Alexis Thomson and Alexander Miles - Manual of Surgery

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In _pleurodynia_--_intercostal fibrositis_--the pain is in the line of
the intercostal nerves, and is excited by movement of the chest, as in
coughing, or by any bodily exertion. There is often marked tenderness.

A similar affection is met with in the _shoulder and arm_--_brachial
fibrositis_--especially on waking from sleep. There is acute pain on
attempting to abduct the arm, and there may be localised tenderness in
the region of the axillary nerve.

_Treatment._--The general treatment is concerned with the diet,
attention to the stomach, bowels, and kidneys and with the correction
of any gouty tendencies that may be present. Remedies such as
salicylates are given for the relief of pain, and for this purpose drugs
of the aspirin type are to be preferred, and these may be followed by
large doses of iodide of potassium. Great benefit is derived from
massage, and from the induction of hyperaemia by means of heat. Cupping
or needling, or, in exceptional cases, hypodermic injections of
antipyrin or morphin, may be called for. To prevent relapses of lumbago,
the patient must take systematic exercises of all kinds, especially such
as bring out the movements of the vertebral column and hip-joints.

[Illustration: FIG. 109.--Volkmann's Ischaemic Contracture. When the
wrist is flexed to a right angle it is possible to extend the fingers.

(Photographs lent by Mr. Lawford Knaggs)]

#Contracture of Muscles.#--Permanent shortening of muscles results from
the prolonged approximation of their points of attachment, or from
structural changes in their substance produced by injury or by disease.
It is a frequent accompaniment and sometimes a cause of deformities, in
the treatment of which lengthening of the shortened muscles or their
tendons may be an essential step.

#Myositis.#--_Ischaemic Myositis._--Volkmann was the first to describe a
form of myositis followed by contracture, resulting from interference
with the arterial blood supply. It is most frequently observed in the
flexor muscles of the forearm in children and young persons under
treatment for fractures in the region of the elbow, the splints and
bandages causing compression of the blood vessels. There is considerable
effusion of blood, the skin is tense, and the muscles, vessels, and
nerves are compressed; this is further increased if the elbow is flexed
and splints and tight bandages are applied. The muscles acquire a
board-like hardness and no longer contract under the will, and passive
motion is painful and restricted. Slight contracture of the fingers is
usually the first sign of the malady; in time the muscles undergo
further contraction, and this brings about a claw-like deformity of the
hand. The affected muscles usually show the reaction of degeneration. In
severe cases the median and ulnar nerves are also the seat of
cicatricial changes (ischaemic neuritis).

By means of splints, the interphalangeal, metacarpo-phalangeal, and
wrist joints should be gradually extended until the deformity is
over-corrected (R. Jones). Murphy advises resection of the radius and
ulna sufficient to admit of dorsiflexion of the joints and lengthening
of the flexor tendons.

Various forms of _pyogenic_ infection are met with in muscle, most
frequently in relation to pyaemia and to typhoid fever. These may result
in overgrowth of the connective-tissue framework of the muscle and
degeneration of its fibres, or in suppuration and the formation of one
or more abscesses in the muscle substance. Repair may be associated with
contracture.

A _gonorrhoeal_ form of myositis is sometimes met with; it is painful,
but rarely goes on to suppuration.

In the early secondary period of _syphilis_, the muscles may be the seat
of dull, aching, nocturnal pains, especially in the neck and back.
_Syphilitic contracture_ is a condition which has been observed chiefly
in the later secondary period; the biceps of the arm and the hamstrings
in the thigh are the muscles more commonly affected. The striking
feature is a gradually increasing difficulty of extending the limb at
the elbow or knee, and progressive flexion of the joint. The affected
muscle is larger and firmer than normal, and its electric excitability
is diminished. In tertiary syphilis, individual muscles may become the
seat of interstitial myositis or of gummata, and these affections
readily yield to anti-syphilitic remedies.

_Tuberculous disease_ in muscle, while usually due to extension from
adjacent tissues, is sometimes the result of a primary infection through
the blood-stream. Tuberculous nodules are found disseminated throughout
the muscle; the surrounding tissues are indurated, and central caseation
may take place and lead to abscess formation and sinuses. We have
observed this form of tuberculous disease in the gastrocnemius and in
the psoas--in the latter muscle apart from tuberculous disease in the
vertebrae.

#Tendinitis.#--German authors describe an inflammation of tendon as
distinguished from inflammation of its sheath, and give it the name
tendinitis. It is met with most frequently in the tendo-calcaneus in
gouty and rheumatic subjects who have overstrained the tendon,
especially during cold and damp weather. There is localised pain which
is aggravated by walking, and the tendon is sensitive and swollen from a
little above its insertion to its junction with the muscle. Gouty
nodules may form in its substance. Constitutional measures, massage, and
douching should be employed, and the tendon should be protected from
strain.

#Calcification and Ossification in Muscles, Tendons, and
Fasciae.#--_Myositis ossificans._--Ossifications in muscles, tendons,
fasciae, and ligaments, in those who are the subjects of arthritis
deformans, are seldom recognised clinically, but are frequently met with
in dissecting-rooms and museums. Similar localised ossifications are met
with in Charcot's disease of joints, and in fractures which have
repaired with exuberant callus. The new bone may be in the form of
spicules, plates, or irregular masses, which, when connected with a
bone, are called _false exostoses_ (Fig. 110).

[Illustration: FIG. 110.--Ossification in Tendon of Ilio-psoas Muscle.]

_Traumatic Ossification in Relation to Muscle._--Various forms of
ossification are met with in muscle as the result of a single or of
repeated injury. Ossification in the crureus or vastus lateralis muscle
has been frequently observed as a result of a kick from a horse. Within
a week or two a swelling appears at the site of injury, and becomes
progressively harder until its consistence is that of bone. If the mass
of new bone moves with the affected muscle, it causes little
inconvenience. If, as is commonly the case, it is fixed to the femur,
the action of the muscle is impaired, and the patient complains of pain
and difficulty in flexing the knee. A skiagram shows the extent of the
mass and its relationship to the femur. The treatment consists in
excising the bony mass.

Difficulty may arise in differentiating such a mass of bone from
sarcoma; the ossification in muscle is uniformly hard, while the sarcoma
varies in consistence at different parts, and the X-ray picture shows a
clear outline of the bone in the vicinity of the ossification in
muscle, whereas in sarcoma the involvement of the bone is shown by
indentations and irregularity in its contour.

A similar ossification has been observed in relation to the insertion of
the brachialis muscle as a sequel of dislocation of the elbow. After
reduction of the dislocation, the range of movement gradually diminishes
and a hard swelling appears in front of the lower end of the humerus.
The lump continues to increase in size and in three to four weeks the
disability becomes complete. A radiogram shows a shadow in the muscle,
attached at one part as a rule to the coronoid process. During the next
three or four months, the lump in front of the elbow remains stationary
in size; a gradual decrease then ensues, but the swelling persists, as a
rule, for several years.

[Illustration: FIG. 111.--Calcification and Ossification in Biceps and
Triceps.

(From a radiogram lent by Dr. C. A. Adair Dighton.)]

Ossification in the adductor longus was first described by Billroth
under the name of "rider's bone." It follows bruising and partial
rupture of the muscle, and has been observed chiefly in cavalry
soldiers. If it causes inconvenience the bone may be removed by
operation.

Ossification in the deltoid and pectoral muscles has been observed in
foot-soldiers in the German army, and has received the name of
"drill-bone"; it is due to bruising of the muscle by the recoil of the
rifle.

_Progressive Ossifying Myositis._--This is a rare and interesting
disease, in which the muscles, tendons, and fasciae throughout the body
become the seat of ossification. It affects almost exclusively the male
sex, and usually begins in childhood or youth, sometimes after an
injury, sometimes without apparent cause. The muscles of the back,
especially the trapezius and latissimus, are the first to be affected,
and the initial complaint is limitation of movement.

[Illustration: FIG. 112.--Ossification in Muscles of Trunk in a case of
generalised Ossifying Myositis.

(Photograph lent by Dr. Rustomjee.)]

The affected muscles show swellings which are rounded or oval, firm and
elastic, sharply defined, without tenderness and without discoloration
of the overlying skin. Skiagrams show that a considerable deposit of
lime salts may precede the formation of bone, as is seen in Fig. 111. In
course of time the vertebral column becomes rigid, the head is bent
forward, the hips are flexed, and abduction and other movements of the
arms are limited. The disease progresses by fits and starts, until all
the striped muscles of the body are replaced by bone, and all movements,
even those of the jaws, are abolished. The subjects of this disease
usually succumb to pulmonary tuberculosis.

There is no means of arresting the disease, and surgical treatment is
restricted to the removal or division of any mass 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, gonorrhoeal,
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 oedema 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 repetition 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 accumulation 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 prone to occur. We have
removed such gouty masses 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 associated 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 passive 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.

_Gonorrhoeal 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 oedema, and sometimes an elongated,
fluctuating swelling, the result of serous effusion into the sheath.
This condition may alternate with a gonorrhoeal 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 analogous 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-glass-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 scraped, 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-glass-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 associated 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.
Associated 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 passive 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 associated with special features.

CHAPTER XIX

THE BURSAE

Anatomy--Normal and adventitious bursae--Injuries: Bursal
haematoma--DISEASES: Infective bursitis; Traumatic or trade
bursitis; Bursal hydrops; Solid bursal tumour; Gonorrhoeal 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. _Adventitious 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 illustrated 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 accumulation of fluid
constituting 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.