—The second stage includes, coincidently with the occurrence of suppuration, the proliferation of considerable granulation tissue, by which more or less protection is afforded; also, when time is afforded, the rapid formation of new bone, whose effect is to wall off the scene of conflict and death from the surrounding tissue, by which event prognosis, so far as the patient’s life is concerned, is improved. Intra-osseous abscesses may quickly coalesce, and the result may be one long tubular abscess extending through the shaft. At other times both bone-marrow and the cancellous tissue are bathed in pus, while if the periosteum have been totally separated the consequence will be a sequestrum whose dimensions correspond with those of the shaft. When periosteum is not loosened the necrosis will probably be central and more or less circumscribed. (See [Plate XXXV].)
Third Stage.
—The third stage is the period of efforts at spontaneous repair. There is a natural effort toward elimination of the sequestrum by the process of softening or liquefaction in the direction of least resistance. This process may extend over months, when surgical relief has been delayed, and may be accompanied by so much other disturbance as to completely ruin a bone or limb for further use. In neglected cases several sinuses may lead down toward the central sequestrum. On the other hand, once this sequestrum of eliminated an extraordinary amount of activity is usually displayed in the direction of repair ([Fig. 224]).
Fig. 224
Acute necrosis of tibia, with formation of cloacæ for affording opportunity for escape of sequestra. Illustrating also the extensive openings which necrotomy may necessitate. (Lexer.)
Symptoms.
—In a general way the signs and symptoms of acute infectious lesions in bone are strikingly similar, and are significant when construed aright. Patients complain usually first of exhaustion, followed by pain, which may become agonizing. This is often accompanied by an introductory chill with high fever, after which the general character of the disease assumes the typhoid aspect. Evening temperature may rise high and be followed by some morning remission. The spleen is usually enlarged, the primæ viæ disturbed, and often we have to do with a fetid diarrhea. In the young the sensorium is early affected and children soon become delirious. The pain, at first vague, quickly focuses in the particular bone or bones most involved, and as it increases in intensity there is a significant tenderness. Ordinarily there appear early reddening and swelling of the affected parts. With all these evidences there is also a characteristic muscle spasm, by which certain posture signs will be produced, varying with the bone involved. Pain is always intensified by the slightest degree of disturbance. In consequence the limbs (for it is the limbs which are usually involved) are contracted, and every effort to overcome the contractures is followed by aggravated pain. The more acute the pain the more vivid the external evidences of inflammation and the edema of the parts, especially below and about the lesion. Thus it may happen that within forty-eight hours there may be swelling and edema of the part involved, which should be regarded as pathognomonic.
A little later, superadded to the other signs of inflammation, there is fluctuation if parosteal abscesses have formed, or possibly the evidences of epiphyseal loosening or complete separation. When the disease is primary in an epiphysis the corresponding joint will be early involved, and the joint symptoms will assume the type of an acute purulent synovitis, but with more pain. It is probable that under few circumstances is complaint of pain more serious or aggravating than in cases of acute osteomyelitis of the fulminating type.
So far only local symptoms have been described. To these there should be added the list of those pertaining to thrombosis and metastatic infection, with their septic and disastrous consequences. The disease is frequently so acute and rapid that even within the first day or two not only are added extensive thrombosis in and along the bones, with rapid purulent degeneration and thrombi, but soon that even more serious general condition to which these lesions so easily give rise—i. e., unmistakable pyemia.