DIFFUSE TUBERCULOUS DISEASE OF THE TARSUS.

Removal of individual bones alone will not meet the requirements of these cases. In the first instance, expectant treatment consisting of rest, tuberculin injections, the injection of iodoform (see p. 118), or Bier's treatment may be tried for a short time, but it must be remembered that this form of disease is very grave and is likely to be followed by internal complications; expectant treatment must therefore not be persisted in too long.

The choice of operative procedures lies between partial tarsectomy, complete tarsectomy, or amputation, and the decision will be influenced by the virulence of the disease, the general condition of the patient, and the presence or absence of tuberculosis elsewhere.

A

B

FIG. 94. INCISIONS FOR PARTIAL TARSECTOMY IN TUBERCULOUS DISEASE OF the TARSUS. A is the incision on the inner, B that on the outer side. By varying the length of the incisions, as much or as little of the tarsus as may be desired can be removed.

Partial Tarsectomy.-When the disease is limited to the bones and joints in front of the transverse tarsal articulation, the best procedure is to remove the affected bones in one mass by a partial tarsectomy. This is done by lateral incisions which preserve the tendons, vessels, and nerves. Two long incisions are made, one on each side of the foot just above the sole, extending on the inner side from the front of the sustentaculum tali to the centre of the first metatarsal, and on the outer side from just below and in front of the external malleolus to the centre of the fifth metatarsal bone (see Fig. 94). These incisions should be carried down to the bones at once. The tibialis anticus and the peroneus longus tendons may be divided, as they must inevitably be separated from their points of attachment during the operation.

All the tissues down to the bone are now raised from the front of the foot in a manner similar to that described for arthrectomy of the ankle (see p. 222), so that the fingers can be made to meet between

the two incisions. The structures on the plantar surface should also be separated from the tarsus, and, in doing this, one must bear in mind the arch formed by the tarsal bones, and should keep close to the bones. In this way all the soft structures are separated from the bony skeleton of the foot throughout the whole extent of the incisions, leaving the entire synovial membrane intact and in connection with the joints. This is quite easy to do on the dorsum of the foot, as the surgeon can see what he is doing, but it is more difficult in the sole.

The next step is to apply a long narrow saw, or Gigli's wire saw, transversely across the bases of the metatarsal bones, about an inch behind the level of the base of the first metatarsal. The saw is then applied transversely across the tarsus opposite the neck of the astragalus and divides it and the corresponding portion of the os calcis. Whilst this is being done, the soft parts must be protected and held out of the way by suitable spatula. After the bones have been divided, a few touches of the knife allow the whole bony mass, together with the synovial membrane and other diseased structures, to be taken away in one piece without infecting the wound.

After-treatment.--The wound is stitched up and a drainage tube is inserted if there is much oozing. The limb should be placed upon a back splint with a foot-piece at right angles, and the weight of the toes will keep the metatarsal bones in contact with the os calcis and astragalus. In arranging the padding, particular care must be taken to bring the foot into proper position and to keep the bones in contact. As healing takes place, the muscles contract and the tendons, which at first are much too long, gradually become shortened and finally act very well.

Results. As a consequence of this operation the foot is considerably shortened, but the functional result is good, and is much better than that obtained by amputation, as the ankle-joint is preserved.

A similar operation may sometimes be performed, even when sinuses are present, if care is taken to deal with them in the manner already recommended (see p. 225). When, however, there are numerous sinuses or when abscesses are present, and the patient is an adult, Syme's amputation at the ankle-joint is much the best practice. In some cases a sub-astragaloid amputation may be done and gives an excellent result. When the anklejoint is also involved in the disease, amputation through the lower third of the leg should be performed.

CHAPTER XXII.

DISEASES OF THE SHOULDER-JOINT.

INFLAMMATORY AFFECTIONS.

SYNOVITIS with effusion, whether acute or chronic, is comparatively rare in the shoulder-joint, and the condition may be readily overlooked if the distension of the capsule is only slight. When it is considerable, the swelling is most marked beneath the anterior edge of the deltoid, and the upper arm is slightly abducted and somewhat internally rotated; fluctuation may sometimes be felt in the axilla.

The treatment follows lines similar to those already described for acute and chronic synovitis (see Chap. XII.), and presents no points of special interest.

It may be well, however, to draw attention to the stiff and painful shoulder-joints which not uncommonly follow injuries in elderly people. After a fall on the hand or shoulder in an elderly patient, it is very common to find that the joint becomes stiff. There is limitation of movements-especially of abduction-accompanied by severe pain.. As a rule there is no evidence of effusion into the joint, and no creaking. The deltoid is often atrophied. An X-ray photograph generally shows no gross changes in the bones.

The symptoms may begin immediately after the injury or some days later. The majority of patients are getting on in years. The affection is very intractable; in some cases, permanent disability remains, others recover partially or completely, but only after a long course of treatment. The treatment consists in active and passive movements, massage, and hot-air baths. Injections of fibrolysin appear to be beneficial in some cases. ACUTE SUPPURATION occurs as a result of penetrating wounds or as a complication of acute epiphysitis of the upper end of the humerus; in the latter case the joint is often affected.

The treatment is identical with that for similar affections elsewhere (see p. 94). The incisions for draining the joint will be found on p. 98.

TUBERCULOUS DISEASE.

Tuberculous disease of the shoulder-joint is not uncommon and is mainly met with in adult life, being most frequent between the ages of twenty and thirty. As in the other joints, the disease may be primary either in the synovial membrane or in the bone, more commonly the latter.

The primary osseous deposits occur most frequently in the great tuberosity of the humerus, and much less commonly in the neck of the scapula. In some cases the acromion process may be the primary seat of the mischief, but when this bone is affected it is usually secondary to tuberculous disease of the deltoid bursa. When the deposit reaches the surface of the bone, it is not uncommon for the deltoid bursa to be infected, with the result that a soft fluctuating swelling forms beneath the muscle often containing rice-like bodies, which manifest themselves by their peculiar creaking sensation on manipulation.

In the early stages of the disease there is increased fullness about the shoulder, with swelling in the axilla, and considerable limitation of movement of the arm, which is held in an abducted position and rotated inwards. In the later stages there is very marked pain on movement, the arm being kept rigidly applied to the side and rotated inwards; later still, abscesses form and point in front of or behind the deltoid. It is not uncommon to find an abscess travelling along the bicipital groove and coming to the surface beneath the skin about the centre of the front of the arm. In other cases it may open into the axilla, and sometimes about the lower limit of the posterior border of the deltoid.

TREATMENT.-The same general rules must guide the surgeon in the treatment of tuberculous disease of this joint as in the case of tuberculous joint disease elsewhere. There are, however, certain special points which may be referred to.

Expectant treatment.-Recovery from the disease in this situation. is practically always followed by stiffness of the joint, which is at great disability to the patient. Moreover, unless very special care be taken to prevent it, and often in spite of such care, stiffness will occur with the arm in such a position that the limb is rendered very useless; that is to say, it is rotated inwards and closely applied to the side. If expectant treatment is to be employed, the limb should be abducted to about 45°, and kept midway between extreme inward and outward. rotation, that is to say with the forearm looking almost directly forwards. Abduction can be secured by a large wedge-shaped pad in the axilla with the base downwards (see Fig. 95), whilst the forearm should be flexed to a right angle. The elbow may be fixed by a plaster of Paris casing or a moulded splint; if desired, the shoulder may be left uncovered so that local applications, may be made to it.

Extension has also been used in cases in which there are severe starting pains at night. If this is to be employed, the patient should be confined to bed, the trunk fixed with sand-bags, counterextension made by a broad bandage passed around the thorax, and a weight applied by means of a stirrup fixed upon the upper arm, which is kept in the position recommended above (see Fig. 96). In most cases, however, in which the pain is so great as to call for extension, operation is desirable.

When there are abscesses in connection with the joint, the question of operation becomes urgent. It is best to treat the abscess first, so as

to cure or reduce it in size. The same remark applies to tuberculous disease of the deltoid bursa.

Operative treatment. -We have not laid stress upon expectant methods, because we are of opinion that early excision is of great value in tuberculous disease of the shoulder, especially as it is essentially a disease of adult life. In children, it is true, we should advise that operative interference be delayed as long as possible, as arthrectomy. of the shoulder-joint is neither an easy nor a satisfactory operation; but in adults, in whom the growth of the limb has ceased, the question of excision will arise early in the course

FIG. 95.-APPARATUS FOR USE IN TUBERCULOUS DISEASE OF THE SHOULDER-JOINT. The wedge-shaped cushion is fixed in position by the straps shown in the figure. The arm-splint is made of moulded gutta-percha or poroplastic material.

of the disease. By it the progress of the disease is cut short, and the patient is given a movable arm which, though weaker than its fellow, is still greatly superior to an anchylosed joint, especially when the limb is in bad position.

There is a further reason for advocating early operation, in that shoulderjoint disease is very frequently associated with or followed by disease of the lungs; the exact connection between the two is difficult to understand, but it certainly is a clinical fact that a large number of patients with disease of the shoulder-joint suffer also from phthisis, and, in a very considerable proportion, the latter affection only sets in after the joint