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Osteomyelitis, its Pathology and Surgical tion, a diaphysitis, while the staphylococcus by prefer

Treatment.

BY ROBERT M. FUNKHOUSER, M.D.

Read before the St. Louis Medical Society, October 26, 1895.

As reports come pouring in in connection with the study of experimental disease, there is borne in upon us the conviction that we are upon the threshhold of most startling and most important information. Instead of preserving the hard and fast lines in etiology and bacteriology, there will appear a number of types or varieties of disease dependent upon the same micro organism or modified by the presence of one or more of them. The trend of thought, based upon experimentation, is, that many diseases are due to the same micro-organisms, but the symptoms differ owing to the individual idiosyncrasy, general condition of the patient, the virulence of the virus, climate, season of the year, injury and the presence or absence of other micro-organisms. For, it has been observed that a streptococcus may give rise to abscesses, or, if of increased virulence, to erysipelas, to general purulent infection and to rapid septicemia. And we must not overlook the fact that what appears to apply to the streptococcus applies to many other microorganisms, viz., that the forms of micro organisms, as in the streptococci which have been classed according to variations in appearance, are not constant and may vary at different periods in a series of cultures of the same

ence, as it were, selects the juxta epiphyseal regions, producing an epiphysitis. Both regions, however, may be affected in the same case. A grave form of osteomy. elitis, rare, running a fatal course in a few days and seen most frequently in children and infants, is usually due to the streptococcus.

The epiphyseal region has been called, by Ollier, "the zone of election of pathological processes." It is here that the tissues are undergoing transitional changes during the period of growth, when the medullary substance is very vascular, is without fat and communicates with the medullary canal and with the periosteum. As the blood vessels have no separate walls of their own the cocci have an easy passage into the young vascular tissue, thus favoring the deposits of pus. The direction of the nutrient artery does not appear to determine the location of the morbid process, as it is usually in the upper end of the femur.

CAUSATION.-A number of observers have produced this disease by injecting pus or virus into the veins of an animal after fracture of one of its bones, causing suppuration of the bone. Ullmann was successful, after many trials, in causing these symptoms by injecting the virus into animals suffering from a considerable loss of blood without any previous injury to the bone being necessary. It is easier to comprehend the types of extra-vascular infection than those forms where no external wound is present, "the intra-vascular infections." The fact must not be overlooked that micrococci are found in the circulation even when no suppuration takes Now, osteomyelitis is a disease dependent upon the place. A favorable opportunity is only lacking for the presence of pyogenic cocci, which may be located in the manifestation of the infection, which may result from medulla, spongy or cortical bone or periosteum, all of the lowering of the vitality of the patient and the locus which, it is possible, may be involved, the compact por-minoris resistentiæ, become weakened by these ever tion never being primarily involved. It is the sequelæ, present and watchful carriers of disease. And a more necrosis in particular, that has been observed in the favorable seat could not be selected than the usual one past, not the disease process which usually runs an where the disease commences, which the changes in acute course. This has been overlooked or misinter-nutrition of a rapidly growing bone offer. preted. To Pasteur belongs the credit of being one of There are predisposing causes as well a direct inthe first to attribute this,inflammation of bone to micro-juries, and bruises and sprains. Long exposure to cold

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tis. I believe it should be tried in conjunction with the surgical treatment. It may serve to hasten resolution and prevent the the extension of the morbid changes. The specimen which I present was taken from a patient who had suffered with osteomyelitis a number of years. The cause, I believe, was due to a very extensive and severe burn. Some of the toes were lost. Every bone of the foot was diseased; there were a num ber of fistulous openings, the ankle joint was affected, and, as can be seen, both the tibia and fibula were shelled out. Though the bones were diseased at the point of amputation she made an excellent recovery with a useful stump.

and wet bear an important relation to this affection. Of course in each case in question it will be necessary Thus, in infectious diseases, particularly the exanthe- to make a bacteriological diagnosis. I am not aware mata, the vitality of the system is lowered and thus more that this treatment has ever been applied to osteomyeli readily affected by the cocci, the infection almost invariably taking place through the blood vessels, although occasionally it may follow the lymphatics, whether the point of infection is the tonsil, skin, intestines or else. where. As the disease spreads the pus extends to the exterior through channels, as the Haversian canals. The pus at first is of a brownish color, containing drops of medullary fat and possessing a diagnostic value. Abs cesses of the bone and periosteum may be caused in a certain number of cases by a mixed infection of cocci, with typhoid bacilli, with the bacillus of tuberculosis and probably with the virus of syphilis. A distinction should be made, which has not been done in the past, between the pyemias and tuberculosis of bone, many cases of both, particularly the latter, having been mistaken for osteomyelitis. There appears to be a certain kinship existing between puerperal septicemia, pyemia, erysipelas and, in fact, between all diseases where there are present streptococci. Streptococci taken from a case of puerperal septicemia having produced abscesses in the ends of long bones of animals near the epihyseal cartilages.

DIAGNOSIS.-The diagnosis of this disease is some times very difficult as it has been mistaken for typhoid fever, acute articular rheumatism, pyemia and tuberculosis of the bone. The chief diagnostic sign in osteomyelitis is the acutely sensitive spot near the junction of the epiphyses. It should be remembered that the acute symytoms of osteomyelitis run a very rapid course.

Early Operation in Osteomyelitis.

BY PINCKNEY FRENCH, M.D

Read before the St. Louis Medical Society, October 26, 1895.

Tuberculosis is the most frequent chronic affection of bone in children and young adults. Osteomyelitis is the most frequent acute inflammatory affection of the bone in children and young adults. After the skeleton be comes fully developed osteomyelitis is rare and tubercu losis of less frequent occurrence.

Surgical literature of the past furnishes descriptions of osteomyelitis following gunshot wounds of cone, comminuted fractures and amputations; but osteomyelitis occurring independently of such injuries was not PROGNOSIS.-The prognosis as to life is favorable, understood until quite recently. Investigations by fore. except in the fulgurant cases, but as to the arrest of the most pathologists elucidated valuable facts which have morbid processes and the usefulness and preservation materially modified the opinion of the surgeon as to the of the limb and joints, it is not promising. Volkmann causes and his practice in the treatment of many reports 32 examples or carcinoma which developed in the granulations protruding from the fistulous openings, additional examples where an inflammatory process has been transformed into a malignant growth.

TREATMENT.—It is of the utmost importance that the disease be recognized at the very earliest stage, as perhaps in no other disease will such favorable results follow the early surgical treatment, the opening up of the deposits of pus. This can be done by the chisel, trephine or drill, whichever instrument the case demands or the surgeon prefers. A free opening down to the medulla in the early stage is necessary; the disease will be arrested, implication and destruction of the tissues avoided, general infection prevented and the life of the patient saved.

diseases.

Formerly we read of pelvic diseases and pelvic peri tonitis as primary affections. Now, we recognize these affections as secondary, depending upon diseases of the rectum and uterine appendages. Peritonitis, both local and general, was regarded as a primary affection, and we heard of idiopathic and traumatic peritonitis. We now know that idiopathic peritontis does not exist and that all peritontis is secondary to other diseases.

Uterine displacements, anteversion and flexion, retro. version and flexion and downward displacements were formerly described with detail, and operative treatment was practiced for their relief and correction. Modern surgeons have learned that the symptoms formerly at tributed to uterine displacements depend chiefly, if not As has been indicated, some bacteria appear to in wholly, on diseases of the uterus and appendages. Sur. crease the severity of the symptoms in some cases of geons once busied themselves with the management of mixed infection, so others are antagonistic. The serum typhlitis and peri-typhlitis as primary affections; now of one streptococcus has proven advantageous for other they are know to be secondary to the real trouble, ap. streptococcic infection. In puerperal fever, where the pendicitis. So, too, surgeons, in not a remote period, infection was due to the streptococcus, the anti-strepto-treated an acute suppurative peritonitis and ostitis as coccic serum proved beneficial, but when the infection primary affections; it is now known that all such affecwas due to the bacterium coli no results were obtained. tions are secondary to osteomyelitis.

Bacteriological researches have established the fact and thick dressing and supportive splint applied.

that all primary suppurations in bone invariably begin in the medullary tissues, and that osteomyelitis is an acute suppurative inflammation of the medullary tissue caused by infection with pus microbes. The facts recently established convince us that the essential excit ing cause of this disease is the presence of the pus microbe; that the infection takes place by their circulation in the blood; that they are received into the circu lation from a suppurating wound or through the respira. tory or intestinal mucous membrane, and that they localize in the medullary tissue because of anatomical peculiarities of capillary vessels, their calibre being four times as great as the arterial branches that supply them.

The

wound is dressed daily and heavily spinkled with iodoform during the after-treatment.

In a brief way we mention the results to be established by the "Early Operation," which is here confidently urged:

1. It affords opportunity for removing the local cause of the disease.

2.

It relieves and prevents pain.

3.

It prevents or limits necrosis.

4.

It prevents septicemia and pyemia.

5.

It prevents infection of adjacent soft structures.

6. It shortens the duration of the disease.

7. It prevents infection and invasion of adjacent joints.

8. It expedites recovery.

9. It greatly diminishes the mortality of the disease.

Cataract.

BY DR FLAVEL B. TIFFANY, KANSAS CITY, MO.

[CONTINUED.]

Histological investigation has also shown that the smaller blood vessels of the medullary tissues have no vessel walls proper. It has been observed by clinicians that in the vast majority of these cases the microbes localize near the epiphyseal lines. This is readily understood by the fact that during the growth of the bone we here find new and imperfectly developed capil· lary vessels, a condition highly favorably to the lodge. ment of microbes. It is believed that pus microbes in. habit persons in perfect health-that they can not cause Cataract sometimes appears in middle life when it disease as long as the circulation in the different tissues goes on to maturity but does not become hard, yet is of of the body remain normal. It has been shown that the a greater consistency than the ordinary so called infanmedullary tissue is so altered in nutrition by acute tile or congenital cataract. Be this nuclear or congenifebrile diseases, such as smallpox, scarlatina, typhoid tal, it is whiter, more uniform, and less striated in apfever or measles, and that they are prepared for an at-pearance than the senile cataract. The cortex sometack of suppurative inflammation. Having thus defi times assumes a satiny appearance or like mother of nitely determined the true cause, it is now considered pearl. I have a case now due to an attack of la grippe prudent and proper surgery to expose freely the medul. where the lens is of a flaky spermaceti appearance not lary cavity in every case of acute suppurative osteo unlike boric acid crystals. myelitis, just as soon as the diagnosis can be firmly es tablished in order that the seat of the inflammation may be subjected to direct and efficient treatment.

This mode of procedure is termed "Early Operation," and should be done before secondary suppurative periostitis, ostitis and synovitis have appeared, which is evi denced by much swelling and tenderness of the adjacent soft structures. Esmarch's apparatus being applied and the primary focus of the disease being accurately located, an incision is carried through the soft structures down to the bone, usually in the vicinity of the epiphy seal junction. The soft tissues are reflected and the bone is opened along its center with mallet and chisel. If no pus is found, bloody serum will escape, and the increased vascularity and softness of the medullary tissues will be readily recognized. The free opening of the bone does not, by any means, complete the opera tion, but every particle of the infected tissues within the medullary cavity must be removed by a sharp bone curette; therefore the size of the opening to be made into the bone depends chiefly upon the extent of the disease in its interior.

Sterilized hot water and peroxide of hydrogen are used to disinfect the cavity after the curettment, and the wound is then carefully packed with iodoform gauze

In advanced lenticular cataract there may be specks on the capsule from cell proliferation; or, if the lens has undergone great degeneration, its detritus may be precipitated on its capsule. The deposits on the capsule give an idea of the stage to which the opaque lens has arrived, and suggests lesions of deeper tissues of the globe. Cataract produced by a strain of the power of accommodation seems to be more frequent in the astig. matic eye where the astigmatism is against the rule. (The astigmatism of the myopic eye is usually in the 90th meridian; while that of the hyperopic eye is in the 180th).

Soft and lamellar cataract is of early life, usually congenital. Infantile is usually hereditary and is very frequently due to consanguinity, to dissipation or excesses on the part of one or both parents. The sins of the progenitor are frequently visited upon the progeny in this way.

Congenital cataract as the name implies, exists at birth and is brought about from an arrest of, or from mal nutrition during the development in utero.

Lamellar or zonular cataract is another mark in the child evidencing some indiscretion or sin committed either wittingly or unwittingly by the parent.

Glass blowers who are exposed to intense radial heat

are especially susceptible. Concussion from the passage mass. In this case the portions of the lens remaining of a cannon ball and lightning stroke have produced were movable, which is frequently the case where the this form of cataract.

Traumatic cataract may be induced by an injury that will give rise to a puncture of the lens capsule, to luxation of the lens, or to a concussion sufficient to change the nutrition of this body.

FIG. 12.

ANTERIOR POLAR CATARACT.-This form of cataract (A, Fig. 12) may be congenital or infantile, usually in fantile. The opacity is confined to the anterior pole and is seen as a small dot in the center of the pupil. Anterior polar cataract is due to the ulceration of the cornea, which perforates and allows the aqueous humor to escape, where upon the iris, the lens fall forward, and the zenith of the lens comes in contact with the cornea. There is then an exudation of lymph with ad. hesion of the capsule of the cornea. The opacity is limited to a small circular space because of the contracting of the pupil. Subsequently, the cornea heals, the aqueous humor is re-established, the chamber deepens; but the deposit of lymph upon the capsule interferes with the nutrition and a permanent opacity remains; thus, anterior polar cataract is formed. It is also occasionally formed by an exudation of lymph from kerati tis where there is no ulceration of the cornea, but from its swelling, the anterior chamber is so shallowed as to allow the endothelial layer of the cornea to come in contact with the capsule of the lens; lymph is thrown out, interfering with osmosis, followed by permanent opacity of the lens. Occasionally, there is a shred remaining which runs from the opaque spot of the cornea to the apex of the lens.

CASE.-N. W., a negro, was admitted to my clinic March, 1891, with the history of having had a needling of the cataract when he was a child. A portion of the central part of the lens of the right eye had been ababsorbed leaving a white cretaceous shell of its cortical portion. One-half of the lens of the left eye was partially absorbed, the other half consisted of a chalky

needling had not been properly done. The discission here evidently was made too extensively and the lens was luxated from its bed. The needle probably was passed too deeply so as to rupture the hyaloid membrane, allowing the vitreous to come in contact with the lens. Such a casualty is very liable to result in a tardy absorption with cretaceous metamorphosis of a portion of the lens. In such a case as is manifested here, the vitreous frequently becomes fluid and there is a peculiar gelatinous trembling or shaking of the iris. The prog. nosis is always unfavorable.

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PATHOLOGY.

A cataract is formed by metamorphosis with degeneration of the lens tissue brought about by imbibition of fluids through the capsule or by arrest of nutrition or by mal-nutrition. The lens first swells and vacuoles are formed which are filled with a fluid or semi-fluid containing metamorphosed tissue with perhaps pus corpuscles. The fluid eventually disappears and there is a contraction of the tissues and the lens diminishes in size. In senile or hard cataract the opacity is due to sclerosis which begins at the nucleus of the lens. The lens from detritus may become fluid, containing broken down lenticular substance. Not infrequently we have deposition of cretaceous or chalky substance.

[graphic][merged small][merged small]

The symptoms are both subjective and objective. The principal subjective symptom is that of diminution of vision varying from a slight haziness to almost complete blindness according to the extent and density of the opacity. If it is infantile cataract and the opacity is at or near the axis the patient looks to one side, above, or below, to gain a more distinct image of the subjects, and has a habit of passing his little hand rapidly before his eyes. If the opacity is allowed to remain for some length of time there ensues an involun

frequently give a stellate appearance. In this form of cataract the patient may complain of seeing objects double or multiplied; for instance, when looking at the moon, he will say that he sees several moons. This is due to the fact that the rays of light passing between the opaque striæ form separate images of the object up. on the retina.

PROGRESS.

tary oscillation of the globe, known as nystagmus, and this oscillating is quite rapid. It is usually of a lateral motion, sometimes vertical, and sometimes rotary, dis appearing, in a measure if not entirely, if vision be gained by an early operation; but if the operation is deferred, the nystagmus is liable to continue although fair vision is secured by the removal of the lens. This form of cataract is especially liable to produce strabismus. In early life the patient complains sometimes of diplopia as well as of polyopia (double or multiplied vision). The progress of the cataract may be determined The pupil in these little patients, with this affection somewhat by the width of the striæ. A cataract with instead of being black is of milky, greyish white, opal- broad, opalescent, opaque striæ is of rapid development, escent color, varying in degree according to the stage very fine, multiple strise, as in hard cataract indicate a of development Sometimes the opacity is a dense, more tardy development. In fluid cataract, the striæ white circular spot, situated in the center of the are less distinct or even wanting, the lens is of a milky pupil (as in Fig. 13). In this patient the eyes were white appearance, and no nucleus is to be seen. slightly undeveloped, being somewhat micropthalmic, quently in this form of cataract there is a feeble develthe nystagmus was of the rotary form, and the irides did opment of the mental faculties. I have noticed this not respond promptly to the mydriatic, the pupils only more especially in negroes. partially dilating.

Fre

[graphic]

FIG. 14.

In some cases there may be greyish spicule radiating from the white center, assuming a stellate appearance (Fig. 14); if the opacity is limited to the pole of the lens, either anterior or posterior, and is very small, as is frequently the case, it being merely a white speck, it might be overlooked by the casual observer as it is only brought to view, especially the posterior polar cataract, by means of the oblique illumination or by the ophthalmoscope. If the cataract is lamellar or zonular, as in Fig. 15 radiating or centripetal striæ will be seen.

FIG. 15.

These striæ vary in length and are arranged somewhat like the spokes of a wheel with a greater definition at the peripheral portion, becoming less distinct as they approach the center.

The strise of the soft or cortical cataract are wider and less numerous than in the hard or nuclear, and the opacity is of lighter milky white color than hard cataract.

Soft or infantile cataract runs a more rapid course of development than hard cataract. Looked at with the ophthalmoscope, the bright reflex of the retina will be seen between the opaque striæ, and these strise and dots

FIG. 16.

In senile cataract the patient complains of a haziness of vision, requires strong light for near objects, and is obliged to change his glasses frequently for a stronger pair; but sooner or later he finds that there is no glass that will give him satisfaction. Frequently, after a certain stage of development, he can see even better without a glass or he finds that a weak concave glass im proves vision. This condition is termed "second sight," and is due to a swelling of the lens which renders the eye temporarily myopic. The lens, however, increases in opacity, vision becomes more dim, and the patient will speak of seeing a dark spot before the eye which he sometimes designates as simulating a spider or small fly, and in whatever direction he looks, the spot will be projected in this direction and will assume a different shape and size according to the stage of development of the cataract. The patient often claims of seeing this spot on the book or on his plate and tries to brush it away. He finds that he can see to read better at twilight or in daylight with his back to the light or if the eyes

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