—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.