CHAPTER XXVIII

.

SURGICAL DISEASES OF THE FASCIÆ; APONEUROSES; TENDONS AND TENDON SHEATHS; MUSCLES AND BURSÆ.

Fasciæ and aponeuroses are such non-vascular and indifferent tissues that they have practically no primary diseases, except such fibrous and malignant tumors as have their origin in them; nevertheless they suffer in a variety of morbid processes. They lose vitality and break down under the influence of both acute and chronic septic infections. By virtue of their resistant structure, when they slough they break down slowly and the process ends usually with the help of scissors and forceps. Many an old suppurating lesion, especially of the hand and foot, is kept active by the fact that dense, fibrous tissue remains concealed, which ought to have separated. Under these circumstances free incisions should be made and all necrotic tissue trimmed away.

Pus which has formed beneath these fibrous investments will give pain largely in proportion to the intensity of the process and the unyielding character of the fasciæ; hence the urgency of early incision in case of deep phlegmon. Moreover, the direction of least resistance may cause pus when confined to travel where its presence is most undesirable, as from the neck beneath the deeper muscle planes down into the thorax. When pus escapes from beneath firm tissue it is usually by a small opening, after which it may spread out again beneath the skin before finally escaping. This condition has been called “_collar-button abscess_.” Care should be exercised in opening the superficial collection not to miss the small opening. The fascia must be split sufficiently to permit of thorough cleaning out of whatever collection there may be beneath it.

In the presence of cicatricial contraction of the skin, in shortening of muscles by chronic spasm, as in wryneck, or in certain deformities--for instance of the foot--numerous signs of a shortening or contraction of fasciæ and aponeuroses are seen. In many instances of club-foot it thus becomes necessary not merely to divide tendons but to make extensive incisions through the plantar aponeurosis or elsewhere, in order to release sufficiently the parts whose extension is desired. Underneath the joint contractures which have been produced by burns and their resulting scars similar conditions will be found, which in old and extensive cases constitute bridles of dense tissue that make it almost impossible to release the parts.

DUPUYTREN’S CONTRACTION.

Dupuytren’s contraction presents the most serious and insidious appearance of slow but almost irresistible contraction of fibrous elements which the human body presents. It is produced by contraction of the palmar fascia, with its numerous minute prolongations, rather than by flexor tendons. It is seen in the hands of men who from the nature of their occupations are subject to much irritation of the palmar surface. It begins nearly always in the fourth or fifth fingers, but may spread to and involve all the digits and even the thumb. The view held by Adams and others that it is a chronic hyperplastic inflammation, with scar-tissue contraction of the palmar fascia and of the adjoining connective and fatty tissue, which does not involve them evenly, but only at certain points, is correct, at least when small nodules may be felt in the palm which are the precursors of the disease. Either hand may be affected, but generally both are involved. It is found in from 1 to 2 per cent. of those who depend upon their hands for their support. Deformity may proceed to pressure dislocation and finally to ankylosis. Its causation then is very obscure; it is rarely the result of definite injury, but follows continued irritation of the surface. It seems to have a local origin, and yet it is frequently associated with the gouty diathesis to such an extent that the prolonged use of alkalies will relieve some cases. The first significant sign of the condition is the formation of small nodules in the palm of the hand, as stated, and this usually precedes the finger contraction by a year or two.

[Illustration: FIG. 110

Dupuytren’s contraction. (Adams.)]

[Illustration: FIG. 111

Dupuytren’s contraction of palmar fascia, showing contracted fingers. (Burrell.)]

=Treatment.=--There is considerable difficulty in treating these cases satisfactorily. Cooper advised subcutaneous division of the tense bands and forcible stretching of the fingers; this rarely proves sufficient. Adams advocated multiple sections made with a small tenotome, which is more effective. The best method is that of Kocher, which consists in excision of the fascial bands by longitudinal incisions along the cords, and the dissection of the skin from the underlying fascia. The cord is carefully dissected, with its prolongations and then completely removed, while the margins of the skin wounds are closed with sutures. The more thoroughly the dissection is performed the more satisfactory the result. The fingers should be straightened and kept from contraction by the use of a mechanical device. In desperate cases the entire skin of the palm has been removed, with the diseased fascia, and a plastic operation made with skin taken from the thigh or the chest, the flap being sutured in place but not detached completely for ten to twelve days.

Two somewhat allied conditions involving the hand and the foot are the so-called _lock_ or _trigger-finger_ and _hammer-toe_.

LOCK OR TRIGGER-FINGER.

Lock or trigger-finger implies a peculiar obstruction to free movement of the finger, which requires extra effort and then is overcome quickly, as if a knot had been slipped through a small opening. It is supposed to be due to a thickening of the tendon at some point, as by a small fibroma, which becomes entangled along the course of the sheath, through which it is moved with difficulty. It is probably due to a local irritation, as in the case of Dupuytren’s contraction. Injury to the tendon sheath may also produce a similar condition.

=Treatment.=--Should it fail to respond to rest and massage the sheath should be opened and the cause of the difficulty sought out and removed.

HAMMER-TOE.

Hammer-toe produces deformity with more or less ankylosis. An angle is formed between the first and second phalanges, and the tip of the toe is made to bear more than its proportion of weight. This deformity is in large degree due to the use of shoes which are too short. In consequence there will develop over the protruding joint a corn or bunion.

=Treatment.=--Should the trouble come on in childhood the toes should be fastened to a straight splint and shoes for a time abandoned, while later they should be properly adapted to the needs of the case. In troublesome cases complete excision of the involved joint gives satisfactory results.

SURGICAL DISEASES OF THE TENDONS AND TENDON SHEATHS.

TENDOSYNOVITIS.

Acute inflammation of a tendon sheath is known as _tendovaginitis_ or _tendosynovitis_. It always implies an infection, and occurs about the hands and feet. It is a frequent complication of felons. Many felons begin in such a manner that it is difficult to decide which part of the fibrous structures of the finger is first involved. Infection having once occurred within a tendon sheath will travel rapidly until it meets with a natural barrier. The frequency of these lesions makes it important to recall here the anatomy of the tendon sheaths of the hand. There is a common palmar tendon cavity, which connects with the thumb and little finger and the space above the annular ligament, but communication with the first, second, and third fingers is ordinarily destroyed. This accounts for the apparent vagaries of cases where infection beginning in the thumb spreads to the little finger before the others are involved. It will also show the location where incisions should be made.

[Illustration: FIG. 112

Cicatricial contraction and deformity resulting from consequences of neglected phlegmon and osteomyelitis of hand. (Lexer.)]

=Suppurative Tendosynovitis.=--Suppurative tendosynovitis needs prompt intervention, as adhesions may result from retention of exudate, or lest necrosis of tendon occur from perversion of its nutritive supply. Ordinarily it is the result of a local infection, perhaps through a small, trifling surface irritation, but it results occasionally as a metastatic expression of gonorrhea, or distinct septic infection. A gonorrheal tendosynovitis is, however, less likely to suppurate, but more likely to assume the plastic form and interfere with function by producing adhesions between a tendon and its sheath. The combination of virulent bacteria and susceptible tissues will produce local destruction in almost as short a time as in the appendix. The pain is intense, because of the inelasticity of the structures.

[Illustration: FIG. 113

Suppurative tendosynovitis (felon), with sloughing tendons and necrotic bone. Unfortunately poulticed for two weeks. (Lexer.)]

=Treatment.=--Every appearance of this kind calls for early incision, by which not only the skin but the tendon sheath as well should be freely incised. An incision at either end of the involved sheath, with flushing and drainage, may save a tendon and preserve function. Incision should not be delayed, as destruction may have occurred and deformity be the result. When the common palmar sheath is involved a long incision from the base of the index finger, around the base of the thumb and up the wrist to a point considerably above the annular ligament, will afford considerable relief. It will, moreover, shorten the time of ultimate restoration of function.

=Chronic Tendosynovitis.=--Chronic tendosynovitis may be the result of rheumatism, in which case it assumes the plastic form, or of gonorrhea; the same being true of a tuberculous invasion, which may vary much in intensity. In the subacute forms the deposition of tubercles may lead to a plastic outpour which, being detached by constant motion of the parts, is broken into masses whose minute portions become rounded off by friction and condensed by time, and appear as the so-called “_melon-seed_ or _rice-grain_ bodies.” Some of the same material may be found adherent to the walls of such a cavity. In slower forms there is less tendency to plastic outpour, but much more to the formation of granulation tissue, such as is seen in tuberculous lesions in all parts of the body. When, therefore, a case of this general character presents we have the signs of local tuberculosis, or of dropsy of the tendon sheaths, with the fluctuation somewhat modified by the presence in the fluid of rice-grain or melon-seed bodies. Should, in such a case, an acute infection be added we will have the chronic symptoms merged suddenly into acute. A tendovaginitis of this type appears as a ridge or swelling along the course of one or more tendons. It will be elastic and fluctuate in proportion to the distention of the sheath. When the palmar bursa is involved there is usually, in the palm of the hand, a bag of fluid which may be forced above the wrist by pressure, while frequently the little bodies above described are recognizable by the sensations (crepitus) which they produce. The plastic type rarely proceeds to suppuration or ulceration unless secondarily infected. The granulation type proceeds to ulceration and destruction.

=Treatment.=--Treatment of the rheumatic and gonorrheal forms is at first rest, with later passive and forced motion, in order to break up adhesions and prevent their re-formation. If one wait too long he meets with great difficulty in these efforts and the cases become exceedingly tedious. Forcible motion should be practised under nitrous oxide anesthesia and should be repeated every two or three days. Meanwhile massage should be employed. If pain or reaction be extreme ice-cold applications should be applied. Extreme swelling may be combated by the use of a rubber glove. If this be worn, ichthyol-mercurial ointment should be used beneath it, in order to promote absorption.

Treatment of the tuberculous cases is often disappointing. Non-operative measures afford but temporary benefit, while operation to be effective should be thorough. It should consist of free incision, with exposure in whole or in part of the affected channel or cavity, thorough cleaning out of its contents, removal of all edematous or tuberculous tissue or granulations, and the use of an antiseptic as strong as it can be employed.

The new _opsonic_ serum treatment, now being placed on trial as this work goes to press, promises much in the treatment of all these septic affections, though detailed statements would be premature.

TENDOPLASTY.

It was a step in advance in surgical technique when Stromeyer and Dieffenbach, in 1842, introduced the method of subcutaneous division of tendons and aponeuroses, and showed how easily contracted tendons could be lengthened by tenotomy. From their time until somewhat recently tenotomy has held its place in the treatment of various deformities, and until Anger, Gluck, Hoffa, and others have taught the surgical profession what can be done by various plastic and suture methods in overcoming defects and atoning for loss of function in paralyzed muscles. To the surgery of tendons and muscle terminations have been added the further resources of tendon suture, _i. e._, _tenorrhaphy_, and _tendoplasty_, by which latter something more than the mere suture is meant, _i. e._, the plastic rearrangement and grafting of tendons one upon another.[20]

[20] The method of transplanting one tendon upon another is to be credited to Nicoladoni, who perfected it in 1882. Later it fell into disuse, but was revived in this country, especially by Goldthwait, of Boston, in 1896.

[Illustration: FIG. 114

FIG. 115

FIG. 116

FIG. 117

FIG. 118

FIG. 119

FIG. 120

FIG. 121

Illustrating various methods of dealing with tendons in tendoplasty. (After Vulpius.)]

_Tendon suture_ is practised as an emergency measure when one or more tendons has been accidentally divided, this being considered now as much a part of the surgeon’s duty as to close any other part of the wound. No additional resource or expedient is needed, it being necessary only to observe the principles of asepsis, which should be maintained in every case. A tendon raggedly divided should be cleanly cut and its edges brought together with formalin-gut or freshly boiled silk. A series of divided tendons should be treated after the same fashion, matching the ends as closely and completely as possible. After uniting the tendon ends, if the case be clean, the tendon sheath should be closed and the parts put at rest, in such a position that no tension is made upon the injured sinew until it is seen to have united.

[Illustration: FIG. 122

FIG. 123

Shortening a tendon.]

It was a great service, in which perhaps Gluck figured most conspicuously, to show that when tendon ends could not be neatly coapted an animal material could be interposed in such a way as to serve as a trellis along which cells could group, or around which they might organize, and thus gradually and finally become a part of the complete tendinous cord. Silk and catgut have best served this purpose, and new tendons have gradually formed around these artificial substitutes, to the length of 10 Cm. In every fresh case where there has been such loss of original structure as to justify a measure of this kind, or in certain old cases where tendons have long since sloughed away, it may be possible to resort to these expedients.

It has been possible to _transplant fresh tendons_ from the smaller animals and to see them serve the same purpose in a satisfactory manner.

Among these methods of tendoplasty is _tendon grafting_, by which a part or all of the tendon of an active muscle is inserted into the terminal portion of a paralyzed muscle and thus made to assume to a greater or less extent the purpose and function of the latter; in other words it assists in ingeniously diverting the activity and direction of a given muscle to a purpose different from its original intent. By this diversion a more equal or equable distribution of muscle force is afforded the parts into which the affected muscles are inserted. For its successful performance only those muscles which are still active can be utilized. Among the simplest of cases where this expedient can be used are those produced by traumatic and peripheral paralyses, or traumatic loss of a given tendon or a set of tendons. It is rarely to be practised as an emergency measure, but as an expedient to be availed of later. It finds its greatest usefulness in cases of long standing. It is equally applicable where muscles and tendons have been divided by injury, or paralyzed by injury to their nerve supply, as well as where deformities are produced by chronic neurotic disturbance, by scars, by excessive callus, etc. It proves equally serviceable in paralyses of spinal origin, particularly those due to anterior poliomyelitis.

Tendon grafting will serve both as a substitute in cases of lost function and as a provision against future deformity. In cases of the ordinary paralyses of children, tendoplasty should be deferred for several months after the occurrence of the paralysis. In the case of growing children it is desirable not to wait too long, as other objectionable features may present themselves. In the congenital and hereditary paralyses and in conditions like athetosis or the dystrophies of syringomyelia, meningocele, etc., also in such conditions as habitual dislocations of the patella, much can be accomplished by a carefully planned tendoplasty. It will be easily seen then how wide a field of usefulness lies before one who familiarizes himself with the recent technique of tendon surgery.

[Illustration: FIG. 124

FIG. 125

Two methods of tendon implantation and fixation. (After Vulpius.)]

[Illustration: FIG. 126

FIG. 127

FIG. 128

Transplantation of a portion of the anterior tibial tendon, into the bone or into the opposed group of muscles. (After Vulpius.)]

So far as technical considerations are concerned these operations should be performed only with the minutest attention to asepsis. When this has been secured a permanent dressing may be applied, the limb being left in the position most desired, and maintained there for several weeks. For this plaster of Paris makes the best support. The use of the rubber bandage will permit the operation to be bloodlessly made, by which it is greatly facilitated. If careful suturing be practised, there will be but little tendency to subsequent oozing or interference with repair. Fine discrimination is always needed in the matter of adjusting the length of tendon ends and the point of their fixation. A useless tendon which has been long stretched over a curved joint will have become elongated, and the tendon to be applied to it should be affixed farther down than would be otherwise necessary. The disposition of the upper portion of the useless tendon and muscle may also call for serious attention. It is rarely necessary to extirpate them. They are already atrophied, and to remove them would be to still further reduce the dimensions of the part. The excluded portions can thus be simply discarded. When there has been deformity with more or less pseudo-ankylosis the malposition should be forcibly redressed and the tendon grafting deferred until a subsequent time; the latter, to be successful, should be performed alone.

Incisions are usually made along and over the course of the tendons to be exposed, but not so close that the cutaneous scar can interfere with the tendon sheath. The lower end of a paralyzed muscle will appear very differently from that of one which is healthy; in the former instance the tissue will have lost its muscular character, and will be yellowish white and fatty. A fascia which has been stretched out of shape may be sutured in folds and will serve of itself to give support and shape to the part which is renewed.

The methods of uniting tendons are so numerous that they can be better estimated by a glance at the accompanying diagrams after Vulpius than by description (Figs. 124 to 128). It is not necessary to utilize all of the tendon of a healthy muscle, as it can be split and a portion diverted to its new function. It is not to be expected that tendons thus arranged will perfectly serve their purpose the first time they are used. There must elapse a period of education of the nerves and muscles whose relations are thus altered, and improvement in the use of the parts thus operated will accrue for months and even years. It is desirable that tendon surfaces thus applied to each other be made broad and extensive in order that their adhesion may be more firm.

[Illustration: FIG. 129

Showing methods of lengthening tendons. (Burrell.)]

A modification of tendon grafting consists in implanting the tendon end into the periosteum instead of into some other tendon. There are various ways of making this implantation, either by simple suture or by boring into the bone or canalizing under a periosteal bridge. Fig. 129 illustrates how the tendon of the tibialis anticus can be utilized in both ways. It will thus be seen that a tendon can be given either tendinous, periosteal, or osteal implantation. Tendons thus utilized rarely undergo necrosis or degeneration. So long as the possibility of infection be excluded almost anything can be done with these structures, in spite of their apparent lack of vascularity and vitality.

There are times when it is necessary to _lengthen a tendon_ as well as to shorten it. Fig. 129 illustrates methods by which both of these measures can be performed. Analogous methods have been practised with muscles themselves, although here the circumstances are different and nothing similar can be accomplished. Portions of the pectoralis major have been grafted into the biceps for paralysis of the latter.

_Liberating the ring finger in musicians_, by dividing the accessory tendons of the extensor communis digitorum, is an expedient suggested some years ago by Brinton. It is made by an incision less than a quarter of an inch long, through the skin and fascia, just below the carpal articulation of the metacarpal bone of the ring finger, and above the radial accessory slip, parallel with and on the radial aspect of the extensor tendon of that finger. The point of a narrow blunt-pointed bistoury is then inserted flatwise beneath the accessory slip down to a point just in front of the knuckles of the ring and middle fingers, where the blunt point should be felt beneath the skin. The bistoury is now turned upward, the middle finger strongly flexed, and the ring finger extended so as to make the slip tense when it is divided. The accessory slip on the other side of the extensor tendon is similarly divided through a distinct incision. Snug compression is made with a bandage over the wounds, with the thumb free, and after two days the patient is permitted to use the fingers in piano-playing in order to prevent reunion of cut surfaces.

MYOTOMY AND TENOTOMY.

Myotomy is a measure seldom practised. It is performed either subcutaneously or by open incision. _Tenotomy_ is indicated whenever contracted tendons need simply to be divided, either in chronic orthopedic cases or after injuries or operations when it is desired to put muscles temporarily at rest. The tendo Achillis has thus been divided to prevent the consequences of muscle spasm when dealing with certain fractures, especially compound fractures of the leg. There are obvious advantages obtaining in subcutaneous tenotomy when properly performed; the freedom from hemorrhage, the minuteness of the opening, the rapidity of healing, are all in its favor. It is performed with a small-bladed knife, known as the tenotome, with either sharp or blunt point, the cutting portion being from 1 to 2 Cm. in length. The sharp-pointed tenotome suffices for its own insertion, the blunt one being used after an opening has been made with a sharp one. The puncture is made obliquely through the skin, which should be drawn a little aside from the site of the deeper opening in order that it may be hermetically closed as it slips back into place. Whether the cutting blade should be turned outward or inward will depend largely on the preference of the operator and the location of the tendon. In some locations, as about the hamstring tendons, the puncture should be made with the sharp instrument and the deeper tenotomy with the blunt one. If the tendons alone have been divided there will be trifling hemorrhage and the puncture can be occluded without entrance of air. Similarly an _aponeurotomy_ may be performed. Not only may the tendons be divided by the open method, but everything else which resists. This is practised more in contracted knee-joint and in club-foot, when operated on by Phelps’ method, than anywhere else. Special indications for the operation will be given in other parts of this work.

GANGLION.

This term is applied to a cyst of new-formation, which occurs in connection with the sheath of a tendon, having a lining membrane continuous with the sheath and containing thick, gelatinous, mucoid fluid. It is termed “_weeping sinew_.” It is often seen on the back of the wrist in connection with the extensor tendons, but may occur in various parts of the body. It probably begins as a hernia of the synovial membrane through a weak spot in the tendon sheath, which tends to increase in size, weakening surrounding structures by pressure, and interfering more or less with the function of the tendon whose sheath is involved. These cysts sometimes connect with joint cavities, especially those occurring behind the knee-joint; as a rule, however, they do not. At first they constitute merely a disfigurement; later they produce natural impairment of function. In the majority of cases the sac becomes finally shut off from the tube with which it originally connected.

When these lesions are new they may be successfully dealt with by forcible rupture, such as can be made by firm pressure. When old, or when rupture has failed, they should be treated by incision, practised the same as a tenotomy, by moving the skin to one side, pricking the sac, turning the blade of the tenotome so as to permit the fluid to be emptied by pressure, and then, by manipulating the point, irritate and do some damage to the sac lining. Such provocation as this will be followed by a hemorrhage, and the resulting clot may obliterate the sac by organization and cicatricial contraction. This failing, excision is the only expedient which promises success. The slightest operation upon a ganglion should be done under aseptic precautions.

FELON, OR WHITLOW.

Felon, or whitlow, was discussed in the previous chapter, especially the form which has its origin around the root of the nail. It often originates in tendon sheaths and even in bone or close to it. It is so often accompanied by a suppurative _thecitis_, _i. e._, tendosynovitis of destructive form, especially when not primarily incised, that the necessity for early treatment needs to be emphasized. It gives rise to excessive pain, with throbbing, and to swelling of livid hue and intense degree. The parts involved are too essentially fibrous and resisting to yield, hence the intensity of the pain. Deep incision at the earliest moment, for the purpose of relieving tension, is the only proper treatment. To temporize with hot poultices, etc., is to invite necrosis and sepsis. This incision may be made with local anesthesia. Even though little pus be obtained the relief of tension will afford the greatest comfort (Figs. 130, 131 and 132).

[Illustration: FIG. 130

Felon of thumb. (Burrell.)]

[Illustration: FIG. 131

Neglected suppurating thecitis resulting in palmar abscess. (Burrell.)]

[Illustration: FIG. 132

Same, dorsal aspect. (Burrell.)]

A more striking example of similar trouble is that which gives rise to _palmar abscess_, the suppurative process extending up the wrist beneath the annular ligament, and down into the little finger and thumb. This is not infrequently the result of infection of callosities in the palm of the hand. Infection may travel rapidly, and when confined beneath resisting structures will prove exceedingly destructive; the muscles of the forearm may melt down and great permanent damage be done.

Here, as when the finger alone is involved, early, free, and deep incision will prove the salvation of the part. These incisions should be made as indicated in Figs. 133 and 134, _i. e._, parallel with the nerves, tendons, and vessels, all of which should be spared, as well as the palmar arch. Should the latter be divided, the vessel ends may be ligated or the wound packed. If cavities be left by the destructive process they should be opened and the part treated by continuous immersion in warm water, or the openings may be packed with gauze saturated in brewers’ yeast. A few days of this treatment will clean up all sloughs.

[Illustration: FIG. 133

Diagram of palmar incisions.]

[Illustration: FIG. 134

Diagram of dorsal incisions. (Burrell.)]

SURGICAL DISEASES OF THE MUSCLES.

CONTUSIONS OF THE MUSCLES.

Muscles react like other tissues under the influence of contusions. Hemorrhages not too copious are gradually absorbed, and muscle tissue repairs itself, as indicated in the chapter on Wounds and their Repair. Much outpour of blood into a muscle will temporarily seriously impair its function, while pigmentation or ecchymosis may result after a few hours or days, according to the depth of the injury. There is the same liability to suppuration after infection of muscles as elsewhere. A large hematoma can scarcely form within a muscle, save in consequence of a rupture of a considerable portion of its substance. _Strains_ and _sprains_ of lesser degree of violence provoke impairment of function proportionate to their severity. In nearly every instance there is a certain amount of rupture of muscle fiber and outpour of blood.

RUPTURE OF THE MUSCLES.

Complete rupture across a muscle is unusual. It may occur in the belly of the muscle or near one of its terminations. A tendon may be torn out of a muscle or may itself snap. These accidents are almost invariably accompanied by symptoms that indicate both the nature and location of the injury. A severe strain followed by intense pain, with a sensation of yielding, leaves little doubt as to what has happened. Unless the muscle lie deeply its parting may be appreciated by palpation, though the depression or interval may be obliterated by the outpour of blood. The large tendons of the arm and shoulder have been ruptured by a violent effort, the abdominal muscles by contusions and by such efforts as wrestling, the sternomastoid by excessive traction during forceps delivery, and the tendons of the legs and ankles by jumps during such games as lawn tennis, etc.; while the frequency with which the muscles of the perineum and even the sphincter ani are torn during parturition is well known. It is also well known that muscles are weakened by the exanthemas and the infectious diseases.

=Treatment.=--An injury of this kind and of moderate degree seen early may be treated by physiological rest and position. (See chapter on Treatment of Wounds.) When, however, there is marked impairment of function, such as will follow the yielding of one or more tendons or muscle insertions, then suturing offers the greatest promise of a cure. When the quadriceps tendon is torn away from the patella or the tendo Achillis from the heel, prompt suture under aseptic precautions will save a long period spent in partial recovery of function.

Occasionally one or more tendons will be completely _avulsed_, as when a finger is torn out of the hand and brings with it one or more of the tendons belonging to it. In accidents of this kind six to twelve inches of tendon and muscles may be lost. In such a case nothing can be done except to care for the wound resulting from the injury.

DISLOCATION OF TENDONS AND MUSCLES.

Tendons and muscles are occasionally dislocated, that is, forced from their normal positions. Accidents of this kind usually occur with the long tendon of the biceps, which is torn from its bicipital groove; the peronei and the posterior tibial in the leg, the extensor muscles of the thigh, and those of the back of the wrist. The lower angle of the scapula is normally held down by a small portion of the latissimus dorsi; should this be displaced the scapula rises somewhat in wing form. These injuries lead to more or less loss of function, and, when they become disabling, may justify operation, which would include incision, exposure of the tendon in its abnormal position, and its restoration to its proper place where it should be held by sutures. Such operation should be followed by enforced physiological rest of the part.

HERNIA OF MUSCLES.

Hernia of muscle is the name applied to the escape of muscle through a ruptured fascial or aponeurotic covering. Such a protrusion will be recognized only during the contraction of the muscle and will disappear at other times. When the diagnosis is made the edges of the rent in the fascia should be united by sutures and the part put at rest.

WOUNDS OF MUSCLES.

Wounds of muscles in no way differ from other wounds which have been considered in the chapter on Wounds and their Treatment. If circumstances permit there is every indication for the suture of a divided muscle in order that its function may be less impaired after the wound is healed. These sutures, when inserted, should be made to separately include the divided fascia or aponeurosis with which the injured muscle is in relation.

MYALGIA.

There are numerous painful affections of muscles known as _myalgia_. It is questionable whether a rheumatism of muscle fiber ever occurs. That which patients describe as muscular rheumatism is not that which it is termed. Sometimes it is the result of previous exudate between muscle fibers, sometimes the result of hemorrhage of interstitial type. Muscles thus affected are more or less tender and give pain when used. It will usually be found that there is some marked toxic condition, such as uric acid, syphilis, or lead poisoning, behind it.

=Treatment.=--Many of the muscle pains of which patients complain after operation, which are also toxic, are relieved by the administration of aspirin in 0.5 Gm. doses. The injection of a small amount of atropine into the body of the muscle will often give relief. Those remedies which hasten elimination, including hot baths and massage, are often of great value.

MYOSITIS.

This may be _non-inflammatory_ and be due to prolonged use of a member, as in writers’ cramp; or _toxic_, as in lead palsy; or _traumatic_, caused by minute lacerations and hemorrhage. The more acute forms may be due to extension from neighboring foci or to direct infection. A form of infection involving both muscles and tendon sheaths, and lately recognized, is the postgonorrheal. It has been shown that _gonorrhea_ may produce an active disturbance in synovial sheaths and in muscle structures and a _gonococcus myositis_, as well as a _gonococcus tendovaginitis_, are now well recognized. These do not always proceed to suppuration, but may provoke loss of function for some time.

The suppurative form of myositis is seen more often after typhoid and gonorrhea than after the other internal infections, but may occur after any of them. In these cases abscess results in the belly of the muscle involved, while the pus evacuated will show the appropriate organism. It is met with less often in endocarditis and erysipelas.

Any or all the active and destructive infections may occur primarily in muscle structure. They are usually the result of an extension, although they maybe even in this way very disastrous. The amount of muscle destruction that may be seen in a limb after an infected and neglected compound fracture is astonishing.

=Myositis Calcificans.=--Calcification and ossification of muscles are alike due to deposition of calcium salts, but under different circumstances. _Myositis calcificans_ may be the result of tuberculous disease following caseation, as it does in lymph nodes and in other parts of the body, or occurring as a general deposit throughout the muscles, essentially an infiltration, as is seen in the muscles of the legs. _Myositis ossificans_ implies a formation of true bone in muscle substance. A peculiar form arising in the adductor longus results from the pressure of the limb against the saddle; this has been known as _rider’s_ or _cavalryman’s bone_. Something similar in the deltoid has been called _drill bone_, because usually seen in soldiers who carry their weapons upon the shoulders; while a form which occurs in the brachialis anticus has been referred to as _fencer’s bone_, and one in the calf muscles as _dancer’s bone_. It occurs in two types, one of which is characterized by ossification in succession of the various muscles, this occurring first in the trapezii, latissimi, and rhomboidei. In explanation of these lesions, it has been suggested that all of these connective mesoblastic tissues may manifest certain atavistic tendencies and thus revert to bone. The question is certainly not one of periosteal origin. Binnie has shown, in a remarkable case reported by himself, that ossification is both of the fibrous and cartilaginous type. Only in the localized forms can the periosteum be suspected. In these it may be that there has been detachment of some of its tissue or escape of some of its cells into the muscle area. The ossifying lesions of surrounding muscles will sometimes interfere with the motions of joints after they have been injured. Any localized calcareous or ossific deposit which can be recognized may be removed.

=Myositis Syphilitica.=--This occurs in gummatous form, no muscles being exempt; those of the tongue are most frequently involved. It is seen also in the sternomastoid. Not infrequently these gummas have been mistaken for malignant tumors. Sometimes they degenerate and sometimes suppurate. A lesion of this kind will usually be multiple, but it may have enough infiltration around it to be difficult of recognition. Lesions of this kind are also seen in hereditary cases. A more distinctively interstitial affection of muscles leads sometimes to their contracture, as seen about the arms, beginning with malaise and incoördination, and extending to disabling lesions. These will yield to properly directed antisyphilitic treatment.

=Myositis Tuberculosa.=--This affection is usually the result of extension from adjoining foci. As in the case of syphilis it may assume the infiltrating or the gummatous type. It is more frequently encountered than the muscular expressions of syphilis; it does not yield nearly as readily to treatment, and calls for excision of the affected area and for cauterization or other protection as against re-infection.

PARALYTIC AFFECTIONS OF MUSCLES.

More or less permanent paralysis is sometimes the result of contusion or direct injury of a nerve trunk. Thus the paralysis of the deltoid which follows injury to the circumflex nerve in connection with dislocations of the shoulder is a frequent accident. It does not require continued pressure upon the nerve to produce this. It may follow a dislocation reduced within a few moments. Again, paralysis of the arm muscles is occasionally the result of pressure made by crutches. It has been known to occur from similar pressure while the patient was upon the operating table with his arm hanging over the table’s edge. This is an accident which should be carefully avoided. Moreover, it follows sometimes from mere violent muscle effort. The condition, while simple in its etiology, is difficult and sometimes impossible to cure.

=Treatment.=--The treatment should consist mainly of massage and electricity, with the elimination of all possibility of toxemia. The resources of tendoplasty (see above) should also be considered, as well as those of neuroplasty.

ATROPHIES AND CONTRACTURES OF MUSCLES.

Muscular paralysis is always followed by atrophy, which will lead to marked diminution in size of the part; when the atrophy concerns a single muscle or muscle group it will frequently be followed by deformity due to action of the opposing muscles. Tonic spasm of muscles unopposed may lead to contractures, often with ankylosis. The degree of deformity which is produced may eventually require amputation of a limb.

Other forms of contractures are produced either as the result of central or spinal scleroses or as expressions of irritative spasm provoked by a neighboring bone or joint trouble. The two types may cause similar deformities, which vary widely in their etiology. The former are seen in certain cases of brain and spinal-cord diseases, the latter especially in connection with tuberculous arthritis. Inasmuch as the flexors are stronger than the extensors these deformities consist largely of hyperflexion. Ultimately the shape and growth of bones and the nutrition, appearance, and function of the part are influenced.

Muscle atrophy which is the result of confinement in one position, as after the treatment of fractures, is of minor importance and tends to disappear spontaneously as soon as function is resumed.

=Treatment.=--In most of these instances patience may be easily overtaxed while waiting the tardy results of massage and such correction as apparatus may afford. Very frequently the additional help of an anesthetic, with forced movements, often with tenotomies and sometimes with tendon grafting, will be required. When contractures can be foreseen, as they may be in connection with many lesions which produce them, such as burns and others not specifically mentioned, they should be guarded against by splints, apparatus, or whatever may best serve the purpose.

PARASITIC AFFECTIONS OF THE MUSCLES.

The parasitic affections of muscles are rare. Trichinosis rarely produces tumors which come under the surgeon’s hands. Still there may result from it a form of myositis with formation of cysts which may so far interfere with muscle function as to demand removal. _Hydatid cysts_ and _cysticercus_ are extremely rare, especially in this country.

DISEASES OF THE BURSÆ.

There are two types of bursæ in the body: first, the _subcutaneous_, or _mucous_, which are loose sacs containing a clear mucoid fluid. They develop regularly when bony prominences are exposed to friction and develop adventitiously wherever undue irritation is produced. Thus beneath every _bunion_ there will be found a good-sized and thickened bursa.

_Synovial bursæ_, the second type, are met with in close proximity to joints, and between tendons which play upon each other. They frequently communicate with the joint which they overlie, and infection may easily spread from one to the other. They are liable to traumatism, either extrinsic or intrinsic, the former from chafing or more direct injury, the latter by excessive muscle exertion. When infected they suppurate, forming abscesses of conventional type. As the result of contusions they are frequently filled with blood, in which case there is a _bursal hematoma_. _Acute bursitis_ usually merges into localized abscess.

[Illustration: PLATE XXX

Foreign Body (Broken Needle) in Foot. Buffalo Clinic. (Skiagram by Dr. Plummer.) Illustrating the Value of this Method of Exactly Locating a Foreign Body and involving the Tissues Considered in