DISEASES OF FASCIE.

DUPUYTREN'S CONTRACTION of the palmar fascia is the only affection of the fasciæ requiring notice. It has been attributed to gout and rheumatism, and to habits or occupations necessita

FIG. 60.

ting pressure in the palm or flexion of the fingers. It consists in a shortening of the prolongations of the fascia from the palm on to the sheath of the flexor tendons. The tendons themselves are not affected. The contraction generally begins in the fascia of the little or ring finger, and later may affect that of the middle finger, and at times the forefinger and also the thumb. The affected fingers (Fig. 60) are drawn toward the palm, and in severe cases may become fixed in contact with it. It may be distinguished from a contracted tendon by the latter forming a tight cord, which can be traced under the annular ligament: whereas in Dupuytren's contraction the Dupuytren's Contraction of tendon is free, though the skin is adherent the Palmar Fascia. (From to the fascia, and thrown thereby into a cast in St. Bartholomew's transverse puckers. Treatment.-Except

Hospital Museum.)

in the early stages, when steps should be taken to prevent further contraction by suitable splints, elastic tension, etc., division of the affected portions of the fascia, followed by extension, is requisite. This may be done by single or by multiple, subcutaneous division, or by an open antiseptic incision. Multiple subcutaneous division is, in my opinion, the preferable method.

DISEASES OF BURSE.

Bursa, wherever situated, and whether existing naturally or formed adventitiously, are liable to become acutely or chronically inflamed.

ACUTE BURSITIS may occur spontaneously, but is generally excited by injury, or undue pressure, as from constant kneeling. The inflammation comes on rather suddenly, the part appearing red, hot, and swollen; it is apt to terminate in suppuration, which, if timely incisions are not made, may become diffuse and phlegmonous. Evaporating lotions, an ice-bag or a few leeches, may, if applied early, check the inflammation, but a free incision must be made as soon as there are signs of suppuration.

CHRONIC BURSITIS is very apt to occur in bursæ that are subjected to continued pressure or irritation, and may lead to several distinct conditions. Thus, 1. Bursa may become simply

In this state they

enlarged and distended with bursal secretion. form globular, fluctuating, often translucent, tense, or flaccid swellings; their walls are but slightly thickened; and there is no heat or redness of the skin. 2. They may become enlarged, slightly thickened, and distended with a serous or dark fluid containing small masses of fibrin resembling melon seeds. These melon-seed bodies may be formed from extravasated blood, fibrinous deposits, or detached portions of thickened synovial fringes, and their presence may sometimes be detected by the crackling sensation they give when the bursa is handled. Sometimes, in place of or together with melon-seed bodies, fibrous cords are found stretching across the cavity of the bursa. 3. They may become enlarged and the walls greatly thickened by inflammatory infiltration, and the deposit of fibrin in their interior. A small central cavity may remain, or they may be solid throughout. They then appear as firm, non-elastic, solid-feeling tumors, and when situated over the tuberosity of the ischium, or in front of the patella, may cause much inconvenience.

Treatment. When simply enlarged, painting with the liniment of iodine or strapping will sometimes disperse them. If this fails they should be punctured, the fluid evacuated, the melon-seed bodies, if present, squeezed out, and firm pressure applied. When greatly thickened or solid they must be dissected

out.

The situations in which these various conditions of the bursæ are most frequently met with are-over the patella, the housemaid's knee, as it is often called; over the olecranon, the miner's bursa; over the tuber ischii, the weaver's bottom or coachman's bursa ; over the great trochanter; under the semi-membranosus; and under the psoas tendon. Adventitious bursæ may also be found under corns or over points of bone subjected to pressure, as the metatarso-phalangeal joint of the great toe, the outer side of the foot in talipes varus, etc. (See Bunion, Talipes.)

The bursa patelle is the one which is most frequently affected, and what has been said about diseases of bursæ in general applies particularly to it. A few words may be added concerning the bursa beneath the semi-membranosus. When enlarged it forms a tense or semi-fluctuating ovoid swelling in the popliteal space; but becomes flaccid or disappears altogether on flexing the knee. Counter-irritation or pressure will generally disperse it. If these fail it may be punctured or incised and drained antiseptically; but the greatest precaution must be taken to prevent septic changes occurring, as it often communicates with the knee joint.

DISEASES OF THE ARTERIES.

ARTERITIS OF INFLAMMATION of the arteries may be acute or chronic.

ACUTE ARTERITIS was formerly thought to be of frequent occurrence as an idiopathic affection, but as such it is now known not to exist. Acute traumatic arteritis, however, is very common, occurring as it does in the simple or plastic form in the process of healing of an artery after injury or ligature, or from the presence of a non-infective thrombus; while as a septic, infective or suppurative affection it is occasionally met with as the result of the extension of septic or infective inflammation to an artery from the surrounding tissues, or as the result of the presence of a septic or infective embolus brought by the blood-stream from a like inflammation of a distant part, as the heart in ulcerative endocarditis. Plastic or adhesive arteritis has already been discussed under the Healing of Arteries. Of septic and infective arteritis all that need be said here is that when due to extension from the surrounding tissues it may lead to the softening and giving way of the arterial walls, and, unless a clot forms above, to hemorrhage; while when due to an embolus it may lay the foundation of an aneurism, or, more rarely, may lead to the rupture of the vessel. It is believed to be the chief cause of aneurism in children.

CHRONIC ARTERITIS mainly affects the deeper layer of the intima, not, as a rule, the other coats. Hence it is often spoken of as endarteritis, or more familiarly as atheroma. It is the commonest disease of the arteries, and to some extent is generally present in persons over forty. It is most frequent in the aorta and large vessels, that is, in those containing the greatest amount of elastic tissue, and is more often met with in the arteries of the lower than in those of the upper limbs.

Causes.-Mechanical strain or vascular tension is looked upon as the most frequent exciting cause. Thus it is attributed to-1, occupations necessitating severe and prolonged exertions; 2, the abuse of alcohol, which produces an increased and forcible action of the heart; 3, chronic Bright's disease, in which the blood pressure, in consequence of capillary fibrosis or spasm of the arterioles, is increased; 4, plethora, in which the arterial tension is also raised; 5, syphilis, which is attended by fibroid change in the small vessels; and, 6, gout, in that it may produce Bright's disease. In addition, however, to the increased vascular tension to which the above-mentioned conditions may give rise, gout, syphilis, and alcohol may also lead to primary degenerative changes in the coats of the arteries in common with the degenerations they induce in the tissues generally throughout the body, and hence, together with advancing age, and the male

sex, may be looked upon as predisposing as well as exciting

causes.

Pathology.-Arteritis begins as a small round-cell infiltration of the deeper layers of the intima-those next the muscular coat. This gives rise to characteristic grayish-white, slightly elevated, tough, semi-gelatinous patches on the inner surface of the vessel. The patches frequently begin around the entrance of the small lateral branches, increase by their edges, and by coalescing with others produce extensive tracts of the disease. The inflammatory infiltration, in conseqnence of the absence of new vessels, may undergo-1, fatty, 2, calcareous, or, 3, fibroid degeneration. 1. The patches formerly gray become yellowish-white, breaking down into a cheesy mass or completely liquefying into a puriform fluid consisting of fatty débris, cholesterine crystals, and minute oil-drops. The layers of the intima next the blood are at first continued unbroken over the fatty patch, which is then called an atheromatous abscess. These layers, however, may subsequently give way, leaving the softened and fatty mass in contact with the blood (atheromatous ulcer). Portions of the fatty material may now be washed away by the blood-stream and become lodged in some of the smaller arteries and capillaries, where they seldom, however, do any harm, as the emboli are non-infective. At times, however, a larger vessel may become plugged, when gangrene may ensue. As the atheromatous material is washed away by the blood, fibroid thickening of the external coat and sheath of the artery takes place opposite the base of the ulcer, so preventing perforation of the artery; but as the new tissue is very inelastic it is liable to yield to the pressure of the blood and an aneurism occur. 2. Instead of the patch undergoing fatty softening lime-salts may be deposited in it. This secondary calcification must be distinguished from the pri mary calcification, to be shortly mentioned. The intima may be continued over the calcareous patch, or it may break away, leaving it exposed to the blood current, thus constituting a nidus for the deposition of fibrin and the formation of a thrombus, portions of which again, in their turn, may be washed away by the blood and form emboli. 3. The small-cell infiltration in the inflamed patch instead of undergoing any of the former changes may advance to the production of fibrous tissue, and a dense fibroid thickening result.

The Effects of Chronic Arteritis.-1. The artery may become dilated, elongated, and tortuous; 2, it may yield at the atheromatous patch, producing an aneurism; and 3, it may rupture under violence. In addition to the above effects depending upon the loss of elasticity of the vessel, thrombosis

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and embolism may occur as already stated, and give rise to gangrene, aneurism, or rupture.

Signs-Except in the superficial vessels where atheroma is productive of rigidity and a tortuous condition of the artery, it gives no special evidence of its presence.

It

The

Syphilitic Arteritis.-This term is applied to a fibroid change in the arteries occurring during the later stages of syphilis. is most common in the arteries of the brain. The inner coat is chiefly affected, and becomes greatly thickened, so that the lumen of the vessel is almost or entirely obliterated. change consists in an extensive infiltration of small round- and spindle-cells, which later become developed into an imperfect fibrous tissue. The outer coat is likewise implicated, but to a less extent, while the muscular coat either escapes or is merely encroached upon by the cells infiltrating the inner coat. The disease is very chronic, and may terminate in thrombosis, or may lead to the formation of an aneurism.

Obliterative arteritis is a rare disease, characterized by great pain spreading up the course of the artery, loss of pulse in the vessel, and often gangrene of the part supplied by it. Its pathology is not known.

PRIMARY DEGENERATION OF ARTERIES.-We have already seen that fatty, calcareous, and fibroid degeneration may follow chronic endarteritis. These changes may, however, occur as primary affections, and may next be considered.

Primary fatty degeneration begins in the superficial layers of the intima, immediately under the endothelium. It takes the form of yellowish-white patches, very slightly projecting into the vessel. The patches can be readily stripped off from the deeper layers, which when thus exposed are found healthy; whereas, in atheroma, it is the deeper layers which are the seat of the disease. It is attended with no signs, and is of little practical importance.

Primary calcification is of more importance. It should be distinguished from calcification occurring as a secondary change in endarteritis. Primary calcification begins in the muscular layer of the middle coat, and is more common in the smaller than in the larger arteries, and in those of the lower than in those of the upper extremity. It is a disease of advancing age, and is a frequent cause of senile gangrene. In primary calcification the lime salts are deposited in the form of rings instead of in irregular patches, as in secondary calcification.

Fibroid Degeneration.-For a description of this a work on Medicine must be consulted.