Manual of Surgery, Alexis Thomson [new books to read txt] 📗
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The finger becomes the seat of a swelling, which is more evident on the dorsal aspect, and, according to the distribution and extent of the disease, it is acorn-shaped, fusiform, or cylindrical. It is firm and elastic, and usually painless. The movements are impaired, especially if the joints are involved. In its early stages the disease is amenable to anti-syphilitic treatment, and complete recovery is the rule.
Hydatid DiseaseThis rare disease results from the lodgment of the embryos of the tænia echinoccus, which are conveyed to the marrow by the blood-stream. The cysts are small, usually about the size of a pin-head, and they are present in enormous numbers scattered throughout the marrow. The parts of the skeleton most often affected are the articular ends of the long bones, the bodies of the vertebræ, and the pelvis.
As the cysts increase in number and in size, the framework of the bone is gradually absorbed, and there result excavations or cavities. The marrow and spongy bone first disappear, the compact tissue then becomes thin, and pathological fracture may result. The bone becomes expanded, and the cysts may escape through perforations into the surrounding cellular tissue, and when thus freed from confinement may attain considerable dimensions. Suppuration from superadded pyogenic infection may be attended with extensive necrosis, and lead to disorganisation of the adjacent joint.
Clinical Features.—The patient complains of deep-seated pains. In superficial bones, such as the tibia, there is enlargement, and it may be possible to recognise egg-shell crackling, or unequal consistence of the bone, which is hard in some parts, and doughy and elastic in others. The disease may pursue an indolent course during months or years until some complication occurs, such as suppuration or fracture. With the occurrence of suppuration the disease becomes more active, and abscesses may form in the soft parts and in the adjacent joint. In the vertebral column, hydatids give rise to angular deformity and paraplegia. In the pelvis, there is usually great enlargement of the bones, and when suppuration occurs it is apt to infect the hip-joint and to terminate fatally.
Examination with the X-rays shows the characteristic excavations of the bone caused by the cysts. The disease is liable to be mistaken for central tumour, gumma, tuberculosis, or abscess of bone.
The treatment consists in thorough eradication of the parasite by operation. The bone is laid open and scraped or resected according to the extent of the disease, and the raw surfaces swabbed with 1 per cent. formalin. In advanced cases complicated with spontaneous fracture or with suppuration, amputation affords the best chance of recovery.
The lesions in the bones resulting from actinomycosis and from mycetoma, have been described with these diseases.
Constitutional Diseases attended with Lesions in the BonesThese include rickets, scurvy-rickets, osteomalacia, ostitis deformans, osteomyelitis fibrosa, fragilitas ossium, and diseases of the nervous system.
RicketsRickets or rachitis is a constitutional disease associated with disturbance of nutrition, and attended with changes in the skeleton. The disease is most common and most severe among the children of the poorer classes in large cities, who are improperly fed and are brought up in unhealthy surroundings. There is evidence that the most important factors in the causation of rickets are ill-health of the mother during pregnancy, and the administration to the child after its birth of food which is defective in animal fat, proteids, and salts of lime, or which contains these in such a form that they are not readily assimilated. The occurrence of the disease is favoured, and its features are aggravated, by imperfect oxygenation of the blood as the result of a deficiency of fresh air and sunlight, want of exercise, and by other conditions which prevail in the slums of large towns.
Pathological Anatomy.—The most striking feature is the softness (malacia) of the bones, due to excessive absorption of osseous tissue, and the formation of an imperfectly calcified tissue at the sites of ossification. The affected bones lose their rigidity, so that they are bent under the weight of the body, by the traction of muscles, and by other mechanical forces.
The periosteum is thick and vascular, and when detached carries with it plates and spicules of soft porous bone. The new bone may be so abundant that it forms a thick crust on the surface, and in the flat bones of the skull this may be heaped up in the form of bosses or ridges resembling those ascribed to inherited syphilis.
In the epiphysial cartilages and at the ossifying junctions, all the processes concerned in ossification, excepting the deposition of lime salts, occur to an exaggerated degree. The cartilage of the epiphysial disc proliferates actively and irregularly, so that it becomes softer, thicker, and wider, and gives rise to a visible swelling, best seen at the lower end of the radius and lower end of the tibia, and at the costo-chondral junctions where the series of beaded swellings is known as the “rickety rosary.”
The ossifying zone is increased in depth; the marrow is abnormally vascular; and the new bone that is formed is imperfectly calcified. The result is that the bones may never attain their normal length, and they remain stunted throughout life as in rickety dwarfs (Fig. 133), or the shafts may grow unequally and come to deviate from their normal axes as in knock-knee and bow-knee.
Fig. 133.—Skeleton of Rickety Dwarf, known as "Bowed Joseph," leader of the Meal Riots in Edinburgh, who died in 1780.
(Anatomical Museum, University of Edinburgh.)
These changes are well brought out in skiagrams; instead of the well-defined narrow line which represents the epiphysial cartilage, there is an ill-defined, blurred zone of considerable depth.
In the shafts of the long bones, owing to the excessive absorption of bone, the cortex becomes porous, the spongy bone is rarefied, and the bones readily bend or break under mechanical influences. When the disease is arrested, a process of repair sets in which often results in the bones becoming denser and heavier than normal. In the flat bones of the skull, the absorption may result in the entire disappearance of areas of bone, leaving a membrane which dimples like thin cardboard under the pressure of the finger—a condition known as craniotabes.
Changes in the Skeleton before the Child is able to walk.—The fontanelles remain open until the end of the second year or longer, and the frontal and parietal eminences are unduly prominent. There is sometimes hydrocephalus, and the head is characteristically enlarged. The jaws are altered so that while the upper jaw is contracted into the shape of a V, the lower jaw is square instead of rounded in outline, and the teeth do not oppose one another. In the thorax, the chief feature may be the beading at the costo-chondral junctions, principally of the fifth and sixth ribs or its walls may be contracted, particularly if respiration is interfered with as a result of bronchial catarrh or adenoids. The contraction may take the form of a vertical groove on each side, or of a horizontal groove at the level of the upper end of the xiphi-sternum; when the sternum and cartilages form a projection in front, the deformity is known as “pigeon-breast.”
The spine may be curved backwards—kyphosis—throughout its whole extent or only in one part; or it may be curved to one side—scoliosis.
In the limbs, the prominent features are the deficient growth in length of the long bones, the enlargements at the epiphysial junctions, and the bending, and occasional greenstick fracture, of the shafts. The degree of enlargement of the epiphysial junctions is directly proportionate to the amount of movement to which the bone is subjected (John Thomson). The curves at this stage depend on the attitude of the child while sitting or being carried—for example, the arm bones become bent in children who paddle about the floor with the aid of their arms; and in a child who lies on its back with the lower limbs everted, the weight of the limb may lead to curvature of the neck of the femur—coxa vara. The clavicle or humerus may sustain greenstick fracture from the child being lifted by the arms; the femur, by a fall. From the extreme laxity of the ligaments, the joints can be moved beyond the normal limits, and the child is often observed to twist its limbs into abnormal attitudes.
In Children who have walked.—In these children the most important deformities occur in the spine, pelvis, and lower extremities, and result for the most part from yielding of the softened bones under the weight of the body. Scoliosis is the usual type of spinal curvature, and in extreme cases it may lead to a pronounced form of hump-back. The pelvis may remain small (justo-minor pelvis), or it may be contracted in the sagittal plane (flat pelvis); when the bones are unusually soft, the acetabular portions are pushed inwards by the femora bearing the weight of the body, and the pelvis assumes the shape of a trefoil, as in the malacia of women. The shaft of the femur is curved forwards and laterally; the bones of the leg laterally as in bow-leg, or forwards, or forwards and laterally just above the ankle. The deformities at the knee (genu valgum, genu varum, and genu recurvatum), and at the hip (coxa vara), will be described in the volume dealing with the Extremities.
The majority of cases seen in surgical practice suffer from the deformities resulting from rickets rather than from the active disease. The examination of a large series of children at different ages shows that the deformities become less and less frequent with each year. Those who recover may ultimately show no trace of rickets, and this is especially true of children who grow at the average rate; in those, however, in whom growth is retarded, especially from the fifth to the seventh year, the deformities are apt to be permanent. It may be noted that the scoliosis due to rickets has little tendency towards recovery.
Treatment.—The treatment of the disease consists in regulating the diet, improving the surroundings, and preventing deformity. Phosphorus in doses of 100th grain may be given dissolved in cod-liver oil, and preparations of iron and lime may be added with advantage. To avoid those postures which predispose to deformities, the child should lie as much as possible. In the well-to-do classes this is readily accomplished by the aid of a nurse and the use of a perambulator. In hospital out-patients the child is kept off its feet by the use of a light wooden splint applied to the lateral aspect of each lower extremity, and extending from the pelvis to 6 inches beyond the sole.
When deformities are already present, the treatment depends upon whether or not there is any prospect of the bone straightening naturally. Under five years of age this may, as a rule, be confidently expected; the child should be kept off its feet, and the limbs bathed and massaged. In children of five or six and upwards, the prospect of natural straightening is a diminishing one, and it is more satisfactory to correct the deformity by operation. In rickety curvature of the spine, the child should lie on a firm mattress, or, to allow of its being taken into the open air, upon a double Thomas' splint extending from the occiput to the heels; the muscles acting on the
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