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ON THE

PATHOLOGY OF ACUTE PERIOSTITIS.

BY

CLINTON T. DENT, F.R.C.S.,

ASSISTANT SURGEON TO ST. GEORGE'S HOSPITAL.

(Received May 24th-Read June 14th, 1881.)

THE geographical distribution of disease is a subject which has received its due share of consideration, but a branch of this wider question, viz. :-the variations in different countries and among different nationalities of diseases everywhere common, has not perhaps met with the attention which it deserves. I am inclined to think that the disease treated of in the present paper may possibly furnish evidence that given pathological changes may vary in their progress and results according to the nationality of the patient in whom they are manifest; this is the case with other diseases. Among the Germans and the Turks, for instance, there is a remarkable susceptibility to carbolic acid poisoning.1

Sufficient proof that the pathology of acute periostitis has been matter for difference of opinion is afforded by its varied nomenclature. Thus, it has received the name of "acute periostitis," "osteomyelitis " (Billroth), " péri1 Billroth's Chir. Klin.,' 1876, p. 39.

2 Surg. Path. and Therapeutics,' London, 1877, p. 289.

ostite phlegmoneuse" (Giraldés), "ostéite phlegmoneuse diffuse," "abcès sous-périostique aigu," "ostéite epiphysaire," &c. The exact relation which acute periostitis and osteomyelitis bear to each other, as well as to the articular affections with which they are so often associated, have long been matters of dispute; so also have their effects with regard to the extent of necrosis which usually follows. Among French surgeons the opinion originating with Chassaignac is very generally held, that total necrosis of the shaft will not take place as a sequel of acute periostitis alone, but that osteomyelitis must have coexisted. German writers seem also to have adopted the same conclusion very generally. On this question there seems to be some difference of opinion between continental surgeons and those in this country; but the difference is less than it might appear at first sight, and can be well estimated from a critical résumé in the 'London Medical Record," by Mr. Holmes, on the subperiosteal removal of the entire diaphysis of the bone for diffuse phlegmonous periostitis. Two points may be gathered from this paper:-(1) That osteomyelitis need not necessarily be associated with acute periostitis, and (2) that the entire diaphysis of a bone may be so completely necrosed, as a result of periostitis unaccompanied by osteomyelitis, as to render its subperiosteal removal justifiable and necessary.5 Thus in the case recorded by

1 Cornil et Ranvier, Manuel d'Histologie Pathologique,' Paris, 1881, p. 399.

2 Chassaignac, Mém. de la Société de Chirurgie,' tome iv, p. 281.

3 See a case of acute periostitis of the tibia reported in Billroth's ' Chir. Klin.,' 1867, p. 487, Berlin, 1869.

4 For 1876, p. 73.

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5 Cases where this has been done are referred to in the London Med. Record' for February 15th, 1876, p. 73, by Mr. Holmes. See also the 'Lancet,' vol. i, 1866, p. 340 (referred to by Verneuil in the 'Gaz. Hebd. de Med. et Chirurg.,' 1866, No. 21, p. 321); Med.-Chir. Proceedings,' vol. viii, p. 434 (Mr. W. Pye's case); Weinlechner, Allg. Wien. Med. Zeit.,' No. 24, 1879 (referred to in the London Med. Record,' August 15th, 1879); Holmes, 'St. George's Hosp. Reports,' vol. x, p. 500, and Surgical Treatment of the Diseases of Childhood,' 2nd ed., p. 385, and elsewhere.

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Mr. Holmes, in which he performed this operation, there was no trace of osteomyelitis in the part of the bone (the tibia) examined. I shall presently have to advert to

similar cases.

Considerable difference of opinion prevails with regard to the exact tissue where the changes commence in acute periostitis. The majority of English writers1 seem to hold that the affection either commences in the deeper osteogenetic layer of the periosteum, or as a superficial ostitis, and that effusion or pus raises up the tendinous periosteum, thus leading to the denudation and necrosis of the bone. I do not think that the view is with us generally entertained, that acute spontaneous osteomyelitis is an affection of common occurrence, but it would seem to be otherwise on the Continent, judging by the writings. of continental surgeons, particularly of German surgeons, and from the descriptions of their cases. The term abcès sous-périostique aigu employed by Chassaignac, signifies partial agreement with the opinion that acute periostitis begins beneath the periosteum. Cornil and Ranvier state that the disease consists principally in diffuse suppuration, which may have its seat in any part of the bone-beneath the periosteum, in the superficial layers, in the osseous tissue, or in the central medulla, which is tantamount to saying that there are no means of distinguishing clinically between acute periostitis and osteomyelitis. Billroth and other German surgeons go further, and express very decided views on this affection. Billroth, for instance, in an exceedingly able and suggestive essay on these diseases, states that acute periostitis commences as inflammation of the outer cellular layer of the periosteum; according to his views the fibrous periosteum is destroyed subsequently by suppuration, and thus the bone becomes exposed. Extension inwards of the inflam

2

1 Cf. for instance, Holmes's Principles and Pract. of Surg.,' 1st ed., p. 392, and 'A Syst. of Surg.,' 2nd ed., vol. iii, p. 741; also Crampton "On Periostitis," Dublin Hosp. Reports,' vol. i, p. 331.

2 Surg. Path.,' Hackley's Transl., pp. 289–293.

mation may lead to osteomyelitis. Further, according to Billroth, if it be denied that the outer layer of the periosteum constitutes part of that membrane, but is to be looked upon as the intermuscular cellular tissue, then there is no such thing as acute periostitis, for the tendinous part of the periosteum, he remarks, is as little liable to primary inflammation as the fascia or tendons. I hope to be able to show directly that this does not hold good universally, but that the views of Cornil and Ranvier, which have just been adverted to, are nearer the mark.

2

With regard, first, to the curious affection which attacks the terminal phalanges of the fingers (panaritium periostale of the German writers) and to which the term "whitlow" is somewhat loosely applied by writers in this country, it may be remarked that this is considered by some to be due to acute spontaneous osteomyelitis. Now I do not think that this opinion is generally shared in this country; and it appears rather to me that the older view is more correct. From some slight injury-often from no appa rent cause-inflammation of the cellular tissue, tending to become diffuse, commences in the pulp of the finger. Owing to the close connection which exists between all the tissues of the part, from the skin down to the perios teum and bone, and the unyielding nature of these tissues, necrosis of the whole phalanx readily results. It would seem prima facie most improbable that the affection should begin as osteomyelitis, but it is not unnatural that this complication should follow, although Chassaignac partly denies that subperiosteal abscess will give rise to osteomyelitis; but he is here speaking of the disease as

1 Billroth writes, "Akute spontane Osteomyelitis ist mit Ausnahme der Endphalangen (panaritium periostale) an den oberen Extremitaten selten," 'Chirurg. Klin.,' 1871-76, Berlin, 1879, p. 426.

2 See Crampton, op. cit., p. 333.

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3 Humphry On the Skeleton,' pp. 18 and 394.

4 Chassaignac, who at one time appeared to doubt whether osteomyelitis was ever produced by subperiosteal abscess, seems to allow that this may take place by a case which he records in the 'Mém. de la Société de Chirurgie,' Tome iv, 1857, p. 320. An essay on the subject by the same author, entitled

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