OSTEOMYELITIS.
Acute inflammation of bone may originate either beneath the peri osteum or in the medullary cavity; the modern view tends towards the acceptance of the theory that in most, if not in all, cases of acute osteo myelitis involving the shaft of the long bones formerly known as acute necrosis the diseased process originates in the medullary cavity by the introduction of pyogenic organisms carried in the blood-stream, the periosteum being invaded later on.
Absolute rest in bed and the usual palliative remedies to minimise pain, fever and constitutional disturbance are clearly indicated.
As soon as diagnosis has become established there should be no delay in relieving the abnormal tension of the tissues. A free and deep incision should be made over the centre of tension and tenderness, This incision should extend freely and should open the periosteum. If in 24 hours the pain, rise of temperature, and general malaise have not subsided, then the medullary canal must be opened up. There should be no hesitation in cutting out by the angular gouge a strip of bone, so as to make a long deep channel or gutter in the diaphysis in every case where pus is found on trephining the cavity of the bone. After the free evacuation of all pus and shreds of sloughing tissue, the medullary cavity should be flushed with warm saline solution or cleansed by the application of Peroxide of Hydrogen on wool or swabbed with solution of Eusol or Biniodide of Mercury (r gr. tor oz.). The cavity may then be freely drained by the insertion of one or more tubes, or it may be packed loosely with gauze. No stitching of the wound is required or permissible.
As a rule it is not considered a safe procedure to strip back the peri osteum at this early stage of the inflammatory action and to resect the whole or any part of the shaft, because it is usually impossible to deter mine the extent to which resolution may be aided by the incisions, but if the entire diaphysis is obviously dead and lying free in a large abscess cavity resection may he carried out after such delay as will allow a firm involucrum to be formed and to maintain after removal of the sequestrum the normal configuration of the limb. In all cases where the opening up of the medullary canal has been delayed till the disease has been permitted to advance, any loosened and dead bone should be removed at the operation, unless in the case of the femur or humerus, where it will be advisable to postpone sequestrotomy in order to encourage the outgrowth of new bone from the periosteum, so as to provide a strong casing fur future support of the limb.
Should the mischief be found to have invaded the neighbouring joint, which is especially liable to occur at the hip owing to the intra-articular nature of the epiphysis, the joint will require to be opened and the de tached and dead epiphysis will require removal.
After operation the limb should be fixed upon a suitable splint and antiseptic dressings applied, and every means employed while waiting for the separation of the sequestrum whereby the natural resistance of the tissues may be strengthened against the Staphylococcus aureus, which is the chief agent in the infection. In addition to open-air treatment, improved hygiene, and careful feeding, Vaccine therapy may be employed, the culture used being obtained from the secretion of the wound.
In hopeless cases amputation may be demanded, but this should not be undertaken in the presence of symptoms indicative of a general in fective or pymic state. In acute cases it is more likely to be required when the inflammation has led to extensive joint disorganisation; at a later stage the exhaustion caused by prolonged suppuration in the soft tissues and the plugging of important veins or where a flail-like limb has resulted from total destruction of the shaft of a long bone, amputa tion will be called for.
When evidence of separation of the sequestrum is obtainable by passing a probe into one of the sinuses and striking upon loose dead bone the operation of sequestrectomy should be considered. This should not be resorted to in a hurry when all is going well, for two reasons—the dead piece of bone, if small, being constantly submitted to the erosive action of the living phagocytic cells, may in some cases be entirely dissolved or disintegrated piecemeal without further operation; and, again, delay may be wise when a large portion of the diaphysis of the femur or humerus has been destroyed in order to enable the periosteum to manufacture a cylinder of new bone (the involucrum) from the osteoclasts which have escaped destruction before performing any extensive cutting operation for the release of the dead shaft. It is, however, a mistake to procras tinate too long till the sheath of new bone becomes hard and thick.