SOME CASES OF BONE CAVITIES TREATED BY STOPPING WITH PARAFFIN
published at Manchester in 1848, gives a better idea of the appearances presented than any verbal description could convey. The illustration is a precise representation of what was seen so far as shoulders and face went. The presentation is hereby also explained and the improbability of the child passing through the os uteri unaided, the shoulders and what represented the head being between them and filling up the dilatation of ,the os uteri with the foetus beyond its circumference and within
... e uterus. Hitherto her labours have been natural and she has three children. In most cases of defective development of this ,kind labour has been premature and the foetus dead. When the foetus is dead and premature it may be assumed that the auperabundant liquor amnii described by observers in such cases would aid delivery by the free downward rush, accompanied by pains. Expulsion also would be facilitated by the -circumstance of the yielding nature and quality of being easily moulded and compressed of that which is dead and decomposing in contradistinction to that which is alive. In °the present case there was no descent of the child on account of malposition. Had Nature been left to her unaided efforts there is reason to believe that the liquor amnii would have drained entiiely away and that the foetus would have remained in the firm embrace of the contracted uterus, with ineffective attempts at expulsion. The foetus was a full-term male and as far as outward inspection went complete, with the exception notified. On birth it lived for a few minutes-the eyes moving and rolling, muscular movements passing over the body and limbs. Subsequently rigor mortis was well marked, and the length of the child was over 17 inches. The mother said that she had been frightened about the supposed time of her conception but I do not consider that this had anything to do with what is here described. The subsequent course of ,her recovery was uneventful. Guildford. UP to a few years ago the treatment of chronic abscess of bone and chronic osteomyelitis was in a very unsatisfactory state ; the condition was treated by palliative means for as long as possible, during which time the cavity increased in size until it reached the surface. It was then opened, scraped, plugged with gauze, and gradually filled from below. Now, as the newly-formed granulation tissue had to be converted in sequence into fibrous tissue, osteoid tissue, and finally true bone this process took a long time to complete, a cavity of the size of a hen's egg usually remaining open for about four months and then resulting in a scar, which was depressed and adherent to the underlying bone and very liable to break down. To overcome the long convalescent period many attempts have been made to fill the bone cavity with various substances, the wound is then sewn up, and having healed by primary union the substance in the cavity is gradually absorbed and replaced by bone, but as the wound is quite healed the patient is able to go about his usual work and is independent of the changes going on in the bone beneath the surface. In the evolution of the present methods the following materials have been used as stopping :-1. Blood clot. This did well for small cavities provided they were made perfectly aseptic but in larger spaces it is liable to break down. 2. Strands of catgut were placed in the cavity in the hope that the blood would clot more firmly around them. This was not found in practice adequately to fulfil its object. 3. Pieces of sterilised sponge. These weJe not absorbed and hence did not carry out the main object of their use. 4. Pieces of decalcified bone. With these the crevices could not be filled, which seems to be one of the essentials of success, and in the majority of cases their use was followed by failure. 5. Plaster-of-Paris. This could be well sterilised, but it took a long time to set firm, was not absorbed at all, and in most cases led to such irritation that it was ultimately discharged, leaving the cavity to be filled up from below, with the presence of an open wound. 6. The method introduced by Mikulicz of filling up the cavity with a mixture of iodoform and paraffin. This, wi 5h modifications, is the method now generally in use. Moorhof uses a mixture of iodoform, 60 parts, spermaceti and oil of sesame of each 40 parts, this mixture being chosen, first, because of its antiseptic properties, and secondly, because it is said to be more easily absorbed than paraffin. In 1905 he had recorded 195 cases of different sorts without a single failure. Cases treated in a similar manner have been recorded in this country by Seymour Jones and Corner. The cavity is scraped out, sterilised, and dried carefully so that the mixture may come into contact with every part of the wall ; it is then filled with the mixture and after this has set firm the soft parts are sewn over it. In the first of the three following cases such a method was tried but without success. On considering this case and several others of similar failure attempted by various surgeons it appeared to me that certain modifications might be applied which would decrease the likelihood of failure, and on putting them into practice, as in the last two cases, I found the method was completely successful. The notes of the cases are as follows. CASE I.-The patient, a youth aged 18 years, was admitted to the London Hospital on May 6h, 1907. Six months before admission an abscess had formed in the right ankle. One month later the abscess was opened at an infirmary where he had been since with sinuses still discharging. He was then sent to the London Hospital for further treatment. On admission there was a sinus one inch above the right external malleolus, which ran in for one inch leading to the bare end of the tibia; over the lower end of the anterior surface of the right tibia was a scar three inches long, with a sinus at the upper end leading to bare bone. The tibia was much thickened beneath the scar ; two inches above its upper extremity was another sinus leading to bare bone. A radiograph showed much thickening, with irregular formation of new bone around the lower end of the tibia ; in the centre of this could be seen a sequestrum about two inches in length with an irregular outline. At the operation an incision was made over the scar and the outer wall of the involucrum was removed ; the sequestrum was loosened by chiselling and removed; the sinuses were scraped and the cavity was plugged with sterile gauze strips. The wound was replugged daily until the tenth day. On this day an ansesthetic was readministered, the cavity was scraped out, and the bleeding was stopped as far as possible with pressure by gauze plugging. The periosteum was reflected but was found to be very thick, cartilaginous, and inelastic, so that it could not be drawn across the cavity. Attempts were then made to dry the cavity with a modification of Moorhof's apparatus, air being passed through tubes containing formalin and calcium chloride to dry the air. It was, however, found impossible to get the walls perfectly dry. The cavity was then filled with Moorhof's mixture, this being poured in at a temperature of 114° F., at which it is a liquid. It did not harden well or quickly in the cavity. The periosteum was sewn across with Pagenstecher thread as far as possible and the skin was united with silkworm gut. On the day after the operation the patient's temperature rose to 102° and a bright 1 St. Thomas's Hospital Reports, vol. xxxii., p. 433.