Fig. 135
Hygroma of a prepatellar bursa (“housemaid’s knee”). (Lexer.)
Chronic bursitis constitutes a circumscribed collection of fluid, often with thickening of the bursal sac, and frequent deposition of products of exudation. Here, too, pus may form as the result of infection, while calcification sometimes takes place in old cases. A chronic bursitis is likely to be either of syphilitic or tuberculous origin. It is usually seen beneath old bunions, and in the prepatellar bursa, which is equally exposed to irritation, and which also gives rise to housemaid’s knee. This lesion used to be considered as always of syphilitic character, but this is far from correct.
Hygroma, or hydrops, is a term frequently applied to these localized collections of fluid. The former is more likely to be of tuberculous origin, and the retained fluid may contain rice-grain bodies. A chronic bursitis, originally of traumatic origin, may become infected and present a tuberculous lesion, or it may be influenced if not caused by a syphilitic diathesis, especially about the knee, where these conditions generally occur. Other bursæ which produce disturbances that eventually take the patient to a surgeon are met with in the following locations: beneath the ligamentum patellæ, which will give a prominence on each side of the ligament, particularly when the knee is flexed; over the tubercle of the tibia; beneath the quadriceps extensor tendon, which will cause a swelling two or three inches above the upper border of the patella; between the tendon of the semimembranosus and inner head of the gastrocnemius, which will present in the popliteal space as a somewhat globular swelling; beneath the deltoid; beneath the gluteus muscles, where the tendons pass over the great trochanter; between the tendo Achillis and the calcis; over the outer malleolus, occurring in tailors by virtue of the position in which they work. Large bursæ often develop on the outer sides of club-feet, on the ends of amputation stumps, and wherever there is prolonged irritation of mild degree.[21]
[21] A bunion is in many instances due to flat-foot, causing the great toe to turn out. This condition should be remedied by the usual arch, or raising the inner border of the shoes. Four out of the five tendons attached to the great toe tend also to draw it outward. If the tripod of the foot can be restored without operation this should be done.
The treatment of acute bursitis is that of threatening phlegmon in any other part of the body. As soon as the presence of pus can be determined, or even before, a free incision should be made. Such an incision should not be entirely closed after evacuation of the sac, but should be permitted to heal by granulation.
Chronic bursitis, whether with or without formation of granuloma, is best treated by excision, when the sac has become thickened and a new formation has practically occurred. Housemaid’s knee, for instance, like bunion, is more satisfactorily treated by a clean excision of all diseased tissue than by any other less radical method. Every tuberculous lesion of this kind should be rigorously extirpated, and every syphilitic lesion should be treated by constitutional as well as by local measures, the former being, save in exceptional instances, the more important of the two.[22]
[22] The Radical Cure of Bunions.—The term bunion is generally used to indicate a painful swelling over the inner aspect of the ball of the great toe; it is never seen on the feet of those who go barefooted, but is the result of badly fitting shoes, almost all of which crowd the great toe outward, thus making its base more prominent and exposing it to irritation and pressure. The inner border of the foot is nearly a straight line, but shoes are rarely made to conform to this. The result of the consequent partial dislocation of the toe, and of the pressure made at its base, is chronic periostitis, and the development of a bursa. It becomes greatly thickened and forms a small tumor, usually sensitive and painful. The dislocation often proceeds to such a degree that the great toe lies across the others, either over them or under them, in such a position as to receive and deserve the name hallux valgus, which is generally given it when this is pronounced. There is nothing to do but to exsect the head of the first metatarsal bone, and at the same time excise the bursa and some of the overlying and thickened skin.