A system of practical medicine. By American authors. Vol. 2 - Unknown

The points of resemblance are manifest, just as they are between a syphilitic and a variolous pustule, but they end in both cases when we come to study the evolution of the phenomena either from an anatomical or from a clinical standpoint. They may be expressed as follows in tabular form:

OSSEOUS LESIONS DUE TO INHERITED SYPHILIS.	RICKETS.
The swellings, particularly those of the long bones, show themselves at or soon after birth.	Rarely appear before six months, generally still later.
A history of syphilis or evidence of existing syphilis in one or both parents.	No such history necessarily.
Preceded or accompanied by snuffles, coryza, and cutaneous and mucous lesions.	No such prodromata.
No such prodromata in most cases.	Pallor, restlessness, sweating, nausea, diarrhoea, etc. constitute a combination of symptoms which often precede the bone disease.
Cachexia absent or moderate.	Cachexia marked.
Physiognomical peculiarities of syphilis present.¹²¹	Not present as a group.
Circumscribed tumors on frontal and parietal bones, rarely on occiput.	Cranial bones thickened in spots, usually upon the occiput.
Ribs not markedly affected.	All or nearly all involved.
Swellings on long bones or extremities irregular.	Extremities symmetrically enlarged.
Disease of ribs, when existent, not ordinarily coincident with that of other bones.	Nearly always so.
Fontanels close at usual period.	Closure delayed.
Other syphilitic symptoms present; enlargement of phalanges, metatarsal bones, etc.	Syphilitic symptoms absent.
Often accompanied by sinuses, synovitis, abscesses, cutaneous ulcers, etc.	Little external or surrounding involvement.
Generally disappears by resolution, without leaving any permanent change.	Usually leaves some bending of shaft and distortion of the neighboring joint.
Mortality among children in whom many bones are involved is very great.	Much less.
Specific treatment useful.	Of no benefit.
In the first stage there is an exuberant calcification of the ossifying cartilage, causing necrosis of the new-formed tissue and a consecutive inflammation, which terminates in the separation of the epiphyses.¹²²	This is less marked. There is formed, instead, a soft and non-calcified osteoid tissue.

¹²¹ See p. [313].

¹²² This table is founded on one which I added to the translation of Cornil made by Dr. Simes and myself, and is compiled chiefly from the excellent work of Dr. Taylor already alluded to.

The diagnosis of the bone lesions of hereditary exostosis can readily be recognized in a short time by noting the fact that they are stationary, even if their later appearance, larger size, the absence of syphilitic history or symptoms, and the resistance to specific treatment left us in doubt.

The diagnosis from accidental separation of the epiphysis, or from fractures, may be made from the history of the case.

In cases of separation of the epiphysis, complicated with suppuration, sinuses, etc., the trouble may be mistaken for a similar condition due to non-specific inflammation. In all the recorded instances, however, the latter has occurred much later in life, is attended with much more acute inflammatory symptoms, lymphangitis, etc., and is of course without concomitant symptoms of syphilis. In both these cases there is a decided osteo-periostitis, and as so much depends on the early and vigorous use of specific treatment, it may be worth while to contrast the two forms of the disease.

SYPHILITIC OSTEO-PERIOSTITIS.	NON-SPECIFIC OSTEO-PERIOSTITIS.
Occurs in infants under three months of age.	No instance of its occurrence in children under one year of age.
History of syphilis in child and its parents.	No history of syphilis; sometimes a history of traumatism.
Implication of other bones.	Usually confined to one bone.
Coincident with the development of the shaft of the bone.	Coexists with the ossification of the epiphyses.
Other lesions of syphilis: nodes, skin eruptions, etc.	No such symptoms.
All the local symptoms comparatively mild.	Pain, redness, and swelling very marked.
Disease sharply localized.	Involves neighboring parts.
Lymphatics of limb unaffected.	Lymphangitis present.
Beneficial effect of specific treatment if employed early.¹²³	No such effect.

¹²³ Cornil, op. cit., p. 274.

Syphilitic dactylitis in the inherited variety of the disease, as in the acquired, consists of two varieties. The one of these which usually appears earlier involves chiefly the periosteum and the fibrous and integumentary structures surrounding a joint, usually a metacarpo- or metatarso-phalangeal articulation, involving a phalanx, and is characterized by slow, almost painless, swelling and discoloration of the affected member. (Fig. 9.) This is due to a gummous infiltration which, after absorption under proper treatment, leaves the toe or finger temporarily stiff, but not permanently disabled.