Manual of Surgery, Alexis Thomson [new books to read txt] 📗

it is attended with much pain. Other forms of onychia occur during secondary syphilis simultaneously with the skin eruptions, and may prove obstinate and lead to shedding of the nails. They also occur in inherited syphilis. In addition to general treatment, an ointment containing 5 per cent. of oleate of mercury should be applied locally.

Ingrowing Toe-nail.—This is more accurately described as an overgrowth of the soft tissues along the edge of the nail. It is most frequently met with in the great toe in young adults with flat-foot whose feet perspire freely, who wear ill-fitting shoes, and who cut their toe-nails carelessly or tear them with their fingers. Where the soft tissues are pressed against the edge of the nail, the skin gives way and there is the formation of exuberant granulations and of discharge which is sometimes fœtid. The affection is a painful one and may unfit the patient for work. In mild cases the condition may be remedied by getting rid of contributing causes and by disinfecting the skin and nail; the nail is cut evenly, and the groove between it and the skin packed with an antiseptic dusting-powder, such as boracic acid. In more severe cases it may be necessary to remove an ellipse of tissue consisting of the edge of the nail, together with the subjacent matrix and the redundant nail-fold.

Subungual exostosis is an osteoma growing from the terminal phalanx of the great toe (Fig. 107). It raises the nail and may be accompanied by ulceration of the skin over the most prominent part of the growth. The soft parts, including the nail, should be reflected towards the dorsum in the form of a flap, the base of the exostosis divided with the chisel, and the exostosis removed.

Malignant disease in relation to the nails is rare. Squamous epithelioma and melanotic cancer are the forms met with. Treatment consists in amputating the digit concerned, and in removing the associated lymph glands.

CHAPTER XVIII
THE MUSCLES, TENDONS, AND TENDON SHEATHS Injuries: Contusion; Sprain; Rupture —Hernia of muscle —Dislocation of tendons —Wounds —Avulsion of tendon. Diseases of Muscle and of Tendons: Atrophy; “Muscular rheumatism”—Fibrositis; Contracture; Myositis; Calcification and Ossification; Tumours. Diseases of Tendon Sheaths: Teno-synovitis. Injuries

Contusion of Muscle.—Contusion of muscle, which consists in bruising of its fibres and blood vessels, may be due to violence acting from without, as in a blow, a kick, or a fall; or from within, as by the displacement of bone in a fracture or dislocation.

The symptoms are those common to all contusions, and the patient complains of severe pain on attempting to use the muscle, and maintains an attitude which relaxes it. If the sheath of the muscle also is torn, there is subcutaneous ecchymosis, and the accumulation of blood may result in the formation of a hæmatoma.

Restoration of function is usually complete; but when the nerve supplying the muscle is bruised at the same time, as may occur in the deltoid, wasting and loss of function may be persistent. In exceptional cases the process of repair may be attended with the formation of bone in the substance of the muscle, and this may likewise impair its function.

A contused muscle should be placed at rest and supported by cotton wool and a bandage; after an interval, massage and appropriate exercises are employed.

Sprain and Partial Rupture of Muscle.—This lesion consists in overstretching and partial rupture of the fibres of a muscle or its aponeurosis. It is of common occurrence in athletes and in those who follow laborious occupations. It may follow upon a single or repeated effort—especially in those who are out of training. Familiar examples of muscular sprain are the “labourer's” or “golfer's back,” affecting the latissimus dorsi or the sacrospinalis (erector spinæ); the “tennis-player's elbow,” and the “sculler's sprain,” affecting the muscles and ligaments about the elbow; the “angler's elbow,” affecting the common origin of the extensors and supinators; the “sprinter's sprain,” affecting the flexors of the hip; and the “jumper's and dancer's sprain,” affecting the muscles of the calf. The patient complains of pain, often sudden in onset, of tenderness on pressure, and of inability to carry out the particular movement by which the sprain was produced. The disability varies in different cases, and it may incapacitate the patient from following his occupation or sport for weeks or, if imperfectly treated, even for months.

The treatment consists in resting the muscle from the particular effort concerned in the production of the sprain, in gently exercising it in other directions, in the use of massage, and the induction of hyperæmia by means of heat. In neglected cases, that is, where the muscle has not been exercised, the patient shrinks from using it and the disablement threatens to be permanent; it is sometimes said that adhesions have formed and that these interfere with the recovery of function. The condition may be overcome by graduated movements or by a sudden forcible movement under an anæsthetic. These cases afford a fruitful field for the bone-setter.

Rupture of Muscle or Tendon.—A muscle or a tendon may be ruptured in its continuity or torn from its attachment to bone. The site of rupture in individual muscles is remarkably constant, and is usually at the junction of the muscular and tendinous portions. When rupture takes place through the belly of a muscle, the ends retract, the amount of retraction depending on the length of the muscle, and the extent of its attachment to adjacent aponeurosis or bone. The biceps in the arm, and the sartorius in the thigh, furnish examples of muscles in which the separation between the ends may be considerable.

The gap in the muscle becomes filled with blood, and this in time is replaced by connective tissue, which forms a bond of union between the ends. When the space is considerable the connecting medium consists of fibrous tissue, but when the ends are in contact it contains a number of newly formed muscle fibres. In the process of repair, one or both ends of the muscle or tendon may become fixed by adhesions to adjacent structures, and if the distal portion of a muscle is deprived of its nerve supply it may undergo degeneration and so have its function impaired.

Rupture of a muscle or tendon is usually the result of a sudden, and often involuntary, movement. As examples may be cited the rupture of the quadriceps extensor in attempting to regain the balance when falling backwards; of the gastrocnemius, plantaris, or tendo-calcaneus in jumping or dancing; of the adductors of the thigh in gripping a horse when it swerves—“rider's sprain”; of the abdominal muscles in vomiting, and of the biceps in sudden movements of the arm. Sometimes the effort is one that would scarcely be thought likely to rupture a muscle, as in the case recorded by Pagenstecher, where a professional athlete, while sitting at table, ruptured his biceps in a sudden effort to catch a falling glass. It would appear that the rupture is brought about not so much by the contraction of the muscle concerned, as by the contraction of the antagonistic muscles taking place before that of the muscle which undergoes rupture is completed. The violent muscular contractions of epilepsy, tetanus, or delirium rarely cause rupture.

The clinical features are usually characteristic. The patient experiences a sudden pain, with the sensation of being struck with a whip, and of something giving way; sometimes a distant snap is heard. The limb becomes powerless. At the seat of rupture there is tenderness and swelling, and there may be ecchymosis. As the swelling subsides, a gap may be felt between the retracted ends, and this becomes wider when the muscle is thrown into contraction. If untreated, a hard, fibrous cord remains at the seat of rupture.

Treatment.—The ends are approximated by placing the limb in an attitude which relaxes the muscle, and the position is maintained by bandages, splints, or special apparatus. When it is impossible thus to approximate the ends satisfactorily, the muscle or tendon is exposed by incision, and the ends brought into accurate contact by catgut sutures. This operation of primary suture yields the most satisfactory results, and is most successful when it is done within five or six days of the accident. Secondary suture after an interval of months is rendered difficult by the retraction of the ends and by their adhesion to adjacent structures.

Rupture of the biceps of the arm may involve the long or the short head, or the belly of the muscle. Most interest attaches to rupture of the long tendon of origin. There is pain and tenderness in front of the upper end of the humerus, the patient is unable to abduct or to elevate the arm, and he may be unable to flex the elbow when the forearm is supinated. The long axis of the muscle, instead of being parallel with the humerus, inclines downwards and outwards. When the patient is asked to contract the muscle, its belly is seen to be drawn towards the elbow.

The adductor longus may be ruptured, or torn from the pubes, by a violent effort to adduct the limb. A swelling forms in the upper and medial part of the thigh, which becomes smaller and harder when the muscle is thrown into contraction.

The quadriceps femoris is usually ruptured close to its insertion into the patella, in the attempt to avoid falling backwards. The injury is sometimes bilateral. The injured limb is rendered useless for progression, as it suddenly gives way whenever the knee is flexed. Treatment is conducted on the same lines as in transverse fracture of the patella; in the majority of cases the continuity of the quadriceps should be re-established by suture within five or six days of the accident.

The tendo calcaneus (Achillis) is comparatively easily ruptured, and the symptoms are sometimes so slight that the nature of the injury may be overlooked. The limb should be put up with the knee flexed and the toes pointed. This may be effected by attaching one end of an elastic band to the heel of a slipper, and securing the other to the lower third of the thigh. If this is not sufficient to bring the ends into apposition they should be approximated by an open operation.

The plantaris is not infrequently ruptured from trivial causes, such as a sudden movement in boxing, tennis, or hockey. A sharp stinging pain like the stroke of a whip is felt in the calf; there is marked tenderness at the seat of rupture, and the patient is unable to raise the heel without pain. The injury is of little importance, and if the patient does not raise the heel from the ground in walking, it is recovered from in a couple of weeks or so, without it being necessary to lay him up.

Hernia of Muscle.—This is a rare condition, in which, owing to the fascia covering a muscle becoming stretched or torn, the muscular substance is protruded through the rent. It has been observed chiefly in the adductor longus. An oval swelling forms in the upper part of the thigh, is soft and prominent when the muscle is relaxed, less prominent when it is passively extended, and disappears when the muscle is thrown into contraction. It is liable to be mistaken, according to its situation, for a tumour, a cyst, a pouched vein, or a femoral or obturator hernia. Treatment is only called for when it is causing inconvenience, the muscle being exposed by a suitable incision, the herniated portion excised, and the rent in the sheath closed by sutures.

Dislocation of Tendons.—Tendons which run in grooves may be displaced as a result of rupture of the confining sheath. This injury is