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The periosteum, which is thick and easily separable, is raised from the new case with an elevator, and with the chisel or gouge enough of the new bone is taken away to allow of the removal of the sequestrum. Care must be taken not to leave behind any fragment of dead bone, as this will interfere with healing, and may determine a relapse of suppuration.
In such cases, a portion of periosteum and bone is usually detached and the condition may then properly be called one of fracture. In some cases of this kind recovery is tardy, because of the difficulty in maintaining perfect apposition of the divided structures, and reactionary inflammation is not of sufficient extent to enhance prompt repair.
One of the temporal arteries was ligated, and the scalp cleansed and reapplied. The hanging ears and the skin of the forehead were successfully restored to their proper position. The patient had no bad symptoms and little pain, and the shock was slight. Where the periosteum had sloughed the bone was granulating, and at the time of the report skin-grafting was shortly to be tried.
Simple structures, such as skin, cartilage, bone, periosteum, and tendon, for example, have a high power of regeneration, and in them the reparative process may result in almost perfect restitution to the normal.
In superficial bones, such as the sternum, the formation of tuberculous granulation tissue in the deeper layer of the periosteum, and its subsequent caseation and liquefaction, is attended by the insidious development of a doughy swelling, which is not as a rule painful, although tender on pressure.
If the articular surface is extensively diseased, a thin slice of bone should be removed, and if foci in the marrow are then revealed, it is better to gouge them out than to remove further slices of bone, as this involves sacrifice of the cortex and periosteum.
Less frequently there is more than one collection of pus under the periosteum, each being derived from a focus of suppuration in the subjacent marrow. The pus perforates the periosteum, and makes its way to the surface by the easiest anatomical route, and discharges externally, forming one or more sinuses through which fresh infection may take place.
Where the periosteum has been perforated by pus making its way to the surface, there are defects or holes in the involucrum, called cloacæ. As these correspond more or less in position to the sinuses in the skin, in passing a probe down one of the sinuses it usually passes through a cloaca and strikes the dead bone lying in the interior.
It is rarely possible by external examination to recognise deep-seated osseous foci in the vicinity of joints; but if they are near the surface in a superficial bone such as the head of the tibia there may be local thickening of the periosteum, œdema, pain, and tenderness on pressure and on percussion. X-ray Appearances of Tuberculous Joints.
If a portion of the periosteum be detached by injury or disease, there is risk that a layer of the subjacent bone will lose its vitality and be cast off. Microscopic Structure of Bone. If a very thin slice of bone be cut from the compact tissue and examined under a microscope, numerous minute openings are seen.
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