+DISEASES OF THE BONES+
+Congenital Defects of Bones.+ Various congenital deformities of the
limbs occur because of interference in various ways with the proper
and normal formation of these cartilaginous masses. If, for any
reason, the cause of which in most cases is not clear, any of these
cartilaginous masses fail to be formed in the embryonic tissues,
naturally no ossification can occur, and in such cases there may be a
partial or complete lack of development of the corresponding bone. The
amount of this congenital deformity may vary from the absence of an
entire foot, to the absence of one or several digits, or one or more
phalanges.
The deformities produced by such a failure to deposit the
cartilaginous base of the bones are very numerous, and in some cases
lead to great deformity and loss of function. This lack or increase of
the reformation in cartilage, results in most extraordinary
deformities.
No special type of deformity merits special attention; the condition
in each case must be decided by inspection and X-ray examination.
In many of these cases, especially where the lesion affects the
digits, the capability of the individual is but little impaired,
whilst in other cases, where bones are absent, marked deformity and
impairment of function may occur. Some of the cases, notably webbed
toes, are comparatively easily corrected; other cases however, offer
little chance of sufficient cosmetic or functional gain to make a
surgical operation necessary or desirable.
+Atrophy of Bone.+ Various causes may lead to atrophy of bone. The
method by which atrophy is brought about is peculiar, and is due to
the action of special giant cells, called osteoclasts. Wherever
extensive atrophy of bone takes place, microscopic inspection shows
such giant cells lying closely adjacent to the trabeculae of the bone
which is being resorbed, and the trabeculae in that immediate vicinity
slowly disappear under the action of these giant cells. Their action
is very similar to the action of giant cells in the soft tissues about
absorbable foreign bodies. This process is called _lacunar
resorption_.
In old people the amount of absorption oftentimes is very great; the
process is then termed _senile atrophy_. It may be marked in the skull
and in the long bones, and in many cases of fracture of the neck of
the femur, a moderate amount of lacunar resorption precedes the
fracture which results from slight violence. In certain cases this
resorptive process in old people is extreme, and leads to great
fragility of the bones, with repeated fractures from slight violence,
which under ordinary circumstances, would cause no injury at all.
A mere lack of use of bones may also lead to a certain amount of
atrophy from lacunar resorption. This may be seen after amputations,
where the stump of bone which is left from the amputation slowly
undergoes lacunar resorption and sometimes a marked diminution in
size. The same thing may also be seen in the bones of people who for
long periods of time have been deprived of the use of their limbs,
either by the application of apparatus around fractures, or by disuse
for other reasons.
Lacunar resorption also occasionally follows lesions of the central
nervous system, part of the atrophy being due to disuse of the limbs
from the paralysis, and part of it also being dependent in some
indirect way upon the nerve lesion.
Atrophy of bone also may be brought about by pressure. It is to be
remembered that the bone, as a matter of fact, is not a perfectly
rigid material, but that processes of new formation and resorption are
constantly taking place, even under normal conditions. If, for any
reason, bone is put under constant pressure, a certain amount of
readjustment of the bony constituents takes place in order to adapt
the bone to its altered condition. The most striking example of this
sort of atrophy is perhaps the Chinese ladies’ feet, where the bones,
being bent into an abnormal position, beginning early in childhood,
ultimately show enormous deformity and an entire rearrangement of the
trabeculae of the bone. The same thing also may be seen occasionally
after pressure and deformity from contracture of muscles or from the
pressure of scars. This process, which ordinarily leads to loss of
function, in a certain limited number of cases aids function, for
whilst certain fractures of the joints may lend to deformity of the
articular facets of those joints, by absorption of certain portions
and new formation in others, a readjustment of the joint surface may
take place, so that a marked increase of function may occur.
A certain amount of atrophy also may be brought about by the pressure
and development of tumors.
+Hypertrophy of Bone.+ In many cases new growth of bony tissue is due to
the new formation of periosteal bone, and is an expression of an
attempt at repair of one or the other of the numerous destructive
processes. In other cases true hypertrophy of the bone, with no
connection with any reparative process, may occur.
A notable example of this is seen in the growth of bone which
sometimes occurs after amputation, especially in young people. The
increased size of the bones which is seen in many definite diseases
will be mentioned under the proper headings.
+Caries and Necrosis.+ Various pathologic processes produce destruction
of bone. The destructive process may cause the death of large areas of
the affected bone at once, and in that case, a large fragment of
necrotic bone may remain in situ and still maintain its contour.
Destruction of bone of this sort is described by the clinical term
_necrosis_.
Other processes cause a gradual molecular softening and destruction of
bone, which ultimately may be very extensive, but at no time is there
present any appreciable large mass of bone. Destruction of this sort
is described by the clinical term _caries_.
As a means of differentiating clinical conditions, the use of these
two words is desirable. As a clinical term, _necrosis_ usually means
destruction by pyogenic infection, and _caries_, destruction by the
gradual extension of a tuberculous process. This clinical distinction,
however, is not an exact one, because destruction of large areas of
bone, described as necrosis, is occasionally brought about by
syphilitic infection, and rarely by tuberculosis, whilst molecular
destruction of the bone is brought about by a considerable variety of
processes, the chief of which, it is true, is tuberculous infection,
but actinomycosis and syphilis may both lead to the gradual
disintegration of the bone, without the formation of large necrotic
masses of bone.
The presence of necrotic bone connected with the surface of sinuses,
from which comes a discharge of pus, should always lead to the
consideration of tuberculosis, actinomycosis, and syphilis. The
presence of large sequestra of bone should immediately suggest the
presence of osteomyelitis or of syphilis.
+Treatment.+The details of the treatment of the various forms of
destructive processes in bone will be found under their special
headings, chiefly under osteomyelitis and tuberculosis.
In all cases of caries it is desirable to remove completely the
softened areas in the bone. This may be done by curettment and
drainage, or by excision of the entire bone, or series of bones, in
certain cases, or rarely by amputation.
The difficulty in all these cases is to recognize the exact limits of
the carious process. It must be borne in mind that at the time of
operation upon carious bones the field of vision of the surgeon is
almost always limited; moreover, the bleeding which always takes place
from the bone-marrow in such cases, also obscures the field, and even
if these two causes were not present, it is frequently extremely
difficult, by naked-eye examination to determine the exact limits of
the destructive process. As a general rule, it can be said that the
carious area is at least a quarter of an inch wider than appears upon
visual inspection.
In cases of necrosis with large bone defects, the difficult thing is
to cause a growth of the bone toward the central cavity after removal
of the sequestrum. The various methods applicable to such cavities are
mentioned in detail under “Osteomyelitis.”
+PERIOSTITIS+
+Acute Periostitis.+ The older text books always laid great stress upon
the occurrence of an acute infectious inflammation of the periosteum.
Acute suppurating periostitis alone does not occur, and most of the
cases which have been described as such are really mild cases of
superficial osteomyelitis, with abscess formation beneath the
periosteum, and possibly slight inflammation of the periosteum itself.
These cases ordinarily lead to only a slight destruction of the outer
layer of the cortical bone.
+Symptoms.+ These are the same as in acute osteomyelitis, except in a
very much milder form. There is usually a rise of temperature,
oftentimes with a chill, with circumscribed tenderness over some
portion of the shaft of one of the long bones.
+Treatment.+ Incision over such an area shows an elevated periosteum,
with a small, localized abscess beneath it, with bare, white, somewhat
vascular bone cortex. Incision alone in most cases suffices to cure
the disease, although if the process has extended sufficiently deep
to cause a superficial necrosis of the outer layer of the cortex,
removal of a small sliver of necrotic bone may be necessary.
+Chronic Periostitis.+ A long-continued and chronic irritation of the
periosteum, sufficient to cause a proliferation of the osteogenetic
cells of the periosteum, is common in a great many diseases. A chronic
thickening of the periosteum with a new formation of bone, is seen
frequently after traumatism, blows or contusions; sometimes after the
occurrence of superficial abscess of the soft tissues in the immediate
vicinity of the shaft of the long bone, described as chronic ulcer of
the surface of the tibia; or after certain infectious diseases,
notably syphilis. It also may occur after various other local
infections. In such cases the thickening of the periosteum ordinarily
is pretty sharply localized.
A general thickening over the periosteum, and over several or many of
the bones of the body, also occurs in the disease known as _toxic
osteoperiostitis ossificans_, seen in diseases with long continued
suppuration. It also is common after syphilitic disease, either
congenital or acquired.
+Symptoms.+ The symptoms of chronic periostitis with new formation of
bone are invariable. In a certain number of cases there is a constant,
heavy, dull pain, at the point of thickening, with at times more or
less acute exacerbation; at other times the lesion is associated with
no pain whatever, and the patient’s attention is first called to the
disease by the presence of the enlargement of bone. Recognition of the
condition may depend upon X-ray examinations for indefinite pains in
or over the bone.
Chronic periostitis is not really a disease itself, but a
manifestation of the reaction of the periosteum to some irritant.
+Treatment+ of the condition depends, first of all, upon a recognition
of the cause and a removal of the cause, when possible. In many cases,
especially those in which no pain is present, nothing in the way of
therapeutic measures can be done.
The chronic thickening of the periosteum, seen in many definite bone
diseases, will be mentioned under those diseases.
+Osteomyelitis.+ Infectious osteomyelitis is acute suppuration of the
bone, always due to the infection of the bone marrow by pyogenic
microorganisms. The process is essentially like the process seen in
furuncle, and begins in the marrow of the alveolar spaces, which
communicate freely with each other, but are enclosed by a dense shell
of cortical bone. Hence the process may quickly at first involve the
entire marrow of an infected bone, because the products of bacterial
infection are retained in this dense shell, while the primary focus
can only be reached by extensive bone operation.
Most cases are due to the staphylococcus pyogenes aureus and a few to
the streptococcus. Typhoid bacilli may cause suppuration. The
infecting organism is present in pure culture but sometimes a mixed
infection occurs, and such cases are said to be severe.
In cases of chronic osteomyelitis with open sinuses and exposed bone,
a great variety of organisms, pathologic and saprophytic, may be
present. Hence infectious osteomyelitis is not a specific disease, but
is acute inflammation of bone that may be produced by any one of a
variety of pathogenic organisms, or by a mixed infection.
Any pyogenic organism which can be carried in the blood may be
deposited in the bone and produce suppuration. Some of these organisms
may settle by preference in the bone marrow, others beneath the
periosteum, or in the joint.
Certain general causes favor the occurrence of osteomyelitis. Children
are chiefly affected and it occurs in boys about three times as often
as in girls. Acute osteomyelitis frequently occurs after injuries of
moderate severity, because such injuries may lower resistance of the
bones and make them unusually susceptible to pyogenic infection. One
of the commonest causes is the infection of a compound fracture, and
before the days of asepsis, such cases were very frequently fatal.
Under modern methods the infection, when it does occur, is generally
slight, although the destruction of bone may greatly delay healing and
may lead to the formation of small sequestra and indurating sinuses.
Infection of a similar sort may occur subsequent to amputation.
Osteomyelitis nearly always begins in the diaphysis of the long bones,
usually near the epiphyseal line. This is an important point,
clinically, because tuberculosis practically begins in the epiphysis.
In rare cases, however, osteomyelitis begins in the epiphysis, and so
may simulate tuberculosis. The femur and tibia are the bones most
frequently attacked, but no bone is exempt. Usually only one bone is
affected, but cases of multiple bone infections are not rare.
The primary area of infection is always in the bone marrow. The bony
trabeculae and the cortex are destroyed only secondarily. The process
nearly always begins in the diaphysis, but then may extend into the
epiphysis and produce suppuration of the joint. Once the organisms
have gained access to the marrow, they produce a toxin which causes
necrosis of the adjacent marrow cells, and this necrosis may extend
over a very considerable portion of the bone before marked
infiltration with leucocytes occurs. The infection usually extends
quite early through the dense cortex by way of the Haversian canals,
and produces an inflammatory exudation and suppuration between the
periosteum and the outer layer of the cortex, which is designated
_subperiosteal abscess_.
Such an abscess may strip the periosteum from the bone over very
extensive areas. The infection may then extend to the adjacent soft
parts, muscles and subcutaneous tissue, and form an abscess outside
the periosteum.
If, from spontaneous opening of the abscess or from operation, a fatal
result is avoided, the infective process may be limited and the
process of repair may begin.
As a rule, a portion of the infected marrow and cortex become
completely necrotic, and the lime-bearing portion of the bone
persists as a more or less extensive sequestrum.
The periosteum in the early stages may be separated from the bone by a
collection of pus, and in such cases it appears as a thin fibrous
membrane beneath the muscles, separated from the bone by the abscess
cavity.
Secondary changes occur in the soft tissues surrounding the seat of an
acute suppuration of bone. During the acute stage there may be a
definite abscess of the soft parts, with an infiltration which
simulates phlegmonous inflammation, or, by rupture of the abscess,
various sinuses may be formed leading down to the necrotic foreign
body. In long continued cases the skin and subcutaneous tissues become
thickened by the formation of scar tissue, due to the presence of the
involucrum and the persistence of sinuses, and by thickening of the
soft tissues, an affected limb may for years be nearly twice its
normal size.
+Symptoms.+ The disease usually begins with a sharp onset, the first
symptom being a sudden localized pain in the vicinity of the
epiphyseal line, or in the shaft of some one of the long bones. This
pain is extremely intense, and in typical cases is most excruciating.
Motion of the joints at this time is not painful, but the pain
produced by percussing the bone, even lightly, may be intense. An
extremely valuable diagnostic point is continued gentle pressure at
some point over the shaft of the bone at a distance from the point of
greatest constant pain.
Usually, at a very early period, there appears swelling of the soft
parts about the bone. This swelling, at first, is neither hot nor red,
but soon becomes edematous, red, and shows pitting on pressure, and at
that time may simulate acute phlegmon.
In some cases the adjacent joint early becomes tender, hot and
swollen, and this may occur even when there is no real extension of
the infectious process to the joint itself. If extension does occur to
the joint, swelling, tenderness, and pain on motion become more
intense. The temperature usually is elevated to a considerable
degree—103°F. or 104°F.—and usually the pulse is greatly accelerated.
Evidence of constitutional disturbance and absorption of infectious
material occur early. The tongue is dry, coated and tremulous; the
face is drawn and flushed. Delirium of a mild type is a very common
symptom, and in some cases this delirium may persist for a
considerable length of time after the bone has been drained. Abscess
of the soft parts may give deep or superficial fluctuation. Sinuses
may appear. The leucocyte count is usually very high—25000 to
35000, and chiefly of a polynuclear type.
Such a clinical picture is perfectly distinct, and it is difficult to
overlook typical cases, especially after the fluctuation in the soft
parts has occurred. The diagnosis of early cases, however, is
sometimes very difficult, and even in the hands of experienced men,
who have the lesion in mind, is frequently impossible. Even in severe
cases, occasionally the pain itself is not severe for several days,
when there may come a sudden exacerbation of symptoms.
In the chronic stages of osteomyelitis the symptoms are usually
characteristic. The limb is enlarged, the enlargement being partly due
to thickening of the soft tissues, but chiefly to the formation of the
involucrum. Usually running down to the sequestrum, are enormous
sinuses, from which comes a foul, purulent discharge. On passing a
probe, dead bone can be felt at the bottom of the sinuses. It must be
borne in mind, however, that in a great many cases, after attacks of
osteomyelitis of moderate severity, small localized abscesses are
formed in the shaft of the long bones, with no sinus communicating
with the surface. An abscess of this description, as has already been
stated, is always surrounded by a wall of dense bonelike cortical
bone.
Such an abscess may persist for years with no symptoms beyond a
moderate enlargement of the shaft of the bone at the point of abscess,
and the enlargement may be so slight that it is not recognized by the
patient. In other cases the entire shaft may be enlarged, but the bone
may not be tender. In most cases, however, such a localized abscess
sooner or later gives rise to recurring attacks of pain, which, as a
rule, are extremely violent. The intervals between such attacks may
vary from days to weeks, or to months, or even to years. The attacks
of pain may come on, apparently, perfectly spontaneously. Associated
with these attacks of pain, the bone over the abscess usually is
exceedingly tender to touch. With the attacks of pain may come a rise
of temperature, or in some cases, there may be no disturbance of the
general condition. This kind of abscess may be of small size, no
larger than a pea, or may involve a great portion of the shaft of the
bone; in such abscesses no definite sequestrum may ever form.
The recognition of such conditions depends upon recurrent attacks of
violent pain over circumscribed areas of bone, with or without
constitutional disturbance, and nearly always with extreme local
tenderness.
+Treatment.+ In the acute stage there is suppuration of the marrow, more
or less extended throughout the shaft, with often a subperiosteal
abscess and perhaps abscess of the soft parts.
The indications are the same as in any other acute suppuration; the
pus must be evacuated and the bone cavity drained. This demands not
only an incision into the soft parts, but an opening into the shaft of
the bone. If a piece of necrotic bone is present, it should be
removed.
In the chronic stage there is usually an old necrotic shaft perforated
by sinuses, and often freely movable, inclosed by a shell of dense
periosteal bone. The sequestrum must be removed, but the bony defect
fails to heal, and for months persists as a filthy, discharging
cavity, with the constant danger of secondary infection and phlegmon,
or erysipelatous inflammation. The healing of this cavity is very
difficult and requires a very long time.
Many methods have been tried for the filling of these bone cavities
with blood clot, iodoform and oil of sesame, but they have not been
successful, because it is almost impossible to render such cavities
absolutely aseptic.
+Tuberculosis of Bone.+ Tuberculosis of bone is always dependent upon
infection of the marrow of bone by the tubercule bacillus. This germ
obtains entrance to the bone marrow and causes the formation of
miliary tubercules which arise from the proliferation of the
connective tissue of the marrow around the primary tubercule. Other
secondary tubercules are formed by extension of the tubercule
bacillus. The centres of these tubercules become caseous, and, by
fusion of adjacent caseous areas, also cause softening in the bone
marrow.
The tuberculous process, as a rule, begins in the epiphysis in the
long bones, and may affect any of the bones.
+Symptoms.+ In cases of tuberculous disease confined to the bones alone,
the first symptom usually is pain, which ordinarily is not severe and
has a gradual onset. Oftentimes, at first on palpation, no difference
in the shape of the bone can be detected.
Toes affected by a tuberculous process, slowly enlarge at first
without heat or pain; ultimately the skin becomes thickened, and
reddened, and the digit is painful to pressure or motion. Oftentimes
the skin is perforated at one or more points by sinuses lined with
tuberculous granulations, through which caseous pus is discharged.
The diagnosis in these cases always lies between tuberculosis,
actinomycosis, syphilis, and osteomyelitis, and exact determination of
the origin of the cause oftentimes can be made only by inoculating
animals with a discharge from the sinus, or by detection of pyogenic
organisms, or of the miliary tubercule, the histologic unit of
tuberculosis, or by detecting the peculiar yellow bodies seen in
actinomycosis.
+Treatment.+ From a clinical point of view tuberculosis of bone should
be considered in the same category as malignant disease, and the
indications for treatment in all cases of tuberculous bone disease are
the same as in malignant disease; which is, complete removal of the
infected area, whenever it is possible.
In some cases the mere opening and curetting of tuberculous areas in
bone is oftentimes enough to set up sufficient reaction in the bone
and in the surrounding tissues, to put an end to the tuberculous
process. Complete resection of bones may at times be avoided by this
treatment.
In addition to the local treatment of opening, curetting and drainage,
or the complete excision of the bone, the greatest care should be
employed in the management of the general hygiene of the patient,
including feeding and fresh air. Often removal to a climate which is
unfavorable to the development of tuberculosis in general, is also
extremely desirable.
+Syphilis of Bone.+ The lesions produced in bones by syphilitic
infection may be congenital or acquired, and, as in other syphilitic
lesions, the manifestations may be protean.
Most children with congenital syphilis, show an irregularity of the
epiphyseal line, which results in the latter becoming markedly
toothed, instead of constituting a straight line across the bone, at
right angles to the long axis of the shaft.
Besides the irregularity of the epiphyseal line, three other changes
are seen in the bones of syphilitic infection. The most common lesion
is one which affects the periosteum and leads to the formation of
periosteal bone. This periosteal formation may occur either in
congenital or in acquired syphilis, and it may affect one or many
bones. In some cases there is an enormous thickening of the epiphysis
of the bones, and as a result of the epiphyseal thickening, secondary
changes in the joints occur, so that the thickening of bones and the
changes in the facets of the joints, suggest fracture or dislocation.
In other cases, the thickening affects only the shafts of the long
bones, generally of the leg or arm, although no bones are exempt. In
some cases, both in the congenital and acquired forms, there may be
marked proliferation of the endosteum of the bone, with or without
thickening of the periosteum, although thickening of the periosteum
usually is present. This process, as a rule, affects one bone in its
entirety, and most commonly affects the bones of the lower leg,
notably the tibia. As a result of these changes the bones are enlarged
and thickened, and in some cases, from endosteal thickening, the
marrow canal is very largely or entirely obliterated. In some cases
true gummata of the bone are formed. These gummata may appear in the
spongy portion of the bone, sometimes in the shaft, or in the
epiphysis. They also appear to be formed in the lower layers of the
periosteum and lead to circumscribed nodular thickenings on the
surface of the bone.
+Symptoms.+ These vary with the different pathologic conditions present.
The periosteal thickening may occur at any time of life over any bone
of the body.
The presence of circumscribed periosteal thickening of bone in itself
should always lead to the suspicion of the presence of syphilis.
Pain, as a rule, is only very slight, and the diagnosis depends upon
the history and the detection of other syphilitic lesions.
The cases in which there is both endosteal and periosteal thickening,
occur chiefly in children and are of a congenital nature.
The physical symptoms are very characteristic. The bone usually
affected is the tibia, which is enlarged to a most marked degree, and
often shows a pronounced bowing forward, similar to the bowing and
thickening of the tibia seen in osteitis deformans. The bone is
extremely dense and obviously heavier than normal. The bones are
moderately tender to pressure, but have nothing like the extreme
tenderness noted on pressure in osteomyelitic bones.
In cases of gummata of bones the symptoms vary. In some cases the
gummata are on the surface of the bone, especially the sternum, and at
times on the long bones. In such cases there appear a softening and
reddening of the skin about the affected area, which remains indolent
for a long time.
If such an area opens spontaneously, or is opened by incision, the
contents are seen to be composed of a yellow, rather gelatinous
material, quite like the caseous material from a tuberculous abscess.
+Treatment.+ In most cases the regular anti-syphilitic treatment is
indicated. In cases of periosteal thickening, the results vary with
the time at which the treatment is begun. In the early cases, a
thorough anti-syphilitic treatment may lead, after a varying length of
time, to complete disappearance of the newly formed periosteal bone.
On the other hand, if the periosteal process has lasted for a long
time and the bone has become densely cortical, although
anti-syphilitic treatment may lead to a diminution of the localized
pain, the dense bone does not disappear. In cases of combined
endosteal and periosteal thickening, the pain usually disappears under
anti-syphilitic treatment but the changes in the bone persist.
+Osteomalacia+ is an acquired disease which causes marked softening and
changes in the bones. The disease begins irregularly and often
progresses with or without remissions. The progress is more marked
during pregnancy. The first sign is pain in the bones, which is
increased by pressure, and this is especially true of pressure over
the ribs. There are also muscular cramps and contractures.
+Osteitis Deformans.+ (_Paget’s Disease_). This is a chronic disease of
the bones and may affect one or more bones of the body. The onset is
insidious, and before actual deformity occurs, long indefinite pains
in the legs may have existed, with occasional tender points over the
bone.
The bony changes are first noticed in the bones of the legs and are
most marked in the tibia, femur and fibula. As a result of structural
changes, these bones become bowed, while their internal trabecular
structure is altered.
The extent of the affection in the bones of the legs varies a great
deal and usually is not symmetric. The lower extremities are bowed
outward, and also are usually bent forward, the curves being due to
changes in the femur and the lower leg.
+Treatment.+ In the absence of any knowledge as to the cause of the
disease, the treatment of osteitis deformans must be largely
symptomatic. Certain drugs have been recommended; among these are
iodide of potash and arsenic. Most such patients are in poor general
condition, and effective feeding often gives marked relief of the
symptoms from which they are suffering.
For severe pain, counterirritants are valuable, especially the actual
cautery. Massage is of use in some cases for improving the general
condition.
+Tumors of Bone.+ All the primary tumors of bone are of the connective
tissue group, but various secondary tumors of epithelial origin may
occur.
Osseous tumors may arise from the periosteum or from the marrow. If
they arise from the periosteum they may extend early to the adjacent
soft tissues and involve and destroy them. If the tumor arises in the
marrow, it is for a long while cut off from the adjacent soft tissues
by the thick cortex, and about the extending medullary tumor may also
come a reactive proliferation by the periosteum, so that as the tumor
extends it still may, for a long time, be surrounded by a shell of
bone which prevents infection of the soft parts. After a time,
however, the reactive periosteum shell usually becomes perforated at
one or more points, and then the medullary tumor extends to the
adjacent tissues. The cause of these tumors is absolutely unknown.
+Fibromata+ are not very common tumors of bone. They arise generally
from the periosteum and are most common about the face, and are rarely
seen in the long bones. Many of these tumors are closely allied to
some of the fibrous forms of sarcoma, and it is often difficult to
distinguish them histologically.
+Chondromata+ are fairly common tumors of bone. They may appear
externally to the cortex, or sometimes they grow in the medullary
canal. They may arise directly from the marrow, probably from remnants
of the provisional cartilage cells. They also appear frequently to
arise from the epiphyseal line.
Chondromata appear generally as multiple masses, nodular in shape, and
are frequently seen on the lower leg, about the knee joint. They
usually are painless, firm and hard, and not tender to pressure.
+Treatment+ consists in removal by operation.
+Osteomata+ are bony tumors which generally arise by growth of the
periosteum, and form solid bony masses external to the cortex of the
bone, when they are called _exostoses_.
The density of the bone composing the tumor varies a great deal, some
being very hard and ivorylike, while others are like the cellular
marrow of the long bones.
Osteomata may be surrounded by a layer of fibrous periosteum or, in
certain cases, beneath the periosteum appears a layer of cartilage
producing the so-called _exostosis cartilaginea_. The latter formation
is the one which is most common in the vicinity of the epiphyseal line
of the long bones, notably of the leg.
Osteomata form circumscribed hard nodular masses of bony consistency,
and are usually painless. They may cause interference with function
from their size, especially when they appear in close connection with
a joint.
+Treatment+ is complete and thorough removal.
+Sarcomata+ are the most common tumors of bone; they are malignant, and
when removed, tend to recur, either locally or by metastasis, in
different parts of the body. The metastases usually are distributed by
the circulation.
These tumors may arise from the marrow, but generally in the epiphysis
of the bone and extend to the shaft only at a later stage of their
development. As the tumor advances, it causes a softening and an
absorption of the original cellular marrow until it approaches the
periosteum.
In many cases the periosteum, as about any form of foreign body, then
begins to proliferate and forms a shell of periosteal bone surrounding
the tumor. In that way the shell of the bone oftentimes becomes very
much enlarged before there is any extension of the process through
the shell to the adjacent tissue. By destruction of the marrow and of
the cortex, great softening of the bone may occur so that spontaneous
fractures not infrequently are seen.
Other sarcomata arise from the periosteum, and usually originate from
one side of the bone, although occasionally they entirely surround the
bone. In the periosteal sarcomata, a new formation of bone is common
and the bone is frequently arranged in a radical way, giving a most
remarkable picture on the X-ray plate.
+Myeloma+ is a very rare malignant tumor of bone. Such tumors always
appear only in connection with bone, are usually multiple, and are of
the same type as other lymphoid tumors.
The cells of such tumors resemble very closely the type of plasma
cell. These cells are arranged in masses without an intercellular
substance, and the tumors are closely allied to the malignant
lymphomata. The cases are always associated with albuminuria.
+Symptoms.+ The chief symptoms of malignant tumors are swelling and
pain, both of which oftentimes are extreme. The swelling may be
spherical or spindle shaped.
+Extension+ to the joints may not occur for a great length of time. In
many cases X-ray examination is the most reliable method of detecting
the character of the bony change.
+Treatment+ of all sarcomata is early and complete removal. This means
in nearly all cases, amputation of the affected bone, and it is
important that the amputation should be of the entire bone through the
joint between the bone and the body, rather than amputation of the
bone in continuity. The reason for this is, that even in sarcomata,
which have not extended to the soft parts, very frequently there have
occurred metastases of tumor-cells throughout the blood sinuses of the
affected bone, often times at a distance of several inches from the
site of the original primary tumor.
+Carcinomata.+ Cancer of bone always is secondary to cancer in some
epithelial organ. The infection may take place by direct extension
through the blood or the lymphatics.
In cases of metastatic invasions of bone, spontaneous fractures
oftentimes are the first symptom which calls attention to the fact
that metastases have occurred.
+Treatment.+ As in other malignant tumors, the indication is for
absolute and radical removal whenever possible. Unfortunately, this
very seldom can be done, because at the time the bone has become
affected by extension to any great degree, radical operation is
impossible. Many times, however, extensive operations must be
undertaken for the removal of bone.
+Cysts of Bone+ are rare lesions which practically always occur
secondary to other lesions. They may occur as the result of the
degeneration and softening of bone sarcomata. Some of the cases of
bone cysts undoubtedly represent the entire destruction of sarcomatous
processes. Occasionally echinococcus cysts of bone occur.
+Treatment.+ Cysts of bone due to softening of the centre of sarcomatous
tumors, like sarcomata themselves, are to be treated by complete
removal, best usually by amputation. Cysts of bone not due to the
presence of sarcomatous tissue, should be opened and drained in some
cases. Cysts due to the presence of echinococcus, should be opened and
drained, with the removal of every vestige of the echinococcus.