CARIES Is the term applied to a process in bone when the osseous tissue dis integrates piecemeal, corresponding to ulceration in the soft tissues. The disease being nearly always the result of tubercle, constitutional treatment is invariably demanded, and the indications are the same as in tuberculosis and scrofula—viz., Cod-Liver Oil and Malt Extract ; overfeeding : the removal of the patient to a seaside place sheltered from east winds and protected from the north; open-air life; Iodides (chiefly Ferri Iod.). Phos phates, Hypophosphites, Calcium Chloride, and other remedies mentioned under Scrofula and Tuberculosis.
Local treatment in the early stage will consist of absolute rest, and this is of great importance when the caries is in the vicinity of joints, and the application of splints should be so arranged that the entire limb is placed in a state of repose, whilst the appliance will be such as will enable the patient to move about or be carried in the open air. In cases where pus has not formed and the diagnosis of tubercle is made clear, sanatorium treatment supplemented by the Vaccine method, which consists in the injection of minute doses of Tuberculin, will often effect complete resolu tion. Some surgeons report excellent results from the use of the plan of producing a local congestion of the part by constricting the vein without retarding the supply of arterial blood by the application of an elastic bandage to the limb for short periods daily. The local application of a weak Oleate of Mercury Ointment with gentle friction acts in a similar manner by increasing the flooding of the diseased area with lymph, bringing the protective fluids of the body into more immediate contact with the dis eased area, which is comparatively shut out from the general circulation.
When, in spite of these contervative measures, pus formation super venes, more active local treatment is demanded, and the surgeon is never justified in waiting for the spontaneous discharge of matter, as this in evitably leads to the infection of the abscess cavity with pyog,enic organ isms. The skin having been sterilised, a free incision should be made and the softened or carious bone completely removed by curetting or gouging, every portion of diseased tissue being taken away, the cavity treated with iodnform emulsion, or wiped dry, and the skin incision sealed up by fine sutures without drainage in order to secure complete union by first intention without sinus formation. That this form of treatment may succeed it must be undertaken before the skin becomes red. Red ness indicates a secondary infection, which will prevent primary union and ultimately end in sinus formation.
Walton has improved the old technique. After making the skin wound the lips of the incision arc protected by gauze to prevent their infection by the contents of the abscess cavity, which after evacuation is swabbed out with Carbolic Acid and treated by a per cent. Gelatin and Formalin solution, after which it is next dried by pumping in hot air, and then filled with sterilised Paraffin which melts at 12o° F. The lips of the incision in the periosteum being sutured the skin wound is likewise stitched, and primary union thus effected without the delay of healing by organised blood-clot being necessary. Some surgeons prefer Moorhors mixture, which consists of Iodoform 6, Spermaceti 4, and Sesame Oil 4. In all these methods it will be noted that the fundamental point is to do away with the necessity of drainage. Stiles advises the total removal of the lower end of the diaphysis when the disease is situated in a long bone, and most surgeons do a complete resection when the small bones of the carpus and tarsus have become carious. When sinuses have already formed the case must always be regarded as a septic one; pyogenic organ isms plus the tubercle bacillus have then to be dealt with. Formerly there was no alternative left to the surgeon but to cut down upon the bone, removing the sinus tissue by careful dissection, and after gouging or curetting all carious osseous tissue and removing sequestra, should such be present, the cavity was packed with iodoform gauze and drained, healing occurring by granulation from the t ottom. The results were generally unsatisfactory owing to infection of the newly incised surfaces. A very distinct advance has been made by Beck, who fills the cavity with warm Bismuth jelly instead of gauze packing, and in many cases the sinuses have been made to heal up completely without any operation save the injecting of the sinuses through a fine syringe of the emulsion so as to penetrate every recess in the sinuous track. This plan does away with the numerous antiseptics and caustics formerly employed for this purpose as described in previous editions. Should failure follow the injection, diseased bone is sure to be found at the bottom of the sinus, and a radical removal is essential to success before further attempts to excite healing by the Bismuth Jelly. Vaccine treatment as in the non suppurative cases with open-air treatment should always be resorted to, and repeated investigations of the opsonic index made.