The principles and practice of modern surgery

At the outset of a study of surgical diseases of the osseous system it is necessary to emphasize a fact which students and young practitioners are liable to forget, namely, that bone, even the densest, is a tissue, and that as such it is liable to infection, suppuration, gangrene, etc., just as is any other tissue; that all infectious processes are identical in general character, their gross manifestations varying only by virtue of the peculiar characteristics of the tissue in which the infection occurs. Bone is vascular, and even that exceedingly hard variety, which is met with in the petrous portion of the temporal, or the ivory exostosis, has sufficient connection with the vascular system to permit of its proper nutrition. The firmest and hardest bone will bleed when divided or injured, and any tissue which will thus bleed can react injuriously to various irritants.

All bone-marrow begins as red marrow, with 1 or 2 per cent. of fat, and ends by becoming yellow, with 60 or 70 per cent. of fat, and whether this change shall take place suddenly or rapidly depends upon diverse conditions. Many years ago it was claimed by Bourgery that bone is simply a large cavernous arrangement where stagnation of the blood current favors the deposition of fat. Fatty alteration progresses from periphery to centre, and the bones of the hands and feet undergo fatty alterations before those of the trunk and pelvis. In other words, the truncal skeleton remains as “red bone” longer than the balance of the osseous system, and he whose sternum has become a “yellow bone” should have reached a ripe old age. In long bones distal extremities first become fatty. Individual peculiarities seem to govern these changes. Thus the neck of the femur will sometimes be fatty and friable at the fortieth year, or reasonably firm and still red at the eightieth. This fatty condition is not to be confounded with true osteoporosis or rarefaction in bone, though it is often associated with it. When the two conditions are combined we have osteoporosis adiposa. Into this condition immobilized limbs pass more easily than those which are used. Their weeks have been equal to years of ordinary inactivity. Red bone seems to be too highly vascular to be a favorite site for tubercle, and distinctly yellow bone too non-vascular. Consequently bone tuberculosis is less often seen at the extremes of life. White bone, as those who make anatomical preparations call it, is most favorable for tuberculous infection on account of its minimum contents of blood and fat. These bones come from phthisical subjects.

ACUTE OSTEOMYELITIS.

This condition was never accurately recognized until described by Chassaignac, in 1853, and even he missed many of its distinctive features, although he gave to it a most descriptive name, “typhus of the limbs.”

Pathology.

—The disease is a distinctly infectious process, limited sometimes to the bone-marrow and internal portion of the bone, sometimes apparently involving every particle of the osseous structure. Its onset is sudden, its manifestations acute and serious, and its ravages, when not promptly checked, most extensive. The following more or less distinct varieties may be distinguished:

• The staphylococcus;
• The streptococcus;
• The pneumococcus;
• The tuberculous;
• Miscellaneous infections, including the colon bacillus, the typhoid bacillus, etc.

It is known that the virulence of cocci growing under pressure is thereby much enhanced; hence the extreme rapidity of some of these disease processes may be thereby better explained.

The mechanism of the infection and the lesions produced by the organism are essentially similar, and may be described together. These consist of rapid thrombosis, coagulation necrosis, and suppuration, along with the local destruction incident thereto, and with unlimited possibilities in the way of auto-intoxication from the local lesions and from the disturbance of the general economy and interference with excretion. Every severe case is accompanied by more or less of general septic intoxication, presumably from the ptomaine produced by the bacteria, while in many instances, particularly those where the bacteria at fault seem extremely virulent, the intoxication is overwhelming and the course a rapidly fatal one. Death has been known to follow within thirty-six hours after the first symptom of an acute osteomyelitis. For the average case three more or less distinct stages can usually be distinguished: first, a period of purulent infiltration, with the formation of local foci in the bone-marrow and speedy secondary involvement of the periosteum and synovial membrane; second, a period of sequestration or formation of a sequestratrum inside of an abscess cavity; third, the stage of repair.

First Stage.

—During this period there occurs violent inflammatory infiltration, localized areas becoming at first hyperemic, then infiltrated with hemorrhagic exudate, whose rapidity of production will indicate the intensity of the infection. Often at the same time are found enlargement of the spleen and hemorrhagic exudations in distant serous cavities, such as the pleura and pericardium. The locally infected areas of bone-marrow break down into collections of pus, which spread either toward the epiphyseal line or else along the Haversian canals toward the periosteum, which becomes both infiltrated and loosened. The loosening is particularly marked about the shafts rather than the joint ends, while, as a rule, that end of the bone toward which the nutrient artery is directed is the one whose epiphyses are first loosened. Nevertheless about the knee it would seem as though the lower end of the femur and upper end of the tibia are the particularly predisposed localities.

In many instances obliteration of nutrient vessels and thrombosis are early features. The area of separation of the periosteum is usually an index of the extent of deep destruction. From the periosteum the infection may extend toward the covering of the soft parts, in which case there may be a parosteal abscess, or it may perforate toward the joint cavity, leading quickly to pyarthrosis and destruction of joint structures. It would appear in children, particularly, that the epiphyseal cartilage often forms a barrier to the advancement of the lesion in the direction of the joint, and thus it happens that we have acute necrosis of the shaft of a long bone, with perforation through the periosteum at both of its ends. In adults this takes place less often, the joint ends being often primarily involved. Softening and separation of cartilages are usually secondary to the other processes. It is possible even to have the primary infection in the joint end proper, and extension therefrom to the epiphyses permitting of epiphyseal separation and extrusion of this fragment as a sequestrum. This separation occurs in many instances rapidly and before the attendant is aware of what has happened.

Second Stage.

—The second stage includes, coincidently with the occurrence of suppuration, the proliferation of considerable granulation tissue, by which more or less protection is afforded; also, when time is afforded, the rapid formation of new bone, whose effect is to wall off the scene of conflict and death from the surrounding tissue, by which event prognosis, so far as the patient’s life is concerned, is improved. Intra-osseous abscesses may quickly coalesce, and the result may be one long tubular abscess extending through the shaft. At other times both bone-marrow and the cancellous tissue are bathed in pus, while if the periosteum have been totally separated the consequence will be a sequestrum whose dimensions correspond with those of the shaft. When periosteum is not loosened the necrosis will probably be central and more or less circumscribed. (See Plate XXXV.)

Third Stage.

—The third stage is the period of efforts at spontaneous repair. There is a natural effort toward elimination of the sequestrum by the process of softening or liquefaction in the direction of least resistance. This process may extend over months, when surgical relief has been delayed, and may be accompanied by so much other disturbance as to completely ruin a bone or limb for further use. In neglected cases several sinuses may lead down toward the central sequestrum. On the other hand, once this sequestrum of eliminated an extraordinary amount of activity is usually displayed in the direction of repair (Fig. 224).

Symptoms.

—In a general way the signs and symptoms of acute infectious lesions in bone are strikingly similar, and are significant when construed aright. Patients complain usually first of exhaustion, followed by pain, which may become agonizing. This is often accompanied by an introductory chill with high fever, after which the general character of the disease assumes the typhoid aspect. Evening temperature may rise high and be followed by some morning remission. The spleen is usually enlarged, the primæ viæ disturbed, and often we have to do with a fetid diarrhea. In the young the sensorium is early affected and children soon become delirious. The pain, at first vague, quickly focuses in the particular bone or bones most involved, and as it increases in intensity there is a significant tenderness. Ordinarily there appear early reddening and swelling of the affected parts. With all these evidences there is also a characteristic muscle spasm, by which certain posture signs will be produced, varying with the bone involved. Pain is always intensified by the slightest degree of disturbance. In consequence the limbs (for it is the limbs which are usually involved) are contracted, and every effort to overcome the contractures is followed by aggravated pain. The more acute the pain the more vivid the external evidences of inflammation and the edema of the parts, especially below and about the lesion. Thus it may happen that within forty-eight hours there may be swelling and edema of the part involved, which should be regarded as pathognomonic.

A little later, superadded to the other signs of inflammation, there is fluctuation if parosteal abscesses have formed, or possibly the evidences of epiphyseal loosening or complete separation. When the disease is primary in an epiphysis the corresponding joint will be early involved, and the joint symptoms will assume the type of an acute purulent synovitis, but with more pain. It is probable that under few circumstances is complaint of pain more serious or aggravating than in cases of acute osteomyelitis of the fulminating type.

So far only local symptoms have been described. To these there should be added the list of those pertaining to thrombosis and metastatic infection, with their septic and disastrous consequences. The disease is frequently so acute and rapid that even within the first day or two not only are added extensive thrombosis in and along the bones, with rapid purulent degeneration and thrombi, but soon that even more serious general condition to which these lesions so easily give rise—i. e., unmistakable pyemia.

The general symptoms are common to the disease, no matter what bone be involved. Local symptoms will change in accordance with their location. While not so common, the flat bones, like the pelvis, cranium, and sternum, may be involved in active manifestations of this disease. The same is true even of the vertebræ, but, as a rule, it is in the long bones of the extremities that its ravages are most frequently seen.

Prognosis.

—The prognosis depends upon the early recognition of the disease and prompt surgical relief. There is perhaps no disease less amenable to purely medicinal treatment, and if bones are to be saved in their entirety early and free incision is called for. Consequently when the case is seen late it almost invariably entails necrosis, with more or less disturbance of function, or possibly such a serious condition as to call for amputation. The fulminant cases when not early recognized and promptly operated often prove fatal, and death has been known to follow within thirty-six hours after the onset of the first symptom, the fatal result being due to overwhelming septic infection, with thrombosis, etc. Almost every case, however, if seen sufficiently early can be saved.

Complications.

—The complications are to be divided into the constitutional and the local. The former refer rather to the spread of septic infection and its more or less disastrous and remote ravages. Metastatic infections may produce serious or fatal complications, while, when less acute, important functions may suffer a serious impairment. Among the local sequels are to be considered mainly the results of destruction of bone tissue and neighboring joint structures. When the disease occurs in young and rapidly growing children partial or complete arrest of development in the bone involved is not infrequent. This may lead to inequalities in length of the femora or humeri. It may lead also to compensatory hypertrophy of bone, with perhaps considerable distortion during subsequent growth.

An entirely distinct consequence of osteomyelitis is bone abscess, in which the acuteness of symptoms has long since subsided, but in which a distinct local focus remains.

Etiology.

—The disease is an infection from the beginning, but the source of the infection is not always easy to trace. Two distinct causes seem to conspire to produce the majority of these bone infections—microörganisms of more than ordinary virulence, and a predisposing condition of the system, due sometimes to constitutional weakness or inherited taint, or to the results of exposure and fatigue. The causes of suppuration have been discussed in Chapter III. It is a fact, however, that the majority of cases occur in children and after a combination of exposure and fatigue—as, for instance, sitting upon the ice after being exhausted by skating—all of which would be inoperative to produce an infection were not the germs at hand ready to assail every tissue whose resistance is thus temporarily lowered.

The infection may occur from within or from without—from within perhaps through the alimentary canal or the respiratory tract, probably from the tonsils and the pharynx. Infection from without may occur through an abrasion or scratch, a blister upon the foot made by an ill-fitting shoe or by a skate-strap. These cases occur generally in the young, more often in boys than in girls, probably because in the former more opportunities for infection are permitted. Bone infections, however, are possible even in the newborn, in which case the infection may occur through the pharynx or through the umbilicus, while the local resistance may have been lowered by the injury due to mechanical delivery, turning, etc. In elderly people the disease is almost unknown.

Diagnosis.

—The disease for which this is most commonly mistaken is acute rheumatism. There may have been some excuse for this in the past because of the lack of general knowledge of bone infections; now there is none. The majority of cases of necrosis following osteomyelitis which have come under the writer’s observation were the result of errors in diagnosis.

Rheumatism is never followed by suppuration and seldom produces a septic type of disease; its painful lesions are rarely so painful as those due to osteomyelitis. Lesions of rheumatism are usually multiple; those of bone infection are mostly single. The first complaint of pain in the latter is generally along the shaft of a bone than at the joint end, while this is not true of rheumatism. Moreover in acute osteomyelitis the disease assumes from the outset a seriousness which is seldom approximated by acute inflammatory rheumatism.

Treatment.

—The treatment for acute osteomyelitis is essentially surgical. Anodynes may be necessary for relief of pain, but no time should be lost, when once the diagnosis is made, in making incisions to expose the bone involved, and then opening to its interior to relieve tension and to remove septic products. The incision over the femur or tibia, for instance, may be ten or twelve inches in length. The tissues will invariably be found edematous or infiltrated, with evidence of the proximity of pus; the periosteum will be thickened and infected, and between it and the bone, as well as outside of it, there may be collections of pus. If seen late the characteristic muscle appearances already described may be noted. The periosteum should be incised to the bone throughout the length of the incision, and then an ordinary bone drill may be used to perforate the bone for exploratory purposes. From the punctures in the bone thus involved will exude purulent fluid, often sanious, thus indicating the condition within. A deep groove or channel should now be cut, opening into the marrow cavity, in which numerous foci will be found, or in which all distinctive structure of bone-marrow may be lost, the cavity being filled with pus. The pus cavity should be scraped and disinfected with hydrogen peroxide and cauterized with zinc chloride or its equivalent, and then packed, the wound being left open. Even this may not be sufficient, but if there be epiphyseal separation, or evidences of joint infection, the neighboring joints should be explored under aseptic precautions; if pus be found they should be opened, washed out, and drained. Meanwhile if in the soft tissues exposed by the incision the parosteal veins are found filled with septic thrombi, they should be opened as far as exposed and their contents removed.

These operations are often severe, but nothing in the way of operative treatment can be so severe nor so serious as the disease itself when left unoperated; the rule is stringent that every infected tissue, and especially every infected bone interior, should be exposed and cleaned out. Only in this way can lives be saved. Moreover, it is necessary to carry out this treatment in the fulminant cases as early as possible; and errors in diagnosis by which it may be postponed until metastatic infection or grave pulmonary and cardiac complications have set in are unfortunate. So long as the local indications are as above described, surgical treatment is desirable, whether the systemic complications are pronounced or not. The immediate effect of the operation having passed the relief thus afforded will often be so pronounced that within twenty-four hours patients may be out of danger.

The results of this operation are a wound which will discharge at first freely, and which so soon as septic material is out of the way will begin to granulate. Ordinarily no attempt should be made to close such a wound, though much may be done to favor rapidity of granulation. While some antiseptic dressing is always employed, it will be of advantage occasionally to change the character of the same, and to alternate between various antiseptics, the effect of any one drug being apparently lost after it has been used for some time.

There are some cases where an entire diaphysis or bone shaft will be found separated from one or both epiphyseal terminations, lying in a subperiosteal abscess cavity, bathed in pus, and dead beyond possibility of repair. This is total necrosis of the shaft from an acute infectious process, and is to be treated by complete removal of all dead and dying tissue. In the case of the forearm or leg it may be that the remaining bone, when only one is involved, as is usual, will be sufficient to maintain the integrity of the limb until new bone can be reproduced within the periosteal bed occupied by the old one. More or less complete regeneration of bone is possible, particularly in the young, and in connection with compensatory hypertrophy of the parallel bone will permit the restoration of the leg to partial or complete usefulness. On the other hand, should this later prove a complete failure, amputation and substitution of an artificial limb may be required.

When the disease has involved the articular side of an epiphyseal line, and when there is complete epiphyseal separation with consequent pyarthrosis, the probable consequence will be necessity for a complete or partial resection of the joint and the probability of subsequent ankylosis. Patients may find later that a modern artificial limb with its possibilities will be preferable to such a condition, and may readily consent later to an amputation which they would at first refuse.

Acute Infectious Periostitis.

—This is an infection of the same general character and type as the osteomyelitis just described, but refers to those cases where the disease apparently is confined to the periosteum and the outermost layer of the bone. In its possibilities for harm it is scarcely less serious, although in its tendency to spontaneous perforation and escape of pus it is less likely to prove fatal.

Causes.

—The causes and the general clinical manifestations are practically identical. The disease is perhaps less grave in its acute manifestations, the localization of pain more exact, with ordinarily less tendency to joint complications. Local tenderness is exquisite, and particularly in those bones which lie near the surface—e. g., the tibia—and early recognition of fluctuating areas is easy. It may be localized over a small area, or the entire periosteum of the shaft may be involved; in which case, so soon as pus forms and the periosteum is separated from the bone, there is probability of acute necrosis of the shaft. Here, again, there may be a tendency to mistake at least the first signs of the disease for acute rheumatism, from which it must necessarily be early differentiated as above.

Treatment.

—Here also there is the same necessity for immediate intervention, if possible before pus be formed, in order that there may be little or no periosteal separation and encouragement to necrosis. Anesthesia is necessary, with prompt incision, the use of the sharp spoon, and disinfecting agents: no attempt should be made to close the wound, but drainage should be favored in every way. The intensity of the pain is promptly relieved and the whole clinical picture immediately changed by such a procedure.

The ordinary bone felon upon a terminal phalanx is practically an expression of this type of disease, and experience corroborates the wisdom of deep and early incision, even in the case of so small a bone entity as a phalanx.

Acute Epiphysitis.

—This is a term applied rather indiscriminately to a form of acute osteomyelitis involving primarily and especially the epiphyseal lines, or to a condition of hyperemia and neurovascular excitement at epiphyseal junctions stopping short of suppuration, but giving rise to intense pain, muscle contraction, joint tenderness, etc. It is often seen at the upper end of the tibia. Sympathetic disturbance may extend even to serous effusion into a joint, although this is not necessarily the case. The limbs are early drawn up, and every attempt to extend them simply aggravates the distress. So long as there are no evidences of suppuration, it is sufficient in these cases to apply a sufficient degree of traction to overcome muscular contracture and to straighten the limbs. This should be applied first under anesthesia, and the patient kept under anodynes for a few hours thereafter. So soon, however, as the muscles are tired out by the steady traction, pain subsides, and the intensity of the condition may be thus relieved within forty-eight hours or less. It would be well to continue physiological rest and traction as long as there remains the slightest tenderness. Should evidences of suppuration at any time supervene, incision and evacuation of pus and exudate should be practised. Should epiphysitis occur in one of two parallel bones, there may result such failure of growth of that bone as shall cause marked deformity in the attacked hand or foot. In some of these cases, should operation be required on one bone, the other may be shortened at the time, or later, by exsection of a portion of the shaft, or even of the epiphyseal junction.

Periostitis Albuminosa.

—This is a rare manifestation of bone disease, only given an identity of its own since 1868, when Ollier first distinguished it, since which time it has been the subject of considerable controversy. The name refers to a condition less acute than the infectious periostitis just described, almost always localized in a single bone, necessitating incision and evacuation of a fluid which is gelatinous or mucoid in appearance rather than purulent. It is because of the peculiarity of the subperiosteal collection of fluid that it received the name periostitis albuminosa, and it was not generally regarded until recently as a variety of the infectious form of periostitis. It is, however, now conceded as being a mitigated form of infection, in which the products of exudation assume the serous rather than the purulent type. In some instances it appears to be the tubercle bacilli which are at fault. At all events, the organisms which produce the disease are more or less virulent, else the clinical form of the disease would be less serious than it really is. Cultures made from these subperiosteal collections have in almost all recent instances revealed the presence of some one of the numerous pyogenic organisms. Quite recently Dor has described a polymorphic microbe, in instances of this kind, which he has called the Bacillus cereus citreus, with which he claims to have been able to reproduce the disease in animals.

Chronic and Latent Osteomyelitis.

—As in the lungs, however, chronic lesions are met with, and as in the lungs, again, it is possible for collections of microörganisms to become more or less encapsulated and for a long time to lie latent until some provoking cause excites them again into activity. In this way are to be explained the numerous instances of recurring abscesses within the bone necessitating repeated operations, often at long intervals. (See Plate XXXVI.)

Possible Consequences of Any and All of the Bone Infections.

—Bone is a living tissue, calcified and stiffened by inorganic material for the purpose of giving it strength; it may suffer remotely from the consequences of local infections, the same as other tissue. Thus it may have its nutrition impaired so as to produce atrophy on one hand, or increased so as to lead on the other to hypertrophy, either regular or irregular in outline. Again in its texture it may be altered to a wide extent between the sponginess or porosity on one side (osteoporosis), or to the density attained by ivory (osteosclerosis) on the other. Similar changes are also noted in cases of bone tuberculosis, which is to be considered by itself. The densest bone has sufficient vitality to permit its nutrition and life, and may assume dimensions much larger than that of the original, and a hardness which will defy the best steel instruments should it become necessary to operate upon it. The other extreme of osteoporosis includes a condition where the bone has barely sufficient inorganic material to permit it to retain its shape and ordinary proportions. Such bone is fragile in the extreme and scarcely serviceable as a supporting tissue. The principal portion of its bulk is constituted by marrow tissue, which makes it extremely vascular, but far from strong. When spongy it is ordinarily unserviceable for its proper function. Astonishing pictures of osteosclerosis and osteoporosis side by side are present in many instances of disease, the latter being often evidence of more or less ossification of new-formed granulation tissue. This is often a happy combination, because the bone, which has been sadly weakened by disappearance of its calcareous material by liquefaction and by absorption, is reinforced along some of its lines by a pillar of osteosclerotic tissue, by means of which it still functionates as a more or less useful support (Fig. 226).

The operating surgeon should familiarize himself with the density of normal bone in various locations, as in many operations upon the deeper bones he detects healthy bone rather by the sense of touch and of hearing, and the resistance which it offers to his instruments, than by sense of sight.

TUBERCULOSIS OF BONE.

In Chapter IX, on Tuberculosis in general, we entered into considerable detail in regard to the nature of tuberculous lesions, which were stated to be essentially the same whether occurring in hard or soft tissue, the active agent being the now well-known Bacillus tuberculosis, which, finding lodgement, for instance, in the osseous tissue, acts as a specific irritant, and so provokes the production, first, of a typical tubercle, and, later, of typical granulation tissue, by whose ravages the distinctive signs of bone tuberculosis are produced. This process, then, is in no respect different in bones from similar lesions in other parts, though modified to a slight extent pathologically, to a greater extent clinically, by the dense environment. Nevertheless, trifling or most extensive destruction of bone substance is produced by this tissue, while by continuity or by metastasis there is more or less involvement of the adjoining textures, either parosteal or articular. It is by granulation tissue that so-called caries is produced, and it is by the same tissue that distinct portions of bone are sometimes completely segregated from their vascular surroundings and shut off from nutrition, so that they die and form what are known as sequestra. Necrosis may then be the result of tuberculous disease.

So long as the process is active, this granulation tissue tends to enlarge its boundaries, and, like pus, to spread in the direction of least resistance. When produced in the shaft of a long bone this may lead to involvement of the entire shaft, or there may be liquefaction and absorption of dense bone and the formation of a sinus from the marrow cavity to the periosteum, beneath which the granulation tissue will spread, and through which it will sooner or later perforate, to resume its progress toward the surface, always in the direction of least resistance. In this progress tendon sheaths or bursæ may be involved, or dense aponeuroses may turn the granulation column aside, causing it to perforate toward the surface at some remote point; while it may spread out more or less beneath the skin before finally causing its destruction. Sooner or later, if uninterrupted by treatment, this escape will occur, and then we have the condition of a tuberculous ulcer of the skin, from which leads down, by a devious path, a sinus toward the original focus.

When this original focus has been juxta-epiphyseal there is involvement of the epiphyseal cartilage and a pathological diastasis, which may early lead to spontaneous or pathological luxation. Or, again, a focus having once originated at an epiphyseal extremity, tends usually to perforate quickly into a joint cavity, after which a considerable length of time is usually expended in filling up this joint cavity with exuberant granulation tissue. This is the material so often found in tuberculous joints, and is well characterized by the name given to it by the Germans, fungous tissue, they calling such joint affections fungous joint inflammations. (See previous chapter.)

Seen thus in joints, after it has been long exposed to friction and to more or less pressure, it may have lost some of its original luxuriant features. It is best seen when it is freshest and has been exposed to least disturbance. Under these circumstances it is vascular, dark red in appearance, friable, and easily removed from the tissue upon which it has grown. Ordinarily it is infectious, and by its inoculation into animals is capable of reproducing the disease.

Pathology.

—The pathology of tuberculosis of bone may then be virtually summed up in saying that it consists of the ravages produced by the presence of this granulation tissue, with the irritative hyperplasia of surrounding tissues which its presence always excites, even though they be not actively infected. This is the explanation for the majority of cases of caries, of tumor albus, of Pott’s disease, of spina ventosa, and of the condition which has been known under many other names.

Varieties.

Acute Miliary Tuberculosis of Bone.

—This corresponds to a similar invasion of the lungs. It might be fittingly described as an acute tuberculous form of osteomyelitis. It may run its destructive course within a short time and cause such involvement of structures as to necessitate amputation of a limb, or it may appear in the truncal skeleton as a primary disease, spreading rapidly therefrom and involving the viscera or the cerebrospinal membranes, and causing an early death, perhaps within a few weeks after its onset. This condition has been more prevalent than is generally understood, and has not even yet received the attention it deserves. It is less painful than the pyogenic forms of osteomyelitis, and may assume less of the septic and more of the typhoid or meningeal type of disease. The pain also may be less severe, though reflex symptoms, especially muscle spasm, will be an early and marked feature of these cases. When a limb is involved the case may not be hopeless; but when involving the cranium, spine, or trunk it is fatal, and little can be accomplished by treatment. The operative treatment for parts which are accessible is given under Acute Osteomyelitis.

Chronic Tuberculous Osteomyelitis.

—This is the ordinary form of the disease, and is exceedingly common. In some sections it constitutes nearly one-third of the diseases necessitating surgical treatment in clinics and hospitals. This is particularly so in the thickly settled portions of the European continent. In Buffalo it constitutes from 15 to 20 per cent. of cases found in my wards and in my clinic. The proportion some years has been larger.

Symptoms.

—The essential symptoms of bone tuberculosis are muscle atrophy, muscle spasm and pain, direct or referred, and upon the existence of these, coupled with local tenderness and local swelling, a diagnosis can almost always be made. Muscle atrophy is distinct, and is not alone that of disuse, but is a distinctive evidence of the tuberculous process. It involves the parts above and below the lesions.

Muscle spasm is never lacking, but is most noticeable about the spine and the joints of the extremities. In Pott’s disease, for instance, the condition causes a stiffening of the back and an inflexibility of the spine. About the joints it leads gradually to fixation, usually in the condition of more or less flexion, the flexor muscles being ordinarily stronger than the extensors in all parts of the body. Thus we see the knee and the elbow drawn up, and most other joints in a condition of flexion so far as it may be permitted.

It is characteristic also that muscle spasm is frequently exaggerated, usually in a reflex way, by which pain is always augmented. These sudden but brief contractures occur more often during sleep than during the waking hours, and give rise to the so-called starting pains, usually nocturnal, which are noted in nearly every case of this kind.

The pain is in large measure the result of contracted muscles pulling tender joint surfaces together, and is consequently augmented during the muscle spasms just described to an extent causing the patient to cry out even during sleep. There is also usually a more or less deep-seated and constant pain or soreness, manifested in increasing degree as the lesion advances. These pains are also often referred, lesions in the upper ends of long bones usually giving rise to pain which patients refer to the lower ends. In hip-joint disease pain is often referred to the knee, and in Pott’s disease to the anterior part of the trunk. Slight but slowly increasing disturbance of function of a joint inaugurated by trifling muscle spasm, with complaint of aching pain, is significant and needs careful examination, it being a mistake to anesthetize patients for this purpose, as by the anesthetic the pathognomonic muscle spasm is abolished and mistakes in diagnosis favored.

It will be seen that these features are also met with in tuberculous-joint disease, the fact being the conditions are not only allied but often associated.

Treatment.

—The treatment of tuberculosis of bone is constitutional and local. The former consists in the best possible hygiene and in those measures which are everywhere recognized as helpful in similar conditions. I believe in the internal use of benzosol, or its equivalents, in doses sufficiently large to influence the tissues. In addition the tonics and evacuants should be judiciously used. But it is mainly with local treatment that we shall here have to deal.

The local treatment may be divided into the non-operative and the operative. The former consists in enforcing the general principles of physiological rest, which is done partly by orthopedic apparatus proper and partly by the general principles of traction, and is resorted to mainly in a class of cases treated of under Orthopedic Surgery, the best methods for the purpose, apparatus, etc., being found in the next chapter.

Aside from this a hopeful method has been that suggested by Bier, consisting of making an artificial chronic congestion, it having been long known that tubercles do not thrive when bathed in much blood. The congestion is secured by wearing an elastic bandage above the point involved, elastic constriction being made to a degree as great as may be comfortably borne. The result is venous congestion, possibly edema of the parts below, which to be made effective should be carried nearly to the tolerable extreme. Constriction may be at first enforced for only a short time, but can be later borne for longer periods, until a time is reached when the patient can wear a bandage almost continuously. Marked improvement in many cases follows this method.

The operative treatment consists in ignipuncture, curettage, or formal extirpation. Ignipuncture is the insertion into the bone focus of the glowing point of the thermocautery. It should be practised under an anesthetic, and when the bone is superficial the cautery should be plunged through the skin, making it burn its way into the depth of the bone. This is not difficult when the cancellous tissue is that at fault. If the bone be deep an incision may be made down to it, after which the cautery is applied as above. The result in almost every instance is relief from pain.

This effect seems to be brought about partly by relief of tension, partly by destruction of diseased tissue, and by the acute congestion which is the result of vigorous counterirritation. It need occasion no fear nor difficulty, and is applicable to all accessible bones. It must not be expected to cure every case, but is a measure which may be confidently expected to relieve pain and to do good.

The radical form of treatment is necessary when it can be determined that the carious process is advancing or that pus or caseated deposits are present. This is made known in various ways; but when reasonably sure of their presence it is best to begin the operation as an exploration, going as far as the findings may justify. This may include scraping out of a small focus, or it may entail removal of a large portion of a bone or resection of a joint, or even amputation, according to the severity of the deep lesion. It is best to do whatever may be necessary, and to do it all at once. The operator should not rest content with mere operative attack, but should carefully disinfect the entire tract, cutting away or removing with the spoon the sinus wall and fungous tissue, which he should follow wherever it may lead, disinfecting freely with hydrogen peroxide or caustic pyrozone, and then using an active caustic, like zinc chloride or the actual cautery, unless caustic pyrozone has already been used. In this way material may be destroyed which has escaped the instruments used, and absorbents are eared or closed and protection afforded. My personal preference is for a packing made of bismuth subiodide gauze, soaked in a mixture of balsam of Peru containing 10 per cent. of guaiacol, which I find more advantageous than anything I have used. There should be added to these measures, however, whatever may be necessary in the way of after-treatment, both local and constitutional, and the surgeon should be prepared to operate once or twice again should latent foci subsequently manifest themselves or should there be recrudescence of the active disease.

BONE ABSCESS.

Bone abscess is a term applied to deep and circumscribed collections of pus within the bone, mainly within the shafts of long bones. They are due either to the acute ravages of pyogenic cocci or to the slower lesions produced by the tubercle bacillus. They are frequently evidences of return of disease in its acute type after a long period of latency. The manifestations are usually localized, in this respect differing from those of acute osteomyelitis. The pain is deep-seated and boring, while there is local tenderness, often with considerable enlargement of the overlying bone. The lesion occurs more often in the tibia than in all of the other bones together—at least under those clinical conditions which entitle it to be called bone abscess. The pain is frequently nocturnal or osteoscopic, and patients may endure it for weeks or months before seeking relief.

The surgeon may always expect to find a layer of condensed, sometimes extremely hard bone around these local foci, and it is due to this that they do not either perforate or diffuse and cause extensive trouble.

Treatment.

—Treatment is always operative; it should consist in anesthesia, exposure of the bone, effective exploration by means of the bone drill, as the hypodermic needle would be used for exploration in the soft parts, and then the free use of the bone chisel or other instruments by which the area may be widely exposed. The density and firmness of the bone under these conditions will sometimes almost defy the best-tempered instruments. Care should be taken to make the external opening nearly the size of the deep focus, in order that the surface may not heal too readily and before the deeper part is filled. The same directions with regard to cauterization and packing the cavity obtain as given before.

SYPHILIS OF BONE.