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and a considerable quantity of fetid pus evacuated. The symptoms were not promptly or materially ameliorated by this treatment. The disease rapidly spread, so that in ten days after the trephining of the bone a second operation was demanded and a longer incision made, extending two inches below the knee and well down to the ankle. It was found that about four-fifths of the shaft of the tibia were completely dead, the periosteum being separated almost entirely from this portion of the bone. The dead portion of the bone was removed, comprising about fourfifths of the shaft, the division being made well out into healthy bone. The after-treatment was the same as applied in the former case, including immobilisation of the leg in a fracture-box.

This youth made a rapid recovery, and the result in his case is absolutely perfect, a skiagraph showing practically no deformity in the tibia. He has grown almost to manhood, is leading an active life, and has positively no lameness, the two limbs being the same length and apparently of the same strength.

Case III.-R. M., a boy, aged 13 years, in December, 1893, received a blow on the left ankle too insignificant to attract attention. Three days after this injury a painful, red swelling appeared just above the joint on the tibial aspect of the leg. This at first was thought to be rheumatism. It extended up the leg so rapidly, and the redness and swelling increased so that it was later thought to be erysipelas. I saw him five days after the appearance of the swelling. His pain was excruciating. He was overwhelmed with sepsis, and his condition appeared most precarious. The diagnosis of acute infectious osteomyelitis was made and no time lost in opening the pus cavity. An incision was made the whole length of the tibia and an enormous amount of stinking pus poured out. · Everywhere the periosteum was detached. and likewise the epiphyseal lines were separated, so that the entire shaft of the bone was found literally floating in a pus sac. The bone was lifted out without the application of a particle of force or the stroke of a knife to free a single attachment.

After proper preparation of the wound it was packed with iodoform gauze and outside dressings applied. The leg was put into an ordinary fracture-box and immobilised by packing about it snugly a quantity of wheat bran. For many days the issue was doubtful, but finally improvement began and progressed steadily. The leg was kept in a fracture-box until the wound had healed and new bone formed, after which time a light plasterof-Paris dressing was applied and the boy allowed to go on crutches. At the end of eight months the new bone was deemed strong enough to support the weight of the body. On account of the destruction of the epiphyseal lines there was considerable deformity in this case, the tibia not growing in length. Nevertheless the limb is perfect in function, and when a thick-soled shoe is worn no lameness is apparent. A most interesting fea

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[graphic]

JOHNSTON : Fig. 5. Anterior view of left leg, showing false articulation seven years after

exsection of fibia.

ture of the skiagraph is the exhibition of a false joint in the new tibia about three inches above the ankle-joint.

Case IV.-A boy aged 12 years was seized with pain in his shin. This was soon followed by redness and swelling. The trouble was at first ascribed to rheumatism. Later Dr. Warinner was called and pronounced it osteomyelitis. I first examined him at the Old Dominion Hospital. His leg was enormously swollen and very red, and fluctuation was present throughout the entire extent of the tibia. The boy being profoundly septic, and his condition being alarming, operation was immediately performed.

An incision was made extending the whole length of the tibia. When the bone was exposed it was discovered to be entirely denuded of its periosteum, and, like Case III., was lying loose in a pus sac. It was simply lifted out without any resistance by adherent membranes or epiphyses. As in the other cases, the wound was cleansed and dressed antiseptically and the leg placed in a fracture-box.

Prompt relief from constitutional symptoms supervened and the boy's general health rapidly improved. He made excellent progress and was able leave at the end of eight weeks with a light plaster-of-Paris dressing. He was allowed to go on crutches, with the leg suspended, at the end of ten weeks. In six months the bone, which was much distorted, was able to bear the weight of his body.

It will be seen, by reference to the skiagraph of this case, that, unlike Case II., formation of the bone was incomplete, there being a hiatus of fibrous tissue about the middle of the bone. The leg is sufficiently strong, however, to bear the weight of the body without the aid even of a cane. In consequence of the removal of the entire shaft and the destruction of the epiphyseal junction there is, of course, much shortening of the new tibia, but by means of a high shoe there is but little lameness. The function of the limb is excellent.

Case V.-L. J., a boy, aged 11 years, referred by Dr. H. H. Henry, was admitted to the Old Dominion Hospital, January 5, 1903. At the time of his admission his condition was deplorable. He had an acute osteomyelitis of the left tibia and a very acute inflammation in the right hip-joint. He was so profoundly septic that his life was despaired of. His symptoms had developed with great rapidity and violence, following a slight hurt. The whole of the left leg was very red and enormously swollen. Fluctuation was present over the whole tibial region.

An incision was made the entire length of the shin-bone, which was found suspended in a pus sac, and, like Cases III. and IV., the bone was free. No force was required to extract it, it being literally lifted out of its bed. This case was treated

[graphic]

JOHNSTON : Fig. 6.-SKIAGRAPH OF CASE IV.

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