Surgery, with Special Reference to Podiatry Part 14

+Osteitis Deformans.+ (_Paget's Disease_). This is a chronic disease of the bones and may affect one or more bones of the body. The onset is insidious, and before actual deformity occurs, long indefinite pains in the legs may have existed, with occasional tender points over the bone.

The bony changes are first noticed in the bones of the legs and are most marked in the tibia, femur and fibula. As a result of structural changes, these bones become bowed, while their internal trabecular structure is altered.

The extent of the affection in the bones of the legs varies a great deal and usually is not symmetric. The lower extremities are bowed outward, and also are usually bent forward, the curves being due to changes in the femur and the lower leg.

+Treatment.+ In the absence of any knowledge as to the cause of the disease, the treatment of osteitis deformans must be largely symptomatic. Certain drugs have been recommended; among these are iodide of potash and a.r.s.enic. Most such patients are in poor general condition, and effective feeding often gives marked relief of the symptoms from which they are suffering.

For severe pain, counterirritants are valuable, especially the actual cautery. Ma.s.sage is of use in some cases for improving the general condition.

+Tumors of Bone.+ All the primary tumors of bone are of the connective tissue group, but various secondary tumors of epithelial origin may occur.

Osseous tumors may arise from the periosteum or from the marrow. If they arise from the periosteum they may extend early to the adjacent soft tissues and involve and destroy them. If the tumor arises in the marrow, it is for a long while cut off from the adjacent soft tissues by the thick cortex, and about the extending medullary tumor may also come a reactive proliferation by the periosteum, so that as the tumor extends it still may, for a long time, be surrounded by a sh.e.l.l of bone which prevents infection of the soft parts. After a time, however, the reactive periosteum sh.e.l.l usually becomes perforated at one or more points, and then the medullary tumor extends to the adjacent tissues. The cause of these tumors is absolutely unknown.

+Fibromata+ are not very common tumors of bone. They arise generally from the periosteum and are most common about the face, and are rarely seen in the long bones. Many of these tumors are closely allied to some of the fibrous forms of sarcoma, and it is often difficult to distinguish them histologically.

+Chondromata+ are fairly common tumors of bone. They may appear externally to the cortex, or sometimes they grow in the medullary ca.n.a.l. They may arise directly from the marrow, probably from remnants of the provisional cartilage cells. They also appear frequently to arise from the epiphyseal line.

Chondromata appear generally as multiple ma.s.ses, nodular in shape, and are frequently seen on the lower leg, about the knee joint. They usually are painless, firm and hard, and not tender to pressure.

+Treatment+ consists in removal by operation.

+Osteomata+ are bony tumors which generally arise by growth of the periosteum, and form solid bony ma.s.ses external to the cortex of the bone, when they are called _exostoses_.

The density of the bone composing the tumor varies a great deal, some being very hard and ivorylike, while others are like the cellular marrow of the long bones.

Osteomata may be surrounded by a layer of fibrous periosteum or, in certain cases, beneath the periosteum appears a layer of cartilage producing the so-called _exostosis cartilaginea_. The latter formation is the one which is most common in the vicinity of the epiphyseal line of the long bones, notably of the leg.

Osteomata form circ.u.mscribed hard nodular ma.s.ses of bony consistency, and are usually painless. They may cause interference with function from their size, especially when they appear in close connection with a joint.

+Treatment+ is complete and thorough removal.

+Sarcomata+ are the most common tumors of bone; they are malignant, and when removed, tend to recur, either locally or by metastasis, in different parts of the body. The metastases usually are distributed by the circulation.

These tumors may arise from the marrow, but generally in the epiphysis of the bone and extend to the shaft only at a later stage of their development. As the tumor advances, it causes a softening and an absorption of the original cellular marrow until it approaches the periosteum.

In many cases the periosteum, as about any form of foreign body, then begins to proliferate and forms a sh.e.l.l of periosteal bone surrounding the tumor. In that way the sh.e.l.l of the bone oftentimes becomes very much enlarged before there is any extension of the process through the sh.e.l.l to the adjacent tissue. By destruction of the marrow and of the cortex, great softening of the bone may occur so that spontaneous fractures not infrequently are seen.

Other sarcomata arise from the periosteum, and usually originate from one side of the bone, although occasionally they entirely surround the bone. In the periosteal sarcomata, a new formation of bone is common and the bone is frequently arranged in a radical way, giving a most remarkable picture on the X-ray plate.

+Myeloma+ is a very rare malignant tumor of bone. Such tumors always appear only in connection with bone, are usually multiple, and are of the same type as other lymphoid tumors.

The cells of such tumors resemble very closely the type of plasma cell. These cells are arranged in ma.s.ses without an intercellular substance, and the tumors are closely allied to the malignant lymphomata. The cases are always a.s.sociated with alb.u.minuria.

+Symptoms.+ The chief symptoms of malignant tumors are swelling and pain, both of which oftentimes are extreme. The swelling may be spherical or spindle shaped.

+Extension+ to the joints may not occur for a great length of time. In many cases X-ray examination is the most reliable method of detecting the character of the bony change.

+Treatment+ of all sarcomata is early and complete removal. This means in nearly all cases, amputation of the affected bone, and it is important that the amputation should be of the entire bone through the joint between the bone and the body, rather than amputation of the bone in continuity. The reason for this is, that even in sarcomata, which have not extended to the soft parts, very frequently there have occurred metastases of tumor-cells throughout the blood sinuses of the affected bone, often times at a distance of several inches from the site of the original primary tumor.

+Carcinomata.+ Cancer of bone always is secondary to cancer in some epithelial organ. The infection may take place by direct extension through the blood or the lymphatics.

In cases of metastatic invasions of bone, spontaneous fractures oftentimes are the first symptom which calls attention to the fact that metastases have occurred.

+Treatment.+ As in other malignant tumors, the indication is for absolute and radical removal whenever possible. Unfortunately, this very seldom can be done, because at the time the bone has become affected by extension to any great degree, radical operation is impossible. Many times, however, extensive operations must be undertaken for the removal of bone.

+Cysts of Bone+ are rare lesions which practically always occur secondary to other lesions. They may occur as the result of the degeneration and softening of bone sarcomata. Some of the cases of bone cysts undoubtedly represent the entire destruction of sarcomatous processes. Occasionally echinococcus cysts of bone occur.

+Treatment.+ Cysts of bone due to softening of the centre of sarcomatous tumors, like sarcomata themselves, are to be treated by complete removal, best usually by amputation. Cysts of bone not due to the presence of sarcomatous tissue, should be opened and drained in some cases. Cysts due to the presence of echinococcus, should be opened and drained, with the removal of every vestige of the echinococcus.

CHAPTER XI

+DISEASES AND INJURIES OF THE ARTERIES AND GANGRENE+

+Gangrene+ is a term employed to denote the death of a part of the body, in ma.s.s.

_Necrosis_ and _mortification_ are terms used in a similar sense though necrosis is reserved in surgery to mean death of bone.

Gangrene may result from the gradual or sudden cessation of the arterial supply, or from a stoppage of the venous outflow. In general the etiology of gangrene comprises:

1. Traumatic causes.

2. Const.i.tutional causes.

3. Thrombosis and embolism.

4. Cold.

5. The effect of certain chemicals.

Before entering into a consideration of these subjects, it is wise to first consider the varieties of gangrene.

There are two forms in which gangrene is observed: _dry_ and _moist_.

+Dry gangrene+, or mummification, is a condition which occurs in consequence of a gradual diminution and final cessation of the blood supply, with the venous outflow intact. In this way, aided by evaporation and the venous return, there is a gradual drying of the parts. Diseases of the arteries and increasing pressure upon them from growing tumors, causes this variety.

+Moist gangrene+ is due to the sudden arrest of the arterial supply, or a similar obstruction to the venous return.

This is the variety commonly met with from crushing or cutting accidents; from the effects of carbolic and other acids; from cold; and from thrombosis and embolism.

A _thrombus_ is a blood clot occluding the lumen of a vessel. An _embolus_ is a loosened part of a thrombus or any other foreign substance, free in the blood stream, such as a drop of fat, an air globule, or a detached particle of tissue from growths in the heart or vessels. Any one of these may find lodgment in a terminal vessel, and plug it.

Moist gangrene therefore differs from dry gangrene in that the arrest of circulation takes place more or less suddenly when the tissues are suffused with blood.

The dry form of gangrene does not occur regularly in the diseases in which it might be expected, and though a true wet gangrene is not found, neither is the typical mummification.

Moist gangrene may occur in diabetes, in senility and in Reynaud's disease, and probably a.s.sumes this form on account of the sudden onset of inflammation in the part from some slight abrasion, or from weak heart action.