Surgery, with Special Reference to Podiatry Part 10

While so few instances of cancer secondary to varicose ulceration are seen, it rarely appears before the age of forty. It is usually seen where varicose ulcers as well as the scars they produce are found. The base of the characteristic ulcer is hard, nodular and irregular, made up of firm warty granulations, and often covered with sloughs. It bleeds easily and has a foul discharge. The edges are hard and everted. The borders and base present a peculiar and striking thickness and hardness, as though the ulcer were imbedded in cartilage, while the granulations feel firm and appear red and warty.

The amount of pain, the involvement of neighboring lymphatic glands and the rate of growth vary. Epitheliomata which have developed from congenital warts, moles, or nevi are apt to be very malignant. When epitheliomatous degeneration occurs in a chronic ulcer, it first begins to get hard about the edges, which become everted and gradually bound down to the deeper tissues. The granulations about the margins become large, red, nodular, hard and bleed very readily. This condition spreads over the entire ulcer, which a.s.sumes a sloughing and foul character. The diagnosis is confirmed by the microscopic examination of a section cut from the edge of the ulcer.

+Treatment.+ Malignant ulcer can be cured only by the destruction or removal of the new growth. For its treatment, caustics with or without curetting, excision or radiotherapy may be employed. The best caustics are a.r.s.enic, chloride of zinc, caustic potash and formalin.

The objections to this method are the extreme pain; the lack of certainty as to the removal of all of the neoplasm; the fact that the lymphatics and glands are not dealt with, as well as the fact that unless the treatment is thorough, the growth is stimulated rather than r.e.t.a.r.ded. The scar is also apt to be unsightly. Without doubt excision forms the best method of treatment. The incision should be wide of the ulcer, and all indurated tissues and any lymphatics or glands that are involved must be removed.

In some cases it may be necessary even to amputate the leg in order to effect a cure. The X-rays from the Coolidge tube are to be recommended, as the cross fire effect of these rays in some cases is of great benefit. Recently radium has been used in these ulcers of the leg with good results. The gamma rays are to be preferred as they are more penetrating and should be applied two or three hours a day for a number of days. At least from 50 to 200 milligrams of radium bromide must be used in order to obtain any effect. Recently beta rays have been found to be as effective as the gamma rays. In order to prevent a radium burn the rays have to be filtered before they are applied.

CHAPTER IX

+DISEASES OF JOINTS-THE SEROUS AND SYNOVIAL MEMBRANES+

The moist glistening membrane lining the abdomen (_peritoneum_) and that lining the chest (_pleura_) are similar to the synovial sac between the bone ends at joints or the synovial sheaths of tendons.

+Bursae.+ A bursa, which is a sac lined with serous membrane, placed over a joint or other prominent part for protection, is also quite similar. All of these membranes are smooth and moist, giving lubrication to movable parts, thus: the peritoneum covering the intestines, permits of their easy worm-like action within the abdomen; the pleura makes for the free rise and fall of the lungs; the _synovial sacs_ of joints allow the bones to ride smoothly one upon the other; the _synovial sheath_ of a tendon acts like a silken sleeve in which the tendon slides up and down and, lastly, pressure over a bony point causes the member to move aside because of the slipping of the walls of the bursa, one upon the other, when compressed.

+INJURIES AND DISEASES OF BURSAE.+

_Synovial bursae_ exist normally in connection with tendons or with certain joints, and may be developed by continued friction or pressure at certain parts of the body. Deep bursae are sometimes connected with the joints, or are in very close relation with them.

+Injuries of Bursae.+ Wounds of bursae may be either contused, incised, lacerated, or punctured, and, if they become infected, may prove most serious injuries. Wounds of bursae should be thoroughly disinfected and drained; they usually heal with obliteration of the sac.

+Acute Bursitis.+ This affection usually results from an injury or from continuous irritation of a bursa, and is characterized by tenderness, pain, redness of the skin, and swelling or distension of the bursa. If suppuration occurs, the inflammation is apt to extend to the surrounding cellular tissue, or, if in close proximity to a joint, the latter may be involved. Bursitis can usually be diagnosed from other affections by the rapidity of development of the inflammatory symptoms, the location of the swelling in relation to certain tendons or joints, and its globular shape.

+Treatment.+ This consists in elevating the part and putting it at rest on a splint, and in the application of cold or pressure. If, however, the pain and swelling due to effusion continue, and there is evidence of suppuration, the bursa should be freely opened and irrigated, and subsequently packed with sterilized or iodoform gauze. Under this treatment the cavity soon becomes obliterated as healing occurs. The bursae most commonly involved are the _prepatellar_ and that over the metatarsal joint of the great toe.

+Chronic Bursitis.+ This affection may result from acute bursitis which does not terminate in suppuration, or may develop slowly from long continued irritation or pressure, or from tubercular infection of the bursae and is accompanied by little pain.

The most marked feature in chronic bursitis is the distension of the sac with fluid, and in some cases the walls of the sac become so thickened that the bursa is converted into a solid tumor. Chronic bursitis of the prepatellar bursae is not infrequent, and is commonly known us _Housemaid's knee_, resulting from long continued pressure upon the knee occurring in those whose occupation causes them to constantly bear pressure upon this part.

Gumma of the prepatellar bursa is very common, and should be suspected in every case of suppuration of this bursa without a.s.signable cause.

It often results in extensive sloughing.

Hernial protrusion of a portion of a bursa is sometimes seen after injuries of bursae.

+Treatment.+ The treatment of chronic bursitis, if the sac is distended with fluid, consists in removal of the fluid by aspiration, or by making an incision and introducing a drain. The greatest care should be observed to keep the wound aseptic. The bursae may be removed by dissection. This is the only treatment which is likely to be of use in cases where the bursa is very thick or is converted into a solid tumor. In removing these growths by dissection, great care should be exercised to avoid opening the neighboring joints.

+Bunion.+ This is a bursal enlargement over the metatarsophalangeal articulation of the great toe, which is very frequently observed with hallux valgus, this being the most universal cause. The part is swollen and tender upon pressure, and if suppuration occurs the pain is severe, and cellulitis is apt to develop, involving the surrounding parts, or the joint may be involved, caries of the bones of the articulation resulting.

+Treatment.+ If suppuration has not occurred, the part should be protected from pressure by a circular s.h.i.+eld of felt or plaster; if suppuration has taken place, the part should be incised and drained, and if the joint is found diseased it should be curreted and dressed with an antiseptic dressing; if malposition of the toe exists, its position should be corrected by amputation of the head of the metatarsal.

+Inflammation of Synovial and Serous Membranes.+ When the serous and synovial membranes are attacked by inflammation, the stage of congestion is accompanied by exudation of serum and fibrin from the surface, and the endothelial cells become swollen and detached in large numbers. The serous exudation may be sufficient to fill the entire cavity involved. There is a form of dry or fibrinous inflammation, without fluid exudate, in which the surface of the membrane loses its polish, becoming dry and red, and adhesions readily form wherever the surfaces are in contact.

In suppurative inflammation, pus is produced by emigration, and also by the detached endothelial cells. If fibrin is present, false membranes form on the surface and the membrane itself appears to be greatly thickened. At a later stage the proliferating cells invade these layers of fibrin and they become organized into connective tissue, and new vessels develop on them. Their tendency, however, is to disappear after a time, and the membrane returns to its original condition, unless the inflammation has been very intense, in which case the new connective tissue becomes permanent. Chronic inflammation of these membranes is marked by general thickening of all the layers, the formation of dense connective tissue in the fibrinous membranes, strong adhesions, and sometimes complete obliteration of the cavities, their endothelial lining disappearing entirely.

+SYNOVITIS+

Like other structures of the body the joints are subject to injury and disease and because of the nature and course of pathologic processes in them, one should bear in mind their anatomic construction.

The expanded ends of the bones in the joints are covered with a thin layer of cartilage and are bound to each other by a dense capsule which is firmly attached to the bones at their necks, where it is closely connected with the periosteum. The joint cavity is lined (excepting where additional fibrocartilages are present) with a synovial sac which sometimes communicates with a bursa.

Inflammations of varying intensity are of frequent occurrence; they maybe due to rheumatism or gout, to traumatism, to the action of microorganisms, or, to disturbances of innervation. They may be slight or severe, acute or chronic. They may terminate in resolution, in permanent new formations, more or less deforming and disabling, or in the destruction of the articulation.

Inflammations may arise in the joint structures proper or may extend to it from contiguous structures, such as the cancellous bone ends, the overlying tendons or the periarticular connective tissue. They may be largely confined to a single structure, the synovial membrane being ordinarily affected, or they may involve the whole joint.

+Acute synovitis.+ Synovitis may occur as a result of a simple injury, such as a subcutaneous wound, a contusion, or a sprain. Exposure to cold and the presence of a movable cartilage are also common causes.

Aseptic conditions in the synovial membrane seldom extend to the other joint structures (see "Arthritis") and heal with or without impairment of the joint, depending on the degree of inflammation.

+Symptoms.+ The joint is painful, especially upon motion, and particularly so at night. It is swollen and tense and may be fluctuating. At the knee, the patella is floated up from the condyles and can be depressed upon slight pressure. The joint is held in a position of partial flexion which permits of the greatest ease, because of the diminished tension in this position.

Local heat and tenderness are not necessarily great, and const.i.tutional symptoms, if present, are moderate in degree.

In the suppurative affections of joints, all of the above symptoms are intense and there is a general arthritis.

After a few hours or days the intensity of the symptoms subsides, the pain lessens, the swelling diminishes, as the effusion and extravasated blood are absorbed, the limb takes its natural position, and recovery promptly takes place. If there has been much hemorrhage into the joint, adhesions due to the organization of the clot may cause some restriction of motion.

+Treatment.+ The joint must be placed at rest and an ice bag kept in constant contact. Even pressure with cotton and broad bandages often hastens absorption, but cannot at first be borne with comfort.

In rare instances aspiration of the effusion must be resorted to, but the certainty should exist that absorption is impossible, before a joint is punctured. The greatest care must be exercised in introducing a needle into a joint to avoid infection.

+Chronic Synovitis.+ While it is true that an inflammation of a synovial membrane cannot long remain without extending to the other joint structures, the fact remains that symptoms peculiar to synovitis often persist for months. These are properly viewed as const.i.tuting a condition of chronicity. The active swelling and abundant effusion, belonging to the acute stage, subside, but an undue amount of fluid remains, with some pain and weakness.

If, with proper treatment and rest, these symptoms persist, there is an extension of the process to the bone ends and an exacerbation of symptoms.

The subsidence of a chronic synovitis generally leaves a weak and impaired joint, though pain may be absent. Movements, especially in extension, are restricted, and grating or cracking remain as evidences of the roughened membrane.

+Treatment.+ The mere presence of a superabundance of fluid in a joint does not in itself const.i.tute a diseased state, but may be the evidence of impaired circulation of the part. Absorption may occur with rest and tight bandaging, or with ma.s.sage, friction, and baking, results may often be obtained. Certain cases resisting such procedures are best treated with a plaster of Paris cast to immobilize the part for several months. When the affection is of long standing and the joint is much distended it may be termed _hydrops articuli_ or _hydrarthrosis_.

When, in spite of all the methods of treatment here described, the condition does not yield, very good results may be obtained by the aspiration of the fluid, and the injection of a few drams of a three per cent. or five per cent. solution of carbolic acid. This operation, though simple, requires every aseptic precaution, and should never be performed in the presence of any acute symptoms.

For other phases of Synovitis see Arthritis.

+ARTHRITIS+

The structures of a joint are: bone, cartilage, ligaments, synovial membrane and, in some cases, fibrocartilage. Hence, a joint inflammation is an inflammation of all of these structures, and is designated, _arthritis_.

The inflammation may begin in any one of these structures, but sooner or later, all are involved. The synovial membrane, however, when inflamed, seems to prove an exception to the rule in that inflammation may or may not extend from it to the rest of the joint. If such an extension does take place we have an arthritis.

We may therefore have two distinct cla.s.ses of joint inflammation: (1) the varieties of synovitis, and (2) the varieties of arthritis. These inflammations may be acute or chronic.

In synovitis there is only the inflammation of the synovial membrane, while in arthritis there is inflammation of the synovial membrane plus inflammation of the bone covering (_periost.i.tis_); of the bone (_osteitis_); of cartilage (_chondritis_); of bone marrow (_osteomyelitis_); and also a cellulitis of the ligaments attached to the joint involved.