enlargement which is made more conspicuous by wasting of the limb above
and below. Nevertheless by actual measurement it will usually be found
to have a greater circumference than its fellow of the opposite side.
Its covering skin is pale and often glistening, with prominent veins,
while in proportion to the distention by fluid there will be more or
less distinct fluctuation. When the joint is evidently distended and
does not fluctuate the inference is that it is filled with granulation
tissue. There will also be marked thickening of all the articular
coverings, the synovial membrane itself being often as thick as sole
leather. At points where perforation may threaten there may be dimpling
and retraction of the skin, with fixation and discoloration.
=Symptoms.=--_Tuberculous joint disease is characterized especially by
loss of function, muscle spasm, muscle atrophy, pain and tenderness_
of rather significant character, and the other joint features already
mentioned. _Loss of function_ may be partial or complete. It depends
on the amount of tenderness and the deformity already produced by
muscle spasm. Motility is more or less restricted even under an
anesthetic. This is induced by actual limitation of motion by products
of exudation, by muscle spasm and wasting, and by the involuntary
shrinking of the patient when tender joint surfaces are pressed against
each other.
[Illustration: FIG. 207
Backward displacement of tibia due to the muscle spasm of a tuberculous
knee-joint, with final bony ankylosis. (Lexer.)]
_Muscle spasm_ is one of the most significant features of these cases
as well as almost the earliest. It is of the greatest diagnostic value,
and, if genuine, should never be neglected. It subsides under the use
of an anesthetic, hence it is not advisable to employ anesthetics for
diagnostic purposes. It produces at first fixation, without particular
deformity, but may lead later to this or to pronounced subluxation.
It is most helpful in the early stages when it does not particularly
interfere with a medium range of motion, and seems to lock the joint
before the extreme of motility is reached. Muscle spasm is pronounced
even after muscle atrophy is well advanced, and serves more and more
to fix joints until they are held by adhesions formed within. _Muscle
atrophy_ is also significant and begins about the time when diagnosis
becomes fairly possible, _i. e._, in the early stage of the disease.
With the advance of disease it becomes more pronounced and a joint
which is fixed by intra-articular lesions will stand out prominently
because of the notable wasting of the muscles by which ordinarily it
would be moved. It is this which gives the elbow and knee especially
their spindle shape. (See Plate XXXIV.)
_Pain_ is also a characteristic feature, especially that which is
produced by motion and allayed by rest and that which is accompanied
by involuntary muscle spasm, and occurs during sleep, _i. e._, the
so-called _osteocopic or starting pains of tuberculous panarthritis_.
These occur most distinctively in children, but may be complained of at
any period of life. Children thus affected will cry out sharply during
their sleep and appear for a few seconds very much distressed, and yet
do not awaken sufficiently to recall or describe their sensations.
The explanation of this phenomenon is a sudden reflex spasm of the
muscles by which tender joint surfaces have been suddenly pressed
tightly together and pain thereby provoked. Something of this kind may
occur in syphilitic bone disease, but, taken in connection with the
other signs and symptoms above mentioned, such pains are practically
pathognomonic.
The various measures to which orthopedists and surgeons resort for
employment of traction, by splints or weights, are directed against
overcoming muscle spasm by tiring out the muscles. It must not be
thought that by any reasonable degree of traction joint surfaces are
actually separated widely from each other. All that it is expected to
accomplish is by a steady pull to exhaust the muscles, and prevent them
from thus exercising deleterious pressure by pulling joint surfaces
together.
The pain complained of is by no means necessarily limited to the joint
involved; in fact, some of the most significant pains are those which
are described as _referred_. These furnish illustrations of the fact,
well known to physiologists, that _irritation in the course of a nerve
is referred to its distribution_; thus in hip-joint disease most of
the pain will be centred in the knee, and when the knee is involved
the ankle will be the part to which the patient will refer much of his
discomfort.
There also comes an overuse of the unaffected joints of a limb by which
the diseased joint may be spared as far as possible. The flexors, as
a group, being always stronger than the extensors, the former will
overcome the latter in time, and these joint _contractures are a later
expression of chronic muscle spasm_. This is true even when atrophy is
well advanced.
Tuberculous joint disease usually has at first no particular
constitutional complications. These come on later in proportion as the
general health suffers from the confinement entailed by the disease.
General health will suffer quicker when the lower limb is involved
than when it is the upper. By the time joint lesions are well advanced
careful observation will usually reveal a rise of evening temperature
and progressive anemia. The symptoms included under the term _hectic_
are those belonging to the destructive stage and are due to a
combination of causes in which auto-intoxication figures largely.
=Diagnosis.=--Tuberculous joint disease is usually easy of recognition,
except perhaps in the earliest stages. (See the general subject of
Orthopedic Surgery.) Differential diagnosis between this condition and
syphilis, or between it and hysteria, has occasionally to be made,
and may at first cause some difficulty. An hysterical hip or knee may
so strongly simulate tuberculous disease as to lead one at first into
serious doubt. Again, as between the tuberculous and non-tuberculous
forms of hydrarthrosis, there may often be doubt, even after aspiration
and examination of the fluid. In fact, that which began as one may
terminate as the other. Fortunately in these last cases local treatment
is about the same for each, and, while the question of diagnosis
may never be absolutely satisfactorily decided, the patient may
nevertheless recover in either event.
=Treatment.=--The treatment of tuberculous arthritis should be both
local and general, one being about as important as the other. The
general treatment for this as for every other tuberculous disease may
be summed up as follows: The remedies for tuberculous disease are
_oxygen_ and _hypernutrition_. The best place for the patient is the
place where these means can be procured. As explained above, this
will, to a considerable extent, depend upon the circumstances of the
patient or the family. When it can be afforded a high altitude is
almost as good for joint tuberculosis as for that of the lungs. The
nearest approach that can be made to it will be the most desirable.
Hypernutrition will in some cases consist almost in forced feeding.
Here as elsewhere in tuberculous disease it is of at least theoretical
as well as of practical advantage to saturate the system with some
bactericidal remedy, if such there be, and for obvious reasons.
Creosote or its congeners, in more or less palatable form, seem at
present to best serve this purpose. In addition to this arsenic, iron,
and the iodides, the latter especially if there be any suspicion of
syphilitic complication, can be used to advantage. In proportion as
patients become confined to the house their elimination is usually
restricted. All measures then by which elimination may be improved will
be indicated.
The use of _tuberculin_, or some of its modifications, has been
occasionally followed by excellent results. It is an agent to be
employed with great discretion, but is well worth a trial in those
cases where its effects may be carefully watched.
_Locally_ the most important measure is the enforcement of
_physiological rest_ of the affected parts. This may imply confinement
to bed, especially when the spine, the pelvis, and the hip are
affected, but should be reinforced by mechanical contrivances, by which
traction or “_extension_” may be carried out. The purpose of traction,
as mentioned above, is to overcome muscle spasm and thus ensure rest.
It is effected by many of the orthopedic apparatuses. (See chapter
XXXIII.[32]) It may be enforced by fixed dressings of plaster, etc.
[32] The fundamental idea expressed in all of the methods for
enforcing rest by traction is of American origin, and constitutes
one of the advances in surgery for which the world is indebted
to America. For a long time it was referred to in Germany as the
American method, and yet now the Germans claim so much for it that
one of their surgeons has written a book of 600 pages devoted to the
employment of traction for various surgical purposes, in which but
very little credit is given to the men who originated it.
[Illustration: PLATE XXXIV
Normal Knee-joint. (Child, seven years old.)
Tuberculosis of Knee, with Partial Dislocation.
(Child, seven years old.)]
With a better appreciation of the pathology of the condition numerous
methods were devised by which the germs should be attacked _in loco_.
Thus various antiseptics have been injected in varying strengths,
either into joint cavities or around them. Lannelongue devised a
“sclerotic method,” by which zinc chloride solutions were injected
into the peri-articular tissues, to so condense and harden them as to
imprison and destroy their contained germs. The method, however, is
an extremely painful one and has not found general favor. For a long
time iodoform was employed for the same purpose, in emulsions of 10
per cent. and 20 per cent. strength, in sterilized glycerin or olive
oil. It affords a curious paradox that the iodoform itself must be
sterilized before being thus used. This emulsion has been injected
into the peri-articular tissues or into joint cavities, which, when
containing appreciable amounts of fluid, should be first emptied and
washed out; all of which can be done through the same small trocar used
for introduction of the iodoform. The verdict of surgeons today is
rather against the employment of iodoform, since they have learned to
not rely upon it because of disappointment so often following its use.
Bier, in 1891, advised the so-called _congestion treatment_ of
tuberculous joints, basing it upon the fact that tuberculosis does not
develop in lungs which are the seat of venous stasis from valvular
heart disease. He proposed to produce an artificial stasis, in the
joint structures and about them, by which living germs should be
destroyed and their disease products encapsulated, claiming that as
the result of the hyperemia thus produced the alexins are thus brought
into more complete contact with the bacilli. The method is applicable
to the limbs below the shoulder and hip. It consists in the application
of an Esmarch bandage above the affected joint, applied with sufficient
firmness to obstruct the returning blood, but not to interfere with
the arterial supply. If there be room the limb is also bandaged below
the joint with an ordinary cotton roller. This congestion is kept up
at daily intervals for increasing periods, beginning with perhaps half
an hour and continuing until it is in operation at least half of the
time. Meantime other methods of treatment are not interdicted. In the
earlier stages of tuberculous joint disease this method has given very
encouraging and pleasing results. (See Fig. 208.)
_Tuberculous hydrops_ may be treated by aspiration and elastic
compression. Should fluid distend the joint it should be opened and
thoroughly cleaned, then closed and perhaps drained.
The treatment of _pyarthrosis_ and of _peri-articular cold abscess_
has long been a mooted subject. The orthopedic surgeons still adhere
to mildly or absolutely non-operative measures, whereas the general
surgeon prefers to adopt more radical methods. Each case should be
judged on its own merits, and these should include a careful estimation
of the general condition of the patient. Should evidences of septic
intoxication be present or the ordinary general signs of the presence
of pus, then these collections should be opened and cleaned out. If
hectic can be excluded, then other considerations will indicate what
is best. At all events there will be seen many cases where a delay
in operation will be advisable, in order to permit of improvement of
the general condition by measures above described. To merely open
up a tuberculous focus and leave at least two fresh raw surfaces
exposed to contamination is rather to invite the spread of the
disease than to correctly meet the indication. Every old focus will
be lined or surrounded with a more or less dense membrane formerly
called _pyogenic_, but now more correct knowledge shows it to be
_pyophylactic_. (See p. 113.) To leave this _in situ_ is to leave
germ-laden walls, while to dissect it thoroughly is to make a larger,
fresh raw surface and to open up innumerable absorbent vessels. Thus,
whether it be removed in whole or in part, or allowed to remain, some
sufficiently strong caustic material should be promptly employed, by
which both destruction of living residual germs and closure of the
mouths of the absorbents shall be effected. This has been set forth
more fully when dealing with cold abscesses in general, but is of so
much importance that it may be reiterated here. Whether the actual
cautery, pure carbolic acid, strong zinc chloride solution, or some
other agent be used should depend upon circumstances, but every portion
of the surface which it is proposed to leave more or less exposed to
the possibility of infection should be thus protected. In proportion
to the intensity of the caustic action there will be separation of
more or less cauterized and sloughing material, for whose escape
provision should be made; but it will be separated by the granulation
process, aided by an active phagocytosis, and when removed will leave
a granulating surface which is but slightly absorbent. These facts
pertain to small incisions for drainage as well as to extensive
arthrectomies.
_The operative treatment_, then, of tuberculous arthritis varies
from tapping, with or without drainage, to complete arthrectomy or
amputation. When the joints of the foot or ankle are extensively
diseased, and the patient, as usually happens, is in poor condition, it
may appear that amputation will afford the most complete relief, and
that a stump with an artificial member will be of much more use to the
individual than a mutilated, tender, and disabled foot.
[Illustration: FIG. 208
Calcified mass in old “cold abscess” about hip-joint. (Buffalo Clinic.
Skiagram by Dr. Plummer.)]
To incision with or without drainage is given the name _arthrotomy_.
When the joint is widely opened and portions removed with the sharp
spoon or otherwise, it is known as _arthrectomy_. When bone is
removed irregularly the measure is called _atypical resection_. When
entire bone ends are removed the operation becomes an _exsection_ or
_resection_. The ordinary arthrectomy is not sufficient when foci are
present in the epiphyses. Here at least atypical resection is called
for. Arthrectomy may properly include a wide exposure of articular
surfaces and the removal of the thickened and diseased synovia, with
its fringes, or with the cartilages, by which cancellous structure is
more or less widely exposed. When arthrectomy is undertaken it should
be thoroughly made and by a large incision, since the more completely
the joint cavity can be inspected and attacked the better are the
interests of the patient subserved. All fresh or cold abscess cavities
which connect with the joint or lie in contact with it should also be
attacked at the same time, and those which do not communicate with it
should be separately drained. While drainage by tube or other means
will usually suffice, there are cases where the disease is so extensive
that it will pay to pack the cavity with balsam gauze for a few days,
placing secondary sutures by which the incision can be closed after its
removal. In the shoulder and hip, for instance, such a method will give
satisfactory results.
The advantage of avoidance of resection is the non-interference with
the epiphyses and their junctions, thus permitting the growth of the
bone to continue. _Therefore complete and typical excisions should be
practised as seldom as possible, especially in growing children._ They
may be practised to advantage even in advanced age, and the writer
has seen satisfactory results after complete excision of tuberculous
joints in senile cases. When operating upon a tuberculous tarsal joint
the surgeon is likely to find one or more of the tarsal bones so much
involved in the tuberculous disease that he is compelled to scrape it
out and thus leave a cavity almost the size of the bone itself. Should
he have to do this to a series of the bones it would be better to make
a formal resection of the tarsus or possibly an amputation. The cavity
should be left open with a sufficiently large incision so that it may
be easily packed. A cavity of this kind left unpacked will fill up
with clot, which will disintegrate and the result will be much less
satisfactory. In the former case there is an open cavity which fills
with granulations, but this can be kept accessible under observation
and with more effect and comfort. This is equally true of those
cavities where both arthrectomy and bone curettage have been practised.
MOVABLE BODIES IN THE JOINTS.
Several different terms have been applied to loose and movable bodies,
even in the various joints, depending on their size, arrangement,
and appearance. Thus we have the _rice-grain_ or _melon-seed bodies
(corpora oryzoidea)_, which have already been described and are
now supposed to indicate a form of tuberculous synovitis which has
undergone a partial if not complete subsidence. Again we have larger
masses occurring singly or in very small number, especially in the
knee, to which the Germans have given the significant name of _joint
mice_. Also in the knee, owing to its peculiar construction, another
form of movable body is met with, _i. e._, a displaced and more or
less _motile semilunar cartilage_. This condition was first described
by Hey, and especially studied by Allingham, who made it a prominent
feature of what he described as “internal derangement of the knee.”
Lastly, in those joints in which _synovial fringes_ occur, the knee
especially, it is held that portions may become detached by having
been infiltrated and cast off or broken loose, and thus form a fourth
variety of floating body. The joints most often affected are the
knee and the elbow. In many instances there is a history of injury,
especially when the mass is of considerable size. The theory of an
“osteochondritis dissecans” has also been invoked to account for the
resemblance between some of these bodies and the articular cartilages.
Some pathologists have held that they may result from the organization
of clots, which are subsequently rounded off and shaped by attrition
(Fig. 209). These bodies then may consist of condensed fibrinous
material, of cartilage, of true bone, or of hyperplastic and fatty
synovial tassels. To these may be added rare instances of mucoid
connective tissue.
[Illustration: FIG. 209
Floating bodies--“joint mice”--from knee-joint. (Lexer.)]
=Symptoms.=--_Rice-grain bodies_ may be suspected in cases of chronic
tuberculosis and often in arthritis deformans, while in many instances
they may be felt gliding beneath or between the joint structures. A
perfectly loose _floating body_ will produce symptoms which are quite
distinctive. They consist of sudden and intense pain, with such muscle
spasm as to fix the joint and prevent its use, thus “locking it.”
Occurring at the knee the individual is instantly disabled, but usually
learns by some peculiar manipulation, with or without assistance, to
“unlock” the joint, and after a few moments to resume its use. Such a
complaint as this should always suggest the condition. Patients who
have had it for a long time learn how to avoid it as well as how to
relieve it, and will often discover and be able to indicate to the
surgeon the existence of a movable body, and even to describe its usual
resting place.
Partial or complete _dislocation of a semilunar cartilage_ in the knee
is usually the result of traumatism, a distinct history of which can
generally be obtained. It may not have been discovered at the time,
owing to swelling or tenderness, but will produce its peculiar symptoms
later, _i. e._, after use of the joint is resumed. Here, again, so
long as it remain in proper position, it interferes but little; with
a misstep or sudden movement, however, the patient is seized with
sudden and painful disability. Here the movable cartilage may be felt
projecting near its proper location. In such cases as these it is
movable only to a certain extent and makes no free excursion about the
joint. When not detected it may be suspected from the description which
the patient gives of his seizures.
=Diagnosis.=--So far as diagnosis is concerned, when a movable body
can be felt all doubt is set at rest. When it cannot be discovered
its existence may be inferred with an accuracy proportionate to the
patient’s description of his difficulties.
=Treatment.=--The treatment of rice-grain bodies is essentially that
of the chronic hydrarthrosis and probably tuberculous condition which
have led to their formation. It will consist usually in arthrotomy,
with thorough irrigation; often in some form of arthrectomy. With the
larger floating bodies, the “joint mice,” the most radical measures
are the best. In most of these instances there will be some degree at
least of hydrarthrosis. The joint cavity being distended and relaxed,
the indication for arthrotomy is the more urgent, since it will permit
also of irrigation or of dry sponging, with the same benefit with which
analogous intraperitoneal conditions are treated by the same measures.
The joint may be opened by a sufficiently ample incision, through which
the foreign body or bodies may be removed. The operator should not be
satisfied with mere removal of one, but should make a thorough search
for others which may have escaped previous detection.
Perhaps no operative measure in surgery better illustrates the
advantages of asepsis. This operation, which now can be done with
impunity, was in the pre-antiseptic era one which had a discouraging
fatality, death resulting from septic infection in about 40 per cent.
of cases.
FOREIGN BODIES IN THE KNEE-JOINT.
“Joint mice” are of sufficient frequency and significance to justify
brief separate consideration. According to Connell these may be grouped
as follows:
Those composed of foreign material, fatty tissue, fibrous tissue,
etc.;
Those composed of bone, cartilage, or of a mixture of the two.
Among the many explanations offered are the following:
Dry arthritis, with overgrowth of the margins of the cartilages;
Bony growths, separation from their attachments;
Infarct of the articular cartilage, with final separation;
Plate of bone formed outside of the joint and then invaginated;
Calcification or chondrification of enlarged synovial fringes;
Irritation and growth of embryonal cartilage or bone cells in the
synovial fringes;
Concretions whose nuclei are clots, torn fringes, or some foreign
body;
Some portion of the articular cartilages broken off by injury, or
damage and subsequent separation.
Injury figures largely in the opinion of most of the authorities, it
being well established that an injured portion of articular surface may
become subsequently detached by a fatty necrosis, spoken of by König
as osteochondritis dissecans, or by Paget as “quiet necrosis.” Others
imagine that these floating bodies are rarely of traumatic origin.
Symptoms are usually marked and significant. There is sudden sharp and
shooting pain, sometimes so severe as to cause faintness. Along with
this there is “locking” _i. e._, fixation of the joint, usually in the
flexed position, probably due to the entanglement of the floating body
between the articular surfaces or between the bone and the capsule.
[Illustration: FIG. 210
Ankylosis of hip with contracture of knee, following post-scarlatinal
arthritis.]
It is the smaller rather than the larger bodies which give the most
acute symptoms. This “locking” may last for only a few moments or for a
number of hours and may or may not be followed by acute effusion. When
with the above symptoms the presence in the joint of a movable mass can
be made out diagnosis is complete. Some patients discover the movable
body in their own joints before they go to the surgeon.
When the diagnosis is established the removal of the offending material
is imperative. In the pre-antiseptic era this was an extremely
hazardous operation. It is now one involving only theoretical risks.
These bodies are sometimes extremely movable and slip about within the
joint in a manner to almost defy removal even after the joint cavity
is open. If such a body can be felt and fixed by digital pressure, or
by the method of “stockading” suggested by Andrews some years ago, _i.
e._, fixation by forcing sterilized pins into the tissues around it
so that it cannot escape, it is then an easy matter to cut down upon
it and remove it. Otherwise incision may require to be sufficiently
ample to permit insertion of a finger and the general exploration of
the joint before it is encountered. These bodies sometimes exist in
small numbers, and it may be possible to remove several through a
single opening. If the joint be opened and explored it should be done
thoroughly in order that nothing may escape. After removal the capsule
is closed with buried sutures, the balance of the wound closed as
usual, and the limb then dressed upon a splint with absolute fixation
for several days, in order to ensure physiological rest (Fig. 209).
ANKYLOSIS.
The term _ankylosis_ implies _angular deformity_, but is used to
designate partial or complete fixation of joints, such fixation being
usually accompanied by more or less deformity or displacement. It is
a name for a condition and not for a disease, but is always produced
by the latter or by injury. The term itself implies nothing as to the
nature, extent, or appearance of the exciting cause. The actual cause
may have been disease of the joint, of the tissues around it, or may
have been the result of injury rather than of infectious or other
active disease.
For convenience we speak of _fibrous_, _false_, or _pseudo-ankylosis_,
and of that which is _bony_ or _actual_. A more accurate use of terms
would lead us to refer to the former as contracture rather than true
ankylosis.
_Contractures_ are the result of acute, usually septic intra-articular
and peri-articular processes, where muscle spasm is a pronounced factor
and where the intensity of the process has more or less weakened the
joint structures. The profession is hardly in the mood to accept
acute rheumatism as an infectious process. If true or not the acute
rheumatic affections are frequently followed by fibrous ankylosis with
contractures. Disfigurements of this kind are often produced as the
result of the surface lesions of severe burns or ulcerations, followed
by cicatricial contraction and the formation of dense bands and scar
tissue. This is a condition which can always be foreseen and which
should be guarded against with very great care. (See Treatment of
Burns.) Contractures also occur as the result of certain diseases of
the spinal cord, either as the result of active contraction of one set
of muscles, or of paralysis, by which the opposing muscles are deprived
of resistance and thus draw the limb out of shape.
_True ankylosis_ is sometimes fibrous, sometimes osseous, and
occasionally both combined. The older the case the more probable is
actual osseous union of joint surfaces. Bony ankylosis implies a
sharply destructive type of arthritis, which may have been originally
of pyogenic, gonorrheal, or tuberculous character, or else indicates
a series of very slow ossific and calcific changes, such as are
connected with the osteo-arthritis already described. Many of these
cases are to be referred to lesions of the cord, and many of them are
of polyarticular character. Fig. 195, illustrating one of the cases of
so-called “ossified men” under the writer’s observation, will portray
a series of lesions of this kind, most of the vertebral as well as the
other joints being involved in an absolute osseous union.
[Illustration: FIG. 211
Bony ankylosis of hip. (Ransohoff.)]
[Illustration: FIG. 212
Bony ankylosis of knee. (Ransohoff.)]
[Illustration: FIG. 213
Bony ankylosis of hip with deformity. (Ransohoff.)]
When a joint is stiff bony ankylosis may be inferred. So long as
there is any motion possible it is essentially of the fibrous type.
The condition is one easy of recognition, and is seen in all degrees
of completeness. In many instances joint fixation is accompanied by
adhesions of tendons and tendon sheaths, while as time passes all the
structures around a joint thus fixed become less movable and more
stiffened. Even the patella may become firmly attached to the bony
surface upon which it normally rests, and thus interfere with motion
of the knee almost as much as though the femur and the tibia were
alone involved. Occasionally one of the acute exanthems is followed
by contractures of a joint, with or without actual joint lesions,
by which when neglected distressing deformities are produced; such,
for instance, as partial flexion and fixation of the knees, or such
stiffening of the hips as to prevent the thighs from being separated.
While in such cases stiffening cannot always be prevented, deformity at
least can be if suitable measures instituted sufficiently early.
Figs. 211 and 212, from Ransohoff, illustrate osseous union in the hip
and the knee, while Fig. 213 illustrates the deformity which may be
produced by contractures and ankylosis at the hip.
The following tabular presentation of the types of ankylosis will
perhaps convey the greatest amount of information in small space:
{ {Capsular
{Peri-articular { { Tendinous
Ankylosis, { {Extracapsular { Tendovaginal
true and false { { { Muscular
{ {Synovial
{Articular {Cartilaginous
{ {Osseous
Murphy has prepared the following table of the types of arthritis which
lead to some of these varieties, and which may be classed as follows:
{(_a_) Primary hematogenous fibrous arthritis
{(_b_) Dry fibrous arthritis. Non-traumatic
{ {With fracture
{(_c_) Traumatic fibrous arthritis {into joint
{ {Without fracture
{ {(contusion)
{ { {Cryptogenetic
{ { { {Typhoid
{ {Hematogenous {Metastatic {Scarlatina
Arthritis { { { {Pyemia
{ { { {Gonorrhea
{(_d_) Suppurative { {Traumatic
{ { { {Tuberculous
{ { {Osteitis {Osteomyelitic
{ {Extension { {(infective)
{ { {Peri-arthritis (phlegmon)
{ { {Panarthritis
{(_e_) Ossifying arthritis (primary)
{(_f_) Static adhesive
=Treatment.=--The best method of treatment should be determined by
the original character of the exciting cause, the duration of the
condition, the amount of deformity present, and the degree of joint
fixation. That which will be possible if done early will be useless
if not resorted to until the case is old and chronic. In every acute
or subacute condition which may threaten ankylosis every possible
precaution should be taken to prevent it. If ankylosis be inevitable
it should occur with the limb in the most suitable position. At the
elbow, for example, this will be the right-angle position; at the knee,
one with the leg almost completely extended. In the lower extremity
traction with weight and pulley will serve a useful purpose in many
instances, either to overcome a threatening condition or to improve
one actually existant. Mechanical measures (_i. e._, use of various
splints or forms of orthopedic apparatus) will sometimes be of great
use. These may be arranged for the purpose of providing absolute rest,
with fixation in a desirable position rather than in one which is
undesirable, or they may be made with such devices as shall permit of
frequent change of position.
The mildest operative measure which can be practised in these cases
is manipulation, either gentle and frequent, combined with massage,
or more violent and painful, such as requires anesthesia for its
performance. The question of when to resort to these manipulations
is one calling for the soundest judgment, as on one side the surgeon
faces the possibility of setting up a renewed and more or less acute
disturbance, and on the other of seeing a joint gradually stiffen,
perhaps in a bad position. There is also a third difficulty, _i.
e._, the necessity for continuing motion in order to prevent the
re-formation of adhesions, and this in spite of the fact that it may
be intensely painful to the patient. Fortunately, however, the use of
nitrous oxide anesthesia usually permits this to be done as often as
may be necessary with a minimum of discomfort.
Firm, fibrous ankylosis will be attacked with great hesitation by the
experienced surgeon. Even though he may succeed in restoring the limb
to a better position, he may feel quite positive that the patient
cannot undergo the pain of the subsequent frequent handling. With
bony ankyloses he may feel that nothing short of radical measures
will suffice. Here it is rarely a question of restoring motility but
rather of overcoming deformity. At the knee a wedge-shaped portion
of the joint may be removed, its angle corresponding to the angle of
deformity, and thus a crooked leg may be restored to the straight
position; in fact, with a raised heel under such a limb it may be
made almost as useful as ever. At the hip one may do a subcutaneous
osteotomy, dividing the femoral neck either with chisel or with a
small and protected saw, and then bringing the limb down into the
normal position of extension, allowing the bone to repair itself, and
effecting improvement only in position, or, by constantly moving it,
securing a false joint; or a more formal exsection may be made and
by removing the head of the femur and clearing out the acetabulum a
degree of motion may be established at this point. At the wrist, elbow,
and shoulder-joint resections will usually give good results if the
operation be performed before the muscles have almost disappeared by
atrophic processes.
Danger attaches to the performance of the so-called bloodless
operations, in that there is a possibility of laceration of nerve
trunks or of large vessels which may have become fixed in the condensed
tissues and be torn with them. There is more danger of this perhaps
at the knee than in other joints, and ruptures of the popliteal
vessels and nerves have been repeatedly reported. The first attempt in
breaking up such a joint should be to increase the degree of flexion.
If by efforts in this direction the tissues can be first released,
then there is less danger of their yielding when extension is made.
Another danger which threatens in all resistant cases, and especially
in elderly people, is fracture of bones. The writer has seen the upper
end of the tibia as well as the neck of the humerus yield under these
circumstances. In the latter event one should endeavor to prevent bony
union, and thus to gain a false joint in place of the original.
In regard to the nature of the operative attacks upon the above types,
the following is copied from Murphy:[33]
A. Extracapsular {1. Tendon elongation (tendoplasty).
disease {2. Tendovaginitis (exsection of sheath).
{3. Cicatrices (removal).
B. Intracapsular {1. Adhesive synovitis (exsection of capsule).
{2. Replacement by aponeurosis or muscle.
{1. Disconnect bones.
{2. Remove neighboring bony processes or
{ prominences.
C. Osseous {3. Liberate soft parts.
{4. Prevent subsequent bony contact.
{5. Interpose tissue to form hygroma or fibrous
{ surface.
{1. Mandibular.
D. Joints suitable {2. Hip.
for operation. {3. Shoulder.
{4. Elbow.
{5. Knee.
{1. Flap formation (skin flap with fascia, or
{ muscular).
{2. Exposure of ankylosed area.
{3. Osseous separation.
E. Technique {4. Transplantation and fixation of interposition
{ flap.
{5. Replacement of bone.
{6. Fixation of parts.
{7. Drainage.
{1. Passive motion
F. Subsequent {2. Active motion.
treatment {3. Forced traction.
[33] Journal American Medical Association, May 20, 1905, p. 1573.
To the various expedients which may be adopted for making stiffened
joints more useful may be given, in a general way, the term
_arthroplasty_. A variety of mechanical contrivances have been resorted
to in the past, operators hoping to be able to secure, for instance, a
movable knee instead of one which is stiff. Artificial joints, made of
celluloid, ivory, etc., have been used for experimental purposes, but
while occasionally they have given good results in animals, they have
rarely been satisfactory in man. For the prevention of re-adhesion,
plates of celluloid, thin metal, gutta-percha, rubber, etc., have been
used. These are either wrapped around a bone end or are used for lining
a bone cavity, and rapidly accumulating experience is showing that this
may be done with great benefit.
Thoroughness of operative work is one of the important contributing
agents to the securement of wide range of motion, especially in
complete removal of synovial membrane, capsule, and ligaments. Soft
parts should be liberated thoroughly. Of the materials which can be
interposed between bone ends in order to prevent reunion, muscular
aponeurosis, with a certain amount of fatty tissue, makes the best
material for interposition. When aponeurosis cannot be secured, then
muscle should be tried, with some fat, as the former flattens out and
undergoes structural changes, with conversion into fibrous tissue.
It should be represented to the patient as a legitimate scientific
experiment, and in such a way that no matter what may happen no blame
can be attached to the operator. In general it may always be stated
that the older the lesion the less satisfactory will be any measure of
treatment except possibly resection and arthroplasty.
ARTHRODESIS.
This term applies to the intentional production of ankylosis in a joint
previously healthy or nearly so, with the intention of stiffening a
useless limb and thus enhancing its usefulness. The measure applies
mainly to those cases of infantile paralysis, with loss of control
of the knee or ankle, or both, when by stiffening the limb it can
be made to serve the purpose of a crutch. It is the last resort in
this direction when there is no possibility for tendon grafting. Long
confinement of a limb in a fixed dressing will lead to considerable
stiffening of the joint, yet a joint so immobilized lacks that firmness
of support called for in cases above mentioned. Therefore when it
is desired to perform arthrodesis the joint is usually opened and
more or less of its articular surface removed, the intent being to
produce the effect in the shortest time and in the best way. It can be
better attained by a removal of articular surfaces with the saw and
the apposition of fresh bone surfaces to each other, their retention
being ensured either by sutures (tendon or wire) or accurate fixation
in plaster of Paris. Under these circumstances drainage should not be
necessary, and limbs can be completely enclosed in a fixed dressing.
MAJOR OPERATIONS ON JOINTS.
Aside from arthrotomy and partial or complete arthrectomy, as above
mentioned, the latter, including removal of synovia or cartilage, and
perhaps curetting of bone foci, the formal _resections_ or _excisions
of joints_ remain to be considered. The latter is the preferable term,
as it is meant to include removal of the component parts that enter
into the construction of joints, while the term resection implies
rather the removal merely of portions of bone.
_Joint excisions_ are practised especially for the following purposes:
(_a_) To atone for the result of old unreduced dislocations; (_b_)
in certain compound dislocations, with or without fracture; (_c_) in
certain comminuted fractures where there is no prospect of recovery
with useful joints; (_d_) in the destructive forms of acute arthritis
where the entire joint is disorganized and the bone ends carious;
(_e_) in tuberculous arthritis or panarthritis, with or without
suppurative complications; (_f_) in occasional instances of disabling
osteo-arthritis; (_g_) for relief of ankylosis, either for improvement
of position (knee) or restoration of motion; (_h_) occasionally after
gunshot injuries. _Excisions required by the exigencies of traumatisms
should be promptly done._ If the case be complicated with septic
infection the prognosis is much less favorable. For convenience of
description excisions may be classified as _primary_, _intermediary_,
and _secondary_. According to the joint involved, as at the knee, the
purpose underlying the operation is to effect an absolutely rigid bony
ankylosis.
The development and perfection of the general method of joint excisions
is a matter of but little more than a century. Previous to that time
amputation was almost the only resort when destruction had occurred.
The most prominent surgeons in the early development of the measure
were Park, of Liverpool, and Moreau, of France. During the latter part
of the past century Ollier, of Lyons, greatly improved the technique
by demonstrating the importance of the periosteum and by introducing
the so-called _subperiosteal methods_. This is of great value in
_uninfected_ cases. It is a mistake, however, to endeavor to save
periosteum which has become involved in the tuberculous process; in
fact, in the presence of tuberculous disease we cannot be too radical
in the removal of all affected tissue.
In the so-called subperiosteal method the operator endeavors, so far as
possible, to preserve the periosteum of the parts exposed to attack,
and, if possible, the capsular ligament as well. Thus at the elbow the
capsule, _if not diseased_ or obliterated, should be preserved, the
osseous tissue being shelled out from within, so far as possible. The
less, then, the connections between the capsule and the periosteum
are disturbed the better. The French apply to this method the term
“subcapsular periosteal.” When the bone covering can be preserved new
bone is easily formed to replace that which has been lost, especially
during adolescence, while the preservation of the capsule, with its
ligamentous connections, affords a better joint cavity than will the
substitute which results from natural processes. Furthermore the
surrounding tendons are less disturbed and the condition remains more
like the original. Nevertheless one does not exsect healthy joints,
and the method is not always easy nor even possible of performance.
It will suffice to say that it should be adhered to only as far as
circumstances may justify or permit.
Surgeons, however, have not been satisfied with the older methods, and
have endeavored to still further enhance motility in operated joints.
(See above--Arthroplasty.) To this end the interposition of muscle,
fascia, or of foreign membrane has been suggested. Thus, after removal
of the head of the femur a strip of fascia lata may be interposed
between the raw-bone surface and the cavity of the acetabulum, being
fastened there by catgut sutures. In the shoulder a similar procedure
has been carried out, utilizing a strip of deltoid muscle. At the
elbow a piece of the pronator radii teres may be detached and fixed by
sutures to the brachialis anticus. In every case the method should be
adapted to the demands made, the intent being to cover divided bone
ends with tissue which will prevent osseous union, as it is known
to do in many cases of fracture where such interposition produces
non-union. In so far as one attempts here to imitate conditions which
are considered undesirable in certain other traumatisms, Murphy has
done more than any other American surgeon, both in the experimental and
clinical study of this subject. (See above.)
For the joints below the hip and shoulder the _bloodless method_ will
facilitate operative work. In case of a septic joint, however, it would
not be advisable to apply the elastic bandage below and then over and
around the joint, as by the pressure thus made some septic material
may be forced into the absorbents. In clean cases the rubber bandage
is a great advantage to the operator. It has this objection, however,
in that hemorrhage which does not occur during the operation has to be
checked after its conclusion, and I have often thought it advisable to
avoid the use of the bandage and to secure vessels as they are divided,
in order that when bleeding has once ceased there be no fear of its
recurrence later.
The question of _drainage_ is one of importance. In a general way one
may feel that in an absolutely clean case drainage is not required,
save possibly a small opening for escape of blood. If practised at all
it should be thoroughly done. Drainage tubes are often too small and
do not permit the escape of either clotted blood or debris of injured
tissue.
The _after-treatment of excisions_ demands, first of all,
_physiological rest_ of the part involved, especially if, as at the
knee, sutures or other expedients for maintaining apposition have
been inserted. When motion is sought there will soon come a time when
passive motion can be begun. This will vary with the size of the joint
and the magnitude of the procedure. Actual rest should be maintained
until firm wound healing has been secured. Passive motion is then
begun, to be practised daily, the sensation of the patient being the
guide as to the range of the movement and extent of manipulation. Thus,
after exsection of an elbow with prompt union of the wound passive
motion should be begun in about two weeks, but it should not be begun
for a month if the joint has been thoroughly disorganized and the
cavity is still discharging. Motion should be begun as early as is
considered feasible in order to guard against a false joint.
_The remote consequences of joint excisions_ are usually very
satisfactory. The best results are obtained in the young, _i.
e._, those whose tissues are still undergoing natural changes and
whose bones are growing. In the course of time, by condensation of
surrounding tissues, a new joint capsule is formed, its interior
smoothed off, apparently covered with endothelium and filled with a
sufficient amount of fluid, similar to that of normal joints, to serve
the purpose; in this way a new joint becomes gradually substituted
for the old, which serves the original purpose, in a surprising and
gratifying way. Even in those of advanced years a satisfactory result
is often obtained. It is often necessary to afford some support, by
which too great a range of motion may be avoided; thus at the elbow the
result at first is what may be called a “flail-joint,” which permits
much undesirable lateral movement. This can be avoided by having light
leather corsets fitted to the forearm and arm, connected by two lateral
hinged braces. This being constantly worn, and no motion permitted
which is not an imitation of the normal, the parts in time adapt
themselves to the purpose, so that all apparatus can after a while be
removed.
Excisions, like amputations, may be practised and the general methods
learned on the cadaver, but their actual performance in the presence
of extensive disease will be found to be a different procedure from
that learned upon the dead body. For reasonably representative cases
typical operations can be devised, with explicit directions. It is
not advisable to try to do such work through too short incisions. A
long incision heals as kindly as one shorter and affords more room for
operative work. The incision should be so planned and executed as to
afford the maximum of exposure with the minimum of damage to important
structures. The region of the great vessels is avoided in all the
classical operations, while nerve trunks, if exposed, are retracted and
kept out of harm’s way. After the knife has once laid open the joint
it is used but little except for the division of resisting structures,
_e. g._, ligaments. The greater part of the work is then done with
elevators, or periostomes with reasonably sharp edges and sufficiently
broad surface, so that the periosteum can be divided with the latter
and separated with the former to the necessary extent. Obviously
epiphyseal junctions should be spared whenever possible, especially in
the young. To remove an entire epiphysis is to materially impair the
later growth of the limb. In some of the most serious cases it will be
found already loosened and lying as a sequestrum in the joint cavity.
In this case it may be easily lifted out of place. Tendons should never
be divided unless absolutely necessary. Incisions in their neighborhood
should be so planned as to be parallel with their direction and permit
their displacement without division. The sharp spoon should be employed
for curetting the interior of a joint capsule or cleaning out a bone
focus (erasion). A capsule involved in tuberculous disease should
be completely extirpated. Diseased bone ends should be sufficiently
exposed to permit of the use of an ordinary saw or a chain or wire
saw.[34] Considerable force will often be necessary in making bone ends
accessible for this purpose. The chisel is rarely used except in cases
of bony ankylosis, where it is not possible to force bone ends through
the opening in order to attack them with the saw. As remarked above,
clean cases may be closed without drainage. Visible vessels should be
secured, and, while a certain amount of oozing may be expected, if
the part be enclosed in suitable compressive dressings and elevated,
it need not cause alarm. The gentle application of an elastic bandage
for three or four hours may afford additional security. It should
not, however, be allowed long to remain. The terminal portion of the
limb will always afford an indication as to the condition of the
circulation. Should it become cyanotic or cold the dressing should be
renewed and the wound examined promptly.
[34] Wyeth’s “exsector” is an admirable substitute, especially at the
shoulder and hip.
=Special Incisions.= =The Shoulder.=--A longitudinal incision suffices
for most cases (Fig. 214). This may be made posteriorly between the
fibers of the deltoid or anteriorly and externally over the bicipital
groove. It is better to separate the deltoid fibers than to divide
them, although they may be divided. Should the straight incision
afford insufficient room another incision at right angles will afford
ample access. The capsule, having been exposed, is opened, the wound
widely separated with retractors, the arm rotated through a wide
arc, while with a stout knife the capsular ligament and the various
muscular attachments around the neck of the bone are divided. The
greater and lesser tuberosities, with their muscles undivided, should
be retained, when circumstances permit. The head of the bone, being
freed, is dislocated and forced out through the wound, where it may be
seized with large forceps and removed with a saw. The higher the bone
is divided the better. Every other consideration, however, should be
sacrificed to removal of all foci of disease. The capsule may then be
extirpated and the glenoid cavity thoroughly cleaned out with a sharp
spoon. Should the case be one of serious infection it is advisable to
make a posterior opening, even through the deltoid, for purposes of
thorough drainage. The greater part of the first incision is to be
closed with sutures, the arm dressed in a comfortable position, with
the elbow at a right angle, and the patient allowed to be up and around
as soon as he feels in the mood for it.
[Illustration: FIG. 214
Excision of the shoulder: _A_, regular incision; _B_, supplementary.
(Ollier.)]
=The Elbow.=--Here a variety of methods have been advised, and the
extent of the operation must depend, to some degree at least, on the
nature and extent of the condition which necessitates it. Partial
excisions have been recommended, though in the writer’s experience
incomplete operations often give less satisfaction than those which
are complete. However, when it is a question of removing callus or
displaced bone fragments, which, after fracture into the joint, impair
its function, then partial resections may be serviceable.
[Illustration: FIG. 215
Excision of the elbow-joint: _A_, von Langenbeck; _B_, Ollier.]
[Illustration: FIG. 216
Excision of the elbow-joint: _A_, Nélaton; _B_, _C_, Hueter.]
[Illustration: FIG. 217
Osteoplastic method: _A_, by external incision; _B_, von
Mosetig-Moorhof.]
The essential incision is a long posterior one, which may be somewhat
modified (Figs. 215, 216 and 217). It is essential here to avoid the
ulnar nerve, which passes between the internal epicondyle and the
olecranon, and the vessels and nerves in front of the joint. If it be
made an inviolable rule to always _keep close to the bone_ both of
these dangers may be avoided. Ligamentous and muscular structures,
among the latter the anconeus, should be spared as much as possible.
After separating the joint surfaces thoroughly, by forced flexion,
it is usually easier to force out the lower end of the humerus and
first remove it, after which the upper ends of the radius and ulna are
exposed and removed. When there is bony ankylosis it is preferable to
divide the bones of the forearm first. The tendon of the triceps is
not only detached from the olecranon, but divided by the first long
incision. After concluding the incision, the capsule, if it remains,
is to be closed with chromic catgut sutures and the end of the triceps
tendon or some of its periosteal attachment united to the periosteum of
the upper end of the ulna.
The arm is now fixed in the right-angle position and held comfortably
to the body by a suitable sling.
=The Wrist.=--It is rare that in disease of the wrist-joint this is
found to be limited to a single bone of the carpus. Should an _x_-ray
examination indicate such limitation then the focus can be exposed and
cleaned by an incision upon the dorsum of the wrist, where it may seem
best adapted for the purpose. Suppurative and tuberculous affections of
the wrist usually necessitate removal of the carpal bones, including,
possibly, the lower extremities of the ulna and radius. When the
wrist-joint is involved it may be sufficient to remove the latter with
the first row of the carpus.
Fig. 218 illustrates the incisions to be recommended for wrist
resection, of which the Langenbeck line is to be preferred.
Occasionally two lateral incisions, with through drainage, will better
serve the purpose. It may be necessary to divide the short radial
extensor, but this may be united again with suture. In most instances
it is possible to retract the tendons to either side and thus clear the
carpal region. By hyperextension the extensor tendons are relaxed and
more room is thus made. The incision marked “_A_” combined with that
marked “_B_” in Fig. 218, affords the best exposure when disease is
extensive. The incision along the inner border of the wrist is made 5
Cm. above the styloid process of the ulna, and between the latter and
the ulnar flexor down to the middle of the last metacarpal bone. Here
the tendon of the latter muscle should be divided at its insertion
and lifted out of its groove in the ulna. The collection of extensor
tendons is then separated from the back of the wrist and lifted up,
it being usually necessary to divide the unciform process of the
unciform bone with forceps. The knife should be kept from the palmar
surfaces of the metacarpal bones in order to avoid injury to the deep
arch. After dividing the anterior radiocarpal ligament the carpus is
extirpated through the ulnar incision. The ends of the ulna and radius
are now easily accessible for removal with forceps or a metacarpal saw.
The same is also true of the proximal ends of the metacarpals. After
spreading the hand and forearm upon a flat splint drainage can be made
to the desired extent and the wound closed.
[Illustration: FIG. 218
Excision of the wrist: _A_, Lister’s radial incision; _B_, Lister’s
ulnar incision; _C_, Ollier; _D_, von Langenbeck.]
[Illustration: FIG. 219
Excision of the hip: _A_, Sayre; _B_, Ollier.]
So far as the _hand and fingers_ are concerned little resecting need be
done, the surgeon usually confining himself to the removal of sequestra
or curetting of carious bone. In cases of compound comminuted fracture
bone fragments may be removed; only in cases of lost or destroyed
phalanges will amputation be necessary.
=The Hip.=--In its structure the hip-joint is one of the simplest
in the body. Although it lies deeply it is easily made accessible.
Fig. 219 illustrates the incisions by which the joint is attacked
for the purpose of exsection. If necessary either extremity of the
incision can be extended or enlarged by a cross-cut. When the joint
is disintegrated by disease, especially when partially dislocated,
the parts will lend themselves to an easy and simple operation. When,
however, the operation is done for ankylosis or for disease, by which
great thickening and fixation have been produced, the measure may
become difficult. For ordinary purposes the simplest method is to drive
a sharp-pointed, strong-bladed knife directly down upon the neck of the
bone from a point midway between the great trochanter and the crest of
the ilium; then keeping the knife-blade in contact with the bone the
incision is carried downward over the trochanter and along the shaft
to a length making it sufficient for easy exposure of the bone and of
the joint. Nothing is gained in these cases by trying to work through
a short incision. A long one heals as readily and makes the operation
more simple. It is as easy to make the entire incision in one cut
as to divide the muscles layer by layer. The capsule of the neck of
the femur being exposed by a wide retraction of wound margins, it is
necessary next to divide muscular attachments to the great trochanter
by raising the periosteum to which they are attached and saving both.
To expose these insertions the femur should be rotated inward and
outward, while the capsule is at the same time divided. The ligamentum
teres, which offers a theoretical obstacle, usually disappears in the
presence of any active disease and is scarcely ever encountered; it can
be divided with curved scissors. Now by more or less powerful effort,
including flexion and adduction to the extreme limit, with more or
less rotation, the head of the bone is forced out from its socket and
through the wound. Whether the bone should be decapitated with chain
saw, metacarpal saw, or by the exsector of Wyeth will depend partly
upon the freedom with which it can be exposed and on the equipment of
the operator. It may be advisable to divide the neck with a chisel.
The trochanter major should be preserved whenever its removal is not
made imperative by the progress of the disease. The head and neck of
the bone having been removed, the acetabulum is now more or less easily
exposed, especially with retractors, and it should be cleaned with a
sharp spoon. The capsule also should be removed, at least when the
operation is done for tuberculous or other infectious condition. It is
advisable to irrigate, then to wipe dry all the original joint surfaces
and raw bone, and finally to cauterize either with pure carbolic or
with zinc chloride, which should be washed away with the irrigating
stream, the intent being to close the mouths of all the absorbents and
prevent absorption from fresh exposure. Sinuses if present should be
thoroughly excised, scraped, and treated in the same way. A drainage
tube is usually preferable to the use of gauze.
The above is the method usually relied upon for hip exsection. Other
methods have been devised, especially by _anterior incision_; of
these the best probably is that of Barker. The cut is made along the
outer border of the anterior surface of the sartorius and rectus,
and through it the femoral neck is reached. By wide retraction the
anterior surface of the joint can be completely exposed and opened,
and through this opening the neck of the femur can be divided with a
chain saw or chisel, before removal of the head from the acetabulum.
The disadvantage of anterior incision is that pertaining to drainage.
Nevertheless this can be obviated with capillary drains. Its advantages
are that splinting and protection can be more perfectly effected, with
less necessity for frequent interference. In other words it makes the
subsequent care of the patient easier. Many English surgeons are in
favor of it. Ollier devised a so-called osteoplastic excision, made
through a curved incision with a downward convexity, the top of the
great trochanter being exposed and divided with a chisel sufficiently
to permit of its being turned up with the flap, and then being reunited
to the main part of the bone after the removal of the neck and head.
This method has its advantages in a limited number of cases, but it has
not become popular in this country. It would seem to be an advantage
to preserve the trochanter, although some surgeons remove it. So long,
however, as disease is confined to the head and neck of the bone it is
unnecessary to remove this projection.
The _after-care_ of a hip excision is not an easy matter. Most surgeons
prefer to maintain the limb in position by the aid of traction, with
sufficient weight to overcome all muscle spasm. If the case be such
that dressings need only be made at long intervals, then it matters
little, but in a septic case in which there is considerable discharge
the problem is sometimes a serious one. Various beds or suspension
splints have been devised, consisting essentially of frames with
cross-strips of stout material, upon which the patient lies. After
raising the frame one or two of these strips are released and the
parts exposed. This arrangement also permits of the easy management
of a bed-pan. In young children a wire splint with a fenestrum, or a
plaster-of-Paris spica or breeches with large opening cut opposite
the wound, will often be serviceable. The tendency is rather toward
adduction, and this should be overcome. Something will depend upon
whether the surgeon is working for ankylosis or for a movable joint.
In the former case a rigid dressing should be employed as soon as the
condition of the wound permits. In the latter passive movement should
be begun as soon as the wound is healed.
While the operation is usually performed quickly, and is not regarded
as serious, it nevertheless has a considerable mortality, especially
in the young and the aged, because of the conditions which necessitate
it. After a complete exsection, even by the most ideal method and in
the most ideal case, the limb remains somewhat shortened. This may
be compensated by raising the heel of the shoe worn on the affected
side. In severe cases it may be necessary to supply even two or three
inches of artificial support for this purpose. Unless this is done
compensatory spinal curvature will ensue.
[Illustration: FIG. 220
Excision of the knee-joint: _A_, semilunar incision; _B_, Ollier’s
incision.]
=The Knee.=--The knee is generally more accessible for operation than
the elbow, as the important structures which should not be disturbed
lie grouped upon its posterior aspect. Protection for one of these is
protection for all, and the freedom with which the joint may be opened
makes it especially easy to do either complete or partial operation.
Here the surgeon should endeavor to preserve the epiphyses, especially
in children, as they have much to do with the growth and length of
the limb. So long as incision is confined to the anterior aspect of
the joint it can be made in almost any manner. The usual method is
that represented by line _A_ in Fig. 220, by which a horseshoe flap is
raised and the joint interior exposed. Occasionally the direction of
the flap is reversed, and it is turned downward rather than upward.
In the former case the ligamentum patellæ is divided; in the latter,
the tendo patellæ. Whichever way the flap is turned it is made to
include the patella, although this bone can be removed at any time. The
lateral ligaments being divided, as well as the crucial, and the limb
completely flexed, exposure of the joint surfaces is made. It is now
possible to do an arthrectomy, a partial exsection or a complete one,
according as the disease is more or less extensive. In the complete
operation the articular surfaces of the femur and of the tibia are
usually removed with an amputating saw. If this be introduced from the
front and made to work its way backward the popliteal vessels should
be amply protected against possible injury. Here it should be borne
in mind that the leg is not constructed in a straight line, but that
there is a lateral angle at the knee, as the femurs diverge as they
pass upward, and this angle should be imitated in directing the saw and
removing the bone end. Again, a slight bend anteriorly will make the
limb more useful than one which is absolutely straight. The intent thus
should be to give the knee at a slight angle anteriorly and interiorly,
and the saw should be manipulated with great care. In a complete
operation the patella is also removed. In tuberculous and other septic
disease the capsule should be completely extirpated. This offers no
difficulty, save at the posterior surface, where it may approach
closely to the region of the great vessels.
Various modifications have been practised in these operations. Some
open the joint by straight cross-incision with division of the patella,
the latter being reunited with tendon or wire sutures. Others have
practised a more complicated H-shaped incision, the transverse portion
being carried either through the patella or just below it. The line
marked _B_ in Fig. 220 was suggested by Ollier. It is questionable
whether any of these methods offer any advantages over the one first
described.
After exsection it is desirable to maintain the bone ends in an
accurate position if speedy reunion be desired, and for this purpose
various methods are in vogue. The bones may be drilled and fastened
together with tendon or wire sutures, or ivory nails may be driven
in, one on each side, directing them obliquely, so that displacement
cannot easily occur, or metal nails may be used for the same purpose.
Another plan is to insert two long metal drills, one on either side,
which perforate the skin two or three inches above the wound, and are
passed downward and toward the other side so as to fix the surfaces, as
it were, by a cross-forked arrangement. After two or three weeks these
drills may be withdrawn. Fixation of this kind is advantageous, for
when complete excision has been practised the surrounding tissues are
lax and the parts are not easily held in position by external dressings
alone. In a clean case, with careful hemostasis, very little drainage
will be required. What is needed can be provided by an absorbable drain
passed through the lower portion of the wound on either side. In a
septic case it would be well to provide for ample drainage on each side.
The limb may be dressed upon a fenestrated wire or gauze splint, which
is easier when frequent change of dressing can be foreseen, or it may
be immobilized in a plaster-of-Paris splint.
=The Ankle.=--The ankle is usually reached by an incision on either
side, three or four inches in length, extending from above each
malleolus downward and forward on to the tarsus. The knife-blade
should be forced to the bone, so as to divide the periosteum, which
is subsequently separated and lifted by an elevator, in order that
the operation may be made subperiosteally. The fibula is usually
first divided, with a chain saw or a chisel, an inch above its tip.
The divided fragment is wrenched from its place with forceps, and
severed from the ligaments by knife or scissors, being careful not
to injure the external lateral ligament. The inner incision is made
in practically the same way, the periosteum separated, the internal
lateral ligament divided, and the end of the tibia forced through the
incision by everting the foot. Its joint end may be removed with a saw,
dividing on the same level and plane with the lower end of the fibula.
Through the gap thus made the astragalus may be either removed or its
upper surface divided with a metacarpal saw. The fresh bone surfaces
left in this way will unite and ankylosis will result, unless fibrous
or muscular tissue be interposed to favor the formation of a false
joint.
As in other operations methods may be varied to meet the exigencies of
certain cases. Longitudinal incisions may be placed farther forward
than indicated above, as is shown in Fig. 221, which illustrated
König’s method. Here the bone surfaces are divided with broad chisels.
A transverse incision of the front and upper part of the ankle may be
made, through which the tendons are exposed, lifted in a group out of
harm’s way, and curetting and bone sawing performed. Kocher makes a
semilunar incision from the outer border of the tendo Achillis to the
outer border of the extensor tendons, its line passing beneath the
external malleolus. By this method the joint is opened and the peroneal
tendons divided, their ends being reunited after the completion of the
balance of the work. This method is usually applicable in children.
Ample drainage is required in these cases, for the operation is seldom
performed in the absence of septic complications. The foot should be
kept in proper and right-angled position by metallic splints, or by
plaster of Paris, the latter preferable, fenestra being cut in order to
make access to the wound.
=Excisions of the Tarsus and Osteoplastic Excision of the
Heel.=--Removal of the tarsal bones is confined usually to cases of
tuberculous disease, and may be performed by a variety of methods.
Thus the tissues of the sole of the foot may be divided transversely
by an incision carried from the tubercle of the scaphoid beneath the
sole and across to a point one inch behind the base of the metatarsal.
Through this, access can be made to the inferior surface of the tarsus.
Conversely the upper portion may be exposed by a similar transverse
incision across the dorsum of the foot, by lateral incisions, or by a
combination of both. It is seldom necessary to divide the tendons, it
being nearly always possible to gather them into a group and lift them
out, while the bones are attacked with a sharp spoon or a chisel.
Occasionally the calcis becomes involved in cancerous or tuberculous
disease and it would appear that removal of the heel proper would be
all that is required. To meet these indications Wladimirov, in 1871,
and Mikulicz, in 1880, independently devised a method by which the
ankle-joint may be opened and as much of the heel and adjoining tarsus
as necessary removed, the foot being later fixed in the extreme equinus
position. This is referred to as _osteoplastic excision or amputation
of the heel_. Fig. 222 illustrates the line of incision, which extends
from the tubercle of the scaphoid beneath the heel to a point on the
opposite side, then obliquely upward and backward to the base of each
malleolus, and then transversely and posteriorly, thus including within
its line the region of the heel. These incisions extend to the bone,
the ankle-joint is opened posteriorly, the lateral ligaments divided,
the lower extremities of the tibia and fibula removed with a saw,
the astragalus and calcis separated from their attachments, and the
posterior articular surfaces of the scaphoid and cuboid also removed.
The lines of division of bone are indicated by dotted lines in Fig.
222. Thus the lower ends of the leg bones are brought into contact
with the upper end of the divided tarsus by straightening the foot in
the extreme equinus position and maintaining this position with wire
sutures or bone or metal pins.
[Illustration: FIG. 221
König’s incision for excision of the ankle.]
[Illustration: FIG. 222
Osteoplastic excision of the foot. (Mikulicz.)]
The cases in which this method is of use are rare, but when indicated
it has usually given satisfactory results. It is a substitute for
amputation of the leg, and it is often an open question as to which
will give the most satisfactory result. It has probably not been
practised a hundred times.
CHAPTER XXXII.
SURGICAL DISEASES OF THE OSSEOUS SYSTEM.
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.
[Illustration: PLATE XXXV
Acute Osteomyelitis, showing Purulent Foci and Accompanying Disturbance
(Kocher.)]
[Illustration: FIG. 223
Typhoid infection of bone; focus in rib. (Lexer.)]
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).
[Illustration: FIG. 224
Acute necrosis of tibia, with formation of cloacæ for affording
opportunity for escape of sequestra. Illustrating also the extensive
openings which necrotomy may necessitate. (Lexer.)]
=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.
[Illustration: FIG. 225
Total necrosis of humerus, as seen by aid of the cathode rays. (Lexer.)]
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.
[Illustration: FIG. 226
Osteogenesis and osteosclerosis in slow infective processes. (Buffalo
Museum.)]
=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.
[Illustration: PLATE XXXVI
Tuberculous Disease of Hip-joint and Pelvis, involving the Muscles
(rare). (Lannelongue.)
_o_, rarefying ostitis (_i. e._, osteoporosis); _f_, fungus granulation
tissue.]
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.
[Illustration: FIG. 227
Tuberculous disease of the hip. (Buffalo Museum.)]
[Illustration: FIG. 228
Healed tuberculosis of the spine. (Buffalo Museum.)]
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.
[Illustration: FIG. 229
Syphilitic gummas of head and face. (After Jullien.)]
[Illustration: FIG. 230
Syphilitic ostitis and osteosclerosis.]
Syphilis of bone may assume the type of _gummatous involvement_ of
the _periosteum_ or of the _bone_ itself or of _syphilitic caries_
and _necrosis_. The former appears usually as a distinct tumor,
ordinarily tender and exceedingly painful, especially at night, it
being characteristic of almost all cases of bone syphilis that the
pain, however great during the day, is exaggerated at night. The true
syphilitic _gumma_, or syphiloma, of _bone_ is but little different
from gumma in other tissues, which may become secondarily infected
and then suppurate with the formation of sinuses, etc. Suppuration,
however, is rare. _Central gumma_, like central osteosarcoma, is
possible, and may lead to expansion of the surrounding bone. Syphilitic
_necrosis_, so far as the bone lesion is concerned, scarcely differs
from the other varieties. It is, however, almost always of the slow
form, and involves more often the _flat_ than the long bones. It is
especially seen in the cranium and the sternum. Syphilis of bone is
often mistaken for rheumatism or pseudorheumatism because of the
deep-seated and somewhat indolent pain. Syphilitic disease of bone
permits occasional spontaneous fracture, the bone affected with this
disease being always more friable than natural. There is also another
form of bone syphilis--namely, the _hereditary_. It leads either to
bone _enlargement_ or to _caries_ and necrosis, the latter usually upon
the cranium, where extensive ulceration and sequestrum formation may be
observed, even the dura being exposed by breaking down of the fungous
tissue.
[Illustration: FIG. 231
Caries of lower end of femur. (Buffalo Clinic.)]
Hereditary bone syphilis is also characterized by osteophytic
formation, by the substitution of gelatinous for spongy bone tissue
in the neighborhood of epiphyses, and by early and easy epiphyseal
separations. It is characterized also by irregularity of ossification
of cartilage and consequent deformity of bone ends, especially about
the phalanges and the metacarpal and metatarsal bones. In almost every
case where doubt would in other respects arise the other evidences of
congenital or acquired syphilis are so plain as scarcely to permit
uncertainty (Fig. 230).
The _possible combination of syphilis and tuberculosis_ in the same
subject may occur, the lesions partaking of one or the other character
according as the tuberculous or syphilitic taint may predominate.
There is urgent necessity in all cases of syphilis in bone, whether
operated on or not, for the _combination of suitable internal treatment
with surgical intervention_. Only by this combination can the efforts
of the surgeon be crowned with success. In failure to appreciate this
fact operation often seems to be almost futile.
CARIES.
Caries is a term applied to infiltration, and substitution in
healthy bone of granulation tissue, which has been in use for many
centuries, from a time long before the pathology of the condition was
understood. Caries never occurs except in the presence of a _specific
irritant_, which, in general, is tuberculous and sometimes syphilitic
in character. The pure type of caries is connected entirely with
the formation of granulation tissue, and the slow ravages connected
with its presence in and substitution for the original bone. As long
as _septic infection_ (pyogenic) is _avoided_ it assumes the _dry_
type, as it used to be known, called by the older writers _caries
sicca_. When the fungous tissue is invaded by putrefactive or pyogenic
organisms suppuration takes place, and then occur the _moist_ forms
of caries, the _caries humida_ of our forefathers, connected with the
presence of pus. When closed areas of bone, small or large, being
thus shut off from nourishment, die as the result of its presence the
complicated condition used to be known as _caries necrotica_. Occurring
under any circumstances, _caries is a result and not a cause_, and is
to be dealt with accordingly.
Peculiar alterations and markings in bone are the consequence of
carious changes, and bones are given a fantastic and peculiar
appearance in consequence. The surface is almost always irregular,
tunnels or canals are formed, and the bone is often honeycombed,
as it were, by the excavations just made. Along with the process
of osteoporosis and disappearance of bone at one point may be seen
osteosclerosis in an adjoining area, and the bone, which is apparently
much weakened by the destructive process, is strengthened in a
compensatory way by the artificial density of the tissue undestroyed.
The clinical evidences of caries are those of joint and bone
tuberculosis or syphilis, which have been already discussed, and its
operative treatment consists always in surgical attack with bone chisel
and sharp spoon, according to the rules already laid down. The bone
which is completely carious calls for _extirpation_--_i. e._, usually
amputation. In the carpus and tarsus _resection_ will often suffice,
and also when the disease is limited to joint ends. Occurring in the
pelvis, ribs, sternum, or cranium, more or less extensive _resections
of flat bones_ are necessary, in the latter place leading to exposure
of the dura (of which one need have no fear). The same rules with
regard to cleansing and packing the wound should be observed as in
operation on tuberculous bones.
NECROSIS OF BONES.
Necrosis corresponds to gangrene of soft parts, and the term, when used
by itself, is limited to death of bone tissue. Necrosis by itself is
a distinct disease, but indicates the termination of some preceding
disease process. It may be considered as:
1. Traumatic;
2. Pathological--_i. e._, the result of disease; or
3. Toxic, due to the presence of specific poisons in the system.
1. =Traumatic Necrosis.=--Traumatic necrosis is due to the
discontinuance of the blood supply by accident or by separation of
the whole or a part of a bone in the same way. Thus in consequence of
_multiple fractures_ fragments occasionally die and require removal.
The same result has been ascribed to traumatic or non-_traumatic
embolism_ of the principal nutrient artery of a bone, but the
possibility of this condition is doubtful, bone being too well supplied
by its surrounding periosteum. Necrosis in connection with fracture is
rare except in compound fractures, and, when a detached fragment can be
seen, may be anticipated by removal of the same.
2. =The Pathological Form.=--The pathological form is due to the
preëxistence either of _tuberculosis_, _syphilis_, or an _acute
infection_, such as _osteomyelitis_. It may also be the result of
_acute infectious periostitis_, where the periosteum is completely
loosened from the shaft of a long bone. These conditions are connected
either with the slow ravages produced by granulation tissue, or with
the acute septic processes by which infected exudates shut off large
areas from sufficient blood supply, or by which in consequence of
septic thrombosis a similar condition results. In consequence there may
be met bone dying in small visible particles, or the entire shaft of a
long bone or several smaller ones may be involved in the destructive
processes.
The portion which dies is known as the _sequestrum_, which may assume
irregular and unusual shapes, varying entirely with the area involved.
The general character and size of a sequestrum will depend upon the
nature of the cause. In acute osteomyelitis it is either a bone shaft
or an epiphysis which thus suddenly dies. In the slower processes the
fragments may be of almost any imaginable size and form--irregular with
jagged ends, or long, extending completely through a bone, either from
end to end or from side to side.
3. =The Toxic Forms Of Necrosis.=--The toxic forms of necrosis
are due mainly to two substances used in the arts--_mercury_ and
_phosphorus_--whose use seems to be inseparable from the manufacture of
many modern industrial products.
_Mercurial necrosis_ may come either from the volatilization of the
metal in factories where mirrors are made or from refineries where
amalgam is distilled. It also occurs from the _internal use_ of the
drug. Its effects are seen more frequently in the alveolar portion of
the lower and upper jaw than elsewhere. It is through some unknown
peculiarity that the jaws are the bones commonly involved in both of
these forms.