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bone, treatment, pain, acute, measures, wound and periosteum

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Under Osteomyelitis is detailed the treatment of acute septic inflam mation of bone of which periostitis is always a part, so that the affection is known sometimes under the names of " Acute Infective Periostitis " or " Acute Necrosis," though probably the causal organism (Staphylococcus (wrens) first starts the inflammatory mischief in the medullary cavity.

Periosteal inflammation does, however, occur and remains fixed in the membrane or layer of immediately underlying bone without manifesting any tendency to spread to the medullary canal.

The treatment in all cases should embrace the internal agents indicated for the primary cause, as syphilis, rheumatism or tuberculosis.

Acute localised periostitis is usually the result of blows, kicks or violent contusions, and should be met promptly by local measures. Absolute rest and immobility of the limb should be secured by a suitable splint which will permit of local applications being made directly to the skin over the inflamed membrane. The limb should be well elevated on a pillow as the patient lies in a comfortable position in bed. The surgeon has the choice of cold or warm applications ; these should be selected by the sensations of the patient. The pain, tenderness and swelling which usually follow direct trauma of limited or circumscribed extent, as in kicks or blows on the crest of the tibia, are best dealt with by Spirit lotion (t in 3) applied upon a double laver of lint covered with oiled silk and held in position by a light bandage or stocking.

Severer cases will require hot or warm fomentations or poultices, and when these fail to afford relief ice, Leiter's tubes or evaporating lotion may be tried, or leeches may he applied, and bleeding encouraged by fomenting the bites afterwards. Should these measures fail to relieve pain, one or two small incisions may be made through the periosteum down to the bone. This plan effectually prevents the injurious effects of prolonged high ten sion, and thus minimises the after ill-effects of the inflammation, and may prevent necrosis.

It is a mistake to wait for signs of fluctuation in severe cases when pain and tension are excessive. Strict aseptic precautions should be taken, and if pus is present the same treatment may be adopted, but the incision should be a bold and free one, and the knife should be felt to reach the hard bone beneath the inflamed periosteum.

The wound should be lightly packed with gauze; antiseptic poulticing should be continued. This may be simply carried out by dressing the wound with boracic fomentations, covered with oiled silk upon the top of which large deep pads of cotton-wool may be secured by a light bandage.

Internal treatment will depend upon the severity of the case and the symptoms present. Where there is much fever a simple diaphoretic preceded by a brisk saline cathartic as i oz. of Rochelle Salt is a good plan. Where syphilis exists, large doses of Iodides are most efficacious in relieving pain and cutting short the disease, and the older surgeons still employ Calomel and Opium in every case. The iodide often relieves the dull nocturnal pains in cases which are not specific, and there is generally no reason why it should not have a trial in every case. The following is a good combination in the early stages; at a later stage the aconite may be omitted : It. Sodii lodidi 3ij.

Tiuct. Aconiti lllxxx.

Liquor. Ammon. Acet.

Syr. Aurantii 5iss.

Aqua Camphora Misce.

Fiat mistura. Capiat 8ss. post cibos ter in die et Nora somni.

When the temperature runs high, large doses of the iodide as a rule are not well borne, and then a mixture containing 5 grs. of Antipyrine and grs. Salicylate of Soda may be given every 4 hours. It often relieves the pain markedly.

Where the periostitis is diffuse it invades the entire length of a long bone; the serious tension which supervenes rapidly may terminate in the death of the bone unless prompt measures be taken to relieve the local and alleviate the constitutional disturbance. The first step in the treatment, as soon as the diagnosis warrants, is to make a series of deep and free incisions parallel with the shaft of the affected bone. These should pass through all the tissues and periosteum down to the bone, and should be extended into the medulla if the temperature does not fall within 24 hours by gouging or by inserting a Hey's saw into the wound as in osteomyelitis.

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