhal, and tuberculous varieties, or is introduced directly through a wound, as in the common pyogenic form of teno-synovitis.

_Teno-synovitis Crepitans._--In the simple or traumatic form of teno-synovitis, although the most prominent etiological factor is a strain or over-use of the tendon, there would appear to be some other, probably a toxic, factor in its production, otherwise the affection would be much more common than it is: only a small proportion of those who strain or over-use their tendons become the subjects of teno-synovitis. The opposed surfaces of the tendon and its sheath are covered with fibrinous lymph, so that there is friction when they move on one another.

The _clinical features_ are pain on movement, tenderness on pressure over the affected tendon, and a sensation of crepitation or friction when the tendon is moved in its sheath. The crepitation may be soft like the friction of snow, or may resemble the creaking of new leather--"saddle-back creaking." There may be swelling in the long axis of the tendon, and redness and dema of the skin. If there is an effusion of fluid into the sheath, the swelling is more marked and crepitation is absent. There is little tendency to the formation of adhesions.

In the upper extremity, the sheath of the long tendon of the biceps may be affected, but the condition is most common in the tendons about the wrist, particularly in the extensors of the thumb, and it is most frequently met with in those who follow occupations which involve prolonged use or excessive straining of these tendons--for example, washerwomen or riveters. It also occurs as a result of excessive piano-playing, fencing, or rowing.

At the ankle it affects the peronei, the extensor digitorum longus, or the tibialis anterior. It is most often met with in relation to the tendo-calcaneus--_Achillo-dynia_--and results from the pressure of ill-fitting boots or from the excessive use and strain of the tendon in cycling, walking, or dancing. There is pain in raising the heel from the ground, and creaking can be felt on palpation.

The _treatment_ consists in putting the affected tendon at rest, and with this object a splint may be helpful; the usual remedies for inflammation are indicated: Bier's hyperaemia, lead and opium fomentations, and ichthyol and glycerine. The affection readily subsides under treatment, but is liable to relapse on a repet.i.tion of the exciting cause.

_Gouty Teno-synovitis._--A deposit of urate of soda beneath the endothelial covering of tendons or of that lining their sheaths is commonly met with in gouty subjects. The acc.u.mulation of urates may result in the formation of visible nodular swellings, varying in size from a pea to a cherry, attached to the tendon and moving with it. They may be merely unsightly, or they may interfere with the use of the tendon. Recurrent attacks of inflammation are p.r.o.ne to occur. We have removed such gouty ma.s.ses with satisfactory results.

_Suppurative Teno-synovitis._--This form usually follows upon infected wounds of the fingers--especially of the thumb or little finger--and is a frequent sequel to whitlow; it may also follow amputation of a finger.

Once the infection has gained access to the sheath, it tends to spread, and may reach the palm or even the forearm, being then a.s.sociated with cellulitis. In moderately acute cases the tendon and its sheath become covered with granulations, which subsequently lead to the formation of adhesions; while in more acute cases the tendon sloughs. The pus may burst into the cellular tissue outside the sheath, and the suppuration is liable to spread to neighbouring sheaths or to adjacent bones or joints--for example, those of the wrist.

The _treatment_ consists in inducing hyperaemia and making small incisions for the escape of pus. The site of incision is determined by the point of greatest tenderness on pressure. After the inflammation has subsided, active and pa.s.sive movements are employed to prevent the formation of adhesions between the tendon and its sheath. If the tendon sloughs, the dead portion should be cut away, as its separation is extremely slow and is attended with prolonged suppuration.

_Gonorrhal Teno-synovitis._--This is met with especially in the tendon sheaths about the wrist and ankle. It may occur in a mild form, with pain, impairment of movement, and dema, and sometimes an elongated, fluctuating swelling, the result of serous effusion into the sheath.

This condition may alternate with a gonorrhal affection of one of the larger joints. It may subside under rest and soothing applications, but is liable to relapse. In the more severe variety the skin is red, and the swelling partakes of the characters of a phlegmon with threatening suppuration; it may result in crippling from adhesions. Even if pus forms in the sheath, the tendon rarely sloughs. The treatment consists in inducing hyperaemia by Bier's method; and a vaccine may be employed with satisfactory results.

#Tuberculous Disease of Tendon Sheaths.#--This is a comparatively common affection, and is a.n.a.logous to tuberculous disease of the synovial membrane of joints. It may originate in the sheath, or may spread to it from an adjacent bone.

The commonest form--hydrops--is that in which the synovial sheath is distended with a viscous fluid, and the fibrinous material on the free surface becomes detached and is moulded into melon-seed bodies by the movement of the tendon. The sheath itself is thickened by the growth of tuberculous granulation tissue. The bodies are smooth and of a dull-white colour, and vary greatly in size and shape. There may be an overgrowth of the fatty fringes of the synovial sheath, a condition described as "arborescent lipoma."

The _clinical features_ vary with the tendon sheath affected. In the common flexor sheath of the hand an hour-gla.s.s-shaped swelling is formed, bulging above and below the transverse carpal (anterior annular) ligament--formerly known as _compound palmar ganglion_. There is little or no pain, but the fingers tend to be stiff and weak, and to become flexed. On palpation, it is usually possible to displace the contents of the sheath from one compartment to the other, and this may yield fluctuation, and, what is more characteristic, a peculiar soft crepitant sensation from the movement of the melon-seed bodies. In the sheath of the peronei or other tendons about the ankle, the swelling is sausage-shaped, and is constricted opposite the annular ligament.

The onset and progress of the affection are most insidious, and the condition may remain stationary for long periods. It is aggravated by use or strain of the tendons involved. In exceptional cases the skin is thinned and gives way, resulting in the formation of a sinus.

_Treatment._--In the common flexor sheath of the palm, an attempt may be made to cure the condition by removing the contents through a small incision and filling the cavity with iodoform glycerine, followed by the use of Bier's bandage. If this fails, the distended sheath is laid open, the contents removed, the wall sc.r.a.ped, and the wound closed.

A less common form of tuberculous disease is that in which the sheath becomes the seat of _a diffuse tuberculous thickening_, not unlike the white swelling met with in joints, and with a similar tendency to caseation. A painless swelling of an elastic character forms in relation to the tendon sheath. It is hour-gla.s.s-shaped in the common flexor sheath of the palm, elongated or sausage-shaped in the extensors of the wrist and in the tendons at the ankle. The tuberculous granulation tissue is liable to break down and lead to the formation of a cold abscess and sinuses, and in our experience is often a.s.sociated with disease in an adjacent bone or joint. In the peronei tendons, for example, it may result from disease of the fibula or of the ankle-joint.

When conservative measures fail, excision of the affected sheath should be performed; the whole of the diseased area being exposed by free incision of the overlying soft parts, the sheath is carefully isolated from the surrounding tissues and is cut across above and below. Any tuberculous tissue on the tendon itself is removed with a sharp spoon.

a.s.sociated bone or joint lesions are dealt with at the same time. In the after-treatment the functions of the tendons must be preserved by voluntary and pa.s.sive movements.

#Syphilitic Affections of Tendon Sheaths.#--These closely resemble the syphilitic affections of the synovial membrane of joints. During the secondary period the lesion usually consists in effusion into the sheath; gummata are met with during the tertiary period.

Arborescent lipoma has been found in the sheaths of tendons about the wrist and ankle, sometimes in a multiple and symmetrical form, unattended by symptoms and disappearing under anti-syphilitic treatment.

#Tumours of Tendon Sheaths.#--Innocent tumours, such as _lipoma_, _fibroma_, and _myxoma_, are rare. Special mention should be made of the _myeloma_ which is met with at the wrist or ankle as an elongated swelling of slow development, or over the phalanx of a finger as a small rounded swelling. The tumour tissue, when exposed by dissection, is of a chocolate or chamois-yellow colour, and consists almost entirely of giant cells. The treatment consists in dissecting the tumour tissue off the tendons, and this is usually successful in bringing about a permanent cure.

All varieties of _sarcoma_ are met with, but their origin from tendon sheaths is not a.s.sociated with special features.

CHAPTER XIX

THE BURSae

Anatomy--Normal and advent.i.tious bursae--Injuries: Bursal haematoma--DISEASES: Infective bursitis; Traumatic or trade bursitis; Bursal hydrops; Solid bursal tumour; Gonorrhal and suppurative forms of bursitis; Tuberculous and syphilitic disease--Tumours--_Diseases of individual bursae in the upper and lower extremities_.

A bursa is a closed sac lined by endothelium and containing synovia.

Some are normally present--for instance, that between the skin and the patella, and that between the aponeurosis of the gluteus maximus and the great trochanter. _Advent.i.tious bursae_ are developed as a result of abnormal pressure--for example, over the tarsal bones in cases of club-foot.

#Injuries of Bursae.#--As a result of contusion, especially in bleeders, haemorrhage may occur into the cavity of a bursa and give rise to a _bursal haematoma_. Such a haematoma may mask a fracture of the bone beneath--for example, fracture of the olecranon.

#Diseases of Bursae.#--The lining membrane of bursae resembles that of joints and tendon sheaths, and is liable to the same forms of disease.

#Infective bursitis# frequently follows abrasions, scratches, and wounds of the skin over the prepatellar or olecranon bursa, and in neglected cases the infection transgresses the wall of the bursa and gives rise to a spreading cellulitis.

#Traumatic or Trade Bursitis.#--This term may be conveniently applied to those affections of bursae which result from repeated slight traumatism incident to particular occupations. The most familiar examples of these are the enlargement of the prepatellar bursa met with in housemaids--the "housemaid's knee" (Fig. 113); the enlargement of the olecranon bursa--"miner's elbow"; and of the ischial bursa--"weaver's" or "tailor's bottom" (Fig. 116). These affections are characterised by an effusion of fluid into the sac of the bursa with thickening of its lining membrane. While friction and pressure are the most evident factors in their production, it is probable that there is also some toxic agent concerned, otherwise these affections would be much more common than they are. Of the countless housemaids in whom the prepatellar bursa is subjected to friction and pressure, only a small proportion become the subjects of housemaid's knee.

_Clinical Features._--As these are best ill.u.s.trated in the different varieties of prepatellar bursitis, it is convenient to take this as the type. In a number of cases the inflammation is acute and the patient is unable to use the limb; the part is hot, swollen, and tender, and fluctuation can be detected in the bursa. In the majority the condition is chronic, and the chief feature is the gradual acc.u.mulation of fluid const.i.tuting the _bursal hydrops_ or _hygroma_. When the affection has lasted some time, or has frequently relapsed, the wall of the bursa becomes thickened by fibrous tissue, which may be deposited irregularly, so that septa, bands, or fringes are formed, not unlike those met with in arthritis deformans. These fringes may be detached and form loose bodies like those met with in joints; less frequently there are fibrinous bodies of the melon-seed type, sometimes moulded into circular discs like wafers. The presence of irregular thickenings of the wall, or of loose bodies, may be recognised on palpation, especially in superficial bursae, if the sac is not tensely filled with fluid. The thickening of the wall may take place in a uniform and concentric fashion, resulting in the formation of a fibrous tumour--_the solid bursal tumour_--a small cavity remaining in the centre which serves to distinguish it from a new growth or neoplasm.

[Ill.u.s.tration: FIG. 113.--Hydrops of Prepatellar Bursa in a housemaid.]

The _treatment_ varies according to the variety and stage of the affection. In recent cases the symptoms subside under rest and the application of fomentations. Hydrops may be got rid of by blistering, by tapping, or by incision and drainage. When the wall is thickened, the most satisfactory treatment is to excise the bursa; the overlying skin being reflected in the shape of a horse-shoe flap or being removed along with the bursa.

#Other Diseases of Bursae# are a.s.sociated with _gonorrhal infection_, and with _rheumatism_, especially that following scarlet fever, and are apt to be persistent or to relapse after apparent cure. In the _gouty_ form, urate of soda is deposited in the wall of the bursa, and may result in the formation of chalky tumours, sometimes of considerable size (Fig. 114).

[Ill.u.s.tration: FIG. 114.--Section through Bursa over external malleolus, showing deposit of urate of soda. (Cf. Fig. 117.)]

_Tuberculous disease_ of bursae closely resembles that of tendon sheaths.

It may occur as an independent affection, or may be a.s.sociated with disease in an adjacent bone or joint. It is met with chiefly in the prepatellar and subdeltoid bursae, or in one of the bursae over the great trochanter. The clinical features are those of an indolent hydrops, with or without melon-seed bodies, or of uniform thickening of the wall of the bursa; the tuberculous granulation tissue may break down into a cold abscess, and give rise to sinuses. The best treatment is to excise the affected bursa, or, when this is impracticable, to lay it freely open, remove the tuberculous tissue with the sharp spoon or knife, and treat the cavity by the open method.

_Syphilitic disease_ is rarely recognised except in the form of bursal and peri-bursal gummata in front of the knee-joint.