Alexis Thomson and Alexander Miles - Manual of Surgery

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[7] Alexis Thomson, _Edin. Med. Journ._, 1906.

[Illustration: 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.

The _clinical features_ are 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
from _involvement 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.

The _diagnosis_ of 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 bone surrounding it, the pus is not
reached by this procedure, the bone should be drilled in different
directions.

[Illustration: 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 the
_serous_ variety, in which an effusion of serous fluid forms under the
periosteum; and _growth 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 the _staphylococcus albus_, the _streptococcus_, or the
_pneumococcus_ also 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 by _the 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 oedema 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 the disease
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.

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 cloacae (Fig. 122).

[Illustration: FIG. 122.--Tubular Sequestrum resulting from Septic
Osteomyelitis in Amputation Stump.]

Like other pyogenic infections, it may terminate in pyaemia, as a result
of septic phlebitis in the marrow.

The _clinical features_ of osteomyelitis in _an amputation stump_ are
those of ordinary pyogenic infection; the involvement of the bone may be
suspected from the clinical course, the absence of 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.

[Illustration: 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.)]

TUBERCULOUS DISEASE

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 tuberculosis# is 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; in
_syphilis_ the shadow of the bone is denser as a result of sclerosis,
and there is usually more new bone on the surface--hyperostosis; in
_periosteal sarcoma_ there is greater erosion and consequently greater
irregularity in the contour 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.

The _treatment_ is 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.

#Tuberculous Osteomyelitis.#--Tuberculous lesions in the marrow occur as
isolated or as multiple foci of granulation tissue, which replace the
marrow and erode the trabeculae 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."

[Illustration: FIG. 124.--Tuberculous Osteomyelitis of Os Magnum,
excised from a boy aet. 8. Note well-defined caseous focus, with several
minute foci in surrounding marrow.]

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 or sequestra 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.

[Illustration: FIG. 125.--Tuberculous Disease of Child's Tibia,
showing sequestrum in medullary cavity, and increase in girth from
excess of new bone.]

_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 vertebrae, 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).

[Illustration: Fig. 126.--Diffuse Tuberculous Osteomyelitis of Right
Tibia.

(Photograph lent by Sir H. J. Stiles.)]

#Diffuse Tuberculous Osteomyelitis in the shaft of a long bone# is
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
satisfactory _treatment_ is 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 in Fig. 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.

[Illustration: 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.)]

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 the
_calcaneus_ to conserve the stability of the heel. When several bones
and joints are simultaneously affected, and there are sinuses with
mixed infection, amputation is usually indicated, especially in adults.

#Tuberculous dactylitis# is 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.

The _clinical features_ are 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.

[Illustration: 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 than those 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.

[Illustration: FIG. 129.--Shortening of Middle Finger of Adult, the
result of Tuberculous Dactylitis in childhood.]

SYPHILITIC DISEASE

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 periostitis_ is 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, tibiae, or ulnae.
Localised tenderness is elicited on pressure, and there is slight
swelling, which, however, rarely amounts to what may be described as a
_periosteal node_.

In the later stages of acquired syphilis, _gummatous periostitis and
osteomyelitis_ occur, 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 as _syphilitic
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,
diploe, 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
pyaemia. Gummatous disease in the wall of the orbit may cause
displacement of the eye and paralysis of the ocular muscles.

[Illustration: 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.