130 Complete Series, Vol. XVI. ORIGINAL ARTICLES which are tied, but the subsequent sutures take up the lateral borders of the vaginal mucosa closely, allowing of no such reefs or New Series, Vol. V., No. 3. mucosa in the fornix is left as two redundant flaps shown in Fig. 10. These flaps are then resected as shown in Fig. 11, after ACUTE INFECTIVE OSTEOMYELITIS.1 BY DAVID C. HILTON, A. M., M. D., Lincoln, Nebr. The phrase, acute infective osteomyelitis, as commonly accepted, defines a class of bone lesions on clinical, etiologic and pathologic grounds. In clinical pathology, the term, osteomyelitis, is used in a collective sense to designate inflammation of all the different tissues of the bone, including the periosteum and the epiphyseal cartilage. Etiologically, acute osteomyelitis, being an inflammatory process, may be mechanical as by fracture, infective as by growth of certain pathogenic organisms, or physiochemic (physiologic?) as is presumed by some in arthritis deformans, osteomyelogenous neoplasmata, etc. The primary cause of acute infective osteomyelitis is the successful inoculation of the bone tissues by any of the pyogenic organisms;-usually in the metastatic cases by the staphylococcus pyogenes aureus alone or associated with the staphylococcus albus, or the streptococcus pyogenes. More rarely the staphylococcus albus and the streptococcus pyogenes are found alone. Bacillus coli communis, bacillus pyocyaneuus, bacillus typhosus, bacillus influenzae, pneumococcus lanceolatus, and others are occasional agents of the affection. Saphrophytic bacteria may be present. Bacillus tuberculosis is also an agent when acute miliary tuberculosis affects the bone, but it is of no surgical importance. The infecting organism may be implanted in the bone by: 1Read before the Nebraska State Medical Association, Omaha, May 4, 1909. (1) Direct , 1910 , Vol. V. implantation-Compound fractures, amputation wounds, bullet wounds, etc. (2) Extension from contiguous tissuesOsteitis secondary to suppurative arthritis, etc. (3) Metastasis-(a) As an accident in the history of a remote focus of infection, the movable tissues (blood and lymph) acting passively as vehicles; (b) As an incident in a blood mycosis. The cases that afford the greatest difficulty in diagnosis are those of metastatic, i. e., haematogenic,-origin. As such, the blood may or may not be the seat of an infectious process. In the one case, bacteria, infected emboli, or bacterial emboli may be swept into the blood stream adventitiously and be transported as passive foreign bodies from the depot of invasion to the depot of redeposit without multiplying or reacting measurably on the body in the interim. This may be true in the formation of metastatic abscesses if septic organisms cannot be recovered from the blood and if the related constitutional symptoms are periodically absent or accountable on the basis of toxaemia. Such an invasion of the blood amounts to an unsuccessful inoculation of it. In the other case, the blood may have been successfully inoculated at the depot of invasion and be the seat of a resident infectious process, a blood mycosis. In such a condition, the infecting organism multiplies. in the blood progressively or intermittently, and in severe cases, profoundly changes it. The inception of a metastatic nidus of infection during the course of a blood mycosis has not only a metastatic aspect, but that of infection by extension from contiguous tissues; the blood being the contiguous tissue. |