The principles and practice of modern surgery

by Roswell Park

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.