Alexis Thomson and Alexander Miles - Manual of Surgery

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[Illustration: 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 associated with _gonorrhoeal 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).

[Illustration: 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 associated 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.

_New growths_ include the fibroma, the myxoma, the myeloma or
giant-celled tumour, and various forms of sarcoma.

#Diseases of Individual Bursae.#--The _olecranon bursa_ is frequently
the seat of pyogenic infection and of traumatic or trade bursitis, the
latter being known as "miner's" or "student's elbow."

[Illustration: FIG. 115.--Tuberculous Disease of Sub-deltoid Bursa.

(From a photograph lent by Sir George T. Beatson.)]

The _sub-deltoid_ or _sub-acromial bursa_, which usually presents a
single cavity and does not normally communicate with the shoulder-joint,
is indispensable in abduction and rotation of the humerus. When the arm
is abducted, the fixed lower part or floor of the bursa is carried under
the acromion, and the upper part or roof is rolled up in the same
direction, hence tenderness over the inflamed bursa may disappear when
the arm is abducted (Dawbarn's sign). It is liable to traumatic
affections from a fall on the shoulder, pressure, or over-use of the
limb. Pain, located commonly at the insertion of the deltoid, is a
constant symptom and is especially annoying at night, the patient being
unable to get into a comfortable position. Tenderness may be elicited
over the anatomical limits of the bursa, and is usually most marked over
the great tuberosity, just external to the inter-tubercular (bicipital)
groove. When adhesions are present, abduction beyond 10 degrees is
impossible. Demonstrable effusion is not uncommon, but is disguised by
the overlying tissues. If left to himself, the patient tends to maintain
the limb in the "sling position," and resists movements in the direction
of abduction and rotation. In the treatment of this affection the arm
should be maintained at a right angle to the body, the arm being rotated
medially (Codman). When pain does not prevent it, movements of the arm
and massage are persevered with. In neglected cases, when adhesions have
formed and the shoulder is fixed, it may be necessary to break down the
adhesions under an anaesthetic.

The bursa is also liable to infective conditions, such as acute
rheumatism, gonorrhoea, suppuration, or tubercle. In tuberculous disease
a large fluctuating swelling may form and acquire the characters of a
cold abscess (Fig. 115).

The bursa underneath the tendon of the _subscapularis_ muscle when
inflamed causes alteration in the attitude of the shoulder and
impairment of its movements.

An adventitious bursa forms over the _acromion_ process in porters and
others who carry weights on the shoulder, and may be the seat of
traumatic bursitis.

The bursa under the _tendon of insertion of the biceps_, when the seat
of disease, is attended with pain and swelling about a finger's breadth
below the bend of the elbow; there is pain and difficulty in effecting
the combined movement of flexion and supination, slight limitation of
extension, and restriction of pronation.

In the lower extremity, a large number of normal and adventitious bursae
are met with and may be the seat of bursitis. That over the _tuberosity
of the ischium_, when enlarged as a trade disease, is known as
"weaver's" or "tailor's bottom." It may form a fluctuating swelling of
great size, projecting on the buttock and extending down the thigh, and
causing great inconvenience in sitting (Fig. 116). It sometimes contains
a number of loose bodies.

There are two bursae over the _great trochanter_, one superficial to, the
other beneath the aponeurosis of the gluteus maximus; the latter is not
infrequently infected by tuberculous disease that has spread from the
trochanter.

The bursa _between the psoas muscle and the capsule of the hip-joint_
may be the seat of tuberculous disease, and give rise to clinical
features not unlike those of disease of the hip-joint. The limb is
flexed, abducted and rotated out; there is a swelling in the upper part
of Scarpa's triangle, but the movements are not restricted in directions
which do not entail putting the ilio-psoas muscle on the stretch.

Cartilaginous and partly ossified loose bodies may accumulate in the
ilio-psoas bursa and distend it, both in a downward direction towards
the hip-joint, with which it communicates, and upwards, projecting
towards the abdomen.

The bursa beneath the quadriceps extensor--_subcrural bursa_--usually
communicates with the knee-joint and shares in its diseases. When shut
off from the joint it may suffer independently, and when distended with
fluid forms a horse-shoe swelling above the patella.

In front of the patella and its ligament is the _prepatellar bursa_,
which may have one, two, or three compartments, usually communicating
with one another. It is the seat of the affection known as "housemaid's
knee," which is very common and is sometimes bilateral, and, less
frequently, of tuberculous disease which usually originates in the
patella.

[Illustration: FIG. 116.--Great Enlargement of the Ischial Bursa.

(Mr. Scot-Skirving's case.)]

The bursa _between the ligamentum patellae and the tibia_ is rarely the
seat of disease. When it is, there is pain and tenderness referred to
the ligament, the patient is unable to extend the limb completely, the
tuberosity of the tibia is apparently enlarged, and there is a
fluctuating swelling on either side of the ligament, most marked in the
extended position of the limb.

Of the numerous bursae in the popliteal space, that _between the
semi-membranosus and the medial head of the gastrocnemius_ is most
frequently the seat of disease, which is usually of the nature of a
simple hydrops, forming a fluctuating egg-or sausage-shaped swelling at
the medial side of the popliteal space. It is flaccid in the flexed, and
tense in the extended position. As a rule it causes little
inconvenience, and may be left alone. Otherwise it should be dissected
out, and if, as is frequently the case, there is a communication with
the knee-joint, this should be closed with sutures.

[Illustration: FIG. 117.--Gouty Disease of Bursae in a tailor. The bursal
tumours were almost entirely composed of urate of soda. (Cf. Fig. 114.)]

An adventitious bursa may form over the _lateral malleolus_, especially
in tailors, giving rise to the condition known as "tailor's ankle"
(Fig. 117).

The bursa _between the tendo-calcaneus (Achillis) and the upper part of
the calcaneus_ may become inflamed--especially as a result of
post-scarlatinal rheumatism or gonorrhoea. The affection is known as
Achillo-bursitis. There is severe pain in the region of the insertion of
the tendo-calcaneus, the movements at the ankle-joint are restricted,
and the patient may be unable to walk. There is a tender swelling on
either side of the tendon. When, in spite of palliative treatment, the
affection persists or relapses, it is best to excise the bursa. The
tendo-calcaneus is detached from the calcaneus, the bursa dissected out,
and the tendon replaced. If there is a bony projection from the
calcaneus, it should be shaved off with the chisel.

The bursa that is sometimes met with on the under aspect of the
calcaneus--_the subcalcanean bursa_--when inflamed, gives rise to pain
and tenderness in the sole of the foot. This affection may be associated
with a spinous projection from the bone, which is capable of being
recognised in a skiagram. The soft parts of the heel are turned forwards
as a flap, the bursa is dissected out, and the projection of bone, if
present, is removed.

The enlargement of adventitious bursae over the head of the first
metatarsal in hallux valgus; over the tarsus, metatarsus, and digits in
the different forms of club-foot; over the angular projection in Pott's
disease of the spine; over the end of the bone in amputation stumps, and
over hard tumours such as chondroma and osteoma, are described
elsewhere.

CHAPTER XX

DISEASES OF BONE

Anatomy and physiology--Regeneration of bone--Transplantation of bone.
DISEASES OF BONE--Definition of terms--Pyogenic diseases:
_Acute osteomyelitis and periostitis_; _Chronic and relapsing
osteomyelitis_; _Abscess of bone_--Tuberculous disease--Syphilitic
disease--Hydatids; Rickets; Osteomalacia--Ostitis deformans of
Paget--Osteomyelitis fibrosa--Affections of bones in diseases of
the nervous system--Fragilitas ossium--Tumours and cysts of bone.

#Surgical Anatomy.#--During the period of growth, a long bone such as
the tibia consists of a shaft or _diaphysis_, and two extremities or
_epiphyses_. So long as growth continues there intervenes between the
shaft and each of the epiphyses a disc of actively growing
cartilage--_the epiphysial cartilage_; and at the junction of this
cartilage with the shaft is a zone of young, vascular, spongy bone known
as the _metaphysis_ or _epiphysial junction_. The shaft is a cylinder of
compact bone enclosing the medullary canal, which is filled with yellow
marrow. The extremities, which include the ossifying junctions, consist
of spongy bone, the spaces of which are filled with red marrow. The
articular aspect of the epiphysis is invested with a thick layer of
hyaline cartilage, known as the _articular cartilage_, which would
appear to be mainly nourished from the synovia.

The external investment--the _periosteum_--is thick and vascular during
the period of growth, but becomes thin and less vascular when the
skeleton has attained maturity. Except where muscles are attached it is
easily separated from the bone; at the extremities it is intimately
connected with the epiphysial cartilage and with the epiphysis, and at
the margin of the latter it becomes continuous with the capsule of the
adjacent joint. It consists of two layers, an outer fibrous and an inner
cellular layer; the cells, which are called osteoblasts, are continuous
with those lining the Haversian canals and the medullary cavity.

The arrangement of the _blood vessels_ determines to some extent the
incidence of disease in bone. The nutrient artery, after entering the
medullary canal through a special foramen in the cortex, bifurcates, and
one main division runs towards each of the extremities, and terminates
at the ossifying junction in a series of capillary loops projected
against the epiphysial cartilage. This arrangement favours the lodgment
of any organisms that may be circulating in the blood, and partly
accounts for the frequency with which diseases of bacterial origin
develop in the region of the ossifying junction. The diaphysis is also
nourished by numerous blood vessels from the periosteum, which penetrate
the cortex through the Haversian canals and anastomose with those
derived from the nutrient artery. The epiphyses are nourished by a
separate system of blood vessels, derived from the arteries which supply
the adjacent joint. The veins of the marrow are of large calibre and are
devoid of valves.

The _nerves_ enter the marrow along with the arteries, and, being
derived from the sympathetic system, are probably chiefly concerned with
the innervation of the blood vessels, but they are also capable of
transmitting sensory impulses, as pain is a prominent feature of many
bone affections.

It has long been believed that _the function of the periosteum_ is to
form new bone, but this view has been questioned by Sir William Macewen,
who maintains that its chief function is to limit the formation of new
bone. His experimental observations appear to show that new bone is
exclusively formed by the cellular elements or osteoblasts: these are
found on the surface of the bone, lining the Haversian canals and in the
marrow. We believe that it will avoid confusion in the study of the
diseases of bone if the osteoblasts on the surface of the bone are still
regarded as forming the deeper layer of the periosteum.

The formation of new bone by the osteoblasts may be _defective_ as a
result of physiological conditions, such as old age and disease of a
part, and defective formation is often associated with atrophy, or more
strictly speaking, absorption, of the existing bone, as is well seen in
the edentulous jaw and in the neck of the femur of a person advanced in
years. Defective formation associated with atrophy is also illustrated
in the bones of the lower limbs of persons who are unable to stand or
walk, and in the distal portion of a bone which is the seat of an
ununited fracture. The same combination is seen in an exaggerated degree
in the bones of limbs that are paralysed; in the case of adults, atrophy
of bone predominates; in children and adolescents, defective formation
is the more prominent feature, and the affected bones are attenuated,
smooth on the surface, and abnormally light.

On the other hand, the formation of new bone may be _exaggerated_, the
osteoblasts being excited to abnormal activity by stimuli of different
kinds: for example, the secretion of certain glandular organs, such as
the pituitary and thyreoid; the diluted toxins of certain
micro-organisms, such as the staphylococcus aureus and the spirochaete of
syphilis; a condition of hyperaemia, such as that produced artificially
by the application of a Bier's bandage or that which accompanies a
chronic leg-ulcer.

The new bone is laid down on the surface, in the Haversian canals, or
in the cancellous spaces and medullary canal, or in all three
situations. The new bone on the surface sometimes takes the form of a
diffuse _encrustation_ of porous or spongy bone as in secondary
syphilis, sometimes as a uniform increase in the girth of the
bone--_hyperostosis_, sometimes as a localised heaping up of bone or
_node_, and sometimes in the form of spicules, spoken of as
_osteophytes_. When the new bone is laid down in the Haversian canals,
cancellous spaces and medulla, the bone becomes denser and heavier, and
is said to be _sclerosed_; in extreme instances this may result in
obliteration of the medullary canal. Hyperostosis and sclerosis are
frequently met with in combination, a condition that is well illustrated
in the femur and tibia in tertiary syphilis; if the subject of this
condition is confined to bed for several months before his death, the
sclerosis may be undone, and rarefaction may even proceed beyond the
normal, the bone becoming lighter and richer in fat, although retaining
its abnormal girth.

The _function of the epiphysial cartilage_ is to provide for the growth
of the shaft in length. While all epiphysial cartilages contribute to
this result, certain of them functionate more actively and for a longer
period than others. Those at the knee, for example, contribute more to
the length of limb than do those at the hip or ankle, and they are also
the last to unite. In the upper limb the more active epiphyses are at
the shoulder and wrist, and these also are the last to unite.

The activity of the epiphysial cartilage may be modified as a result of
disease. In rickets, for example, the formation of new bone may take
place unequally, and may go on more rapidly in one half of the disc than
in the other, with the result that the axis of the shaft comes to
deviate from the normal, giving rise to knock-knee or bow-knee. In
bacterial diseases originating in the marrow, if the epiphysial junction
is directly involved in the destructive process, its bone-forming
functions may be retarded or abolished, and the subsequent growth of the
bone be seriously interfered with. On the other hand, if it is not
directly involved but is merely influenced by the proximity of an
infective focus, its bone-forming functions may be stimulated by the
diluted toxins and the growth of the bone in length exaggerated. In
paralysed limbs the growth from the epiphyses is usually little short of
the normal. The result of interference with growth is more injurious in
the lower than in the upper limb, because, from the functional point of
view, it is essential that the lower extremities should be approximately
of equal length. In the forearm or leg, where there are two parallel
bones, if the growth of one is arrested the continued growth of the
other results in a deviation of the hand or foot to one side.

In certain diseases, such as rickets and inherited syphilis, and in
developmental anomalies such as achondroplasia, _dwarfing_ of the
skeleton results from defective growth of bone at the ossifying
junctions. Conversely, excessive growth of bone at the ossifying
junctions results in abnormal height of the skeleton or _giantism_ as a
result, for example, of increased activity of the pituitary in
adolescents, and in eunuchs who have been castrated in childhood or
adolescence; in the latter, union of the epiphyses at the ends of the
long bones is delayed beyond the usual period at which the skeleton
attains maturity.

#Regeneration of Bone.#--When bone has been lost or destroyed as a
result of injury or disease, it is capable of being reproduced, the
extent to which regeneration takes place varying under different
conditions. The chief part in the regeneration of bone is played by the
osteoblasts in the adjacent marrow and in the deeper layer of the
periosteum. The shaft of a long bone may be reproduced after having been
destroyed by disease or removed by operation. The flat bones of the
skull and the bones of the face, which are primarily developed in
membrane, have little capacity of regeneration; hence, when bone has
been lost or removed in these situations, there results a permanent
defect.

Wounds or defects in articular cartilage are repaired by fibrous or
osseous tissue derived from the subjacent cancellous spaces.

_Transplantation of Bone--Bone-grafting._--Clinical experience is
conclusive that a portion of bone which has been completely detached
from its surroundings--for example, a trephine circle, or a flap of bone
detached with the saw, or the loose fragments in a compound
fracture--may become, if replaced in position, firmly and permanently
incorporated with the surrounding bone. Embedded foreign bodies, on the
other hand, such as ivory pegs or decalcified bone, exhibit, on removal
after a sufficient interval, evidence of having been eroded, in the
shape of worm-eaten depressions and perforations, and do not become
united or fused to the surrounding bone. It follows from this that the
implanting of living bone is to be preferred to the implanting of dead
bone or of foreign material. We believe that transplanted living bone
when placed under favourable conditions survives and becomes
incorporated with the bone with which it is in contact, and does not
merely act as a scaffolding. We believe also that the retention of the
periosteum on the graft is not essential, but, by favouring the
establishment of vascular connections, it contributes to the survival of
the graft and the success of the transplantation. Macewen maintains that
bone grafts "take" better if broken up into small fragments; we regard
this as unnecessary. Bone grafts yield better functional results when
they are immovably fixed to the adjacent bone by suture, pegs, or
plates. As in all grafting procedures, asepsis is essential.

Transplanted bone retains its vitality when embedded in the soft parts,
but is gradually absorbed and replaced by fibrous tissue.

DISEASES OF BONE

The morbid processes met with in bone originate in the same way and lead
to the same results as do similar processes in other tissues. The
structural peculiarities of bone, however, and the important changes
which take place in the skeleton during the period of growth, modify
certain of the clinical and pathological features.

_Definition of Terms._--Any diseased process that affects the periosteum
is spoken of as _periostitis_; the term _osteomyelitis_ is employed when
it is located in the marrow. The term _epiphysitis_ has been applied to
an inflammatory process in two distinct situations--namely, the
ossifying nucleus in the epiphysis, and the ossifying junction or
metaphysis between the epiphysial cartilage and the diaphysis. We shall
restrict the term to inflammation in the first of these situations.
Inflammation at the ossifying junction is included under the term
osteomyelitis.

The term _rarefying ostitis_ is applied to any process that is attended
with excessive absorption of the framework of a bone, whereby it becomes
more porous or spongy than it was before, a condition known as
_osteoporosis_.

The term _caries_ is employed to indicate any diseased process
associated with crumbling away of the trabecular framework of a bone. It
may be considered as the equivalent of ulceration or molecular
destruction in the soft parts. The carious process is preceded by the
formation of granulation tissue in the marrow or periosteum, which eats
away and replaces the bone in contact with it. The subsequent
degeneration and death of the granulation tissue under the necrotic
influence of bacterial toxins results in disintegration and crumbling
away of the trabecular framework of the portion of bone affected.
Clinically, carious bone yields a soft grating sensation under the
pressure of the probe. The macerated bone presents a rough, eroded
surface.

The term _dry caries_ (_caries sicca_) is applied to that variety which
is unattended with suppuration.

_Necrosis_ is the term applied to the death of a tangible portion of
bone, and the dead portion when separated is called a _sequestrum_. The
term _exfoliation_ is sometimes employed to indicate the separation or
throwing off of a superficial sequestrum. The edges and deep surface of
the sequestrum present a serrated or worm-eaten appearance due to the
process of erosion by which the dead bone has been separated from the
living.

BACTERIAL DISEASES

The most important diseases in this group are the pyogenic, the
tuberculous, and the syphilitic.

PYOGENIC DISEASES OF BONE.--These diseases result from
infection with pyogenic organisms, and two varieties or types are
recognised according to whether the organisms concerned reach their seat
of action by way of the blood-stream, or through an infection of the
soft parts in contact with the bone.

INFECTIONS THROUGH THE BLOOD-STREAM

#Diseases caused by the Staphylococcus Aureus.#--As the majority of
pyogenic diseases are due to infection with the staphylococcus aureus,
these will be described first.

#Acute osteomyelitis# is a suppurative process beginning in the marrow
and tending to spread to the periosteum. The disease is common in
children, but is rare after the skeleton has attained maturity. Boys are
affected more often than girls, in the proportion of three to one,
probably because they are more liable to exposure, to injury, and to
violent exertion.

_Etiology._--Staphylococci gain access to the blood-stream in various
ways, it may be through the skin or through a mucous surface.

Such conditions as, for example, a blow, some extra exertion such as a
long walk, or exposure to cold, as in wading, may act as localising
factors.

The long bones are chiefly affected, and the commonest sites are: either
end of the tibia and the lower end of the femur; the other bones of the
skeleton are affected in rare instances.

_Pathology._--The disease commences and is most intense in the marrow of
the ossifying junction at one end of the diaphysis; it may commence at
both ends simultaneously--_bipolar osteomyelitis_; or, commencing at one
end, may spread to the other.