Necrosis without suppuration, described by Paget under the name “quiet necrosis,” is a rare disease, and would appear to be associated with an attenuated form of staphylococcal infection (Tavel).  It occurs in adults, being met with up to the age of fifty or sixty, and is characterised by the insidious development of a swelling which involves a considerable extent of a long bone.  The pain varies in intensity, and may be continuous or intermittent, and there is tenderness on pressure.  The shaft is increased in girth as a result of its being surrounded by a new case of bone.  The resemblance to sarcoma may be very close, but the swelling is not as defined as in sarcoma, nor does it ever assume the characteristic “leg of mutton” shape.  In both diseases there is a tendency to pathological fracture.  It is difficult also in the absence of skiagrams to differentiate the condition from syphilitic and from tuberculous disease.  If the diagnosis is not established after examination with the X-rays, an exploratory incision should be made; if dead bone is found, it is removed.

In typhoid fever the bone marrow is liable to be invaded by the typhoid bacillus, which may set up osteomyelitis soon after its lodgment, or it may lie latent for a considerable period before doing so.  The lesions may be single or multiple, they involve the marrow or the periosteum or both, and they may or may not be attended with suppuration.  They are most commonly met with in the tibia and in the ribs at the costo-chondral junctions.

The bone lesions usually occur during the seventh or eighth week of the fever, but have been known to occur much later.  The chief complaint is of vague pains, at first referred to several bones, later becoming localised in one; they are aggravated by movement, or by handling the bone, and are worst at night.  There is redness and oedema of the overlying soft parts, and swelling with vague fluctuation, and on incision there escapes a yellow creamy pus, or a brown syrupy fluid containing the typhoid bacillus in pure culture.  Necrosis is exceptional.

When the abscess develops slowly, the condition resembles tuberculous disease, from which it may be diagnosed by the history of typhoid fever, and by obtaining a positive Widal reaction.

The prognosis is favourable, but recovery is apt to be slow, and relapse is not uncommon.

It is usually sufficient to incise the periosteum, but when the disease occurs in a rib it may be necessary to resect a portion of bone.

#Pyogenic Osteomyelitis due to Spread of Infection from the Soft Parts.#—­There still remain those forms of osteomyelitis which result from infection through a wound involving the bone—­for example, compound fractures, gun-shot injuries, osteotomies, amputations, resections, or operations for un-united fracture.  In all of these the marrow is exposed to infection by such organisms as are present in the wound.  A similar form of osteomyelitis may occur apart from a wound—­for example, infection may spread to the jaws from lesions of the mouth; to the skull, from lesions of the scalp or of the cranial bones themselves—­such as a syphilitic gumma or a sarcoma which has fungated externally; or to the petrous temporal, from suppuration in the middle ear.