Chapter IX

, on Tuberculosis in general, we entered into considerable detail in regard to the nature of tuberculous lesions, which were stated to be essentially the same whether occurring in hard or soft tissue, the active agent being the now well-known _Bacillus tuberculosis_, which, finding lodgement, for instance, in the osseous tissue, acts as a specific irritant, and so provokes the production, first, of a typical tubercle, and, later, of typical granulation tissue, by whose ravages the distinctive signs of bone tuberculosis are produced. This process, then, is in no respect different in bones from similar lesions in other parts, though modified to a slight extent pathologically, to a greater extent clinically, by the dense environment. Nevertheless, trifling or most extensive destruction of bone substance is produced by this tissue, while by continuity or by metastasis there is more or less involvement of the adjoining textures, either parosteal or articular. It is by granulation tissue that so-called _caries_ is produced, and it is by the same tissue that distinct portions of bone are sometimes completely segregated from their vascular surroundings and shut off from nutrition, so that they die and form what are known as _sequestra_. _Necrosis_ may then be the result of tuberculous disease.

[Illustration: PLATE XXXVI

Tuberculous Disease of Hip-joint and Pelvis, involving the Muscles (rare). (Lannelongue.)

_o_, rarefying ostitis (_i. e._, osteoporosis); _f_, fungus granulation tissue.]

So long as the process is active, this granulation tissue tends to enlarge its boundaries, and, like pus, to spread in the direction of least resistance. When produced in the shaft of a long bone this may lead to involvement of the entire shaft, or there may be liquefaction and absorption of dense bone and the formation of a sinus from the marrow cavity to the periosteum, beneath which the granulation tissue will spread, and through which it will sooner or later perforate, to resume its progress toward the surface, _always in the direction of least resistance_. In this progress _tendon sheaths_ or _bursæ_ may be involved, or dense aponeuroses may turn the granulation column aside, causing it to perforate toward the surface at some remote point; while it may spread out more or less beneath the skin before finally causing its destruction. Sooner or later, if uninterrupted by treatment, this escape will occur, and then we have the condition of a tuberculous ulcer of the skin, from which leads down, by a devious path, a _sinus_ toward the original focus.

When this original focus has been juxta-epiphyseal there is involvement of the epiphyseal cartilage and a pathological _diastasis_, which may early lead to spontaneous or pathological _luxation_. Or, again, a focus having once originated at an epiphyseal extremity, tends usually to perforate quickly into a joint cavity, after which a considerable length of time is usually expended in filling up this joint cavity with exuberant granulation tissue. This is the material so often found in tuberculous joints, and is well characterized by the name given to it by the Germans, _fungous tissue_, they calling such joint affections _fungous joint inflammations_. (See previous chapter.)

Seen thus in joints, after it has been long exposed to friction and to more or less pressure, it may have lost some of its original luxuriant features. It is best seen when it is freshest and has been exposed to least disturbance. Under these circumstances it is vascular, dark red in appearance, friable, and easily removed from the tissue upon which it has grown. Ordinarily it is infectious, and by its inoculation into animals is capable of reproducing the disease.

=Pathology.=--The pathology of tuberculosis of bone may then be virtually summed up in saying that it consists of the ravages produced by the presence of this granulation tissue, with the irritative hyperplasia of surrounding tissues which its presence always excites, even though they be not actively infected. This is the explanation for the majority of cases of _caries_, of _tumor albus_, of _Pott’s disease_, of _spina ventosa_, and of the condition which has been known under many other names.

=Varieties.= =Acute Miliary Tuberculosis of Bone.=--This corresponds to a similar invasion of the lungs. It might be fittingly described as an _acute tuberculous form of osteomyelitis_. It may run its destructive course within a short time and cause such involvement of structures as to necessitate amputation of a limb, or it may appear in the truncal skeleton as a primary disease, spreading rapidly therefrom and involving the viscera or the cerebrospinal membranes, and causing an early death, perhaps within a few weeks after its onset. This condition has been more prevalent than is generally understood, and has not even yet received the attention it deserves. It is less painful than the pyogenic forms of osteomyelitis, and may assume less of the septic and more of the typhoid or meningeal type of disease. The pain also may be less severe, though reflex symptoms, especially muscle spasm, will be an early and marked feature of these cases. When a limb is involved the case may not be hopeless; but when involving the cranium, spine, or trunk it is fatal, and little can be accomplished by treatment. The operative treatment for parts which are accessible is given under Acute Osteomyelitis.

=Chronic Tuberculous Osteomyelitis.=--This is the ordinary form of the disease, and is exceedingly common. In some sections it constitutes nearly one-third of the diseases necessitating surgical treatment in clinics and hospitals. This is particularly so in the thickly settled portions of the European continent. In Buffalo it constitutes from 15 to 20 per cent. of cases found in my wards and in my clinic. The proportion some years has been larger.

=Symptoms.=--_The essential symptoms of bone tuberculosis_ are _muscle atrophy_, _muscle spasm_ and _pain_, direct or referred, and upon the existence of these, coupled with _local tenderness_ and _local swelling_, _a diagnosis can almost always be made_. _Muscle atrophy_ is distinct, and is not alone that of disuse, but is a distinctive evidence of the tuberculous process. It involves the parts above and below the lesions.

_Muscle spasm_ is never lacking, but is most noticeable about the spine and the joints of the extremities. In Pott’s disease, for instance, the condition causes a stiffening of the back and an inflexibility of the spine. About the joints it leads gradually to _fixation_, usually in the condition of more or less flexion, the flexor muscles being ordinarily stronger than the extensors in all parts of the body. Thus we see the knee and the elbow drawn up, and most other joints in a condition of flexion so far as it may be permitted.

It is characteristic also that _muscle spasm_ is frequently exaggerated, usually in a reflex way, by which pain is always augmented. These sudden but brief contractures occur more often during sleep than during the waking hours, and give rise to the so-called _starting pains_, usually nocturnal, which are noted in nearly every case of this kind.

The _pain_ is in large measure the result of contracted muscles pulling tender joint surfaces together, and is consequently augmented during the muscle spasms just described to an extent causing the patient to cry out even during sleep. There is also usually a more or less deep-seated and constant pain or soreness, manifested in increasing degree as the lesion advances. These pains are also often _referred_, lesions in the upper ends of long bones usually giving rise to pain which patients refer to the lower ends. In hip-joint disease pain is often referred to the knee, and in Pott’s disease to the anterior part of the trunk. Slight but slowly increasing disturbance of function of a joint inaugurated by trifling muscle spasm, with complaint of aching pain, is significant and needs careful examination, it being a mistake to anesthetize patients for this purpose, as by the anesthetic the pathognomonic muscle spasm is abolished and mistakes in diagnosis favored.

[Illustration: FIG. 227

Tuberculous disease of the hip. (Buffalo Museum.)]

[Illustration: FIG. 228

Healed tuberculosis of the spine. (Buffalo Museum.)]

It will be seen that these features are also met with in tuberculous-joint disease, the fact being the conditions are not only allied but often associated.

=Treatment.=--The treatment of tuberculosis of bone is constitutional and local. The former consists in the best possible hygiene and in those measures which are everywhere recognized as helpful in similar conditions. I believe in the internal use of _benzosol_, or its equivalents, in doses sufficiently large to influence the tissues. In addition the tonics and evacuants should be judiciously used. But it is mainly with local treatment that we shall here have to deal.

The _local treatment_ may be divided into the _non-operative_ and the _operative_. The former consists in enforcing the general principles of physiological rest, which is done partly by _orthopedic apparatus_ proper and partly by the general principles of _traction_, and is resorted to mainly in a class of cases treated of under Orthopedic Surgery, the best methods for the purpose, apparatus, etc., being found in the next chapter.

Aside from this a hopeful method has been that suggested by Bier, consisting of making an _artificial chronic congestion_, it having been long known that tubercles do not thrive when bathed in much blood. The congestion is secured by wearing an elastic bandage above the point involved, elastic constriction being made to a degree as great as may be comfortably borne. The result is venous congestion, possibly edema of the parts below, which to be made effective should be carried nearly to the tolerable extreme. Constriction may be at first enforced for only a short time, but can be later borne for longer periods, until a time is reached when the patient can wear a bandage almost continuously. Marked improvement in many cases follows this method.

_The operative treatment_ consists in _ignipuncture_, _curettage_, _or formal extirpation_. _Ignipuncture_ is the insertion into the bone focus of the glowing point of the thermocautery. It should be practised under an anesthetic, and when the bone is superficial the cautery should be plunged through the skin, making it burn its way into the depth of the bone. This is not difficult when the cancellous tissue is that at fault. If the bone be deep an incision may be made down to it, after which the cautery is applied as above. The result in almost every instance is relief from pain.

This effect seems to be brought about partly by relief of tension,

## partly by destruction of diseased tissue, and by the acute congestion

which is the result of vigorous counterirritation. It need occasion no fear nor difficulty, and is applicable to all accessible bones. It must not be expected to cure every case, but is a measure which may be confidently expected to relieve pain and to do good.

The _radical_ form of _treatment_ is necessary when it can be determined that the carious process is advancing or that pus or caseated deposits are present. This is made known in various ways; but when reasonably sure of their presence it is best to begin the operation as an _exploration_, going as far as the findings may justify. This may include scraping out of a small focus, or it may entail removal of a large portion of a bone or resection of a joint, or even amputation, according to the severity of the deep lesion. It is best to do whatever may be necessary, and to do it all at once. The operator should not rest content with mere operative attack, but should carefully _disinfect_ the entire tract, cutting away or removing with the spoon the sinus wall and fungous tissue, which he should follow wherever it may lead, disinfecting freely with hydrogen peroxide or caustic pyrozone, and then using an active caustic, like zinc chloride or the actual cautery, unless caustic pyrozone has already been used. In this way material may be destroyed which has escaped the instruments used, and absorbents are eared or closed and protection afforded. My personal preference is for a packing made of bismuth subiodide gauze, soaked in a mixture of balsam of Peru containing 10 per cent. of _guaiacol_, which I find more advantageous than anything I have used. There should be added to these measures, however, whatever may be necessary in the way of after-treatment, both local and constitutional, and the surgeon should be prepared to operate once or twice again should latent foci subsequently manifest themselves or should there be recrudescence of the active disease.

BONE ABSCESS.

Bone abscess is a term applied to _deep and circumscribed collections of pus within the bone_, mainly within the shafts of long bones. They are due either to the acute ravages of pyogenic cocci or to the slower lesions produced by the tubercle bacillus. They are frequently evidences of return of disease in its acute type after a long period of latency. The manifestations are usually localized, in this respect differing from those of acute osteomyelitis. The pain is deep-seated and boring, while there is local tenderness, often with considerable enlargement of the overlying bone. The lesion occurs more often in the tibia than in all of the other bones together--at least under those clinical conditions which entitle it to be called bone abscess. The pain is frequently _nocturnal_ or osteoscopic, and patients may endure it for weeks or months before seeking relief.

The surgeon may always expect to find a layer of condensed, sometimes extremely hard bone around these local foci, and it is due to this that they do not either perforate or diffuse and cause extensive trouble.

=Treatment.=--Treatment is always _operative_; it should consist in anesthesia, exposure of the bone, effective exploration by means of the bone drill, as the hypodermic needle would be used for exploration in the soft parts, and then the free use of the bone chisel or other instruments by which the area may be widely exposed. The density and firmness of the bone under these conditions will sometimes almost defy the best-tempered instruments. Care should be taken to make the external opening nearly the size of the deep focus, in order that the surface may not heal too readily and before the deeper part is filled. The same directions with regard to cauterization and packing the cavity obtain as given before.

SYPHILIS OF BONE.

[Illustration: FIG. 229

Syphilitic gummas of head and face. (After Jullien.)]

[Illustration: FIG. 230

Syphilitic ostitis and osteosclerosis.]

Syphilis of bone may assume the type of _gummatous involvement_ of the _periosteum_ or of the _bone_ itself or of _syphilitic caries_ and _necrosis_. The former appears usually as a distinct tumor, ordinarily tender and exceedingly painful, especially at night, it being characteristic of almost all cases of bone syphilis that the pain, however great during the day, is exaggerated at night. The true syphilitic _gumma_, or syphiloma, of _bone_ is but little different from gumma in other tissues, which may become secondarily infected and then suppurate with the formation of sinuses, etc. Suppuration, however, is rare. _Central gumma_, like central osteosarcoma, is possible, and may lead to expansion of the surrounding bone. Syphilitic _necrosis_, so far as the bone lesion is concerned, scarcely differs from the other varieties. It is, however, almost always of the slow form, and involves more often the _flat_ than the long bones. It is especially seen in the cranium and the sternum. Syphilis of bone is often mistaken for rheumatism or pseudorheumatism because of the deep-seated and somewhat indolent pain. Syphilitic disease of bone permits occasional spontaneous fracture, the bone affected with this disease being always more friable than natural. There is also another form of bone syphilis--namely, the _hereditary_. It leads either to bone _enlargement_ or to _caries_ and necrosis, the latter usually upon the cranium, where extensive ulceration and sequestrum formation may be observed, even the dura being exposed by breaking down of the fungous tissue.

[Illustration: FIG. 231

Caries of lower end of femur. (Buffalo Clinic.)]

Hereditary bone syphilis is also characterized by osteophytic formation, by the substitution of gelatinous for spongy bone tissue in the neighborhood of epiphyses, and by early and easy epiphyseal separations. It is characterized also by irregularity of ossification of cartilage and consequent deformity of bone ends, especially about the phalanges and the metacarpal and metatarsal bones. In almost every case where doubt would in other respects arise the other evidences of congenital or acquired syphilis are so plain as scarcely to permit uncertainty (Fig. 230).

The _possible combination of syphilis and tuberculosis_ in the same subject may occur, the lesions partaking of one or the other character according as the tuberculous or syphilitic taint may predominate.

There is urgent necessity in all cases of syphilis in bone, whether operated on or not, for the _combination of suitable internal treatment with surgical intervention_. Only by this combination can the efforts of the surgeon be crowned with success. In failure to appreciate this fact operation often seems to be almost futile.

CARIES.

Caries is a term applied to infiltration, and substitution in healthy bone of granulation tissue, which has been in use for many centuries, from a time long before the pathology of the condition was understood. Caries never occurs except in the presence of a _specific irritant_, which, in general, is tuberculous and sometimes syphilitic in character. The pure type of caries is connected entirely with the formation of granulation tissue, and the slow ravages connected with its presence in and substitution for the original bone. As long as _septic infection_ (pyogenic) is _avoided_ it assumes the _dry_ type, as it used to be known, called by the older writers _caries sicca_. When the fungous tissue is invaded by putrefactive or pyogenic organisms suppuration takes place, and then occur the _moist_ forms of caries, the _caries humida_ of our forefathers, connected with the presence of pus. When closed areas of bone, small or large, being thus shut off from nourishment, die as the result of its presence the complicated condition used to be known as _caries necrotica_. Occurring under any circumstances, _caries is a result and not a cause_, and is to be dealt with accordingly.

Peculiar alterations and markings in bone are the consequence of carious changes, and bones are given a fantastic and peculiar appearance in consequence. The surface is almost always irregular, tunnels or canals are formed, and the bone is often honeycombed, as it were, by the excavations just made. Along with the process of osteoporosis and disappearance of bone at one point may be seen osteosclerosis in an adjoining area, and the bone, which is apparently much weakened by the destructive process, is strengthened in a compensatory way by the artificial density of the tissue undestroyed.

The clinical evidences of caries are those of joint and bone tuberculosis or syphilis, which have been already discussed, and its operative treatment consists always in surgical attack with bone chisel and sharp spoon, according to the rules already laid down. The bone which is completely carious calls for _extirpation_--_i. e._, usually amputation. In the carpus and tarsus _resection_ will often suffice, and also when the disease is limited to joint ends. Occurring in the pelvis, ribs, sternum, or cranium, more or less extensive _resections of flat bones_ are necessary, in the latter place leading to exposure of the dura (of which one need have no fear). The same rules with regard to cleansing and packing the wound should be observed as in operation on tuberculous bones.

NECROSIS OF BONES.

Necrosis corresponds to gangrene of soft parts, and the term, when used by itself, is limited to death of bone tissue. Necrosis by itself is a distinct disease, but indicates the termination of some preceding disease process. It may be considered as:

1. Traumatic;

2. Pathological--_i. e._, the result of disease; or

3. Toxic, due to the presence of specific poisons in the system.

1. =Traumatic Necrosis.=--Traumatic necrosis is due to the discontinuance of the blood supply by accident or by separation of the whole or a part of a bone in the same way. Thus in consequence of _multiple fractures_ fragments occasionally die and require removal. The same result has been ascribed to traumatic or non-_traumatic embolism_ of the principal nutrient artery of a bone, but the possibility of this condition is doubtful, bone being too well supplied by its surrounding periosteum. Necrosis in connection with fracture is rare except in compound fractures, and, when a detached fragment can be seen, may be anticipated by removal of the same.

2. =The Pathological Form.=--The pathological form is due to the preëxistence either of _tuberculosis_, _syphilis_, or an _acute infection_, such as _osteomyelitis_. It may also be the result of _acute infectious periostitis_, where the periosteum is completely loosened from the shaft of a long bone. These conditions are connected either with the slow ravages produced by granulation tissue, or with the acute septic processes by which infected exudates shut off large areas from sufficient blood supply, or by which in consequence of septic thrombosis a similar condition results. In consequence there may be met bone dying in small visible particles, or the entire shaft of a long bone or several smaller ones may be involved in the destructive processes.

The portion which dies is known as the _sequestrum_, which may assume irregular and unusual shapes, varying entirely with the area involved. The general character and size of a sequestrum will depend upon the nature of the cause. In acute osteomyelitis it is either a bone shaft or an epiphysis which thus suddenly dies. In the slower processes the fragments may be of almost any imaginable size and form--irregular with jagged ends, or long, extending completely through a bone, either from end to end or from side to side.

3. =The Toxic Forms Of Necrosis.=--The toxic forms of necrosis are due mainly to two substances used in the arts--_mercury_ and _phosphorus_--whose use seems to be inseparable from the manufacture of many modern industrial products.

_Mercurial necrosis_ may come either from the volatilization of the metal in factories where mirrors are made or from refineries where amalgam is distilled. It also occurs from the _internal use_ of the drug. Its effects are seen more frequently in the alveolar portion of the lower and upper jaw than elsewhere. It is through some unknown peculiarity that the jaws are the bones commonly involved in both of these forms.

_Phosphorus necrosis_, on the other hand, manifests itself almost entirely in the lower jaw, and occurs usually among the young, in factories where matches are made. It is due to the vapors of phosphorus, which cause a form of nearly distinct maxillary necrosis--a fact which has been so widely recognized as to lead to State legislation preventing the employment of the young in such work.

Phosphorus necrosis _begins as a periostitis_ with the production of osteophytes, and is completed as a nearly total necrosis of the entire bone.

=Treatment of the Toxic Forms.=--The _preventive_ treatment should consist of supervision of the teeth, the use of alkaline mouth-washes, inhalation of terebinthinate vapors, which neutralize those of phosphorus, and the ventilation of establishments devoted to match-making. The curative treatment consists of buccal antisepsis, opening of abscesses, and the removal of diseased bone, especially of dead bone, upon the first provocation. The occurrence of fistulas should always be regarded as pathognomonic of diseased bone. In aggravated cases, such as are rarely if ever seen since legislation has been brought to bear upon the subject, practically complete necrosis of the lower jaw, either _en masse_ or in portions, was far from unknown, and the possibility of regeneration of the bone was for a long time discredited, until the late James R. Wood, of New York, exhibited a specimen, both at home and abroad, which proved its possibility. Since then we have learned that it is possible for bone thus to regenerate, the cause of the disturbance having been removed.

[Illustration: PLATE XXXVII

Necrosis of Shaft of Femur with Sequestra. (Life size.)]

[Illustration: FIG. 232

Phosphorus necrosis of the lower jaw. (Musée Dupuytren.)]

=Sequestrum Formation.=--To the portion of bone which dies is given the name _sequestrum_, while multiple sequestra are by no means uncommon. The sequestrum is white and ivory-like in hardness when it consists of original compact structure. It is rare to find a distinct sequestrum of spongy tissue, as this yields so readily to the presence of granulation tissue and of pyogenic infection. A sequestrum may include an entire bone shaft, or epiphysis, or only a small fragment. A portion of the bone having lost its vitality becomes a foreign body which the surrounding tissues endeavor to extrude or to wall off and surround. The extrusive effort is the one which is usually seen. This is done by the continued presence of granulation tissue, which gradually perforates the surrounding bone at places of least resistance, the result being the slow formation of a sinus or several sinuses, ultimately connecting with the surface, and in which in neglected cases the dead fragment of bone can be seen or felt, or from which it can be withdrawn almost without operation. While this weakening of bone is going on in certain portions a corresponding strengthening process is also being put into effect; and the result is a quantity of new bone, which is often wrapped around the sequestrum and is simply the effort to atone for its pathological weakness and to strengthen it. This new osseous tissue which so often surrounds the sequestrum is called the _involucrum_, and in many instances it is necessary to remove more or less of the involucrum before the sequestrum can be lifted out of its bed or removed. (See Plate XXXVII.)

The whole necrotic process is intelligible if read aright as an endeavor on the part of Nature to get rid of dead and irritating material. When this effort is properly interpreted the natural efforts can be seconded by the interference of the surgeon at a time when disturbance is limited to the minimum and before external sinuses have had opportunity to form. On the other hand, ignorance and neglect may lead to the extreme condition, and most fantastic arrangements of sequestra and involucra are seen in all pathological museums, some of which seem to partake almost of the perplexities of Chinese puzzles. The explanation, however, is always as above afforded. (See Figs. 233, 234 and 235.)

=Treatment.=--The treatment should be surgical, and consist in removal of the dead portions and restoration of the parts to a condition favoring rapid regeneration. It should always be radical, but is sometimes made difficult by the inaccessibility of the fragment or by the density of the involucrum and the necessity for large external openings in order to remove the sequestrum.

Large and powerful forceps and strong and well-tempered bone chisels are usually necessary, while, after making the necessary opening for removal of the sequestrum, the sharp spoon should be used thoroughly to scrape away all the lining material of cavities in which fragments have been lying or all fungous tissue which may fill sinus tracks. It will be well after this to thoroughly cauterize the wall of the cavity, after which it is to be packed.

[Illustration: FIG. 233

Central necrosis of the tibia, long central sequestrum.]

[Illustration: FIG. 234

Sequestrum inside of a core of new-bone tissue, arranged much like a puzzle.]

[Illustration: FIG. 235

Necrosis of tibia, showing sequestra after removal. (All three specimens from the Buffalo Museum.)]

The packing of old bone cavities is of importance, and operators should appreciate the reason for so treating them. The packing is essentially a foreign material which the tissues will naturally endeavor to extrude as they did the sequestrum. The method of extrusion is by filling up beneath and around it with granulation tissue, which later may ossify. The packing is therefore a constant provocation to the formation of this tissue, which is now desirable, and is used mainly for this purpose. It is antiseptic material, and will serve to prevent decomposition of the pyoid material which would otherwise fill such a cavity as the result of waste--Nature’s effort at formative material gone to waste. A number of years ago Gunn suggested the use of _wax_ for this purpose, wax being plastic and incapable of absorption. A piece of white wax was heated in hot water, molded with the fingers to fit the cavity, where it served the purpose of a packing, and was reduced in size with each dressing, as was necessary to permit it still to remain. It is not now used as much as it deserves to be. (See p. 431.)

In favorable cases it may be possible to so thoroughly cleanse the bone cavity without the use of caustics as to justify the attempt, after rigid asepsis, of allowing it to fill with blood, which will coagulate and organize into connective tissue. When this effect is desired the wound should be covered with green silk protective, over which the other dressing may be snugly applied. This healing by the _aseptic blood clot_ is the ideal method when possible.

The extent to which regeneration of bone is possible is often amazing, especially in the young. Thus after removal of the entire shaft of a tibia there may result, in time, not a complete restoration to former integrity, but, in addition, the formation of so much new osseous material as to restore a great degree of strength, and which shall, with the compensatorily hypertrophied fibula, make the leg as useful as ever. In the thigh, however, complete necrosis of the femur means amputation, as it will also in the arm unless the necrotic portion is but a small proportion of the length of the humerus. The treatment of necrosis of the skull, or, in fact, of any bone in the body which is accessible, is based practically on the principles already laid down.

BONE TRANSPLANTATION AND TRANSFERENCE.

In the effort to atone for extensive loss of bone many experiments have been tried, first on animals and afterward on men, success with the former having lent much prospect to the latter. It has been learned, for instance, that portions of living bone can be removed from some of the lower animals and transferred into a bed of more or less healthy sterile human tissues, often with the result that a fragment thus transplanted becomes vitalized and incorporated, and serves the purpose for which it was intended; still these efforts do not in all instances succeed. However, experience has led to the effort to utilize some portion of the patient’s own osseous system. This becomes more easily possible in the case of the forearm or leg where, especially in the latter, a small or less important bone can be utilized to take the place of the greater. Thus, when the entire shaft of the tibia has been removed for necrosis resulting from acute osteomyelitis, the fibula has been sawed across, opposite the site of the ends of the lacking tibial shaft, and transplanted into the trough-shaped depression, thus making it functionate for the lost tibia. Huntington has recently reported a case in which not only was this done, but later the upper and lower ends of the fibula attached to the tibia, with good bony union and with an almost perfect functional result. This will illustrate what elsewhere may be done in this direction.

FILLING OF BONE CAVITIES.

Our methods for removal of sequestra and cleaning out of infected bone cavities are now simplified and made safe. The difficulty which is still universal is to secure a rapid filling or closure of these cavities. If we could be certain of cleaning out every particle of infected tissue and the removal of every germ which might excite putrefaction, then we might resort to Schede’s plan and allow even a large cavity to fill with blood clot and await its organization, but no complicated and infected cavity in such tissue as bone-marrow can ever be so treated to a theoretical degree of perfection. Therefore disappointment often follows this attempt. Senn endeavored to improve upon the plan by the insertion of chips of decalcified bone, but this method is open to the same objection. Dentists have the advantage of surgeons because they deal with small cavities, and in tissues which can usually be thoroughly sterilized. Other things being equal, the methods to which they resort could, with advantage, be imitated by surgeons. In 1903, Mosetig-Moorhof suggested a mass containing iodoform 60 parts, spermaceti 40 parts, and oil of sesame 40 parts. When this mixture is slowly heated to 100° C. and allowed to cool, there remains a soft material which, when desired for use, is melted, being constantly stirred to keep the iodoform properly suspended, while it is poured into the cavity, where it immediately solidifies. It is claimed that its physical properties permit of its gradual absorption and replacement by granulation, and finally by new bone, as has been shown by a series of skiagrams. A cavity in which this preparation is used should be prepared as dentists prepare theirs. It is successful in proportion to the absolute disinfection of the same. For this purpose wide opening and ready access are necessary in order to dry and cleanse. Should oozing be persistent strands of catgut may permit of escape of the blood which enters the cavity. It would probably be best to use the elastic bandage and bloodless method, and to protect for a few moments the solidifying mass before allowing the blood to return to the limb. The originator uses, in his own clinic, a hot-air blast. The air is heated by an electric contrivance, and both dries and disinfects the cavity. After the cavity is thus filled the tissues are closed over it and a sterile dressing applied. It is serviceable in chronic cases and after thorough work. In acute osteomyelitis it is scarcely to be thought of because of the acute character of the infection.

OTHER PARASITIC AFFECTIONS OF BONES.

These are mainly of two varieties--_hydatid disease_ and _actinomycosis_.

[Illustration: FIG. 236

Achondroplasic skeleton. (Porak.)]

=Hydatid Disease of Bone.=--Hydatid disease of bone consists in the development of hydatid cysts, which may be either of primary or secondary origin. Almost all the bones of the skeleton are liable to cyst formation, except the short bones of the carpus, tarsus, and digits. In the long bones they occur most frequently in the region of the epiphyses. The particular vascularity of this region is the main factor in their location at this point. The cysts may be unilocular or multilocular, and around them may be a thin or a large area of infiltration. In other words, their boundaries may be abrupt or not. Their volume is exceedingly variable, unilocular cysts sometimes attaining considerable size and distending the bone beyond its normal proportions. (See