ACUTE PERIOSTITIS.

CLINICAL LECTURE DELIVERED AT ST. GEORGE'S HOSPITAL, LONDON.

BY WARRINGTON HAWARD, F.R.C.S. Eng.,

Surgeon to and Lecturer on Clinical Surgery at St. George's Hospital, etc.

GENTLEMEN,-The subject of my lecture to-day will be acute periostitis, and I have chosen this important disease because there have been recently in the hospital several cases illustrating some of its chief varieties, and some of these patients are still under our observation. I call acute periostitis an important disease, first, because of its comparatively frequent occurrence, and, secondly, because of its destructiveness to both life and limb, if not speedily arrested.

Of its frequency you have had many opportunities of judging, for scarcely a week passes without the admission of a case of this disease into our wards. And surely any disease which is of such frequent occurrence should have, therefore, for us the greatest interest, especially if it be, as in this instance, of serious gravity.

My second reason for regarding acute periostitis as an important disease is that if not recognized and checked at its outset it speedily brings the patient into a condition of serious danger, and, if not fatal to life, may rapidly cripple or destroy one or more of his limbs.

Let me first define for you what I mean by "acute periostitis." It is an inflammation of the fibrous covering of the bone, rapidly leading. to a separation of the membrane from the surface of the bone, by the effusion of inflammatory products beneath it, and also to the obstruction of the periosteal vessels on which the nutrition of the bone largely depends.

It is usual to distinguish two kinds of acute periostitis, the simple and the diffuse, a convenient division, though not always easily made at the outset of the disease. By simple acute periostitis is meant an acute inflammation of the periosteum which, though rapidly leading to the formation of matter, is soon limited to a comparatively small area from its point of commencement. It may occur in apparently healthy

persons, though it is more often seen in those of depressed vitality or who have been debilitated by recent zymotic disease. The symptoms are these. The patient, probably a young person somewhat out of health, receives a blow on one of the more prominent bones. Next day the bone aches severely, the pain being increased by the use of the limb or its dependent position, the temperature rises, and by the second or third night is probably 101° or 102°. The limb now feels hot, and there is acute tenderness over the seat of injury, with a limited elastic swelling upon the bone, and perhaps a blush of redness over the corresponding area of skin. Under appropriate treatment these symptoms may subside without suppuration; otherwise the pain increases, matter forms beneath the periosteum and eventually makes its way to the surface, its escape being followed by a subsidence of the pain and fever, and subsequently probably by the separation of a thin fragment of the outer layer of the bone, the healing of the sinus, and the recovery of the patient.

Such a case you have recently seen in M. J., aged nineteen, an overworked and underfed general servant, who was admitted into the hospital three days after a slight blow on the upper and inner part of the tibia. She complained of great pain and tenderness over this part of the bone, where there was an elastic swelling about three inches long, the skin over which was oedematous and red. Her temperature was 102°, her pulse 120. The limb was placed on a splint, and an incision made without delay through the swelling down to the surface of the tibia, the periosteum being freely divided. An escape of blood-tinged serum occurred, but no pus had formed. Hot boracic dressings were applied, and quinine was given internally. Immediate relief of the symptoms followed, and the girl made a good recovery. In this case the proximity of the swelling to the knee-joint, and the decided evidence of fluid beneath the periosteum, made it desirable to cut down upon the bone without delay; and as, happily, pus had not yet formed, the case came speedily to a good end without any necrosis.

In the early stages of this disease the inflammation may often be cut short by the application of a few leeches, followed by some soothing application, such as a lotion of lead and opium, applied hot and frequently renewed. The limb should of course be kept entirely at rest upon a splint or pillow, and be well raised. The pain in these cases varies greatly with the position of the limb, and is much relieved by keeping the affected part elevated and quiet. Do not, however, neglect the general treatment: the patients are often out of health, and are usually constipated. An aperient therefore may be desirable, and

this may be followed by cinchona and mineral acids, or quinine. Stimulants are best avoided: they increase the pain.

The patient to whom I have referred was notably benefited by the rest, good food, and tonics, as well as by the local treatment.

If, however, in spite of such care, or through the lack of it, the inflammation persists, and fluctuation can be felt in the swelling, an incision should be made without delay, and this incision should divide the periosteum freely. If the fluid has not yet become purulent, so much the better; but in any case a drainage-tube should be inserted, so as to insure the escape of whatever exudation may occur.

Sometimes such periostitis is a manifestation of a chronic form of pyæmia. The pyæmia is chronic, but the periostitis is acute. Many of you have seen a girl (L. K., now about fourteen years old) who has been frequently under my care during the last five years, in whom a great number of the bones have been affected with acute periostitis. In this form of pyæmia, as Sir James Paget has pointed out, the same tissue is apt to be selected by the inflammatory process through the whole course of the disease. This child has had both thigh-bones, both tibiæ, the bones of the arms and forearms, and one wrist affected at different times. She becomes feverish, a bone is painful, and in a few hours a periosteal abscess forms, which may reach a considerable size. On one occasion, before the abscess could be opened, the pus made its way into the intermuscular cellular tissue of the thigh and there formed an immense collection. A most remarkable feature of this case is the anæmia which rapidly ensues on every periosteal attack: the child can be seen to become daily more pallid, and after the healing of the abscess gradually regains her color. I have frequently seen and called your attention to the occurrence of this anæmia in such cases, but in no instance has it been so marked as in this child.

Other examples of pyæmic periostitis are seen after fevers, especially typhoid fever, in which the ribs are peculiarly liable to be the seat of the disease. This form of periostitis in connection with fevers usually ends in recovery after the exfoliation of a thin layer of bone. I would remind you that a syphilitic node―i.e., a localized syphilitic periostitis-may sometimes be acute and very painful, and that acute periosteal swellings are occasionally seen in connection with rheumatism.

You see, however, that the form of acute periostitis which I have hitherto spoken of, though locally damaging, painful, and disturbing, is not a disease of any special gravity, and it presents a marked contrast to the diffuse form, of which I shall next speak. This disease,

known as "acute diffuse periostitis," and sometimes, on account of its common termination, as "acute necrosis," is a serious and dangerous affection, the issue of which will largely depend upon its early recognition and efficient treatment. Every case of it which you have an opportunity of seeing is worthy of your careful examination and study.

Now, one important characteristic of this disease is that it attacks. almost exclusively the young. It is most commonly met with between the ages of ten and fifteen, and more often in boys than in girls. In the majority of cases an injury, often quite a trivial one, seems to have started the inflammatory process; and this may account for its more frequent occurrence in boys, who are more exposed to injury than girls. In some cases, however, no traumatic origin can be discovered. As in the less serious form of periostitis which I first spoke of, the disease selects usually those who are out of health or who are living under unfavorable conditions.

Of those cases lately under our observation, No. 1 was a boy of fourteen years, who lived over a stable. He was in miserable condition, depressed, pale, and ill nourished, and a week before admission had received a blow on the affected bone (the femur); No. 2 was a boy of ten years, also very pale and thin, who lived in a very poor and crowded neighborhood, and who three days before had fallen and hurt the affected limb; No. 3 was a girl nine years of age, who came from an industrial school, of the sanitary state of which we had no knowledge, but she was a delicate, pale, and thin child, and she also had a week previously received a slight injury to the affected tibia.

The symptoms are at first those of fever,-rigors, vomiting, raised temperature; these are soon followed by local pain, generally over one of the long bones of the lower limb; a few hours later there will be found great tenderness to pressure over the bone, and perhaps some deep swelling may be felt; then effusion occurs in one or both of the joints belonging to the bone, the temperature continues to rise, reaching 103° or 104°, fresh rigors occur, and profuse sweating; a little later the whole limb becomes swollen and intensely painful, the skin being more often pallid than red. If free incision upon the bone has not now been made, matter makes its way along the limb and towards the surface, as well as perhaps into one of the adjacent joints; pyæmic symptoms (e.g., pleurisy, pericarditis, pneumonia) probably ensue, and the case in a few days is likely to come to a fatal end.

In some instances pyæmia occurs within a few hours of the commencement of the inflammatory process, and before there has been an opportunity for surgical interference; in other and less severe cases,

when the matter has been let out or has made its way to the surface, the fever abates, and the symptoms are chiefly connected with the suppuration and consequent necrosis. The symptoms in Case No. 1 were typical, and I will briefly relate them; those of the other two cases so closely resembled them that I need not give them in detail.

The boy, who was aged fourteen years, and was weak, pale, and thin, lived over a stable; a week before admission he received a blow on the left thigh. The next day he was feverish and ill; he shivered and vomited and took to his bed. On the third day he had great pain in the left thigh, and on the fourth day the left hip- and knee-joints became swollen and painful. When admitted he looked very ill. Temperature, 103°. Pulse, 120. Tongue dry and brown. Urine 1020, depositing lithates; no albumin. Heart and lungs natural. There was great tenderness along the whole shaft of the left femur, effusion in the corresponding hip- and knee-joints, and intense pain in the whole thigh. There was no swelling of the thigh, except slight oedema near the knee, nor could any deep fluctuation be detected. An incision was made through the periosteum down to the bone on the outer side of the femur, and exit given to several ounces of seropurulent fluid. The outer two-thirds of the femur were felt to be separated from the periosteum for several inches, both upward and downward from the incision. A drainage-tube was inserted and an antiseptic dressing applied. Quinine, port wine, and nourishing food were administered freely. Next day the temperature had come down to 101°, and the boy was much easier. On the fifth day after admission the temperature was 100°, and from this time the symptoms subsided, the incision eventually healing without any separation of bone.

Case No. 2 was an almost exact counterpart of No. 1, except that when the femur was cut down upon no pus was found, but the periosteum was extensively separated from the bone by inflammatory exudation. On the eighth day from admission a large abscess rapidly formed in the deep intermuscular cellular tissue over the inner side of the lower half of the thigh, whence a large quantity of septic pus was evacuated by incision. A counter-opening was made, and the abscess-cavity thoroughly drained and cleansed. From this time the boy went on well, and at the end of three months the incision had healed, and the boy, though still anæmic, was well enough to go to the convalescent hospital. No bone separated, but there remained great periosteal thickening over the lower third of the femur, and a little stiffness of the knee-joint. Almost the same description would apply to the case of the girl (No. 3), only that the bone affected in her