SYPHILITIC OSTEO-PERIOSTITIS.
By C. G. Moore, '09.Senior Medical Student.
By C. G. Moore, '09.Senior Medical Student.
By C. G. Moore, '09.
Senior Medical Student.
The bony manifestations of syphilis occur as secondary and tertiary lesions, and as Keyes, of New York, has pointed out, these so-called “nodes” are simply local periosteal congestions, accompanied by serious effusions without cell hyperplesia. Any bone in the body may be affected by syphilis, but certain of them suffer by preference, such as the thin bones of the nose and pharynx—that is, those exposed to climatic changes and injuries, such as the bones of the skull, ulna, tibia, etc.
We must call special attention to injury as a powerful pre-disposing cause of bone syphilis, for, when we consider that bone lesions may be the only manifestations of existing syphilis, with the presence of a bone lesion before us, with an antecedent history of an injury, we must not forget that we may overlook the true nature of the disease, and hence must be constantly on the alert for the syphilitic taint.
Lancereaux classified the bone lesions under three heads, viz.:
(a) Inflammatory osteo-periostitis.
(b) Gummy tumor of bone.
(c) Dry caries, atrophic form.
(1) Inflammatory osteo-periostitis is the most frequent form, and is characterized by inflammatory phenomena, vascularization and exudation of a serio-glutinous material. It may be either diffuse or circumscribed, and located, as its name implies, in the area of contact with the osseous and periosteal surfaces. The pain is aching, acute, throbbing or boring in character, while tenderness upon pressure and percussion is most exquisitely excruciating. The diagnosis of inflammatory osteo-periostitis is comparativelyeasy, if we remember the characteristics, viz., an oval, painful, boggy or even hard bony lesion, accompanied by nocturnal exacerbations of pain, with a concomitant or antecedent history of syphilis. Ostitis with parenchymatous thickening is somewhat less positive in its character, but with nocturnal pains which are usually constant.
(2) Gummy tumor of bone develops either under the periostum, in the substance of bone, or in the medullary canal. It is simply an intensification of the process found in the inflammatory form just described, the difference being that the cell hyperplasia is more abundant. Much of the new material collects in a circumscribed space, and being more rapidly formed and less capable of organization, it entails more profound lesions by its retrograde metamorphosis. Generally tumor of the bone is, therefore, a much more serious form of disease than osteo-periostitis.
In the long bones the medullary canal is the usual seat of deposit. The bone becomes hypertrophied in a porous manner, the Haversian canals and canaliculi become enlarged and filled with a gummy material which resembles a solution of gum arabic. In the flat bones, especially the cranial bones, the cancellar tissue is attacked, and may cause a separation of the two tables, and often necrosis of one or the other plates results. If it happens to be the inner one which undergoes carious degeneration, brain symptoms will develop.
(3) Dry Caries.—According to Virchow, dry caries is always due to syphilis. This affection is a miniature gummy ostitis. Around one of the vascular canals the gummy material is deposited, this gummy material being later absorbed, leaving a stellate induration. This goes on leaving a funnel-shaped depression, its point leading into the diploe, which may be plainly appreciated by palpation. The essential features of this caries is the fact that no sequestra are formed, no pus extruded, nor is the skin but rarely involved.
The following is a case of syphilis in which osteo-periostitis developed:
On January 22nd, 1909, R. B., age 35, white, a housewife, applied to the Medical Department of the University Hospital Dispensary for treatment, complaining of rheumatism in her back and a sore shin. The patient has been married 14 years and has had four children; the two eldest are the only ones now living. Three years ago she gave birth to a full-term child which only lived a few minutes after expulsion.
One year later she gave birth to another child, which was not at full term, but about six months advanced. She says two days previous to this birth she fell down stairs and struck on her abdomen. When the child was born its thigh was fractured, and the physician who attended her said the fracture was caused by the fall.
Her father died nine years ago, at the age of 68 years, of apoplexy; her mother was killed a few years ago in an accident. She has two brothers and three sisters, all living and in good health, as far as she knows. She is at present living with her husband, and says he is apparently well and sound, but drinks heavily, and when under the influence of liquor abuses her a great deal. Patient denies ever having had tuberculosis, syphilis, diphtheria, typhoid, scarlet fever, malaria, grippe, gonorrhoea, or any of the nervous or malignant diseases. She sometimes has a sore throat when she takes cold, but it only lasts a few days. She has complained of rheumatism in her back and limbs for the past three or four years, and thinks it is worse at night.
Patient never complained of any trouble other than those mentioned until three years ago, when her third child was born. She says that at that time her hair fell out, and an eruption, which itched slightly, broke out all over her body, including her face, but only extended down her arms as far as her wrists. This lasted a few weeks, then seemed to subside, but never entirely disappeared, and when she gave birth to the still-born child, one year later, it broke out again worse than before. She went to Dr. McElfresh, who treated her for about three weeks, giving her some medicine to take internally, also some sulphur ointment. She for a time got some better, but owing to her circumstances was unable to continue treatment with Dr. McElfresh, and has done nothing for her condition until the present time. For the past four months she has been suffering with a pain in her right shin; this has been gradually getting worse, and one week ago began to swell and cause her considerable pain, being worse at night, and sometimes hurting her so much that she is unable to sleep, hence her reason for coming to the dispensary.
Upon questioning her in regard to her general health, she says she feels as well as she ever did, with the exception of the previously mentioned pain.
Her appetite and digestion are good, and her bowels are regular, and she has no lung, heart or kidney trouble. She has had no headaches, nausea, or vomiting, and her menstrual periods have always been regular and painless.
Upon examining patient I found her to be well nourished and well developed, weighing 142 pounds. Her color was good and her pupils about normal in size, reacting to light and accommodation. Both patella reflexes were absent, also Romberg's sign, and there was no enlargement of the mastoid, epitrochlear, post-cervical or inguinal glands. Her pulse was 84 to the minute, regular in rate and force. The tension and volume was good; her temperature was 98.6°. Her heart was normal in size, and on auscultation the sounds were clear and no murmurs were heard. The expansion of both lungs was good, the respirations being 20 to the minute.
Percussion and auscultation were negative; all the abdominal organs seemed to be normal. There was an ecchymotic area under her left eye, which she says was caused by her husband striking her two years ago when intoxicated.
There was a circular reddish macular papular, non-itching eruption which does not disappear on pressure, varying from the size of a bird shot to that of a nickel, and is confined to her back, chest, shoulders and arms, most profuse on the left side, and is not seen on the lower limbs at all. On her left shoulder some of these lesions have developed into pustules, which have become infected and slightly ulcerated; these give her slight pain.
In the corner of her mouth is a scar which looks like the initial sign of lues, but she claims it appeared a few weeks after the breaking out on her body. On examining her mouth no mucus patches or scars were found.
She now has an osteo-periostitis on the anterior aspect of her right tibia. It is moderately swollen, slightly reddened, and is very painful (the pain is aching, acute and boring in character) on pressure, and on tapping the bone with my finger above and below this point it caused her intense pain. (Patient claims she has never received any injury in this location.)
Upon consulting Dr. McElfresh, he remembered the case and said that he had treated her for a short time about two years ago for the initial symptoms of syphilis, but since then has never seen her.
She is now receiving the mixed treatment of protiodid of mercury, gr. ¼, with a saturated solution of potassium iodid three times a day, starting her on ten drops, then increasing it one drop each time taken. I requested her to return when the medicine is finished.