Considerable help may be obtained from a skiagram, especially if taken stereoscopically, and interpreted skilfully, which will show the magni tude of the sequestrum and the thickness of the involucrum. The operation of sequestrectomy will be described later on.
Chronic or subacute osteomyelitis, like the so-called " quiet necrosis " of Paget, may commence insidiously and terminate in the separation of the sequestrum, or eventuate in a circumscribed collection of pus (Brodie's abscess) at the epiphysial junction or in any portion of the bone. These cases are allied to relapsing osteomyelitis where a pocket of pyogenic infection from the original staphylococcic invasion or from the typhoid bacillus may remain latent for many months or years. In such cases there is usually a considerable degree of thickening of the periosteum, hyperostosis and sclerosis, and much mechanical difficulty may he ex perienced in setting free the closely imprisoned sequestrum.
Sequestrectomy is performed after renderingithe limb bloodless by elastic bandaging and the application of Esmarch's tourniquet. A free incision should be made down to the periosteum guided by the situation of the sinuses and the information obtained by a skiagram. The perios teum is to be freely divided and elevated from the shell of new hone by a stout elevator till the cloaca is laid bare. The chisel, gouge or trephine will he required to remove enough of the involucrum to permit of the removal of the sequestrum. Sometimes the old-fashioned plan of tre phining at two spots, including in each disc a cloaca, is the best, a Hay's saw being employed to connect the trephine openings so as to remove a small rectangular plate of bone through which the piece of dead bone may be delivered entire or in two portions, after being snipped with a cutting bone forceps.
After the removal of all dead bone the velvety granulations which line the cavity in which it has lain are to be scraped away with a sharp spoon and the bony walls swabbed with a disinfecting liquid—Eusol, Carbolic Acid, Hydrogen Peroxide or Perchloride of Mercury r in 1,000. The cavity is then packed with gauze and permitted to heal from the bottom by granulations. Mosteig-Moorhors plan allows of the sealing up of the wound without drainage, the cavity having been sterilised by a jet of hot air and filled with a heated mixture of powdered Todoform, Spermaceti and Sesame Oil.
Acute osteomyelitis affecting the flat bones of the skull is to be treated upon the same principles. This is liable to follow infected wounds of the scalp with depressed fractures; the presence of pus between the dura mater and bone (Potts' Puffy Tumour) calls for an immediate incision through the pericranium and the application of the trephine. Syphilitic lesions of these bones may require similar treatment; commencing often in the periosteum, gummata may break down and lead to suppuration, involving the diploe or dura mater, the inflammatory process being further intensified by the introduction of pyogenic organisms.
Under Periostitis will he described the treatment suitable for those cases of acute and chronic inflammation in which the periosteum appears to be primarily affected. Some of these cases are doubtless examples of osteomyelitis, the mischief having originated in the medullary cavity and the pus ultimately finding its way beneath the periosteum. But since there cannot he any difficulty in accepting the frequency of injury (contusions, &c.) as a direct cause of a simple periosteal inflammation, either acute or chronic, and of syphilis and rheumatism attacking the periosteum without invading the medullary cavity, the treatment of periostitis will be described under its own heading.
The so-called "Growing Pains," or Growth Fever, occurring in childhood can hardly be regarded as having a septic origin, though some surgeons consider the condition as allied to a mild form of osteomyelitis and due to the micro-organism of rheumatism. The affection may eventuate in increased growth of the long hones, hut when suppurative results follow the diagnosis may he considered as in error. As a rule rest in bed till the tenderness disappears is all that is necessary in the way of treatment. Should the pains continue severe, small doses of Aspirin may be admin istered.
OTORRHcEA.
The treatment of purulent discharge from the ear will depend upon the removal of the cause when possible and the carrying out of a rigid anti septic system. The subject has been already dealt with under Ear Diseases (p. 242).