—The disease for which this is most commonly mistaken is acute rheumatism. There may have been some excuse for this in the past because of the lack of general knowledge of bone infections; now there is none. The majority of cases of necrosis following osteomyelitis which have come under the writer’s observation were the result of errors in diagnosis.
Rheumatism is never followed by suppuration and seldom produces a septic type of disease; its painful lesions are rarely so painful as those due to osteomyelitis. Lesions of rheumatism are usually multiple; those of bone infection are mostly single. The first complaint of pain in the latter is generally along the shaft of a bone than at the joint end, while this is not true of rheumatism. Moreover in acute osteomyelitis the disease assumes from the outset a seriousness which is seldom approximated by acute inflammatory rheumatism.
Treatment.
—The treatment for acute osteomyelitis is essentially surgical. Anodynes may be necessary for relief of pain, but no time should be lost, when once the diagnosis is made, in making incisions to expose the bone involved, and then opening to its interior to relieve tension and to remove septic products. The incision over the femur or tibia, for instance, may be ten or twelve inches in length. The tissues will invariably be found edematous or infiltrated, with evidence of the proximity of pus; the periosteum will be thickened and infected, and between it and the bone, as well as outside of it, there may be collections of pus. If seen late the characteristic muscle appearances already described may be noted. The periosteum should be incised to the bone throughout the length of the incision, and then an ordinary bone drill may be used to perforate the bone for exploratory purposes. From the punctures in the bone thus involved will exude purulent fluid, often sanious, thus indicating the condition within. A deep groove or channel should now be cut, opening into the marrow cavity, in which numerous foci will be found, or in which all distinctive structure of bone-marrow may be lost, the cavity being filled with pus. The pus cavity should be scraped and disinfected with hydrogen peroxide and cauterized with zinc chloride or its equivalent, and then packed, the wound being left open. Even this may not be sufficient, but if there be epiphyseal separation, or evidences of joint infection, the neighboring joints should be explored under aseptic precautions; if pus be found they should be opened, washed out, and drained. Meanwhile if in the soft tissues exposed by the incision the parosteal veins are found filled with septic thrombi, they should be opened as far as exposed and their contents removed.
These operations are often severe, but nothing in the way of operative treatment can be so severe nor so serious as the disease itself when left unoperated; the rule is stringent that every infected tissue, and especially every infected bone interior, should be exposed and cleaned out. Only in this way can lives be saved. Moreover, it is necessary to carry out this treatment in the fulminant cases as early as possible; and errors in diagnosis by which it may be postponed until metastatic infection or grave pulmonary and cardiac complications have set in are unfortunate. So long as the local indications are as above described, surgical treatment is desirable, whether the systemic complications are pronounced or not. The immediate effect of the operation having passed the relief thus afforded will often be so pronounced that within twenty-four hours patients may be out of danger.
Fig. 225
Total necrosis of humerus, as seen by aid of the cathode rays. (Lexer.)
The results of this operation are a wound which will discharge at first freely, and which so soon as septic material is out of the way will begin to granulate. Ordinarily no attempt should be made to close such a wound, though much may be done to favor rapidity of granulation. While some antiseptic dressing is always employed, it will be of advantage occasionally to change the character of the same, and to alternate between various antiseptics, the effect of any one drug being apparently lost after it has been used for some time.
There are some cases where an entire diaphysis or bone shaft will be found separated from one or both epiphyseal terminations, lying in a subperiosteal abscess cavity, bathed in pus, and dead beyond possibility of repair. This is total necrosis of the shaft from an acute infectious process, and is to be treated by complete removal of all dead and dying tissue. In the case of the forearm or leg it may be that the remaining bone, when only one is involved, as is usual, will be sufficient to maintain the integrity of the limb until new bone can be reproduced within the periosteal bed occupied by the old one. More or less complete regeneration of bone is possible, particularly in the young, and in connection with compensatory hypertrophy of the parallel bone will permit the restoration of the leg to partial or complete usefulness. On the other hand, should this later prove a complete failure, amputation and substitution of an artificial limb may be required.