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.