Complete Text (Part 52)

in the formation of many tumors of the marrow. (c.) There are certain alterations of the epiphyseal carti- lage which occur at the line of ossification, and affect both cartilage and bone. The changes occurring in rachitis are first to be mentioned, and are evinced by an increase in the width of the translucent, bluish-gray zone of proliferation in the cartilage; also by an increase in the width and an irregular course of the white layer of provisional calcifica- 27 418 DIAGNOSIS IN PATHOLOGICAL ANATOMY. tion, and by an irregular extension of the medullary canals with their loops of vessels. With the microscope the normal gro\vth of the cartilage cells is seen to be greatly increased, the cells and intercellular substance are dropsical, the zone of calcification is very wide and provided with numerous, often wide projections ; the formation of bone takes place in a similar irregular manner, and a direct ossification of the cartilage is often apparent. It may be stated in general that those processes which normally follow one another in the transformation of cartilage into bone, pursue their course side by side in rickets. ISIany pieces of cartilage never ossify, and it is from them that enchondromata may be developed at a later period. Another very interesting and important alTcction of tliis zone is due to intra-uterine syphilis^ and indicates hereditary syphilis. In this, too, there is great irregularity in the calci- fication, very similar to that in rickets, and a layer of soft, yellowish-white tissue hes between the calcified portion and the bone, which is considered by Wegner as inflammatory (hence osteochondritis'), and by Waldeyer and Kühner as gummous. A very great development of this tissue may cause a separation of the epipliyses. A special form of osseous tumor, the cartilaginous exostosis, originates in the epiphyseal cartilage. It may occur as a multiple growth on the same or on several bones. A long bony process, the point of which is covered with cartilage, projects from the joint. It seems as if the epiphyseal carti- lage retained its natural function of producing bone even in its pathological outgrowths. (c.) The Marrow. 1. General Appearances. The marrow of the long bones varies greatly in quantity, the medullary spaces of the spongy portion, in particular, be- ing sometimes increased in size (osteoporosis), and sometimes diminished (osteosclerosis). The color is rather more im- portant, not only that of the marrow as a whole or of large THE BONES. ■ 419 portions of it (red, yellow, fatty, translucent, and brown), but also of small circumscribed portions (red, dull yellow, -lemon- yellow, greenish, etc.). The consistency^ which is ordinarily very soft, may become decidedly gelatinous, even quivering, or else more or less indurated ; the latter condition is usually limited to small circumscribed portions of the tissue. 2. Special Morbid Conditions. The marrow undergoes considerable change in the normal processes of development and growth, and is liable to a large number of pathological changes, as has been more and more made evident in recent times. In young people the marrow of all the bones is red and very rich in round, colorless cells with large nuclei ; but after puberty the red color, though retained in the flat bones, vertebraa, etc., is replaced in the long bones by a yellow color, fat being deposited in the cells and fatty tissue formed. This yellow or fatty marrow often becomes of a light brownish color, translucent, and of a jelly- like consistency (gelatinous marrow) in old age. A patho- logical reversion to the red variety sometimes takes place in the fatty marrow of adults, in consequence of inflammation or the development of new formations, and may involve the whole marrow of the bone in which the process is seated, or only limited portions of it ; this reversion invariably takes place before fatty marrow is converted into pus or a new formation. The fatty marrow, on the other hand, sometimes passes over prematurely into the gelatinous variety, as a rule in consequence of some cachexia, and this gelatinous atro- phy is generally associated with atrophy of the cancellated structure of the epiphyses, or osteoporosis. (a.) Of the different forms of inflammation to which the marrow is subject, the ossifying form (osteomyelitis ossificans') is rather reparative or protective in its nature, and often forms a barrier to the extension of more dangerous processes ; it is by this process, for instance, that the medullary cavity is sealed up and recovery rendered possible in fractures, am- putations, and disarticulations of the bones, and also by this process that a bony capsule is sometimes formed round tumors, etc. 420 DIAGNOSIS IN PATHOLOGICAL ANATOMY. Purulent osteomyelitis is manifested by circumscribed yel- low spots from which a thin fluid can be squeezed out, and occurs by preference in the epiphyses, especially of young sub- jects. The yellow spots of suppuration are always surrounded by the red variety of marrow. The pus corpuscles are gen- erally found to be much disintegrated, and the pus is so cor- rosive in character that the operator must be on his guard against infection. Purulent osteomyelitis may give rise to necrosis of portions of the bone, especially in those cases in which the inflammation is of a putrid character (^osteomy- elitis ichorosa) ; these cases are indicated by a more or less dark greenish discoloration of the marrow. , Pus may undergo cheesy degeneration in tlie bones, as well as in other organs, of scrofulous subjects, and the cheesy masses are always surrounded by a red zone. Osteomyelitis caseosa occurs chiefly near the articuhir ends of the bones and there forms the anatomical basis of caries of the joints. (5.) Syphilitic osteomyelitis (^osteomyelitis gummosa') hears a very close resemblance to the cheesy form, the yellow masses to which it gives rise being only rather more dense, of a shade more like that of sulphur, and, as elsewhere, present- ing under the microscope evidence of fatty degeneration. This affection is much more common than was formerly sup- posed, and leads us next to the consideration of tumors in this locality. Tubercle occurs in the marrow both as the circumscribed or secondary form about collections of cheesy material, and as the miliary, disseminated form ; in the latter, the granules are often very difficult of recognition from their close resem- blance to transverse sections of the bony trabeculas ; but their true nature is shown by the facility with which they can be isolated and removed from the red marrow in which they are imbedded. Myelogenous or endosteal sarcoma is generally softer than periosteal sarcoma and, even after having attained the size of the head of an adult, may be enclosed in a thin shell of bony tissue (tumeurs enkystes) which cannot be regarded as THE BONES. 421 the remains of the old bone, but as newly developed from the periosteum. These tumors may be of either the round-, spin- dle-, or giant-cell variety, and the soft round-cell sarcomas, in particular, are very vascular and often the seat of large mul- tiple haemorrhages {sarcoma telangiectodes., fungus lioemato- des^. Cysts, usually multiple, may result from haemorrhages as well as from partial mucous degeneration. Myxoma is rather more rare, enchondroma more common, while primary carci7ioma is very rare and, if indeed it occurs at all, would perhaps be more properly classed as alveolar sarcoma. Metas- tatic nodules of carcinoma, on the other hand, are very com- mon, multiple, and rarely exceed a bean in size. A highly vascular form of carcinoma is also met with which pulsates during life, and may be the seat of hsemorrhages and their consequences, precisely like the similar form of sarcoma. The occasional occurrence of fracture, in consequence of the development of a soft variety of tumor, has been already alluded to. It only remains to mention a few rare changes which are sometimes found in the marrow in certain diseases. In re- lapsing fever a species of local necrobiosis occasionally takes place, and forms a circumscribed mass consisting of disin- tegrated cells and fatty degenerated capillaries. In many cases of leucaemia., etc., a peculiar enlargement or swelling of the marrow is sometimes found, which is as- sociated with a grayish-purple, yellowish, or even puriform, discoloration ; the enlargement as well as the discoloration depends on the presence of masses of the lymphoid, transition form of red blood-corpuscles (nucleated red blood-corpus- cles). Even when the leucaemia is not absolutely myelogen- ous there are invariably found large numbers of those color- less octahedral crystals which have already been spoken of, and which are usually found after death in all bone-marrow, though in smaller numbers. Cohnheim has called attention to a change which he finds in the marrow in pernicious ancemia, and which is very similar to that above described. The marrow is deeply reddened, and is said by him to con- 422 DIAGNOSIS IN PATHOLOGICAL ANATOMY. tain numbers of colored corpuscles with colored nuclei, in addition to the large and small colorless marrow-cells and normal red blood-disks. In tyijlioid fever it is not uncommon to find that the red- dened bone-marrow contains a few nucleated red blood-disks and many cells containing red blood-disks. 3. Morbid Conditions of the Bones in General. The changes which occur in the individual component parts of bone having been described, some of their chief combina- tions in these different parts remain for consideration. (a.) Fracture of bone is attended with changes in all the parts of which bone is composed and in tlie neighboring tis- sues, and the age of a fracture can be approximately deter- mined only through an acquaintance with the modifications which these changes undergo with the lapse of time. The length of time which is required for the reparative process depends in any given case on the extent and nature of the fracture, and the reaction of the bone and soft parts, etc. ; it is therefore impossible to lay down exact rules which will in- clude all cases. In general, however, in simple fracture of a long bone, without excessive displacement of the broken ends, more or less effusion of blood takes place soon after the injury, between the surfaces of the fracture as well as in the surrounding soft parts, and from the condition of tliis blood a conclusion can be drawn as to the age of the injury. At the beginning of tlie second week the blood gradually disappears, while the surrounding soft parts and periosteum become thickened and reddened, and the marrow changes from yellow to red at the seat of fracture. In the third week, while the inflammatory swelling leaves the soft parts, the callus (^periosteal, myelogenous, parosteaV) is formed from the periosteum, the marrow, the fractured surfaces of the bones, and (especially when there is considerable displace- ment) from the neighboring connective tissue. This callus, consisting at first of fibrous, and later of osteoid tissue, be- gins to be converted into bone from within outwards in the THE BONES. 423 fourth week, and between the seventh and ninth week is converted into bone throughout. It is then diminished in size and loses its angles and roughness by concentric atro- phy from without, while excentric atrophy begins simultane- ously in the medullary cavity, which was more or less closed by the myelogenous callus ; the cavity in both ends of the fractured bone is not only thus restored, but the two cavities are united into one, even when one fragment overrides the other. This osteoporosis of the inner layers is the third change undergone by the callus, and compact bone is left only on the outside. The duration of these changes is from ten to twelve weeks in the simplest fractures, but may con- tinue for years in cases of great displacement. A false-joint is said to exist when the fractured ends fail to unite by bone, but this term should be properly limited to those cases in which the medullary cavities are closed by a myelogenous callus, the surface of which is covered with car- tilage, and a true articular cavity lined by connective tissue is consequently formed between the two fractured ends. In spurious false-joint the fractured ends are merely more or less closely united by a fibrous callus. (6.) Eachitis, or rickets, is a disease of early childhood (from six months to five years), but sometimes produces changes which persist up to extreme old age or death. The first stage has already been described, and consists in thickening of the articular ends of the bones (double-joints); the second consists in the deposition under the periosteum of soft, osteoid, but uncalcified layers ; and the third stage of the process consists in greatly increased absorption of the bone from within, consequent widening of the medullary canal, and unnatural redness of the marrow from vascular dilatation, especially in the more severe cases. The two lat- ter processes greatly impair the rigidity of the bones, so much so that bones which are thus affected bend very easily and can readily be cut with a knife, like the bones in osteoma- lacia ; this affection may, however, be distinguished from rickets by the fact that in it the old bones lose their lime-salts 424 DIAGNOSIS IN PATHOLOGICAL ANATOMY. and disappear, while in rickets, the new bone fails to acquire them. Curvature and deformity thus easily result, and may remain permanently after the condition which gave rise to them has been recovered from by a subsequent deposition of lime-salts, sometimes more abundantly even than is normal. ((?.) The various forms of inflammation are very often found combined in the same bone, and even in the same por- tion of the same bone. Nothing is more common, for in- stance, than a combination of purulent osteomyelitis and ossi- fying periostitis, which latter reaches its greatest intensity at that part of the surface corresponding to the seat of the former, but is more widely extended. Ossifying periostitis is also found in the neighborhood of abscesses or gummata of the periosteum, and in tlie caries of the articular ends of bones which results from suppurative arthritis. The height of com- plication is, however, reached in 7iecrosis, particularly when it involves a central portion of the bone. The bit of dead bone, or sequestrum, is surrounded and detached by caries of the bony tissue ; new bone is thrown out from the periosteum, sometimes over the greater part of the surface of the bone and in large quantities, but chiefly over tlie sequestrum, which thus becomes enclosed in a sort of capsule, in which are fis- tulous passages of greater or less size leading down to the dead bone. The surrounding soft parts are in a condition of chronic inflammation, and are likewise more or less rid- dled with fistulse, while ossifying inflammation is set up in the marrow ; the latter process assists in the formation of the capsule of the sequestrum, and may lead to closure of the medullary cavity. (fZ.) A few words may be said with regard to syphilis in bone. As in other tissues, any or every form of inflamma- tion (ossifying inflammation inclusive) may be indirectly of syphilitic origin, though the only forms of a true specific nature are gummous periostitis and osteomyelitis, and these forms can be recognized as specific only when the gummy formation has not been absorbed. If absorption has taken place irregularl}'^ shaped depressions and defects are found TEE BONES. 425 on the surface of the bone, which may be the result of other and entirely different affections, but always awaken the sus- picion of syphilis, especially when they are multiple. This very element of multiplicity may, indeed, excite suspicion of the real nature of inflammations which are apparently per- fectly simple, but never justifies the positive diagnosis of syphilis unless it is supported by other evidences. The par- tiality which is shown by syphilitic inflammation for the anterior surface of the tibia is well known and of clinical value ; its cause may perhaps lie in the extreme liability of the part to mechanical injury. (e.) Brief allusions must finally be made to the condition of the bony tissue bordering on growing tumors. Ossifying inflammation is very apt to be set up both in the periosteum and marrow, and osteoporosis is often combined with these processes, especially when the growth originates in the marrow. These myelogenous tumors often make great de- mands on the periosteum, which is obliged to form new bone constantly in order to cover the increasing surface of the tumor (encysted tumors). IISTDEX. Abdomen, contents of, 100. free bodies in, 102. hiemorrliage into, 101. inspection of, 96. method of examination, 181. Abscess of abdominal walls, 244, 304. of aorta, atheromatous, 37G. of brain, 79. of heart, 12G. of ilio-psoas muscle, 381. of intestine, embolic, 354. of intestine, follicular, 357. of kidney, 213. of kidney, surface of, 204. of liver, 325. of lungs, 145. of muscles, 393. of skin, 19. of spleen, 194. of testicle, 236. of uterus, 254. periarticubir, 405. perinephritic, 201. prevertebral, 384. prostatic, 232. retropharyiifjeal, 180. Acetabulum, alteration of, 402. in dislocation of hip, 407. Acids, as reagents, 6. poisoning from, 297. Acne of cervix uteri, 257. of pancreas, 336. of skin, 24. Addison's disease, 200. Adenoma of kidnev. 220. of ovarv, 269. of prostate, 232. of skin, 35. Alkalies as reagents, 6. poisoning from, 297. Alveolar sarcoma of bones, 421. Amyloid degeneration of coeliac ganglion, 330. of intestine, 366. of kidnev. 208. of liver, 320. of lymph glands, mesenteric, 340. Amyloid degeneration of lymph glands, retroperitoneal, 380. of pancreas, 335. of spleen, 192. of stomach, 294. of supra-renal capsule, 199. of thyroid gland, 179. Anchylosis of joints, 396. Anencephalous foetus, 08. Aneurism, 377. of cerebral arteries, 63. of heart, 127. of valves of heart, 130. Angina, 166, 168. Anthracosis of lung, 138. Anus, condyloma of, 275. prolapse of, 274. Aorta, in general, 372. origin of, 132. Apoplexy, cerebral, 76. Appendices epiploicai, lipoma, 344. Appendix vermiformis, diseases of; 367.