Surgery, with Special Reference to Podiatry Part 12

+Treatment.+ The original infection of the urologic tract must receive the utmost care, in order to eradicate the supply of germs to the circulation. The injection of anti-gonococcic sera or vaccines finds its best application in these cases. The local treatment consists of rest and immobilization of the extremity affected.

The application of either extreme heat or cold to the joint is agreeable and efficacious.

There are many reasons in justification of either of these treatments over the other, but in general it may be said that, in the acute stage, cold is better, while in the latter stages, heat will accomplish more to establish easy motion of the part and to lessen the danger of ankylosis.

Active or arterial hyperemia by baking, is especially valuable in the subacute stage.

+Prognosis.+ In those cases in which the pain and swelling is severe and the const.i.tutional symptoms alarming, we may always expect a true arthritis to exist. In these cases much exudate is formed in the joint, which upon organization, leads to fibrous bands and limitation of the joint function (_fibrous ankylosis_).

In the milder cases, ankylosis is the exception, if proper remedial measures are carried out.

+Rheumatic Arthritis.+ Rheumatic articular affections are common, and are both acute or chronic. In the light of recent investigations it is believed that many of these cases are due to foci of infection in various parts of the body which pollute the blood stream with organisms which subsequently find lodgment in either the organs or joints. Infections existing in the tonsils and teeth roots have been shown to act in this way. There may, however, be cases directly attributable to rheumatism, though these are not so well understood.

+Acute Rheumatism.+ One or several joints may be attacked simultaneously. Subsidence of the inflammation may occur, while others are becoming inflamed.

+Symptoms+ are those of acute synovitis; suppuration never occurs unless there has been a mixed infection, and limitation of motion is a rare sequela. The pain, swelling and tenderness is extreme, and the const.i.tutional symptoms, while being severe are not usually grave. In the _chronic variety_, on the other hand, there may be limitation of motion due to the formation of bands and adhesions after months or years of inflammation. This variety may start as such or may begin as an acute condition.

+Treatment.+ The treatment, besides local rest and heat, consists of the administration of antirheumatic remedies and hygienic precautions.

+Diagnosis+ will rest largely on the blood examination for circulating organisms, the general examination for foci of infection, and the family history.

+Gouty Arthritis.+ Whatever may be the essential nature of gout, its manifestations are common in the smaller joints, such as the fingers and the metatarsophalanges of the great toe. Deposits of urates, chiefly sodium urate, take place in the connective tissue of the joint and also in the cartilage. Consequent upon the irritation of these salts, there is an increase in the connective tissue followed by contraction, impairment of motion, and alteration in the shape of the joint. Repeated attacks of acute inflammation occur, of greater or lesser intensity, and the uratic deposits attain a considerable size, occasionally forming abscesses or ulcerations in the overlying skin.

Like rheumatism, gout is a manifestation of a const.i.tutional state, and requires medical care.

+Infective Arthritis.+ These are the arthritic manifestations of diseases as smallpox, scarlet fever, typhoid fever, measles and erysipelas. They are due to infective material deposited from the circulation, and are in every way similar to septic arthritis, which see. There are always suppurative synovitis and osteomyelitis, with a consequent ankylosis of bony structure. The const.i.tutional symptoms are very intense, and free incision and drainage is indicated.

+Neuropathic Arthritis.+ (_Charcot's Disease_). This is a peculiar osteoarthritis observed in patients with locomotor ataxia. The disease is an acute one, so far as objective conditions are concerned, there being no pain or const.i.tutional derangements of consequence. Without any injury having been received, the joint, particularly the knee, suddenly swells, the intra-articular effusion becoming abundant. This may soon be absorbed and with it the articular ends of the bones wear away and break down into small fragments. The limb becomes atrophied and shrunken, and the joint itself becomes weak, often flail.

This disease seems to be due to nutritive changes in consequence of changes in the spinal cord nerve centres. There is no satisfactory treatment and the patients must be kept in bed.

CHAPTER X

+DISEASES OF THE BONES+

+Congenital Defects of Bones.+ Various congenital deformities of the limbs occur because of interference in various ways with the proper and normal formation of these cartilaginous ma.s.ses. If, for any reason, the cause of which in most cases is not clear, any of these cartilaginous ma.s.ses fail to be formed in the embryonic tissues, naturally no ossification can occur, and in such cases there may be a partial or complete lack of development of the corresponding bone. The amount of this congenital deformity may vary from the absence of an entire foot, to the absence of one or several digits, or one or more phalanges.

The deformities produced by such a failure to deposit the cartilaginous base of the bones are very numerous, and in some cases lead to great deformity and loss of function. This lack or increase of the reformation in cartilage, results in most extraordinary deformities.

No special type of deformity merits special attention; the condition in each case must be decided by inspection and X-ray examination.

In many of these cases, especially where the lesion affects the digits, the capability of the individual is but little impaired, whilst in other cases, where bones are absent, marked deformity and impairment of function may occur. Some of the cases, notably webbed toes, are comparatively easily corrected; other cases however, offer little chance of sufficient cosmetic or functional gain to make a surgical operation necessary or desirable.

+Atrophy of Bone.+ Various causes may lead to atrophy of bone. The method by which atrophy is brought about is peculiar, and is due to the action of special giant cells, called osteoclasts. Wherever extensive atrophy of bone takes place, microscopic inspection shows such giant cells lying closely adjacent to the trabeculae of the bone which is being resorbed, and the trabeculae in that immediate vicinity slowly disappear under the action of these giant cells. Their action is very similar to the action of giant cells in the soft tissues about absorbable foreign bodies. This process is called _lacunar resorption_.

In old people the amount of absorption oftentimes is very great; the process is then termed _senile atrophy_. It may be marked in the skull and in the long bones, and in many cases of fracture of the neck of the femur, a moderate amount of lacunar resorption precedes the fracture which results from slight violence. In certain cases this resorptive process in old people is extreme, and leads to great fragility of the bones, with repeated fractures from slight violence, which under ordinary circ.u.mstances, would cause no injury at all.

A mere lack of use of bones may also lead to a certain amount of atrophy from lacunar resorption. This may be seen after amputations, where the stump of bone which is left from the amputation slowly undergoes lacunar resorption and sometimes a marked diminution in size. The same thing may also be seen in the bones of people who for long periods of time have been deprived of the use of their limbs, either by the application of apparatus around fractures, or by disuse for other reasons.

Lacunar resorption also occasionally follows lesions of the central nervous system, part of the atrophy being due to disuse of the limbs from the paralysis, and part of it also being dependent in some indirect way upon the nerve lesion.

Atrophy of bone also may be brought about by pressure. It is to be remembered that the bone, as a matter of fact, is not a perfectly rigid material, but that processes of new formation and resorption are constantly taking place, even under normal conditions. If, for any reason, bone is put under constant pressure, a certain amount of readjustment of the bony const.i.tuents takes place in order to adapt the bone to its altered condition. The most striking example of this sort of atrophy is perhaps the Chinese ladies' feet, where the bones, being bent into an abnormal position, beginning early in childhood, ultimately show enormous deformity and an entire rearrangement of the trabeculae of the bone. The same thing also may be seen occasionally after pressure and deformity from contracture of muscles or from the pressure of scars. This process, which ordinarily leads to loss of function, in a certain limited number of cases aids function, for whilst certain fractures of the joints may lend to deformity of the articular facets of those joints, by absorption of certain portions and new formation in others, a readjustment of the joint surface may take place, so that a marked increase of function may occur.

A certain amount of atrophy also may be brought about by the pressure and development of tumors.

+Hypertrophy of Bone.+ In many cases new growth of bony tissue is due to the new formation of periosteal bone, and is an expression of an attempt at repair of one or the other of the numerous destructive processes. In other cases true hypertrophy of the bone, with no connection with any reparative process, may occur.

A notable example of this is seen in the growth of bone which sometimes occurs after amputation, especially in young people. The increased size of the bones which is seen in many definite diseases will be mentioned under the proper headings.

+Caries and Necrosis.+ Various pathologic processes produce destruction of bone. The destructive process may cause the death of large areas of the affected bone at once, and in that case, a large fragment of necrotic bone may remain in situ and still maintain its contour.

Destruction of bone of this sort is described by the clinical term _necrosis_.

Other processes cause a gradual molecular softening and destruction of bone, which ultimately may be very extensive, but at no time is there present any appreciable large ma.s.s of bone. Destruction of this sort is described by the clinical term _caries_.

As a means of differentiating clinical conditions, the use of these two words is desirable. As a clinical term, _necrosis_ usually means destruction by pyogenic infection, and _caries_, destruction by the gradual extension of a tuberculous process. This clinical distinction, however, is not an exact one, because destruction of large areas of bone, described as necrosis, is occasionally brought about by syphilitic infection, and rarely by tuberculosis, whilst molecular destruction of the bone is brought about by a considerable variety of processes, the chief of which, it is true, is tuberculous infection, but actinomycosis and syphilis may both lead to the gradual disintegration of the bone, without the formation of large necrotic ma.s.ses of bone.

The presence of necrotic bone connected with the surface of sinuses, from which comes a discharge of pus, should always lead to the consideration of tuberculosis, actinomycosis, and syphilis. The presence of large sequestra of bone should immediately suggest the presence of osteomyelitis or of syphilis.

+Treatment.+The details of the treatment of the various forms of destructive processes in bone will be found under their special headings, chiefly under osteomyelitis and tuberculosis.

In all cases of caries it is desirable to remove completely the softened areas in the bone. This may be done by curettment and drainage, or by excision of the entire bone, or series of bones, in certain cases, or rarely by amputation.

The difficulty in all these cases is to recognize the exact limits of the carious process. It must be borne in mind that at the time of operation upon carious bones the field of vision of the surgeon is almost always limited; moreover, the bleeding which always takes place from the bone-marrow in such cases, also obscures the field, and even if these two causes were not present, it is frequently extremely difficult, by naked-eye examination to determine the exact limits of the destructive process. As a general rule, it can be said that the carious area is at least a quarter of an inch wider than appears upon visual inspection.

In cases of necrosis with large bone defects, the difficult thing is to cause a growth of the bone toward the central cavity after removal of the sequestrum. The various methods applicable to such cavities are mentioned in detail under "Osteomyelitis."

+PERIOSt.i.tIS+

+Acute Periost.i.tis.+ The older text books always laid great stress upon the occurrence of an acute infectious inflammation of the periosteum.

Acute suppurating periost.i.tis alone does not occur, and most of the cases which have been described as such are really mild cases of superficial osteomyelitis, with abscess formation beneath the periosteum, and possibly slight inflammation of the periosteum itself.

These cases ordinarily lead to only a slight destruction of the outer layer of the cortical bone.

+Symptoms.+ These are the same as in acute osteomyelitis, except in a very much milder form. There is usually a rise of temperature, oftentimes with a chill, with circ.u.mscribed tenderness over some portion of the shaft of one of the long bones.

+Treatment.+ Incision over such an area shows an elevated periosteum, with a small, localized abscess beneath it, with bare, white, somewhat vascular bone cortex. Incision alone in most cases suffices to cure the disease, although if the process has extended sufficiently deep to cause a superficial necrosis of the outer layer of the cortex, removal of a small sliver of necrotic bone may be necessary.

+Chronic Periost.i.tis.+ A long-continued and chronic irritation of the periosteum, sufficient to cause a proliferation of the osteogenetic cells of the periosteum, is common in a great many diseases. A chronic thickening of the periosteum with a new formation of bone, is seen frequently after traumatism, blows or contusions; sometimes after the occurrence of superficial abscess of the soft tissues in the immediate vicinity of the shaft of the long bone, described as chronic ulcer of the surface of the tibia; or after certain infectious diseases, notably syphilis. It also may occur after various other local infections. In such cases the thickening of the periosteum ordinarily is pretty sharply localized.

A general thickening over the periosteum, and over several or many of the bones of the body, also occurs in the disease known as _toxic osteoperiost.i.tis ossificans_, seen in diseases with long continued suppuration. It also is common after syphilitic disease, either congenital or acquired.

+Symptoms.+ The symptoms of chronic periost.i.tis with new formation of bone are invariable. In a certain number of cases there is a constant, heavy, dull pain, at the point of thickening, with at times more or less acute exacerbation; at other times the lesion is a.s.sociated with no pain whatever, and the patient's attention is first called to the disease by the presence of the enlargement of bone. Recognition of the condition may depend upon X-ray examinations for indefinite pains in or over the bone.