The principles and practice of modern surgery

by Roswell Park

Bones and Joints.

—Syphilitic manifestations in bones are frequent, but are not so common in the joints. While early syphilitic periostitis is not infrequent the actual lesions of the bone are mostly expressions of late syphilis. Nearly all of them are painful. The pain is worse at night, and is called the osteocopic pain of syphilis. At first these bone lesions are hyperplastic, because of the connective tissue in the bone. Periostitis is a common manifestation, and here, again, the neoplastic tendency of the disease is manifested, in that the periosteum is thickened as well as the bone beneath, and swellings called nodes are thus formed. Nodes are met with more often on the tibia and the sternum than elsewhere, but are frequent upon the skull and clavicles. No bone is exempt from these lesions. They often form at points where there has been previous injury. These swellings are ill-defined, and usually quite tender, while the skin over them is easily movable unless secondary infection has occurred and suppuration is present. The nocturnal pains in these lesions, of which patients often complain, are sometimes excruciating. Should suppuration occur, with subsequent formation of ulcer, there may be necrosis of the exposed bone. Another bone lesion of syphilis assumes the type of ostitis. Physiologically this consists essentially of gummatous involvement of the connective tissue, which may be either localized or diffuse. When this undergoes retrocession there occurs a rarefaction of the bone, by which it is weakened and easily broken, so easily in fact that we have to deal sometimes with what is referred to as spontaneous fracture. There is frequently a thickening and condensation of the entire bone, with some distortion, so that the actual weight of the bone may be nearly doubled. Dactylitis is the name given to syphilitic ostitis of the phalanges, which increase in size and become tender and useless, while the skin becomes glazed. Occasionally the disturbance appears to involve the extra-osseous tissues rather than the bones themselves. Bones which are spongy are liable to this disease. Some of the bones in the face are peculiarly susceptible; hence the loss of the bridge of the nose, or of a portion of the hard palate, by the ulcerative processes so common in this disease.

The joints are subject to changes somewhat similar to those occurring in tuberculous disease. There may be either a gummatous synovitis or an arthritis, or else destruction of articular surfaces. These joint lesions of syphilis are all slow in their course, and sometimes difficult of distinction from tuberculous and other lesions. They have so much in common with the joint expressions of tabes that some writers believe that tabes is necessarily an expression of syphilis of the cord.

As long as no active destruction has occurred within a bone or joint these cases are usually amenable to treatment, but for the actual destructions caused here or elsewhere by syphilis there is no repair possible, and the harm once done cannot be undone. Plastic operations and injections of paraffin may have to be practised for cosmetic purposes and relief of disfigurement.

Muscles and Tendons.

—It is the connective tissue of muscles which suffers most in the luetic affection of these structures. It may be met with as a diffuse process or as a gumma. In the former cases the muscle becomes irregular in shape and size, and in the latter distinct tumors are formed. As such growths advance and contract adhesions to surrounding structures, there is interference with muscle play.

Syphilitic myositis causes little pain, and patients with gummas in muscles are often not seen until ulceration has begun.

The dense fibrous structure of tendons and aponeuroses is frequently involved in late syphilis, causing pain and disability. Little is discovered on physical examination, but considerable loss of function may result. Points of tenderness sometimes are noted along junctions with the adjoining periosteum. Such a tendoperiostitis may be painful, and even crippling.

Bursæ.

—Bursæ are prone to be involved in syphilis, especially those in front of the patella. A gumma frequently develops at this point, where it constitutes a painless, somewhat tender enlargement, which may be dense or elastic. After it has become adherent to the skin it is usually infected, and a chronic ulcer results at this point, which may often manifest gangrenous tendencies. This constitutes one form of so-called housemaid’s knee.