a consideration of the previous history,
especially with reference to an antecedent attack of osteomyelitis. When
the adjacent joint is implicated, the surgeon may be misled by the
patient referring all the symptoms to the joint.

The X-ray picture is usually diagnostic chiefly because all the lesions
which are liable to be confused with Brodie's abscess--gumma, tubercle,
myeloma, chondroma, and sarcoma--give a well-marked central clear area;
the sclerosis around Brodie's abscess gives a dense shadow in which the
central clear area is either not seen at all or only faintly (Fig. 121).

_Treatment._--If an abscess is suspected, there should be no hesitation
in exploring the interior of the bone. It is exposed by a suitable
incision; the periosteum is reflected and the bone is opened up by a
trephine or chisel, and the presence of an abscess may be at once
indicated by the escape of pus. If, owing to the small size of the
abscess or the density of the bone surrounding it, the pus is not
reached by this procedure, the bone should be drilled in different
directions.

[Illustration: FIG. 121.--Radiogram of Brodie's Abscess in Lower End of
Tibia.]

#Other Forms of Acute Osteomyelitis.#--Among the less severe forms of
osteomyelitis resulting from the action of attenuated organisms are the
_serous_ variety, in which an effusion of serous fluid forms under the
periosteum; and _growth fever_, in which the child complains of vague
evanescent pains (growing pains), and of feeling tired and disinclined
to play; there may be some rise of temperature in the evening.

Infection with the _staphylococcus albus_, the _streptococcus_, or the
_pneumococcus_ also causes a mild form of osteomyelitis which may go on
to suppuration.

_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
characterist