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If a periosteal gumma breaks down and invades the skin, a syphilitic ulcer is formed with carious bone at the bottom. A central gumma may eat away the surrounding bone to such an extent that the shaft undergoes pathological fracture. In the rare cases in which it attacks the articular end of a long bone, gummatous disease may implicate the adjacent joint and give rise to syphilitic arthritis.
#Fibroma# is met with chiefly as a periosteal growth in relation to the mouth and pharynx, the simple epulis of the alveolar margin and the naso-pharyngeal polypus being the most common examples.
With few exceptions, tuberculous disease in the interior of a bone does not reveal its presence until by extension it reaches one or other of the surfaces of the bone. In the shaft of a long bone its eruption on the periosteal surface is usually followed by the formation of a cold abscess in the overlying soft parts. Diffuse Tuberculous Osteomyelitis of Right Tibia.
Before the stage of cold abscess is reached, the localised swelling is to be differentiated from a gumma, from chronic forms of staphylococcal osteomyelitis, from enlarged bursa or ganglion, from sub-periosteal lipoma, and from sarcoma. Most difficulty is met with in relation to periosteal sarcoma, which must be differentiated either by the X-ray appearances or by an exploratory incision.
The early recognition of periosteal lesions in the articular ends of bones is of importance, as the disease, if left to itself, is liable to spread to the adjacent joint. The treatment is that of tuberculous lesions in general; if conservative measures fail, the choice lies between the injection of iodoform, and removal of the infected tissues with the sharp spoon.
Syphilitic osteo-arthritis results from a gumma in the periosteum or marrow of one of the adjacent bones. There is gradual enlargement of one of the bones, the patient complains of pains, which are worst at night. The disease may extend to the synovial membrane and be attended with effusion into the joint, or it may erupt on the periosteal surface and invade the skin, forming one or more sinuses.
In relation to the bones also there may be reactive changes, resulting in the formation of spicules of new bone on the periosteal surfaces and at the attachment of the capsular and other ligaments; these are only met with where pyogenic infection has been superadded. Terminations and Sequelæ. A natural process of cure may occur at any stage, the tuberculous tissue being replaced by scar tissue.
A tumour of bone may grow from the cellular elements of the periosteum, the marrow, or the epiphysial cartilage. Primary tumours are of the connective-tissue type, and are usually solitary, although certain forms, such as the chondroma, may be multiple from the outset. Periosteal tumours are at first situated on one side of the bone, but as they grow they tend to surround it completely.
In advanced cases it may be impossible to differentiate between a periosteal and a central tumour, either clinically or after the specimen has been laid open. Pathological fracture is more common in central tumours, and sometimes is the first sign that calls attention to the condition.
In general, it may be said that periosteal tumours are less favourable than central ones, because they are more liable to give rise to metastases. Permanent cures are unfortunately the exception. Treatment. When one of the bones of a limb is involved, the usual practice has been to perform amputation well above the growth, and this may still be recommended as a routine procedure.
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