Schedc's l)lood-clot is not sutticiently permanent to furnish a satisfactory
temporarv framework for the granulations during the time required in
the treating of a large Ijone-cavity. The b<)ne-clii])s wiicn projierly ])re-
pared are not only aseptic, but antiseptic, and .sufficiently tlurable to
serve as a bridgework during the tedious process of
rejiair. The decalcified bone is removed gradually by
the granulations sjiringing from the surface of the cav-
ity and the perijilieral cover, which in due time are
transformed into permanent bone tissue. The more my
experience increases with this method of treating asej)tic
bone-cavities the better are the results.
Essential conditions for success are a.septicity of the
cavity and the absorbalilc material employed in filling
it. The great advantages of thi.- method of dealing with
aseptic bone-cavities are that the external wound heals
by primary intention, and that the bone tissue lost by
disease and ojieration is replaced by new tissue. In
ideal results the process of repair is so complete that no
defect remains at the site of the operation, \\hich is in-
dicated only In- a linear scar. After the cavity has been
pro[)erly prepared, iodoformized decalcified Isone-chips
are poured into it until this is packed with them to the
level of the periosteum. After removal of Esmarch's
constrictor blood escapes between the bone-chips and
coagulates at once, thus forming a desirable and u.sefnl
ccnient-.-^ubstance which permeates the entire packing,
and temporarily glues, as it M'cre, the chips together and
the entire mass to the walls of the cavity. The perios-
teum should be carefully preserved in exposing the bone,
and, after imjjlantation, is sutured over the surface of
the bone-chips with absorbable aseptic sutures. If the l)one is deeply
located, it may become necessary to apj)ly a seccmd and third row of
buried sutures to bring into accurate contact otiier overlying soft jjarts.
The ,skiu is finally sutured with silk or .silkworm gut. In some instances
Bier's osteoplastic re-
section of involu-
crum.
CIRCUMSCRIBED CHRONIC SUPPURATIVE OSTEOMYELITIS 253
it would be imcloubtedly superfluous to secure auy form of (b-aiuage, as,
when the cavity is perfectly aseptic and hemorrhage is not in excess of
reipiirements, liealiug of the entire wound would be accomplished under
one dressing. Experience, however, has taught me that tension arising
from extravasation of blood often exerts an injurious intluenee upon the
process of healing, antl should Ije carefully avoided. A string of large-
sized catgut inserted into the lower angle of tiie wound answers an excel-
lent purpose as a capillary drain. A copious antiseptic dressing is then
applied, the limb immobilized, and placed for at least twelve hours in an
elevated position. A limited suppuration is not incompatible with speedy
healing of the cavity, as many of the peripheral lione-chips are replaced
bv granulations, and the remaining space can later be treated in a similar
manner by secondary implantation of decalcified bone-chips. This, how-
ever, should be postponed until all snpi)uration has ceased and the cavity
has been rendered thoroughly aseptic by appropriate treatment. Bier
has recently advocated osteoplastic necrotomy ( Fig. 2<S1 ). With saw, ham-
mer, and chisel the accessible part of tlie wall of the involucrnm is raised
with the overlying soft parts in the form of a lid, the se(iucstrum re-
moved, the cavity rendered aseptic, Mhen the parts temporarily resected
are replaced and fastened in their former relative positions with sutures.
This method of performing necrotomy is applicable only in exceptional
cases, and even when successful the results are not better than those
following less severe procedures, and we may therefore anticipate that its
sphere of application will be a very limited one.
Circumscribed Chronic Suppurative Osteomyelitis.
This is the bone-abscess of Stanley and the older authors. The eti-
ologv of this form of suppurative inflammation is the same as in the
diliuse variety, only that the primary microbic cause limits its action to
a smaller area. Clinically, two varieties can be distinguished : 1, primary
epiphyseal circumscribed osteomyelitis, known as epiphysitis ; 2, second-
ary circumscrilied osteomyelitis. The first kind is occasionally met with
as a multiple affection, and is then attended by more or less constitutional
disturbance, and not infrequently results in e]ii])]ivseolysis. The second-
ary form occurs in the scar-tissue of bones that have been the seat of an
attack of diffuse suppurative osteomyelitis, the patient apparently having
recovered completely from the primary attack years before. It is still a
question under discussion if in these cases the infection is caused by pyo-
genic microV)es whicii have remained in the tissues in a quiescent state
.since the primary attack, or wiicthcr it is caused by a new infection of
the tissues weakened by the first attack. Rosenbach is of the opinion
that recurring attacks of osteomyelitis in the same bone are caused by
pus-microbes which have remained in the tissues, and which again be-
come pathogenic when the tissues around them are rendered susceptible
to their action by sul)sequent causes. I am strongly inclined to the same
opinion. I have seen numerous cases where, in persons from sixteen to
twenty-five years of age, repeated attacks of circumscribed osteomyelitis
occurred in a bone which during childhood had passed through an attack
of acute osteomyelitis. In the relai>sing form the disease, with few excep-
tions, is cireumscrilied. This would seem to indicate that the action of
254 DISEASES OF THE BOXES.
pus-microbes is mitifrated durinii' tlicir sojourn in the body, or that the
tissues around the infected area are less predisposed to ditlusion of the
infection.
The tiliia, femur, and humerus are tlie bones whicli are most fre-
quently attacked l)v recurrent osteomyelitis. The secondary attacks
occur cither in tlie centre of the sclerosed bone, the former site of the
infected medullary cavity, or near one of the epiphyseal lines. I have
no doulit that secontlary osteomyelitis M'ill be of less fi-equent occurrence
after early operations for osteomyelitis as antiseptic sequestrotomy will
be more generally practised.
Symptoms. — The local symptoms predominate over the general.
Fever is sliglit or entirely absent, excejtt in cases of multij)le epiphvsitis.
The most important local symptoms are pain and tenderness. The pain
is deep-seated, intense, of a boring or gnawing character, and is gene-
rally more severe after exposure to cold, active exercise, and during the
night. It is often intermittent, and has frequently been ^\ronglv inter-
preted as neuralgia of bone. The tenderness is circumscribed, and cor-
responds to the location of the su|ipurating focus. It is due to a circum-
scribed secondary i)lastic periostitis. Tlie external swelling is slight,
and often completely Manting. Usually neither redness nor oedema is
present.
Syphilitic osteomyelitis is to be distinguished from the suppurative
variety by its attacking j)ersons of very difTerent physical conditions, by
its tending to form new bone or causing necrosis, by there often being
no suppuration induced, by its not involving ncigiil)oring articulations,
by its frequent occurrence in cranial bones, and by the favorable result
that usually follows proper treatment.
Pathological Anatomy. — Limited suppurative osteomyelitis gives
rise to a circumscribed abscess, which varies in size from that of a pea
to that of a walnut. Necrosis seldom takes place; if it does, the seques-
tra are small and composed exclusively of cancellated bone. If the
abscess is situated in an epiphysis, it may open into the adjacent joint
and become the starting-point of a suppurative arthritis (Fig. 282).
Throml)o-j)hlebitis, sepsis, and pya?mia are rare complications. The bone
around the cavity is usually thickened and sclerosed. The periostitis
which attends chronic suj)iMirations in bone always assumes a plastic
type, as the periosteum is beyond the reach of ]ius-microbes. Epiphys-
eal osteomyelitis is often associated with chondritis and osteoporosis — con-
ditions which may result in pathological fractures. If in this form of
osteomyelitis the su])puration extends to the periosteum, a circumscribed
supjiurative jieriostitis occurs, which is followed l:)y the formation of
small abscesses jn the epiphyseal region. Limited necrosis in these cases
is of frequent occurrence. Inflammation of joints often complicates
epij)hvsitis.
Treatment. — INIultiple ejiiphysitis should lie treated by early incision
and drainage under strict antiseptic precautions. The use of the chisel
or tre])]iine may liecome necessary to expose deep-seated foci. The
external incision must be made in such a manner as not to endanger the
joint. Early operative treatment is the best-known prophylactic against
the occurrence of joint-complications and pathological fracture. In bone-
abscesses the inflammatory focus can be located externally with accuracy
CIRCUMSCRIBED CIIROXIC SUPPURATIVE OSTEOMYELITIS. 255
by the presence of a oircuniscrihed area of teiidei'iiess, and the centre of
the tender spot constitutes the c;uide in the searcii iiir the aliscess. After
the subperiosteal exposure of the bone the chiselinjj' is done in the direc-
tion of the centre of tlie bone by making a track ])erhaps an inch square.
Fig. 282.
Circumscribed osteomyelitic abscess in lower epiphysis of femur, opening into knee-joint : lining
membrane in upper part of cavity detached.
If the abscess is not found at a certain deptii, the surrounding tissue is
explored with a small drill in different directions until pus is found,
M'hen further excavation is again made with the chisel. As soon as the
abscess has l)een fully exposed, the pus is washed «ut and the size of the
cavity ascertained by pr(il>ing. As the abscess is often surrounded liy a
zone of tissue infiltrated with pus, all of the infected tissues are scraped
out thoroughly with a sharj) spoon, after which it is prepared for the
implantation of decalcified antiseptic bone-chips in the same manner as
in operations for necrosis. These are very favoral)le eases for this pro-
cedure, as the area of infection is limited and tlie mechanical renidval
of the infected tissues can be accomplished with a great deal of certainty.
I have repeatedly seen cavities tlie size of a small orange in the head of
256 DISEASES OF THE BOXES.
the tibia heal under twii dressiiios, with jicrfVet restoration of the boue
destroyed by the disease and removed during tlie operation.
Tubercular Osteomyelitis.
Etiology. — Chronic osteomyelitis of tlie epiphyseal extremities of the
long lioiies and of the short, and the Hat bones, is usually the result
of infection with the bacillus of tuberculosis. This view of its essential
microbic cause was entertained by a number of leading surgeons long
before the bacillus of tuberculosis was discovered by liobert Koch in
1882. What was formerly described as scrofula of bone is now gener-
ally recognized as tubercular osteomyelitis. The modern views regard-
ing the etiology of this form of chronic inflammation of bone are based
on accurate clinical observations, the results of carefully-conducted
experiments on the lower animals, bacteriological investigations, and
pathological research. Tuljcrculosis of bone occurs either as a primary
or secondary affection. In the former instance we take it for granted
that localization of the bacillus has not taken place in any other organ
of the body, and that the tubercular lesion in bone jiresents itself as an
isolated single affection. In the second case the bone afl'cction occurs as
a sec(jndary infection from some antecedent tubercular focus. I am
inclined to believe that primary infection of bone is an exceedingly rare
atlection, and Konig has arrived at the same conclusion on the basis of
an enormous clinical experience. The frequency with which pulmonary
tuberculosis is met with in cases of bone tuberculosis, and the fact that
the lymphatic glands and the thoracic duct are also frecjucntly the seat
of tuberculosis, speak in favor of this assumption. The tubercular
lesions which give rise to metastatic tuberculosis may be very minute,
and elude detection even on making a careful examination on the post-
mortem table. Buhl's assertion that in tubei'cular affections of different
organs without an appreciable old tubercular focus this was not absent,
but overlooked, may yet receive corrol)oration liy careful research in the
future. Schlcnker speaks of the fre([uency with which latent tuberculo-
sis is found at necropsies where non-tubercular affections have caused
death. Out of 61 cases without active or manifest tuberculosis he found
that post-mortem examination revealed the presence of latent tuberculo-
sis in 27 ; that is, in 44 per cent, of the total cases. He believes that
if the examination had been carried farther by the use of the microscope,
the number would have been still greater. The clinical history often
points to some antecedent chronic affection of a tubercular nature. In
such cases the history is very often something as follows : A patient has
passed through an attack of pleuritis, during which he has perhaps
exjiectorated blood, but after a while apparent recovery follows, but the
patient has lost flesh and does not gain in weight ; at the same time the
appetite is impaired. Frecjuently more or less cough remains ; a slight
trauma is f<illowed by chronic osteomyelitis, which in its course fre-
quently involves the adjacent joint. Resection Is performed. Local
recurrence takes place, necessitating finally an amputation, and the
patient recovers from the operation, but dies of pulmonary tuberculosis
in the course of a few years. This gloomy aspect of bone tuberculosis
rests on an extensive clinical experience of surgeons who are certainly
TUBERCULAR OSTEOMYELITIS. 'Ibl
inclined to regard, if possible, the bone atfection as a local disease. The
patient, and often the medical attendant, usnally attribute to trauma an
important role in the causation of bone-and-joint tuberculosis. The
trauma, however, must be regarded at best in the light only of an
exciting cause, as no amount of injury can produce the aifection without
the presence of the essential cause — the microbe of tuberculosis. The
trauma only serves as an exciting cause in the production of bone tuber-
culosis in persons already infected with the bacillus of tnlierculosis. The
clinical fact remains that l)one tuberculosis can l)e traced only in a small
percentage of the cases to a traumatic origin. It is, as A^olkmann
asserted long ago, characteristic that the injury preceding the develnp-
ment of the disease is always slight, often quite insignificant : tnliercu-
losis of bone, even in tuliercular subjects, seldom if ever follows a frac-
ture, as the injury in such cases is productive of such active cell-pro-
liferation tliat it will hold in abeyance the jiathogenie action of the
bacilli ^vhich might reach the seat of injury with the extravasated blood.
In 29.3 cases of tuberculosis of Ijone studied by Watson Cheyne, in 188
no definite cause was assigned, while in 105, or 38.8 per cent, of the
whole number, the trouble was directly ascribed to the injury.
Tubercular disease of bone is more frequent in males than females,
particularly after the first decade, which would indicate that traumatism
must be regarded as an exciting cause in a certain percentage of cases.
Like suppurative osteomyelitis, tubercular osteomyelitis attacks most
frequently young persons and that part of the bones predisposed to the
localization of pathogenic mieroltes, the epiphyseal region of the long
bones.
Heredity is an important factor in the causation of bone tuberculosis,
as well as of tuberculosis of other organs. Tuberculosis of the bones in the
new-born has never been found, but it is well knowii that it can appear
within a few months after birth, and the conditions under which this
occurs are familiar. Besides direct transmission of the disease from
parents to child', a certain vulneraliility of the tissues of congenital origin
must be recognized as an indirect cause. In children so predisposed the
clinical history often reveals obstinate eczema, blepharitis, ciliaris, glan-
dular enlargements, and other infantile affections of unquestionable
tubercular nature preceding the bone affection. Surgeons are well aware
of the fact that the existence of an hereditary tendency to tuberculosis
adds greatly to the gravity of the disease. The course is usually more
rapid, s])(intancous cure less likely, and the prospects of a favoralile
result after operative treatment less favorable than in the acquired form
()f tnlierculosis.
The diseases incident to infiincy and childhood, such as pertussis,
measles, scarlatina, and diarrlnea, frequently furirish the necessary con-
ditions for the development of osteotuberculosis. In the adult the
attack is often preceded by one of the acute infectious diseases, such as
typhoid fever, pneumonia, and j)leuritis. Pregnancy and lactation ai-e
also important etiological factors.
Symptoms and Diagnosis. — The general symptoms are often no
indication of the existence or extent of the local disease, as patients with
quite extensive bone tuberculosis mav present every indication of unim-
paired health, and a small osseous focus may produce a ra])idly-fatal
Vol. 11—17
258 DISEASES OF THE BOyES.
miliarv tiil)eroulosis. In all cases of .suspectrd how tiibcrculosi.s a care-
ful cxaniinatidu should ho made of every oruau, in order to discover the
])riniary tubercular depot or existing coni])lieations. Uncomplicated
tuberculosis of bone is essentially a chronic process, and the General
symptoms furnish but little information in reference to its inHanunatory
character. Febrile reaction is slight or entirely absent. A sligiit rise
of tem|3eratui'e toward evening or during the night is very suggestive.
Progressive anaemia is always an unfavorable symjitom in all inrms of
so-called hical tuberculosis, as it indicates either the ])rescnce of atUbtional
foci in important organs or accompanies the exhaustive purulent dis-
charges after secondary infection with pus-microbes. Tlie occurrence of
mixed infection, with or without a direct infection-atrium, is usually
announced by a high temperature and other symptoms of septic infection.
Emaciation is present when the disease is far advanced and complicated
by abscesses, or when a more important organ is similarly affecte<l.
In incipient cases the local symptoms .should be studied with the
utmost care, individually and collectively.
Pain. — Pain is an almost constant symptom, but its intensity is
subject to great variation. Tension, the most important factor in the
production of pain, is a much less marked feature in tubercular than
suppurative osteomyelitis. C'hildren sufi'ering from spina ventosa com-
plain of little or no pain, although a whole phalanx of a linger may
l)e ahiKist completely destroyed by a central tubercular osteomyelitis.
In rib tuberculosis the pain is either entirely absent or slight. In tuljcr-
culosis of the neck of the femur it is often referred to the knee. It is
aggravated when the disease invades an adjacent joint. In primary
synovial tuberculosis a sudden aggravation of this symjitom announces
the extension of the disease to the bones. This symptom is promptly
relieved in a case of tubercular spondylitis by suspension and fixation,
and rest in the recumbent position, and greatly exaggerated by flexion
of the spinal column, which inflicts increased pressure upon the l)odies
of tile inflamed vertebne. The pain is of a dull, aching character, and
is intermittent, and more severe during the night. The nocturnal ex-
acerbation of the pain, as evidenced in children l^y restlessness during
sleep, moaning, grinding of teeth, and horrible dreams, is often one of
the first symptoms which excite suspicion of the existence of osteo-
tuberculosis.
'Ti'HfJerness. — While tenderness is an important symptom in detecting
and locating suppurative osteomyelitic foci, it is of far greater value as
a tliagnostic aid in the recognition of osteotuberculosis in its earliest
stages. It is caused by a circumscribed periostitis over the tubercular
lesion. The existence of an area of tenderness near a joint, correspond-
ing to a tubercular focus in the interior of a bone, is one of the surest
indications of the existence of tubercular osteomyelitis. In many cases
of epi])hyseal tuberculosis patients have been treated for some sujijjosed
joint lesion simply because this symptom was not carefully searched for,
or, if discovered, its significance was misinterpreted. The existence of
a limited area of tenderness in the epiphyseal line and the absence of
joint lesions M'ill enable the surgeon to k)cate accurately a focus in the
interior of the bone. In the examination of tubercular joints it is im-
jiortant to search for this svmptom over both articular extremities for
TUHEBCULAE OSTEOMYELITIS. 259
the purpose of (Ictecting osseims foci — a matter of great importance, not
onlv from a diagnostic, hut also from a tliera]K'Utic, point of view.
SwelliiKj. — ^Ir. Lawrence and, later, Samuel Cooper showed hy dem-
onstration of numerous specimens of tubercular joints that the spindle-
shaped enlargement is not caused by ex])ansion of the articular extrem-
ities, as was formerly supposed, hut hy swelling of the soft tissues around
the joint. With the exception of diffuse tubercular osteomyelitis of the
shaft of the long hones swelling is usually absent or slight in osteotu-
berculosis. External swelling is absent until the atroi)hic layer of
compact bone yields to the intra-osseous pressure — as ni;iy be seen in
advanced cases of spina ventosa — or until, by pressure-atrophy over
the centre of the focus, the compact layer is ]3erforated and a soft, cir-
cumscribed, boguy swelling forms underneath the periosteum. The
tubercular periostitis which now ensues soon reaches the jiaraperiosteal
tissues, when the swelling increases more rapidly, and is followed i)y the
formation of a tubercular abscess. Such abscesses are prone to migrate
in the same manner as tubercular abscess of an articular origin. CEdema
is usuallv not well marked, even if the abscess is large, unless secondary
infection with jiyogenic microbes has occurred.
i?(Y?/i('.s'.s\— The skin over a tubercular abscess presents an abnormally
pallid appearance until tliis structure has been reached l>y the tubercular
process, when it becomes red or livid. This discoloration precedes the
spontaneous rupture of the abscess underneath it.
Atrophj/ of L'unh. — Atrophy of limb is a constant feature of bone
and joint tuberculosis. It is progressive, and appears in a few weeks,
certainly in a few months, after the beginning of the attack. It has
been attri!)uted to various sources — viz. inactivity, neuritis, vasomotor
changes, and reflex influences. It is in all probability the direct result
of jn'olonged non-use of the limb and reflex influences. It affects not
only the bone, but every tissue of the limb. Atrophy of the muscles
constitutes the most important part of this complication.
DiFFEREXTi.\i. DiA(;xosis. — With few exceptions a chronic inflam-
mation in the epiphyseal extremities of the long liones or in the body of
a vertebra is of a tubercular character. In doubtful cases certain diag-
nostic measures should be resorted to in order to enable the surgeon to
make a differential diagnosis.
Akiilo-pciranflk. — Exploration of a doubtful swelling with a short
steel needle was introduced In- Middeldorpf for the pur])ose of ascer-
taining the consistence and proliable structure of tin' tissue composing
the swelling. This is an exceedingly valualde diagnostic aid, and, if
properly performed, devoid of danger. The puncture is made in the
centre of the tender ai'ea, and in a direction corresponding to the prob-
able location of -the central focus. If the needle meet with any consid-
erable resistance in the bone, it is advanced by rotary movements : the
arrival of its point in the granulating centre or caseous focus is an-
nounced by a sudden loss of resistance. By advancing the needle suf-
ficiently to touch with the point the opposite side of the cavity its
probable size and exact location can be ascertained.
Inociikttion E.rperiments. — In cases of great doubt little fragments