The infection of neighboring joints may either come from perfora tion (Fig. 110e) or from metastasis, but it may arise through close prox imity through the action of toxins or as a collateral (edema (serous exudate).
All these complications mean a considerable aggravation of the process, as they indicate a spreading of the infection, which terminates fatally if it is allowed to progress. Bacteria circulate in the blood dining the acute stage (Levu-, Garre).
The diagnosis is difficult only when large abscesses arc situated close to the bone. Whenever we can separate these from the bone or when on incision we find the periosteum closely adherent to the hone, then we may regard the latter as healthy. The radiograph is of the greatest importance for differentiation (Fig. 111 and Fig. 112b, Plate 10).
For the diagnosis from caries see "Tuberculosis of the Bones." Treatment. —When the nature of the trouble has been determined it is imperative to open the bone-abscess at once to give the pus a means of exit before further destruction can take place. Under Esmarch's constriction and avoiding carefully all tendons, blood-vessels and nerves, we work down to the hone, divide the periosteum and chisel a channel into the bone as far as the suppurative infiltration of the marrow extends; but in doing this we must refrain from further lifting off the periosteum and from all curetting. The purulent masses are removed by careful wiping and the cavity of the bone is drained.
The chronic stage follows in which the process progresses to the new formation of bone, building up of the involucrum, and demarcation and separation of the sequestrum. Examination with the probe and radio graph will tell us the right times (usually after several months) when the sequestrum is loose and when it may be removed through a wide opening which we chisel into the involucrum. Even those cases which are more chronic from the beginning and those which we in not see until they are in the chronic stage are not subjected to the radical operation until the sequestrum is entirely loosened and the involuerum fully formed.
After removing the sequestrum the cavity is cleansed, the sharp spieula of bone are removed and the cavity made as shallow as possible. The cavity in the bone heals by granulation and this may be aided by skin grafting (turning in flaps of skin). All attempts at reducing the bone-cavity at once by osteoplastic measures (according to Liicke, Oilier, and Bier) or by putting in an iodoform filling according to v. Mosetig
Moorhof frequently fail, owing to the persisting virulence of the germs, which do not yet permit of a primary closure.
Shortening of the affected bone or disturbances in its growth are frequent sequelie which demand correction after the primary process has fully run its course. Then we will be able to make use of the involu crum as a substitute for the destroyed bone, especially if we avoid all rough handling, since it is very easily fractured. Primary subperiosteal resection of the diaphysis has now been given up quite generally,-because the formation of bone may fail even when the resection has been done subperiosteally, and also because even an extensive resection does not guarantee a cessation of the disease, but may even open new roads for infection (Smoler).
In cases in which an early resection is demanded before the involu erum may be used as a substitute, owing either to the poor general condi tion of the patient or to threatening amyloid disease, the dead bone is removed subperiosteally and a prosthesis substituted for it at once, made either of aluminum or tin. The shape is determined and the prosthesis made from a plaster cast of another bone of equal size before the opera tion and minor changes are made with a file. This immediate prosthesis prevents the retraction of the soft parts, which would otherwise surely take place during the healing of the purulent process.
Only after suppuration has ceased entirely may a permanent osteo plastic cure be attempted by grafting either free pieces of bone or other materials.
In the French literature we frequently meet with the interpretation of those frequent pains in the bones observed in children during the periods of their most rapid growth as a passing osteomyelitis (Poncet, Comby); but scientific proof of this explanation is still lacking, although we cannot deny that at these times infections of the hones, which are subdued by the protective apparatus without leaving any bad effects, may be quite frequent (osteomyelite de eroissance); also the pains and difficulties from insufficiency in the rapidly growing bones of children with a rheumatic diathesis after overexertion ("Arthritisme") are fre quently due to passing softening of the bones (see Genu valgum; Coxa vary. adolescentium).