Caries of lower end of femur. (Buffalo Clinic.)
Hereditary bone syphilis is also characterized by osteophytic formation, by the substitution of gelatinous for spongy bone tissue in the neighborhood of epiphyses, and by early and easy epiphyseal separations. It is characterized also by irregularity of ossification of cartilage and consequent deformity of bone ends, especially about the phalanges and the metacarpal and metatarsal bones. In almost every case where doubt would in other respects arise the other evidences of congenital or acquired syphilis are so plain as scarcely to permit uncertainty ([Fig. 230]).
The possible combination of syphilis and tuberculosis in the same subject may occur, the lesions partaking of one or the other character according as the tuberculous or syphilitic taint may predominate.
There is urgent necessity in all cases of syphilis in bone, whether operated on or not, for the combination of suitable internal treatment with surgical intervention. Only by this combination can the efforts of the surgeon be crowned with success. In failure to appreciate this fact operation often seems to be almost futile.
CARIES.
Caries is a term applied to infiltration, and substitution in healthy bone of granulation tissue, which has been in use for many centuries, from a time long before the pathology of the condition was understood. Caries never occurs except in the presence of a specific irritant, which, in general, is tuberculous and sometimes syphilitic in character. The pure type of caries is connected entirely with the formation of granulation tissue, and the slow ravages connected with its presence in and substitution for the original bone. As long as septic infection (pyogenic) is avoided it assumes the dry type, as it used to be known, called by the older writers caries sicca. When the fungous tissue is invaded by putrefactive or pyogenic organisms suppuration takes place, and then occur the moist forms of caries, the caries humida of our forefathers, connected with the presence of pus. When closed areas of bone, small or large, being thus shut off from nourishment, die as the result of its presence the complicated condition used to be known as caries necrotica. Occurring under any circumstances, caries is a result and not a cause, and is to be dealt with accordingly.
Peculiar alterations and markings in bone are the consequence of carious changes, and bones are given a fantastic and peculiar appearance in consequence. The surface is almost always irregular, tunnels or canals are formed, and the bone is often honeycombed, as it were, by the excavations just made. Along with the process of osteoporosis and disappearance of bone at one point may be seen osteosclerosis in an adjoining area, and the bone, which is apparently much weakened by the destructive process, is strengthened in a compensatory way by the artificial density of the tissue undestroyed.
The clinical evidences of caries are those of joint and bone tuberculosis or syphilis, which have been already discussed, and its operative treatment consists always in surgical attack with bone chisel and sharp spoon, according to the rules already laid down. The bone which is completely carious calls for extirpation—i. e., usually amputation. In the carpus and tarsus resection will often suffice, and also when the disease is limited to joint ends. Occurring in the pelvis, ribs, sternum, or cranium, more or less extensive resections of flat bones are necessary, in the latter place leading to exposure of the dura (of which one need have no fear). The same rules with regard to cleansing and packing the wound should be observed as in operation on tuberculous bones.
NECROSIS OF BONES.
Necrosis corresponds to gangrene of soft parts, and the term, when used by itself, is limited to death of bone tissue. Necrosis by itself is a distinct disease, but indicates the termination of some preceding disease process. It may be considered as: