Fig. 119.—Femur and Tibia showing results of Acute Osteomyelitis affecting Trigone of Femur; sequestrum partly surrounded by new case; backward displacement of lower epiphysis and implication of knee-joint.Fig. 119.—Femur and Tibia showing results of Acute Osteomyelitis affecting Trigone of Femur; sequestrum partly surrounded by new case; backward displacement of lower epiphysis and implication of knee-joint.
Fig. 119.—Femur and Tibia showing results of Acute Osteomyelitis affecting Trigone of Femur; sequestrum partly surrounded by new case; backward displacement of lower epiphysis and implication of knee-joint.
The Recognition and Removal of Sequestra.—So long as there is dead bone there will be suppuration from the granulations lining the cavity in which it lies, and a discharge of pus from the sinuses, so that the mere persistence of discharge after an attack of osteomyelitis, is presumptive evidence of the occurrence of necrosis. Where there are one or more sinuses, the passage of a probe which strikes bare bone affords corroboration of the view that the bone has perished. When the dead bone has been separated from the living, the X-rays yield the most exact information.
The traditional practice is to wait until the dead bone is entirely separated before undertaking an operation for its removal, from fear, on the one hand, of leaving portions behind which may keep up the discharge, and, on the other, of removing more bone than is necessary. This practice need not be adhered to, as by operating at an earlier stage healing is greatly hastened. If it is decided to wait for separation of the dead bone, drainage should be improved, and the infective element combated by the induction of hyperæmia.
The operationfor the removal of the dead bone (sequestrectomy) consists in opening up the periosteum and the new case sufficiently to allow of the removal of all the dead bone, including the most minute sequestra. The limb having been rendered bloodless, existing sinuses are enlarged, but if these are inconveniently situated—for example, in the centre of the popliteal space in necrosis of the femoral trigone—it is better to make afresh wound down to the bone on that aspect of the limb which affords best access, and which entails the least injury of the soft parts. The periosteum, which is thick and easily separable, is raised from the new case with an elevator, and with the chisel or gouge enough of the new bone is taken away to allow of the removal of the sequestrum. Care must be taken not to leave behind any fragment of dead bone, as this will interfere with healing, and may determine a relapse of suppuration.
The dead bone having been removed, the lining granulations are scraped away with a spoon, and the cavity is disinfected.
There are different ways of dealing with abone cavity. It may be packed with gauze (impregnated with “bipp” or with iodoform), which is changed at intervals until healing takes place from the bottom; it may be filled with a flap of bone and periosteum raised from the vicinity, or with bone grafts; or the wall of bone on one side of the cavity may be chiselled through at its base, so that it can be brought into contact with the opposite wall. The method of filling bone cavities devised by Mosetig-Moorhof, consists in disinfecting and drying the cavity by a current of hot air, and filling it with a mixture of powdered iodoform (60 parts) and oil of sesame and spermaceti (each 40 parts), which is fluid at a temperature of 112° F.; the soft parts are then brought together without drainage. As the cavity fills up with new bone the iodoform is gradually absorbed. Iodoform gives a dark shadow with the X-rays, so that the process of its absorption can be followed in skiagrams taken at intervals.
These procedures may be carried out at the same time as the sequestrum is removed, or after an interval. In all of them, asepsis is essential for success.
Thedeformitiesresulting from osteomyelitis are more marked the earlier in life the disease occurs. Even under favourable conditions, and with the continuous effort at reconstruction of the bone by Nature's method, the return to normal is often far from perfect, and there usually remains a variable amount of hyperostosis and sclerosis and sometimes curving of the bone. Under less favourable conditions, the late results of osteomyelitis may be more serious.Shorteningis not uncommon from interference with growth at the ossifying junction.Exaggerated growthin the length of a bone is rare, and has been observed chiefly in the bones of the leg. Where there are two parallel bones—as in the leg, for example—the growth of the diseased bone may be impaired, and the other continuing its normal growth becomes disproportionately long; less frequently thegrowth of the diseased bone is exaggerated, and it becomes the longer of the two. In either case, the longer bone becomes curved. Anobliquityof the bone may result when one half of the epiphysial cartilage is destroyed and the other half continues to form bone, giving rise to such deformities as knock-knee and club-hand.
Deformity may also result from vicious union of a pathological fracture, permanent displacement of an epiphysis, contracture, ankylosis, or dislocation of the adjacent joint.
Relapsing Osteomyelitis.—As the term indicates, the various forms of relapsing osteomyelitis date back to an antecedent attack, and their occurrence depends on the capacity of staphylococci to lie latent in the marrow.
Relapse may take place within a few months of the original attack, or not for many years. Cases are sometimes met with in which relapses recur at regular intervals for several years, the tendency, however, being for the attacks to become milder as the virulence of the organisms becomes more and more attenuated.
Clinical Features.—Osteomyelitis in a patient over twenty-five is nearly always of the relapsing variety. In some cases the bone becomes enlarged, with pain and tenderness on pressure; in others there are the usual phenomena which attend suppuration, but the pus is slow in coming to the surface, and the constitutional symptoms are slight. The pus may escape by new channels, or one of the old sinuses may re-open. Radiograms usually furnish useful information as to the condition of the bone, both as it is altered by the original attack and by the changes that attend the relapse of the infective process.
Treatment.—In cases of thickening of the bone with persistent and severe pain, if relief is not afforded by the repeated application of blisters, the thickened periosteum should be incised, and the bone opened up with the chisel or trephine. In cases attended with suppuration, the swelling is incised and drained, and if there is a sequestrum, it must be removed.
Circumscribed Abscess of Bone—“Brodie's Abscess.”—The most important form of relapsing osteomyelitis is the circumscribed abscess of bone first described by Benjamin Brodie. It is usually met with in young adults, but we have met with it in patients over fifty. Several years may intervene between the original attack of osteomyelitis and the onset of symptoms of abscess.
Morbid Anatomy.[7]—The abscess is nearly always situated inthe central axis of the bone in the region of the ossifying junction, although cases are occasionally met with in which it lies nearer the middle of the shaft. In exceptional cases there is more than one abscess (Fig. 120). The tibia is the bone most commonly affected, but the lower end of the femur, or either end of the humerus, may be the seat of the abscess. In the quiescent stage the lesion is represented by a small cavity in the bone, filled with clear serum, and lined by a fibrous membrane which is engaged in forming bone. Around the cavity the bone is sclerosed, and the medullary canal is obliterated. When the infection becomes active, the contents of the cavity are transformed into a greenish-yellow pus from which the staphylococcus can be isolated, and the cavity is lined by a thin film of granulation tissue which erodes the surrounding bone and so causes the abscess to increase in size. If the erosion proceeds uniformly, the cavity is spherical or oval; if it is more active at some points than others, diverticula or tunnels are formed, and one of these may finally erupt through the shell of the bone or into an adjacent joint. Small irregular sequestra are occasionally found within the abscess cavity. In long-standing cases it is common to find extensive obliteration of the medullary canal, and a considerable increase in the girth of the bone.
[7]Alexis Thomson,Edin. Med. Journ., 1906.
Fig. 120.—Segment of Tibia resected for Brodie's Abscess. The specimen shows two separate abscesses in the centre of the shaft, the lower one quiescent, the upper one active and increasing in size.Fig. 120.—Segment of Tibia resected for Brodie's Abscess. The specimen shows two separate abscesses in the centre of the shaft, the lower one quiescent, the upper one active and increasing in size.
Fig. 120.—Segment of Tibia resected for Brodie's Abscess. The specimen shows two separate abscesses in the centre of the shaft, the lower one quiescent, the upper one active and increasing in size.
The size of the abscess ranges from that of a cherry to that of a walnut, but specimens in museums show that, if left to Nature, the abscess may attain much greater dimensions.
The affected bone is not only thicker and heavier than normal, but may also be curved or otherwise deformed as a result of the original attack of osteomyelitis.
Theclinical featuresare almost exclusively local. Pain, due to tension within the abscess, is the dominant symptom. At first it is vague and difficult to localise, later it is referred to the interior of the bone, and is described as “boring.” It is aggravated by use of the limb, and there are often, especially during the night, exacerbations in which the pain becomes excruciating. In the early stages there are periods of days or weeks during which the symptoms abate, but as the abscess increases these become shorter, until the patient is hardly ever free from pain. Localised tenderness can almost always be elicited by percussion, or by compressing the bone between the fingers and thumb. The pain induced by the traction of muscles attached to the bone, or by the weight of the body, may interfere with the function of the limb, and in the lower extremity cause a limp in walking. The limb may be disabled frominvolvement of the adjacent joint, in which there may be an intermittent hydrops which comes and goes coincidently with exacerbations of pain; or the abscess may perforate the joint and set up an acute arthritis.
Thediagnosisof Brodie's abscess from other affections met with at the ends of long bones, and particularly from tuberculosis, syphilis, and new growths, is made by a consideration of the previous history, especially with reference to an antecedent attack of osteomyelitis. When the adjacent joint is implicated, the surgeon may be misled by the patient referring all the symptoms to the joint.
The X-ray picture is usually diagnostic chiefly because all the lesions which are liable to be confused with Brodie's abscess—gumma, tubercle, myeloma, chondroma, and sarcoma—give a well-marked central clear area; the sclerosis around Brodie's abscess gives a dense shadow in which the central clear area is either not seen at all or only faintly (Fig. 121).
Treatment.—If an abscess is suspected, there should be no hesitation in exploring the interior of the bone. It is exposed by a suitable incision; the periosteum is reflected and the bone is opened up by a trephine or chisel, and the presence of an abscess may be at once indicated by the escape of pus. If, owing to the small size of the abscess or the density of the bonesurrounding it, the pus is not reached by this procedure, the bone should be drilled in different directions.
Fig. 121.—Radiogram of Brodie's Abscess in Lower End of Tibia.Fig. 121.—Radiogram of Brodie's Abscess in Lower End of Tibia.
Fig. 121.—Radiogram of Brodie's Abscess in Lower End of Tibia.
Other Forms of Acute Osteomyelitis.—Among the less severe forms of osteomyelitis resulting from the action of attenuated organisms are theserousvariety, in which an effusion of serous fluid forms under the periosteum; andgrowth fever, in which the child complains of vague evanescent pains (growing pains), and of feeling tired and disinclined to play; there may be some rise of temperature in the evening.
Infection with thestaphylococcus albus, thestreptococcus, orthepneumococcusalso causes a mild form of osteomyelitis which may go on to suppuration.
Necrosis without suppuration, described by Paget under the name “quiet necrosis,” is a rare disease, and would appear to be associated with an attenuated form of staphylococcal infection (Tavel). It occurs in adults, being met with up to the age of fifty or sixty, and is characterised by the insidious development of a swelling which involves a considerable extent of a long bone. The pain varies in intensity, and may be continuous or intermittent, and there is tenderness on pressure. The shaft is increased in girth as a result of its being surrounded by a new case of bone. The resemblance to sarcoma may be very close, but the swelling is not as defined as in sarcoma, nor does it ever assume the characteristic “leg of mutton” shape. In both diseases there is a tendency to pathological fracture. It is difficult also in the absence of skiagrams to differentiate the condition from syphilitic and from tuberculous disease. If the diagnosis is not established after examination with the X-rays, an exploratory incision should be made; if dead bone is found, it is removed.
In typhoid fever the bone marrow is liable to be invaded bythe typhoid bacillus, which may set up osteomyelitis soon after its lodgment, or it may lie latent for a considerable period before doing so. The lesions may be single or multiple, they involve the marrow or the periosteum or both, and they may or may not be attended with suppuration. They are most commonly met with in the tibia and in the ribs at the costo-chondral junctions.
The bone lesions usually occur during the seventh or eighth week of the fever, but have been known to occur much later. The chief complaint is of vague pains, at first referred to several bones, later becoming localised in one; they are aggravated by movement, or by handling the bone, and are worst at night. There is redness and œdema of the overlying soft parts, and swelling with vague fluctuation, and on incision there escapes a yellow creamy pus, or a brown syrupy fluid containing the typhoid bacillus in pure culture. Necrosis is exceptional.
When the abscess develops slowly, the condition resembles tuberculous disease, from which it may be diagnosed by the history of typhoid fever, and by obtaining a positive Widal reaction.
The prognosis is favourable, but recovery is apt to be slow, and relapse is not uncommon.
It is usually sufficient to incise the periosteum, but when thedisease occurs in a rib it may be necessary to resect a portion of bone.
Pyogenic Osteomyelitis due to Spread of Infection from the Soft Parts.—There still remain those forms of osteomyelitis which result from infection through a wound involving the bone—for example, compound fractures, gun-shot injuries, osteotomies, amputations, resections, or operations for un-united fracture. In all of these the marrow is exposed to infection by such organisms as are present in the wound. A similar form of osteomyelitis may occur apart from a wound—for example, infection may spread to the jaws from lesions of the mouth; to the skull, from lesions of the scalp or of the cranial bones themselves—such as a syphilitic gumma or a sarcoma which has fungated externally; or to the petrous temporal, from suppuration in the middle ear.
Fig. 122.—Tubular Sequestrum resulting from Septic Osteomyelitis in Amputation Stump.Fig. 122.—Tubular Sequestrum resulting from Septic Osteomyelitis in Amputation Stump.
Fig. 122.—Tubular Sequestrum resulting from Septic Osteomyelitis in Amputation Stump.
The most common is an osteomyelitis commencing in the marrow exposed in a wound infected with pyogenic organisms. In amputation stumps, fungating granulations protrude from the sawn end of the bone, and if necrosis takes place, the sequestrum is annular, affecting the cross-section of the bone at the saw-line; or tubular, extending up the shaft, and tapering off above. The periosteum is more easily detached, is thicker than normal, and is actively engaged in forming bone. In the macerated specimen, the new bone presents a characteristic coral-like appearance, and may be perforated by cloacæ (Fig. 122).
Fig. 123.—New Periosteal Bone on surface of Femur from Amputation Stump. Osteomyelitis supervened on the amputation, and resulted in necrosis at the sawn section of the bone. (Anatomical Museum, University of Edinburgh.)Fig. 123.—New Periosteal Bone on surface of Femur from Amputation Stump. Osteomyelitis supervened on the amputation, and resulted in necrosis at the sawn section of the bone.(Anatomical Museum, University of Edinburgh.)
Fig. 123.—New Periosteal Bone on surface of Femur from Amputation Stump. Osteomyelitis supervened on the amputation, and resulted in necrosis at the sawn section of the bone.
(Anatomical Museum, University of Edinburgh.)
Like other pyogenic infections, it may terminate in pyæmia, as a result of septic phlebitis in the marrow.
Theclinical featuresof osteomyelitis inan amputation stumpare those of ordinary pyogenic infection; the involvement of the bone may be suspected from the clinical course, the absenceof improvement from measures directed towards overcoming the sepsis in the soft parts, and the persistence of suppuration in spite of free drainage, but it is not recognised unless the bone is exposed by opening up the stump or the changes in the bone are shown by the X-rays. The first change is due to the deposit of new bone on the periosteal surface; later, there is the shadow of the sequestrum.
Healing does not take place until the sequestrum is extruded or removed by operation.
In compound fractures, if a fragment dies and forms a sequestrum, it is apt to be walled in by new bone; the sinuses continue to discharge until the sequestrum is removed. Even after healing has taken place, relapse is liable to occur, especially in gun-shot injuries. Months or years afterwards, the bone may become painful and tender. The symptoms may subside under rest and elevation of the limb and the application of a compress, or an abscess forms and bursts with comparatively little suffering. The contents may be clear yellow serum or watery pus; sometimes a small spicule of bone is discharged. Valuable information, both for diagnosis and treatment, is afforded by skiagrams.
The tuberculous diseases of bone result from infection of the marrow or periosteum by tubercle bacilli conveyed through the arteries; it is exceedingly rare for tubercle to appear in bone as a primary infection, the bacilli being usually derived from some pre-existing focus in the bronchial glands or elsewhere. According to the observations of John Fraser, 60 per cent. of the cases of bone and joint tubercle in children are due to the bovine bacillus, 37 per cent. to the human variety, and in 3 per cent. both types are present.
Tuberculous disease in bone is characterised by its insidious onset and slow progress, and by the frequency with which it is associated with disease of the adjacent joint.
Periosteal tuberculosisis met with in the ribs, sternum, vertebral column, skull, and less frequently in the long bones of the limbs. It may originate in the periosteum, or may spread thence from the marrow, or from synovial membrane.
In superficial bones, such as the sternum, the formation of tuberculous granulation tissue in the deeper layer of the periosteum, and its subsequent caseation and liquefaction, is attended by the insidious development of a doughy swelling, which is not as a rule painful, although tender on pressure. While the swelling often remains quiescent for some time, it tends to increase in size, to become boggy or fluctuating, and to assume the characters of a cold abscess. The pus perforates the fibrous layer of the periosteum, invading and infecting the overlying soft parts, its spread being influenced by the anatomical arrangement of the tissues. The size of the abscess affords no indication of the extent of the bone lesion from which it originates. As the abscess reaches the surface, the skin becomes of a dusky red or livid colour, is gradually thinned out, and finally sloughs, forming a sinus. A probe passed into the sinus strikes carious bone. Small sequestra may be found embedded in the granulation tissue. The sinus persists as long as any active tubercle remains in the tissues, and is apt to form an avenue for pyogenic infection.
In deeply seated bones, such as the upper end of the femur, the formation of a cold abscess in the soft parts is often the first evidence of the disease.
Diagnosis.—Before the stage of cold abscess is reached, the localised swelling is to be differentiated from a gumma, from chronic forms of staphylococcal osteomyelitis, from enlarged bursa or ganglion, from sub-periosteal lipoma, and from sarcoma. Most difficulty is met with in relation to periosteal sarcoma, which must be differentiated either by the X-ray appearances or by an exploratory incision.
X-ray appearances in periosteal tubercle: the surface of the cortical bone in the area of disease is roughened and irregular by erosion, and in the vicinity there may be a deposit of new bone on the surface, particularly if a sinus is present and mixed infection has occurred; insyphilisthe shadow of the bone is denser as a result of sclerosis, and there is usually more new bone on the surface—hyperostosis; inperiosteal sarcomathere is greater erosion and consequently greater irregularity in thecontour of the cortical bone, and frequently there is evidence of formation of bone in the form of characteristic spicules projecting from the surface at a right angle.
The early recognition of periosteal lesions in the articular ends of bones is of importance, as the disease, if left to itself, is liable to spread to the adjacent joint.
Thetreatmentis that of tuberculous lesions in general; if conservative measures fail, the choice lies between the injection of iodoform, and removal of the infected tissues with the sharp spoon. In the ribs it is more satisfactory to remove the diseased portion of bone along with the wall of the associated abscess or sinus. If all the tubercle has been removed and there is no pyogenic infection, the wound is stitched up with the object of obtaining primary union; otherwise it is treated by the open method.
Fig. 124.—Tuberculous Osteomyelitis of Os Magnum, excised from a boy æt. 8. Note well-defined caseous focus, with several minute foci in surrounding marrow.Fig. 124.—Tuberculous Osteomyelitis of Os Magnum, excised from a boy æt. 8. Note well-defined caseous focus, with several minute foci in surrounding marrow.
Fig. 124.—Tuberculous Osteomyelitis of Os Magnum, excised from a boy æt. 8. Note well-defined caseous focus, with several minute foci in surrounding marrow.
Tuberculous Osteomyelitis.—Tuberculous lesions in the marrow occur as isolated or as multiple foci of granulation tissue, which replace the marrow and erode the trabeculæ of bone in the vicinity (Fig. 124). The individual focus varies in size from a pea to a walnut. The changes that ensue resemble in character those in other tissues, and the extent of the destruction varies according to the way in which the tubercle bacillus and the marrow interact upon one another. The granulation tissue may undergo caseation and liquefaction, or may become encapsulated by fibrous tissue—“encysted tubercle.”
Fig. 125.—Tuberculous Disease of Child's Tibia, showing sequestrum in medullary cavity, and increase in girth from excess of new bone.Fig. 125.—Tuberculous Disease of Child's Tibia, showing sequestrum in medullary cavity, and increase in girth from excess of new bone.
Fig. 125.—Tuberculous Disease of Child's Tibia, showing sequestrum in medullary cavity, and increase in girth from excess of new bone.
Sometimes the tuberculous granulation tissue spreads in the marrow, assuming the characters of a diffuse infiltration—diffuse tuberculous osteomyelitis. The trabecular framework of the bone undergoes erosion and absorption—rarefying ostitis—and either disappears altogether or only irregular fragments orsequestra of microscopic dimensions remain in the area affected. Less frequently the trabecular framework is added to by the formation of new bone, resulting in a remarkable degree of sclerosis, and if, following upon this, there is caseation of the tubercle and death of the affected portion of bone, there results a sequestrum often of considerable size and characteristic shape, which, because of the sclerosis and surrounding endarteritis, is exceedingly slow in separating. When the sequestrum involves an articular surface it is often wedge-shaped; in other situations it is rounded or truncated and lies in the long axis of the medullary canal (Fig. 125). Finally, the sequestrum lies loose in a cavity lined by tuberculous granulation tissue, and is readily identified in a radiogram. This type of sclerosis preceding death of the bone is highly characteristic of tuberculosis.
Clinical Features.—As a rule, it is only in superficially placed bones, such as the tibia, ulna, clavicle, mandible, or phalanges, that tuberculous disease in the marrow gives rise to signs sufficiently definite to allow of its clinical recognition. In the vertebræ, or in the bones of deeply seated joints, such as the hip or shoulder, the existence of tuberculous lesions in the marrow can only be inferred from indirect signs—such, for example, as rigidity and curvature in the case of the spine, or from the symptoms of grave and persistent joint-disease in the case of the hip or shoulder.
With few exceptions, tuberculous disease in the interior of a bone does not reveal its presence until by extension it reaches one or other of the surfaces of the bone. In the shaft of a long bone its eruption on the periosteal surface is usually followed by the formation of a cold abscess in the overlying soft parts. When situated in the articular ends of bones, the disease more often erupts in relation to the reflection of the synovial membrane or directly on the articular surface—in either case giving rise to disease of the joint (Fig. 156).
Fig. 126—Diffuse Tuberculous Osteomyelitis of Right Tibia. (Photograph lent by Sir H.J. Stiles.)Fig. 126.—Diffuse Tuberculous Osteomyelitis of Right Tibia.(Photograph lent by Sir H. J. Stiles.)
Fig. 126.—Diffuse Tuberculous Osteomyelitis of Right Tibia.
(Photograph lent by Sir H. J. Stiles.)
Diffuse Tuberculous Osteomyelitis in the shaft of a long boneis comparatively rare, and has been observed chiefly in the tibia and the ulna in children (Fig. 126). It commences at the growing extremity of the diaphysis, and spreads along the medulla to a variable extent; it is attended by the formation of vascular and porous bone on the surface, which causes thickening of the diaphysis; this is most marked at the ossifying junction and tapers off along the shaft. The infection not only spreads along the medulla, but it invades the spongy bone surrounding this, and then the cortical bone, and is only prevented from reaching the soft parts by the new bone formed by the periosteum. The bone is replaced by granulation tissue, and disappears, or part of it may become sclerosed and in time form a sequestrum. In the macerated specimen, the sequestrum appears small in proportion to the large cavity in which it lies. All these changes are revealed in a good skiagram, which not only confirms the diagnosis, but, in many instances, demonstrates the extent of the disease, the presence or absence of a sequestrum, and the amount of new bone on the surface. Finally the periosteum gives way, and an abscess forms in the soft parts;and if left to itself ruptures externally, leaving a sinus. The most satisfactorytreatmentis to resect sub-periosteally the diseased portion of the diaphysis.
In cancellous bones, such as those of the tarsus, there is a similar caseous infiltration in the marrow, and this may be attended with the formation of a sequestrum either in the interior of the bone or involving its outer shell, as shown inFig. 127. The situation and extent of the disease are shown in X-ray photographs. After the tuberculous granulation tissue erupts through the cortex of the bone, it gives rise to a cold abscess or infects adjacent joints or tendon sheaths.
If an exact diagnosis is made at an early stage of the disease—and this is often possible with the aid of X-rays—the affected bone is excised sub-periosteally or its interior is cleared out with the sharp spoon and gouge, the latter procedure being preferred in the case of thecalcaneusto conserve the stability of the heel. When several bones and joints are simultaneouslyaffected, and there are sinuses with mixed infection, amputation is usually indicated, especially in adults.
Fig. 127.—Advanced Tuberculous Disease in region of Ankle. The ankle-joint is ankylosed, and there is a large sequestrum in the calcaneus. (Specimen in Anatomical Museum, University of Edinburgh.)Fig. 127.—Advanced Tuberculous Disease in region of Ankle. The ankle-joint is ankylosed, and there is a large sequestrum in the calcaneus.(Specimen in Anatomical Museum, University of Edinburgh.)
Fig. 127.—Advanced Tuberculous Disease in region of Ankle. The ankle-joint is ankylosed, and there is a large sequestrum in the calcaneus.
(Specimen in Anatomical Museum, University of Edinburgh.)
Tuberculous dactylitisis the name applied to a diffuse form of the disease as it affects the phalanges, metacarpal or metatarsal bones. The lesion presents, on a small scale, all the anatomical changes that have been described as occurring in the medulla of the tibia or ulna, and they are easily followed in skiagrams. A periosteal type of dactylitis is also met with.
Theclinical featuresare those of a spindle-shaped swelling of a finger or toe, indolent, painless, and interfering but little with the function of the digit. Recovery may eventually occur without suppuration, but it is common to have the formation of a cold abscess, which bursts and forms one or more sinuses. It may be difficult to differentiate tuberculous dactylitis from the enlargement of the phalanges in inherited syphilis (syphilitic dactylitis), especially when the tuberculous lesion occurs in a child who is the subject of inherited syphilis.
Fig. 128.—Tuberculous Dactylitis.Fig. 128.—Tuberculous Dactylitis.
Fig. 128.—Tuberculous Dactylitis.
In the syphilitic lesion, skiagrams usually show a more abundant formation of new bone, but in many cases the doubt is only cleared up by observing the results of the tuberculin test or the effects of anti-syphilitic treatment.
Sarcoma of a phalanx or metacarpal bone may closely resemble a dactylitis both clinically and in skiagrams, but it is rare.
Treatment.—Recovery under conservative measures is not uncommon, and the functional results are usually better thanthose following upon operative treatment, although in either case the affected finger is liable to be dwarfed (Fig. 129). The finger should be immobilised in a splint, and a Bier's bandage applied to the upper arm. Operative interference is indicated if a cold abscess develops, if there is a persistent sinus, or if a sequestrum has formed, a point upon which information is obtained by examination with the X-rays. When a toe is affected, amputation is the best treatment, but in the case of a finger it is rarely called for. In the case of a metacarpal or metatarsal bone, sub-periosteal resection is the procedure of choice, saving the articular ends if possible.
Fig. 129.—Shortening of Middle Finger of Adult, the result of Tuberculous Dactylitis in childhood.Fig. 129.—Shortening of Middle Finger of Adult, the result of Tuberculous Dactylitis in childhood.
Fig. 129.—Shortening of Middle Finger of Adult, the result of Tuberculous Dactylitis in childhood.
Syphilitic affections of bone may be met with at any period of the disease, but the graver forms occur in the tertiary stage of acquired and inherited syphilis. The virus is carried by the blood-stream to all parts of the skeleton, but the local development of the disease appears to be influenced by a predisposition on the part of individual bones.
Syphilitic diseases of bone are much less common in practice than those due to pyogenic and tuberculous infectious, and they show a marked predilection for the tibia, sternum, and skull. They differ from tuberculous affections in the frequency with which they attack the shafts of bones rather than the articular ends, and in the comparative rarity of joint complications.
Evanescent periostitisis met with in acquired syphilis during the period of the early skin eruptions. The patient complains, especially at night, of pains over the frontal bone, ribs, sternum, tibiæ, or ulnæ. Localised tenderness is elicited on pressure, and there is slight swelling, which, however, rarely amounts to what may be described as aperiosteal node.
In the later stages of acquired syphilis,gummatous periostitisand osteomyelitisoccur, and are characterised by the formation in the periosteum and marrow of circumscribed gummata or of a diffuse gummatous infiltration. The framework of the bone is rarefied in the area immediately involved, and sclerosed in the parts beyond. If the gummatous tissue degenerates and breaks down, and especially if the overlying skin is perforated and septic infection is superadded, the bone disintegrates and exhibits the condition known assyphilitic caries; sometimes a portion of bone has its blood supply so far interfered with that it dies—syphilitic necrosis. Syphilitic sequestra are heavier and denser than normal bone, because sclerosis usually precedes death of the bone. The bones especially affected by gummatous disease are: the skull, the septum of the nose, the nasal bones, palate, sternum, femur, tibia, and the bones of the forearm.
In the bones of the skull, gummata may form in the peri-cranium, diploë, or dura mater. An isolated gumma forms a firm elastic swelling, shading off into the surroundings. In the macerated bone there is a depression or an actual perforation of the calvaria; multiple gummata tend to fuse with one another at their margins, giving the appearance of a combination of circles: these sometimes surround an area of bone and cut it off from its blood supply (Fig. 130). If the overlying skin is destroyed and septic infection superadded, such an isolated area of bone is apt to die and furnish a sequestrum; the separation of the dead bone is extremely slow, partly from the want of vascularity in the sclerosed bone round about, and partly from the density of the sequestrum. In exceptional cases the necrosis involves the entire vertical plate of the frontal bone. Pus is formed between the bone and the dura (suppurative pachymeningitis), and this may be followed by cerebral abscess or by pyæmia. Gummatous disease in the wall of the orbit may cause displacement of the eye and paralysis of the ocular muscles.
Fig. 130.—Syphilitic Disease of Skull, showing a sequestrum in process of separation.Fig. 130.—Syphilitic Disease of Skull, showing a sequestrum in process of separation.
Fig. 130.—Syphilitic Disease of Skull, showing a sequestrum in process of separation.
On the inner surface of the skull, the formation of gummatous tissue may cause pressure on the brain and give rise to intense pain in the head, Jacksonian epilepsy, or paralysis, the symptoms varying with the seat and extent of the disease. The cranial nerves may be pressed upon at the base, especially at their points of exit, and this gives rise to symptoms of irritation or paralysis in the area of distribution of the nerves affected.
In the septum of the nose, the nasal bones, and the hard palate, gummatous disease causes ulceration, which, beginning in the mucous membrane, spreads to the bones, and beingcomplicated with septic infection leads to caries and necrosis. In the nose, the disease is attended with stinking discharge (ozœna), the extrusion of portions of dead bone, and subsequently with deformity characterised by loss of the bridge of the nose; in the palate, it is common to have a perforation, so that the air escapes through the nose in speaking, giving to the voice a characteristic nasal tone.
Syphilitic disease of the tibiamay be taken as the type of theaffection as it occursin the long bones. Gummatous disease in the periosteum may be localised and result in the formation of a well-defined node, or the whole shaft may become the seat of an irregular nodular enlargement (Fig. 132). If the bone is macerated, it is found to be heavier and bulkier than normal; there is diffuse sclerosis with obliteration of the medullary canal, and the surface is uneven from heaping up of new bone—hyperostosis (Fig. 131). If a periosteal gumma breaks down and invades the skin, a syphilitic ulcer is formed with carious bone at the bottom. A central gumma may eat away the surrounding bone to such an extent that the shaft undergoes pathological fracture. In the rare cases in which it attacks the articular end of a long bone, gummatous disease may implicate the adjacent joint and give rise to syphilitic arthritis.
Fig. 131.—Syphilitic Hyperostosis and Sclerosis of Tibia, on section and on surface view.Fig. 131.—Syphilitic Hyperostosis and Sclerosis of Tibia, on section and on surface view.
Fig. 131.—Syphilitic Hyperostosis and Sclerosis of Tibia, on section and on surface view.
Clinical Features.—There is severe boring pain—as if a gimlet were being driven into the bone. It is worst at night, preventing sleep, and has been ascribed to compression of the nerves in the narrowed Haversian canals.
Theperiosteal gummaappears as a smooth, circumscribed swelling which is soft and elastic in the centre and firm at the margins, and shades off into the surrounding bone. The gumma may be completely absorbed or it may give place to a hard node. In some cases the gumma softens in the centre, the skin becomes adherent, thin, and red, and finally gives way. The opening in the skin persists as a sinus, or develops into a typical ulcer with irregular, crescentic margins; in either case a probe reveals the presence of carious bone or of a sequestrum. The health may be impaired as a result of mixed infection, and the absorption of toxins and waxy degeneration in the viscera may ultimately be induced.
Acentral gummain a long bone may not reveal its presenceuntil it erupts through the shell and reaches the periosteal surface or invades an adjacent joint. Sometimes the first manifestation is a fracture of the bone produced by slight violence.
In radiograms the appearance of syphilitic bones is usually characteristic. When there is hyperostosis and sclerosis, the shaft appears denser and broader than normal, and the contour is uneven or wavy. When there is a central gumma, the shadow is interrupted by a rounded clear area, like that of a chondroma or myeloma, but there is sclerosis round about.
Diagnosis.—The conditions most liable to be mistaken for syphilitic disease of bone are chronic staphylococcal osteomyelitis, tuberculosis, and sarcoma; and the diagnosis is to be made by the history and progress of the disease, the result of examination with the X-rays, and the results of specific tests and treatment.
Treatment.—The general health is to be improved by open air, by nourishing food, and by the administration of cod-liver oil, iron, and arsenic. Anti-syphilitic remedies should be given, and if they are administered before there is any destruction of tissue, the benefit derived from them is usually marked.
Radiograms show the rapid absorption of the new bone both on the surface and in the marrow, and are of value in establishing the therapeutic diagnosis.
In certain cases, and particularly when there are destructive changes in the bone complicated with pyogenic infection, specific remedies have little effect. In cases of persistent or relapsing gummatous disease with ulceration of skin, it is often necessary to remove the diseased soft parts with the sharp spoon and scissors, and to gouge or chisel away the unhealthy bone, on the same lines as in tuberculous disease. When hyperostosis and sclerosis of the bone is attended with severe pain which does not yield to blistering, the periosteum may be incised and the sclerosed bone perforated with a drill or trephine.
Lesions of Bone in Inherited Syphilis.—Craniotabes, in which the flat bones of the skull undergo absorption in patches, was formerly regarded as syphilitic, but it is now known to result from prolonged malnutrition from any cause.Bossing of the skullresulting in the formation of Parrot's nodes is also being withdrawn from the category of syphilitic affections. The lesions in infancy—epiphysitis, bossing of the skull, and craniotabes—have been referred to in the chapter on inherited syphilis.
Epiphysitis or Syphilitic Perichondritis.—The first of these terms is misleading, because the lesion involves the ossifyingjunction and the shaft of the bone, and the epiphysis only indirectly. The young bone is replaced by granulation tissue, so that large clear areas are seen with the X-rays. The symptoms are referred to the joint, because it is there that the muscles are inserted and drag on the perichondrium when movement occurs; swelling is most marked in the vicinity of the joint, and it may be added to by effusion into the synovial cavity. The baby, usually under six months, is noticed to be feverish and fretful and to cry when touched. The mother discovers that the pain is caused by moving a particular limb, usually the arm, as the humerus, radius, and ulna are the bones most commonly affected; the limb, moreover, hangs useless at the side as if paralysed, and the condition was formerly described assyphilitic pseudo-paralysis.
The lesions met with later correspond to those of the tertiary period of the acquired disease, but as they affect bones which are still actively growing, the effects are more striking. Gummatous disease may come and go over periods of many years, with the result that the external appearance and architectural arrangement of a long bone come to be profoundly altered. In the tibia, for example, the shaft is bowed forward in a gentle curve, which is compared to the curve of a sabre—“sabre-blade” deformity (Fig. 132). The diffuse thickening all round the bone obscures the sharp margins so that the bone becomes circular in section and the anterior and mesial edges are blunted, and the comparison to a cucumber is deserved. In some cases the tibia is actually increased in length as well as in girth.