Osteomyelitis

“ 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 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. ”

“ 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. ”

“ Like other pyogenic infections, it may terminate in pyæmia, as a result of septic phlebitis in the marrow.
The clinical features of osteomyelitis in an amputation stump are those of ordinary pyogenic infection; the involvement of the bone may be suspected from the clinical course, the absence of improvement from measures directed towards overcoming the sepsis in the soft parts, and the persistence of suppuration in spite of free drainage, but it is not recognised unless the bone is exposed by opening up the stump or the changes in the bone are shown by the X-rays. ”

“ The most common is an osteomyelitis commencing in the marrow exposed in a wound infected with pyogenic organisms. In amputation stumps, fungating granulations protrude from the sawn end of the bone, and if necrosis takes place, the sequestrum is annular, affecting the cross-section of the bone at the saw-line; or tubular, extending up the shaft, and tapering off above. The periosteum is more easily detached, is thicker than normal, and is actively engaged in forming bone. ”

“ 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. ”

“ In young animals even rachitis, which is accompanied by various digestive disorders, may serve as the point of origin for infectious rheumatism and all its complications.
In older animals—i.e., in animals from five to six months, or even twelve to fifteen months—infectious rheumatism may occur without a clearly defined cause. It then develops with the symptoms and lesions of that condition known as “osteomyelitis of adolescence” in human pathology. These forms of osteomyelitis are due to infection with streptococci and staphylococci. ”

“ Infection with the staphylococcus albus, the streptococcus, or the pneumococcus also causes a mild form of osteomyelitis which may go on to suppuration.
Necrosis without suppuration, described by Paget under the name “quiet necrosis,” is a rare disease, and would appear to be associated with an attenuated form of staphylococcal infection (Tavel) . It occurs in adults, being met with up to the age of fifty or sixty, and is characterised by the insidious development of a swelling which involves a considerable extent of a long bone. ”

“ Age is an important factor in regard to the action of certain bacteria. Young subjects are attacked by diphtheria, tuberculosis, acute osteomyelitis, and some other diseases with greater frequency and severity than those of more advanced years.
In different races, localities, environment, and seasons, the pathogenic powers of certain organisms, such as those of erysipelas, diphtheria, and acute osteomyelitis, vary considerably. ”

“ The inflammatory lesions at the ends of the long bones--tubercle, syphilitic gumma, and Brodie's abscess, that resemble myeloma, are all attended with the formation of new bone in greater or lesser amount. The myeloma is also to be diagnosed from chondroma, from sarcoma, and from osteomyelitis fibrosa cystica. ”

“ Among diseases which affect the skeleton as a whole and render the bones abnormally fragile, the most important are rickets, osteomalacia, and fibrous osteomyelitis. In these conditions multiple pathological fractures may occur, and they are prone to heal with considerable deformity. ”

“ That is to say, the micro-organisms having begun to germinate in the damaged bone find their way by the blood-stream into other tissues, and developing after their kind, are apt to cause blood-poisoning. Should a surgeon prick his finger whilst operating on a case of septic osteomyelitis his blood also might be poisoned, and he would run the risk of losing his finger, his hand, or even his life. ”

“ In osteomalacia, the bones are profoundly altered, but they are more liable to bend than to break; in rickets the liability is towards greenstick fractures.
Of the diseases affecting individual bones and predisposing them to fracture may be mentioned suppurative osteomyelitis, hydatid cysts, tuberculosis, syphilitic gummata, and various forms of new-growth, particularly sarcoma and secondary cancer. It is not unusual for the sudden breaking of the bone to be the first intimation of the presence of a new-growth. ”

“ An operation upon one maxillary sinus has been known, even in the most skilful hands, to cause death by meningitis or diffuse septic osteomyelitis of the cranium. Post-mortem examinations show that this disaster was due to infection spreading upwards from an infected ethmoid, frontal, or sphenoidal sinus, when local resistance had been diminished, or the virulence of the organisms has been increased by the surgical traumatism of the maxillary sinus. ”

“ In these multiple forms of osteomyelitis the toxaemic symptoms predominate; the patient is dull and listless, or he may be restless and talkative, or actually delirious. The tongue is dry and coated, the lips and teeth are covered with sordes, the motions are loose and offensive, and may be passed involuntarily. ”

“ Even under favourable conditions, and with the continuous effort at reconstruction of the bone by Nature's method, the return to normal is often far from perfect, and there usually remains a variable amount of hyperostosis and sclerosis and sometimes curving of the bone. Under less favourable conditions, the late results of osteomyelitis may be more serious. _Shortening_ is not uncommon from interference with growth at the ossifying junction. _Exaggerated growth_ in the length of a bone is rare, and has been observed chiefly in the bones of the leg. ”

“ The Recognition and Removal of Sequestra.—So long as there is dead bone there will be suppuration from the granulations lining the cavity in which it lies, and a discharge of pus from the sinuses, so that the mere persistence of discharge after an attack of osteomyelitis, is presumptive evidence of the occurrence of necrosis. Where there are one or more sinuses, the passage of a probe which strikes bare bone affords corroboration of the view that the bone has perished. When the dead bone has been separated from the living, the X-rays yield the most exact information. ”

“ DISEASES OF BONE--Definition of terms--Pyogenic diseases: _Acute osteomyelitis and periostitis_; _Chronic and relapsing osteomyelitis_; _Abscess of bone_--Tuberculous disease--Syphilitic disease--Hydatids; Rickets; Osteomalacia--Ostitis deformans of Paget--Osteomyelitis fibrosa--Affections of bones in diseases of the nervous system--Fragilitas ossium--Tumours and cysts of bone. ”

“ If sepsis gains the upper hand in a compound fracture there is, firstly, the risk of infection of the marrow—osteomyelitis—which in former times was liable to result in pyæmia; in the second place, not only do loose fragments tend to die and be thrown off as sequestra, but the ends of the fragments themselves may undergo necrosis ”

“ This clumping together of the hæmatoblasts forms white clots which block the smaller vessels, but in the viscous condition they further the coagulation of the fibrine, and again when they come in contact with the intima, instead of passing through, or moving on, they remain adherent and start the formation of thrombi. This is above all common in given tissues, and the medulla of bone has in this respect a bad preëminence, so that acute suppurative osteomyelitis, is a familiar lesion and is liable to become chronic, and determine distant abscesses and general infection long after. ”

“ It is undoubtedly easy to induce osteomyelitis artificially in living animals.
III. On puerperal fever.—First observation. On the twelfth of March, 1878, Dr. Hervieux was good enough to admit me to his service in the Maternity to visit a woman delivered some days before and seriously ill with puerperal fever. The lochia were extremely fetid. I found them full of micro-organisms of many kinds. A small amount of blood was obtained from a puncture on the index finger of the left hand, (the finger being first properly washed and dried with a STERILE towel,) and then sowed in chicken bouillon. ”

“ In the human subject, multiplication in the blood-stream does not occur to any great extent. In some general acute pyogenic infections, such as osteomyelitis, cellulitis, etc., pure cultures of staphylococci or of streptococci may be obtained from the blood. In pneumococcal and typhoid infections, also, the organisms may be found in the blood.
It is by the vital changes they bring about in the parts where they settle that micro-organisms disturb the health of the patient. ”

“ Results of Bacterial Growth.—Some organisms, such as those of tetanus and erysipelas, and certain of the pyogenic bacteria, show little tendency to pass far beyond the point at which they gain an entrance to the body. Others, on the contrary—for example, the tubercle bacillus and the organism of acute osteomyelitis—although frequently remaining localised at the seat of inoculation, tend to pass to distant parts, lodging in the capillaries of joints, bones, kidney, or lungs, and there producing their deleterious effects. ”

“ On section note thickening of the bone (osteomyelitis ossificans) , thinning (osteoporosis, excentric atrophy) , enlargement of medullary spaces, obliteration of spaces by newly-formed bone (osteosclerosis; bone becomes heavy and solid like ivory) , and caries (pyogenic infection, tuberculosis, syphilis, actinomycosis, neoplasm) . Caries occurs in both spongy and compact bone, but more often in the former. The necrotic bone appears as soft, friable granules (molecular necrosis) or sequestra, between which living bone or granulation-tissue may be found. ”

“ Impacted hip, where the neck of the femur has, in a fall, been driven into the head, is common in old people. Sometimes, especially in young children, the bone is infected, osteomyelitis. Sarcoma occurs. Most tubercular disease of the hip originates at the upper extremity of the femur, tuberculosis generally starting in the head and then attacking the capsule and the soft parts of the joint. If neglected, shortening of the leg may result, in which case the bone has to be broken and set at an angle in order to enable the child to walk. ”

“ In either case there is a communication between the external air and injured bone, and the probability arises of the germs of suppuration finding their way to the seat of fracture. This greatly increases the risks of the case, for septic inflammation and suppuration may lead to delayed union, to death of large pieces of the bone (necrosis) , and to osteomyelitis and to blood-poisoning. In the treatment of a fracture, every care should be taken to prevent any sharp fragment coming near the skin. Careless handling has often been the means of a simple fracture being converted into a compound one. ”

“ Bone incision operations were performed on Barbara Pietczyk, a Polish girl 16 years old. She was operated on six times. During the first operation incisions were made in each tibia. During a later operation pieces of the tibia were cut out where incisions had been previously made. Maczka took an X-ray of the pieces of tibia that were removed. As a result of these bone operations, Maczka observed the development of two cases of osteomyelitis, Maria Grabowska and Maria Cabaj. (Tr. pp. 1445-7.)
A rather large group of muscle experiments were performed. ”

“ As a rule only one joint, usually knee or hip, is involved in tabes and the affection is generally painless. The progress may be acute, subacute or chronic. Syringomyelia, a disease which may be confused with leprosy, may also show joint involvement, usually of the upper extremity.
Bone Affections
Mycetoma.—As the result of the invasion of an extremity—usually the foot—with the causative fungi, disorganization of the tissues involved takes place. The granulomatous process invades muscles and bones and as a result of the sinus formation we have the bones converted into a softened, cheesy mass. ”