[Reprinted from The Philadelphia Monthly Medical Journal, 
November, 1899.] 
GENERAL CONSIDERATIONS ON THE 
PATHOLOGY OF THE SERIOUS FORMS 
OF CHRONIC OSTEOMYELITIS AND 
THEIR COMPLICATIONS. 
Being the Inaugural Lecture to the Course on 
Surgical Pathology, Delivered October 16, 
1899. 
CHARLES GREENE CUMSTON, 8.M.5., M.D. 
Assistant Professor of Surgical Pathology in the Faculty of Medicine, Tufts 
College, Boston, Mass. 
Gentlemen :—lt is with much pleasure that I be- 
gin today my fourth year as incumbent to the chair 
of Surgical Pathology in this Faculty, and I can assure 
you that all my efforts will be used to make these 
lectures as interesting and as instructive as possible. 
As in the former years, it is my intention to devote 
the first lecture to the study of some question of 
surgical pathology worthy of your careful considera- 
tion, and for the present occasion I have selected the 
subject of the serious forms of chronic osteomyelitis 
and their complications, because it is one of great 
practical interest, and to which little attention has 
been paid on this side of the Atlantic. 
A focus of osteomyelitis in one or several bones is 
the most frequent lesion found in the chronic form of 
this affection and may be the cause of much serious 
illness and suffering to the patient, and exacting a 
high degree of skill on the part of the surgeon to bring 
the case to a happy outcome. 
The localizations of this affection are more partic- 
ularly to be found in the long bones, especially at the 
lower end of the femur and upper end of the tibia, 
while in the upper limb we find the upper extremity 
of the humerus and the lower end of the radius and 
ulna. The statements- Ollier regarding the 2 
seat of acute osteomyelitis apply to the chronic forms 
when frequency is considered. The chronic forms 
may also occur in the flat bones, just as the acute 
type does. The bones of the cranium and the short 
bones may also be the seat of the chronic types of 
osteomyelitis, but this is infrequent. 
Osteomyelitis may occur in two ways. Sometimes 
the attacks take place in a focus that was primarily 
the site of an acute process, and little by little will 
increase the extent of the trouble. Sometimes they 
manifest themselves in a bone in the neighborhood or 
at a distance from the primary focus. There are 
lesions, such as hyperostosis, necrosis and abscess of 
the bones, which belong to the less severe types of 
the disease, but usually on account of their extent, 
their persistency and the considerable impotency that 
they produce, the chronic form is rendered very seri- 
ous on account of the bad general condition into 
which the patient is thrown. 
Besides these lesions there are others, such as 
spontaneous fracture, disproportional elongation of 
both bones in a segment of a limb, as, for example, 
the leg or the forearm, which are more peculiar to 
chronic osteomyelitis, and which I shall consider later 
on in this lecture. 
Usually the clinical symptoms will be thus put ,be- 
fore the surgeon. A patient is cured of his acute 
osteomyelitis, and then, considering himself well, goes 
about his usual occupation. After a variable time, 
perhaps one, or even several years, under the influence 
of traumatism or an infectious disease, or even with- 
out any apparent cause, the patient usually feels a 
pain, which is localized in a limb. These pains are 
in the first place dull, and are easily borne by the 
patient, and he may even be able to walk and attend 
to his work. But, after being intermittent, they little 
by little become continuous and ofter take on the 
character of an acute affection, such as they had when 
the patient was first taken with the acute manifesta- 
tions, and, when this occurs, they will present very 
severe exacerbations. 
These attacks of pain may occur at any time dur- 
ing the day, but the principal time for their appear- 3 
ance is in the night. This nocturnal recrudescence 
has been mentioned by a large number of writers. 
The patient cannot sleep, or, if he does doze off for 
an instant, he is instantly wakened by a new attack. 
The privation of sleep is one of the most frequent 
consequences, and at the same time one of the most 
troublesome of this form of chronic osteomyelitis; 
consequently this is often the first symptom of which 
the patient speaks when questioned. He will also 
tell you that the pain is increased by walking, stand- 
ing up or when pressure is exercised over the parts. 
These pains have been compared by patients to a 
sharp point of fire in the center of the diseased spot, 
or to hammer-blows directed on the bone. Others 
will tell you that the pain is with a feeling of 
tearing, while still others will describe it as lancing 
and penetrating. These pains at first sight offer a 
certain resemblance to the osteocopic pains met with 
in syphilis. 
As the disease becomes of long standing, the in- 
tensity, frequency and duration of the attacks of pain 
also increase, the suffering becomes excessive in spite 
of the treatments applied, and several times it has 
happened that these unfortunate patients have come 
to the surgeon, begging him to amputate their limb, 
in order to deliver them from the torture which they 
had been undergoing for the last few years. In pur- 
suance of these symptoms complained of by the 
patient, after having carefully questioned him on his 
antecedents, and after having examined his bone, 
you will usually find either hyperostosis, necrosis or 
an abscess of the bone, but these three lesions may 
be all combined in the same individual, at the seat of 
recurrence of an osteomyelitis. 
Considering now hyperostosis, I would say that it 
is situated in the juxtaepiphyseal region, and, al- 
though this is its usual seat, it may be complete and 
surround the diaphysis in its entire length, but usually 
it is partial and decreases from the epiphysis to the 
diaphysis. Instead of extending around the entire 
circumference of the bone, to which it gives a globu- 
lar form, it may only be localized on a point of the 
latter. 4 
Generally an hyperostosis of the bones is irregular, 
its surface may be smooth, but in most cases it pre- 
sents furrows and cavities of various sizes, giving it 
a variable aspect, to such an extent that in certain 
cases of general hyperostosis, some of the bones look 
like old dry tree-trunks, which have been eaten away 
by insects, and which are only held up by their bark. 
Now if you trephin or perforate with a bone curet 
one of these worm-eaten bones, you will be aston- 
ished that in certain places the bone-tissue will pre- 
sent an unusual degree of hardness, and it will be 
with the greatest difficulty that it can be cut through 
with the gouge; it appears to have lost part of its 
substance, and you will find combined in one bone 
both processes of osteitis, namely rarefying osteitis 
and the compact osteitis. 
It may happen that these hyperostoses will conceal 
an abscess of the bone or a necrosis. This is ex- 
tremely frequent in the tibia. The bone is exteriorly 
deformed. It appears increased in size, but its in- 
terior presents irregular cavities in the bone, out of 
which you will be able to scrape small sequestrums 
and a certain amount of pus. This pathologic con- 
dition explains why spontaneous fractures so often 
occur during a chronic osteomyelitis. 
Abscess of the bone may only show itself a long 
time after the first attack of osteomyelitis and indi- 
cates a wakening up of the former affection, whose 
infectious agent has not become completely destroyed. 
Under some influences this agent takes on its former 
virulence ; at other times the abscess is the direct 
consequence of the acute affection. That is to say 
that the patient, who has suffered a great deal during 
an acute osteomyelitis, and fearing another surgical 
operation, prefers to see a little pus continue to come 
away from the primary focus, and he considers him- 
self fortunate to have already escaped from death; but 
this abscess will continue, suppuration weakens the 
patient, who finally is obliged to consult the surgeon. 
These abscesses present several important symp- 
toms. The first is an increase in size of the diseased 
part, which usually is noticeable at about the same 
time that the pains make their appearance. In the 5 
beginning its increase in size is rather more appre- 
ciable to touch than to sight and it becomes more and 
more pronounced as the disease advances. The ex- 
tent of the tumefaction is not generally of any great 
amount, and according to Broca it rarely is more than 
one-third of the total length of the bone. The swell- 
ing is generally regular and gives the bone a fusiform 
look which appears as if blown out. Above and below, 
the tumefaction insensibly spreads way into the soft 
parts. The surface of the swelling is usually uniform, 
because in abscess of the bone, their size is quite con- 
siderable, and the pus is to be found under the skin 
and sooner or later will make its way outwards. 
A character which has been absolutely demon- 
strated is a local elevation of the temperature, even 
when no inflammatory complication is present. In 
order to detect this symptom you must make a com- 
parative examination of both limbs and have exposed 
them first to the air for a few minutes, in such a man- 
ner as to have placed them in an equilibrium with 
the temperature of the air of the room. 
The skin may present different aspects, according 
to the length of time that the lesion has been present, 
as well as to the extent of the underlying abscess. 
Sometimes it is smooth, elastic and moves easily over 
the underlying tissues ; at other times there may be 
seen a depression, and the skin will be found adherent 
to the periosteum over the cicatrix of a former ab- 
scess which had opened. When you are dealing with 
an abscess which has been present for several months, 
it is infrequent to find the skin presenting a normal 
color, and it will be usually a more or less dark red or 
violet hue. Quite frequently an area of variable color 
is present, sometimes of an intense red, while at 
others pale, which is quite circumscribed. These 
spots have a certain important clinical value because 
they give us a very precise indication as to the point 
of the bone over which we should trephine, in order 
to reach the abscess. The integuments sometimes 
present a particular bronze color over the swelling, 
which is due to an increase in the pigmentary secre- 
tions of the skin, and it may occupy the entire extent, 
or only certain parts of the tumefaction. 6 
The soft parts covering the bones may also be at- 
tacked by the abscess. The latter may have two 
starting points. The first are abscesses by neighbor- 
hood, taking start in an extension of the general 
inflammation of the periosteum and continuing to the 
cellular tissue which surrounds it. These subperios- 
teal abscesses occur in variable numbers during the 
course of the disease. Although generally very lim- 
ited, they are accompanied by the usual symptoms 
met with in abscess of the soft parts. They open 
exteriorly and after having given issue to pus for a 
certain time, they finally end by healing up. They 
have one characteristic, which is this : When a sound 
is introduced by the orifice of the fistula, which per- 
sists after they have broken open, you will never be 
able to reach down on a denuded body surface ; the 
surface of the bone being always covered by a thick 
periosteum. 
Generally speaking, the abscesses which form come 
from the bones and are accompanied by fistulas. These 
fistulas have a peculiar appearance which will always 
allow the surgeon to distinguish them from a fistula 
due to a tuberculosis of the bone. They are de- 
pressed, adherent with hard borders which present 
fungous growths and are undermined. By exercising 
pressure over the integuments in the neighborhood, 
you will not be able to express any caseous matter 
nor the white soft fungous masses such as those found 
in cold abscesses. 
When the opening of these fistulas is sufficiently 
large, a thing which is infrequent, it is possible to in- 
troduce the sound into the cavity. If you can exe- 
cute this maneuver, it will be seen that the instru- 
ment runs a very variable course; the walls of the 
fistulous track are receding and not friable, as in 
caries, and the cavity does not contain any trace of 
sequestrum. In some cases these interosseous fistulas 
are so narrow and so winding in their course that the 
finest silver probe cannot be made to enter them, and 
besides they do not> always open exteriorly. It fre- 
quently happens that abscesses of the soft parts be- 
come cicatrized, and the integuments temporarily 
cover the orifice of the fistulas, up to the time when 7 
the pus which has accumulated in the cavity again 
breaks outwards. This alternating closing and open- 
ing of the fistula may take place quite a number of 
times during the course of the affection. Spontane- 
ous opening of a painful abscess of the bone ex- 
teriorly is generally followed by a temporary decrease 
in the pain, but it should not be considered as a step 
towards recovery. It is necessary that the opening 
be sufficiently large to give free issue to the pus, and, 
if it is inoculated on serum, a growth of strepto- 
cocci, which are usually the cause of osteomyelitis, 
will soon be seen. 
We now come to the consideration of necrosis. 
Necrosis is present when the bone tissues are dead. 
In this case the necrosed tissues or sequestrum play 
the part of septic foreign bodies in the parts in which 
they exist, and by their presence keep up suppura- 
tion. A sequestrum may be found in any or all parts 
of a bone, either in the region of the epiphysis or 
in the juxtaepiphyseal region, or in the diaphysis. 
They may be superficial or deep. Their color is 
usually yellow, and, if they are carefully examined 
you may often detect a large number of small, fine 
drops of pus. Sometimes a diseased bone will con- 
tain only one sequestrum; at others there may be 
several. The sequestrum is completely separated 
from the living tissues, or else it may adhere by some 
small point. It may be free, or, which is most usual, 
bound up by new bone, in which case the latter is 
riddled by cloacae. There may thus exist between 
the sequestrum and the layer of new bone a suffi- 
ciently large space to allow the former to be some- 
what movable. The extent of a sequestsum is very 
variable; usually they do not measure more than 4 
centimeters in length and 5 or 6 millimeters in thick- 
ness. 
When a sequestrum is situated in the juxtaepiphy- 
seal region of a bone, it may irritate the conjugate 
cartilages, perforating them and entering into the 
joint, as is often observed. Besides these lesions of 
chronic osteomyelitis, there are others far more curi- 
ous, which consist in various deformities, resulting 
from troubles taking place in the growth and consist- 8 
ency of the diseased bone, and I will in the first place 
speak of the arrest and excess of growth. 
An arrest in the growth is due to a lesion in the 
juxtaepiphyseal region, and is the more marked the 
younger the patient is, as well as the more severe 
the inflammation. It is seen at its height when the 
inflammation has invaded the bone entirely, or is 
situated at the same time in both its ends. When 
this occurs, it is known as bipolar osteitis. The 
shortening of a bone of a limb which is the seat of 
chronic osteomyelitis is sometimes very considerable, 
when the same bone of the opposite side is compared 
with it. 
Gangolphe, in his reeent work on “The Infectious 
Diseases of the Bones,” gives the photograph of a 
patient who was the subject of an infections acute 
osteomyelitis of the lower end of the right femur, 
at the age of 7. When she entered his service, the 
patient was 18 years old, and up to that time had only 
walked with crutches. The diseased femur was 
shortened to the enormous extent of about 9 centi- 
meters ; and what was more, this lower end was 
singularly changed in its proportions. The internal 
condyle which was more projecting extended very 
much lower than the external and pushed the corre- 
sponding articular surface of the tibia in such a way 
that it gave the general look of a genu valgum. 
Instead of having an arrest in growth, there may 
be on the contrary an excess. The lengthening of 
the bone is the cause of a difference in size of the 
corresponding limbs, and consequently brings about 
limping. We can take as a type the tibia, especially 
so on account of the frequency of its lesions. At the 
end of a few months or a year the diseased tibia may 
grow 2, 3 or 4 centimeters, and often more than the 
healthy tibia. According to Gangolphe, osteomyeli- 
tis, when situated about the middle of the bone, is 
more apt to produce this excess in growth, while, 
when the disease attacks the ends, an arrest in devel- 
opment occurs. 
These modifications in the length of the bone pro- 
duce functional troubles in the limbs. In the first 
place we find a deformity; the normal curves are ex- 9 
aggerated, or, on the contrary, are less marked under 
the influence of too hasty walking. In a limb in 
which there are but two bones, as, for example, in the 
forearm and the leg, one of them may not follow the 
other in its increase in size, and the result is that the 
longest bone is obliged to curve more or less at the 
middle, in order to articulate with the extremities of 
the other. This curve is all the more pronounced the 
larger be the increase in length of the one bone in 
relation to the other. 
This disproportion in the length of two bones of 
one limb will produce a deviation of the hand or of 
the foot. When situated in the leg, when the tibia 
presents an' arrest in growth due to a lesion situated 
in one or both its ends, the foot becomes inclined 
inwards, and the patient places it on the ground on 
its external border, and thus it becomes a pes varus. 
If, on the contrary, the fibula is the seat of disease, 
you will then find a pes valgus. Now turning to the 
upper limb, if the radius is arrested in its growth, 
the hand will be directed upwards on the radial 
border of the forearm. If, on the contrary, the ulna 
is diseased, the hand will be directed inwardly. 
On account of the decrease in the resistance of the 
bone, a detachment of the epiphysis, or even a real 
fracture may occur, This last unfortunate occur- 
rence is sometimes of only short duration, because 
there may be a subperiostial bony layer secreted in 
considerable abundance, which will act as a splint to 
the detached diaphysis. But this is not always the 
case, and generally speaking these kinds of fractures 
constitute a complication which increases the chance 
of septicemia or purulent infection and often necessi- 
tates a very severe surgical operation. 
These spontaneous fractures may occur either 
in the juxtaepiphyseal region or in the diaphysis, 
and the symptoms are not the same in each case. 
Detachment of the epiphysis produces separation of 
the diaphysis from the epiphysis, and occurs very 
rapidly, following necrosis of the neighboring zone of 
spongy tissue, which is near the cartilage of connec- 
tion. It is in the enlarged part of the diaphysis, the 
bulb of the bone, in which this fracture usually oc- 10 
curs, and generally is brought about by an extremely 
slight traumatism, such as muscular contraction or a 
displacement of the limb. These fractures may 
occur very early in the disease. The bony surfaces 
which are separated, or sometimes only adherent by 
a few points, are usually irregular. The fracture is 
not oblique, but is zigzag. The necrosis sometimes 
only attacks the end of the diaphysis, while at others 
it attacks the diaphysis itself. These fractures may 
become consolidated, if they are taken care of early, 
and if the focus at which the detachment of the di- 
aphysis has taken place, is disinfected. 
Fractures occurring in the body of the bone take 
place at variable times, but usually they occur a long 
period after the beginning of the disease. They may 
be situated towards the upper third or the lower 
third of the long bones, the middle being less fre- 
quently the seat. The femur is the bone which is 
most frequently fractured, and this takes place at a 
more or less great distance from the knee. The 
upper and the middle third may also be the seat 
of fracture. The tibia, ribs, and exceptionally the 
humerus, may also be the seat of fracture. Ne- 
crosis is the most essential cause of these lesions, 
but it acts more or less directly in bringing about the 
solution of continuity. Spontaneous fractures may 
take place under two circumstances during the 
course of a chronic osteomyelitis. The bone is laid 
bare ; the loss of substance is too considerable, and, 
consequently, on account of its slight resistance, the 
bone breaks. In the other case you have a bone 
going through the process of repair, and there is a 
layer of bone surrounding the necrosed part, but it is 
not sufficiently solid, and the patient when using his 
limb will feel the bone give way at this weak point. 
These fractures are oftentimes a danger in that they 
may set at liberty a sequestrum, which has been 
invaginated, and which in its turn, on account of its 
shape, may either cause a laceration of an artery and 
thus bring about a dangerous hemorrhage, or irritate 
a neighboring nerve, thus producing a paralysis. 
We have now considered the bone localizations 
and complications of chronic osteomyelitis, and I 11 
will now take up the joint troubles which may be 
observed in this disease. After a variable length of 
time, chronic osteomyelitis may attack the joints and 
extension of the process may take place by various 
mechanisms. An abscess of the bone developed 
during an acute or chronic period, and when situated 
in the center of a hyperostosis, instead of burrowing 
towards the exterior and making its exit by a fistula, 
may push itself way through the spongy tissue of the 
epiphysis up under the diarthrodial cartilage, which it 
will slowly ulcerate and finally perforate. We then 
find in the cartilage the same loss of substance and 
these same depressions similar to those found in 
acute ostepmyelitis. From this a secondary suppu- 
rating arthritis results. Sometimes the contamina- 
tion of the joint may occur by the penetration of a 
sequestrum into its cavity ; at other times we find the 
soft parts, and more particularly the synovial culs-de- 
sac, which have in time relations with the joints and 
the epiphyses, serving as conductors of the infection. 
The arthrites that are observed during the progress 
of a chronic osteomyelitis may either be suppurating 
or not. When the nature of their liquid contents is 
serous, they are not usually grave in their conse- 
quence, but when pus is present, they are dangerous. 
The joints which are most frequently the seat of 
these complications, are in order of frequency, the 
knee, the coxo-femoral joint, the shoulder, and the 
elbow. These arthrites of chronic osteomyelitis offer 
a particular symptomatology, and they appear when 
they are first examined to be very similar to tuber- 
culosis of the joints, and consequently it is most 
essential a correct diagnosis be made in order to 
avoid a mistake in treatment. 
In these cases pain is the first functional symptom 
that the patient complains of; it follows the course 
that I have already mentioned in the beginning of 
this lecture; that is to say, it increases little by little 
in intensity and finally arrives at such a height as 
to render the joints impotent. It may be relieved 
momentarily by quiet and immobility, but it will 
surely recur as soon as the patient moves the limb. 
The joint which, to all external appearances, has 12 
been normal, soon begins to increase in size. This 
increase occurs progressively without producing a 
very marked deformity. After a fatigue or traumatism, 
or an infectious disease, which gives the chronic af- 
fection a start, so to speak, a slight acute attack will 
occur, and which disappears as soon as the patient 
remains quiet. Little by little the joint movements 
become less and less free, and they are all the more 
limited, because they produce so much pain; there 
finally comes a time when the pain, the functional 
impotency and distress force the patient to consult 
his physician, if he does not want to be continually 
quiet. The localization in the joint is at this time 
effected. Now, if you examine a joint, and let us 
take for example the knee, which is usually the one 
attacked, this is what is found. Usually the knee is 
normal, and by palpation the tumefaction appears to 
be situated in the periarticular tissues rather than in 
the joint itself. Prominences are easily felt by the 
examining finger, and sometimes, when the tumefac- 
tion is not very considerable, they may even be seen, 
a condition which never occurs in white swelling. 
There are certain points around the joint which are 
more painful than others. We will not be able to 
feel any fungosities, and the joint will usually appear 
enlarged, while in a white swelling the joint will 
appear increased in height on account of the inflam- 
matory state of the synovial membrane as well as to 
the production of lardaceous tissue. The skin is 
usually normal, especially when the contents of the 
joint are a serous fluid. As in hydarthroses, the liga- 
ments are very much relaxed, and abnormal lateral 
movements may be given to the joint to quite an ex- 
tent. When, on the contrary, we are dealing with a 
suppurating arthritis, we will usually see in the neigh- 
borhood some purulent foci which communicate with 
the epiphyses, and in some places the skin is ulcerated 
and of a violet color. 
At the end of an indeterminable time the periar- 
ticular tissues become changed in their anatomical 
makeup. The quadriceps becomes extremely thin, 
and its lower insertions lose their attachments on 
account of their contact with a purulent focus. The 13 
action of the flexors of the leg outdoes that of the 
extensors ; the lower limb is no longer in extension, 
but is half flexed with abduction and outward rota- 
tion. It thus results that in the. first place we would 
be rather inclined to make a diagnosis of tubercular 
arthritis of the knee, on account of the general aspect 
of the limb, as well as the atrophy of the triceps and 
the swollen condition of the joint. Now, what will 
prevent us from making this error in diagnosis, is the 
fact that we learn from the patient that the lesion 
did not begin in the knee but was first noticed in the 
lower extremity of the femur or the upper extremity 
of the tibia and fibula, and that the patient also gives 
the history of a former acute osteomyelitis. 
An arthritis of the hip, due to an osteomyelitis, 
sometimes presents certain characters that render 
the differential diagnosis with coxalgia a very difficult 
problem. The following case is of interest in this 
respect. The right lower limb of the patient pre- 
sented an abnormal attitude, which at first sight cer- 
tainly looked like a coxalgia. When the patient was 
on the bed, the limb appeared to be elongated, but by 
measurement it was found 3 centimeters shorter 
than the opposite one. The anterosuperior spine 
was lowered and carried forward. When these dis- 
placements were corrected, it was seen that the limb 
was in flexion with abduction and outward rotation. 
The palpation of the femur showed that the upper 
extremity of the diaphysis was noticeably hyper- 
trophied and the greater trochanter was nearly trebled 
its normal size. There were two fistulas in the thigh 
where two abscesses had burrowed outwards. These 
fistulas were not fungous, and between them there 
was an extensive detachment. There was besides on 
the anterior aspect of the thigh, about at its middle 
third, a red depressible and slightly painful point. 
There was no thickening felt in the groin. 
The patient was chloroformed and the fistulas were 
explored and showed that they led directly on the 
denuded greater trochanter. The probe entered into 
a cavity, which ended at the depressible red point on 
the anterior aspect of the thigh already mentioned. 
The tracks of the fistulas were opened up with the 14 
thermocautery and drained. The first incision was 
vertical and was made behind and exteriorly to the 
greater trochanter and immediately led down on an 
absolutely movable sequestrum, which measured 5 
centimeters in length and 2 in breadth. The bor- 
ders of this sequestrum were irregular; its external 
aspect was compact, while the internal was porous 
and concave. After the sequestrum had been removed 
the greater trochanter was chiselled out with a gouge. 
At no point, either in the fistulas or in the cavity of 
the bone, could any membrane be found which could 
be compared to that of a tuberculous abscess. 
Under these conditions it is easy to understand 
how a patient who has an arthritis of the lower limb, 
due to osteomyelitis, may be afflicted most terribly by 
pains and difficulty by movement or in walking. Oc- 
casionally, but only at the beginning of the disease, 
the patient may still do a little work, but he suffers 
in consequence. If you watch these patients walk, 
you will remark that they are careful to keep their 
limb in extension, and in avoiding to bear their weight 
upon it, they draw their leg after them; others will 
use crutches, and, as the foot is no longer placed upon 
the ground, a flexion of the knee will little by little 
take place under the influence of. the muscles of the 
posterior aspect of the thigh, which are in a state of 
constant contraction; and lastly a time will come 
when these unfortunate patients are obliged to take 
their beds and there remain during a more or less 
considerable length of time, and it is when they arrive 
at this condition that the surgeon is called. 
When once an operation has been performed it is 
really astonishing to see how quickly these apparently 
serious cases get well, and Tillaux has well demon- 
strated that the operative results in arthritis, due to 
osteomyelitis, are very much superior to those ob- 
tained in white swellings in general, and in particular 
tuberculosis of the knee, and that a large number of 
resections performed for a socalled tuberculous ar- 
thritis, which gave good results, are really only cases 
of osteoarthritis following a chronic osteomyelitis. 
Besides these characters of a pseudo-tuberculosis of 
the joint, the joint localizations of chronic osteomyeli- tis also present other complications, such as disloca- 
tions and enthyloses, which I will now consider. 
Of all the subdislocations, the most frequent is back- 
ward displacement of the tibia. This is rendered easy 
on account of the position of the limb, which is in a 
more or less considerable flexion ; in this position the 
flexor muscles of the leg or the thigh are contracted, 
as I have already said and pull the tibia backwards; 
the latter slides backwards from the condyles of the 
femur, and little by little projects into the popliteal 
space, at which time one can distinctly feel the con- 
dyles of the femur, which project under the skin and 
cause a very appreciable projection, both to sight and 
to palpation. Dislocation of the patella is variable, 
but very often this bone becomes intimately adherent 
to one or the other of the condyles, and when this has 
occurred it is impossible to give any movements to it. 
Under these circumstances the patella will not move 
when the tibia or the femur become displaced. 
Subdislocation, when it has once occurred, is kept 
up on account of muscular contraction. Under chloro- 
form it may be quite easily reduced, because the 
narcosis causes the contraction of the muscles to dis- 
appear. Salmon justly remarks that this fact gives 
still another argument in favor of muscular contrac- 
tion in the pathological phenomena of backward sub- 
dislocation of the tibia, and that when resection of 
the knee is performed and the limb once more rendered 
straight, the leg may little by little become again 
flexed on the thigh, if it is not firmly held in place by 
a posterior splint. 
It is to these subdislocations that the phenomena 
known by the name of “double knee'' is due, and it 
consists in the following condition ; When the lower 
limb is slightly flexed, you will notice an upper pro- 
jection, due to the flexion of the epiphysis on the 
diaphysis, which is caused by an interposition of a 
spongy tissue between the diaphysis and the cartilage 
of connection, in such a manner that one would at first 
sight think he was dealing with fracture of the patella 
with spreading of the fragments. The lower projec- 
tion is formed by the patella and this deformity is 
increased by the predominating action of the flexor muscles of the leg. An inverse deformity may also 
be noted. The flexure of the diaphysis on the epiph- 
ysis is produced in a contrary sense, and there then 
is seen an angle projecting backwards and instead of 
an anterior projection there is a depression over the 
line of connection. There is no ankylosis, but the 
movements are more limited than normal. 
Another pathological process produced in joints 
by a chronic osteomyelitis, is an incomplete or abso- 
lute immobilization of the articular surface, and this 
ankylosis may be true or false. An ankylosis is a 
true one when the loss of movement is due to a 
change in the parts making up the joints,—namely, 
the bone, cartilage, ligaments and synovial mem- 
brane. It is a false one when impotency is produced 
by some disorder of the peripheral tissues, such as 
the muscles, tendons, cellular tissue or skin. True 
ankylosis results, as I have said, from a loss of the 
most important parts of the joint, but let me add 
that it is infrequent, and usually is incomplete. It is 
very difficult to diagnose from a false ankylosis, when 
first seen, and it is only by means of a complete nar- 
cosis that one can decide whether the ankylosis is 
due to a muscular contraction or not, which is very 
frequently the case. Under the influence of an 
anesthetic, which does away with the pain and the 
resistance of the muscles, one will be able to find 
out whether the surfaces of the joints slide over one 
another or not. 
Another frequent cause of error must be also 
avoided. We might attribute supplementary move- 
ments of a healthy neighboring joint to an ankylosis 
of another joint, and, consequently, the articulation 
should be firmly grasped, and an endeavor to give it 
its natural movements must be made. Besides these 
ankyloses due to retraction or contraction of the 
muscles, there are others which are sometimes the 
result of a bad cicatrix or a sclerosis of the subcuta- 
neous connective tissue. It is the case when there is 
absolute immobility, the adhesions may not be bony, 
but to fibrous bands which are very short and may 
oppose the slightest sliding of the bones. According 
to Malgaigne fibrous tissues may be diagnosed from bony tissues in complete ankylosis, as follows : the 
tentatives of flexion or extension produce no pain in 
a joint, the seat of ankylosis by bony fusion, while 
on the other hand they produce niuch pain from the 
insertions of the fibrous bands when these exist. 
An ankylosis may also occur when there is no in- 
inflammation of the joint, and is simply due to bone 
lesions which deform the joint and prevent the free 
play of the articular surfaces, which no longer slide 
with ease one over the other. Thus, often after a 
chronic osteomyelitis of the lower end of the femur, 
the knee remains nearly completely ankylosed by 
the simple presence of a consecutive hyperostosis, 
although the synovial membrane has undergone no 
inflammatory processes or, at any rate, no suppu- 
rating processes. 
It is exactly the same when two bones unite 
together, such, for example, as in the forearm and 
the leg. The hyperostosis of one may be communi- 
cated to the other by the stalactites, which produce a 
true ankylosis about at the level of the interosseous 
ligament. Occasionally, union between both bones 
is only partial and limited; at other times it is gen- 
eral, and it may be said that they are absolutely 
included in the newly formed bone-tissue. 
It has been thought that in certain cases pro- 
longed immobilization, especially when it takes place 
in a bad position of the joint, might be the cause of 
ankylosis. The hypothesis was emitted that the 
ligaments, which were relaxed in certain positions of 
the joint, became retracted if this position remained 
permanently. This may be correct, but in these 
cases it is difficult to eliminate inflammation, and it 
is usually the latter process which is the cause of the 
bad attitude of the limb, and it is also to inflamma- 
tion that the changes in structure of the ligaments 
are due which produce their retraction. 
In summing up, gentlemen, I would say that we must 
admit the action of these three factors in the produc- 
tion of these ankyloses, namely a bad position of the 
limb, immobility, and inflammation. 
Chronic osteomyelitis does not only attack the 
bones and the joints, but it may extend to other parts of the organism. I would divide these other mani- 
festations into local and general. In the first we have 
troubles in the muscles, the nerves, the arteries and 
the veins in the neighborhood of the infectious focus ; 
while in the second group we have the pathologic 
changes which take place in the kidneys, heart, liver, 
etc. In the first place, gentlemen, let us consider 
the local complications. 
On account of their intimate relationship with the 
bones and the joints, the muscles are attacked by the 
affection at a very early date, and the lesion which is 
most frequently met with, is atrophy. Various and 
different theories have been put forward to explain 
this condition. I would only mention that the theory 
of John Hunter, who thought that all these second- 
ary troubles were due to sympathy, that is to say, 
that the muscles were conscious that the diseased 
parts could not reply to their action, and that it was 
one of the phenomena of the living organism which 
has the most resemblance to human reason. If the 
disease was only temporary, as in ordinary inflamma- 
tion, the muscles would not become atrophied, because 
they were conscious that the parts would soon become 
well. 
A more admissible theory is that of immobilization. 
Muscular atrophy, occurring during chronic osteomy- 
elitis, results from a functional inactivity, as that 
which is produced during immobilization in fractures 
and diseases of the joints. Although this theory 
demonstrates one important fact, that of functional 
inactivity of the muscle, it is certainly insufficient 
to explain these rapid and often general amyotro- 
phies, which occur during the chronic form of the 
disease under consideration. Broca believes that the 
muscle becomes atrophied, because it does not re- 
ceive as much blood as before the disease began. 
This theory does not appear to be realized in the 
large majority of cases, and this pathogenic inter- 
pretation is certainly only rarely applicable. Other 
writers have considered the muscular lesion as sub- 
ordinated to that of the joint; as the latter is not 
always diseased, this theory is not always exact either. 
According to Duplay and Clado, the inflammation in 19 
the joint extends to the muscles, a sclerosis occurs 
which little by little destroys all the muscular fibers, 
and after this course only a tense fibrous tissue with 
a few fat globules intermingled in it in place of the 
muscle is to be found; the muscular fiber appears to 
undergo a fatty degeneration, which commences in 
the depth of the fiber. 
As to the nervous element, in spite of repeated 
examinations, it has always given a negative result. 
Now, as all the preceding theories leave much to be 
desired, a certain number of writers have thought 
that muscular atrophy might be due to neuritis. Ac- 
cording to Descosses, there is a compression caused 
by the inflamed tissues on the nervous endings of the 
joint, which, after a certain time, will produce an 
inflammation of the nerve ;the inflammation will little 
by little extend to the nervous plexus and produce 
an atrophy of the muscles, whose nerves are in a 
diseased condition. When certain muscles are sup- 
plied by a nerve, which is in very direct relation with 
the diseased joint, they are the ones usually attacked 
by atrophy; such, for example, as the quadriceps for 
the knee-joint. There are trophic troubles similar 
to those produced by compression ora nervous lesion 
that may coexist, such as hyperesthesia in certain 
parts of the joint, analgesia, subcutaneous adiposis, 
functional troubles of the skin, which becomes scaly, 
dry and hard in certain points. 
The theory of ascending neuritis, which is similar 
to the foregoing, has this advantage that it can ex- 
plain, not only the lesions of the muscles in the 
neighborhood of the joints or the diseased bone, but 
the atrophy of the entire limb, and that of the healthy 
side as well, a condition of affairs that has been sev- 
eral times met with. 
According to this hypothesis, the inflammation 
extends to the spinal marrow and by its intermediary 
homologous nerves of the healthy side, may produce 
an atrophy on the healthy side as well. Although 
such lesions may take place, and they have been 
demonstrated by the experiments of Hayem in the 
rabbit, guineapig, and cat, as well as by Treub and 
Leyver, they have not been verified by microscopic examinations; consequently other theories have been 
sought for. 
The reflex theory alone explains these various mus- 
cular lesions. Its partisans admit that the irritation 
of the nerves near the joints produce an increase in 
the trophic influence of the nerve-centers and pro- 
duce an amyotrophy by a centrifugal route, or a cen- 
tripetal irritation acts on the nervous centers, not by 
increasing the trophic influence of these centers, 
but, on the contrary, by diminishing it; this would 
be an arrest in the action of the trophic centers by 
reflex influence. 
Now atrophy predominates in the extensor muscles 
of the joint, and it is to be especially noted on the 
anterior aspect of the thigh, the posterior aspect of 
the leg, when an osteomyelitis is situated in the lower 
limb. It consequently results that the antagonistic 
members being no longer equal in their action, alone 
act and produce the faulty attitude of the limb. It 
is in the lower limb that these faulty positions are by 
far the most frequent, and many cases of acquired 
clubfoot during a chronic osteomyelitis have occurred 
on account of atrophy of a group of muscles. 
If the muscular atrophy is not very pronounced, 
and if the muscle-substance itself is not destroyed 
by suppuration, an appropriate treatment with elec- 
tricity and massage may be able to efface the path- 
ologic processes. If, on the contrary, suppuration 
has been extensive, the muscle may be entirely de- 
stroyed, and its only remnant being a thick fibrous 
band adherent to the skin, must be completely cut 
through in order to give the limb its former shape. 
Chronic osteomyelitis may produce various func- 
tional troubles of the nerves. In some cases the 
nerve is compressed by a cicatrix, or is wounded by 
the presence of a hyperostosis, which pushes it 
against a resisting structure, such as the aponeurosis 
or a bone. Thus at the elbow, the ulnar nerve may 
be injured by a hyperostosis situated in this position, 
on account of its passage behind the epitrochlea. 
At other times the nerves may be wounded by a 
sequestrum, whose sharp point constantly irritates 
the coverings of the former, and different symptoms 21 
of varying intensity, according to the gravity of the 
lesion, are observed in these cases. 
In the first place tingling, cramps, and a sensation 
of heat are first complained of, and then there is 
hyperesthesia of the skin, which is soon followed by 
a progressive anesthesia. The muscles which are in 
the first place benumbed, undergo the commencement 
of atrophy, and after a certain time, if, failing an 
operation, the nerves recover their functions, the 
muscular contractility will first be seen to return, and 
afterwards the sense of touch and pain; and later 
still the sense of temperature appears. 
If the compression is considerable, the pain is in- 
tense and will cover all the region supplied by the 
nerve; the patient will complain of shooting pains in 
the first place, and then a numb feeling in the parts, 
followed by a complete or incomplete motor paral- 
ysis ; these symptoms may be of short duration 
only, and the sensibility and contractility soon re- 
turn. 
The symptoms of contusion of the nerves are not 
sensibly different from those occurring in the former 
condition; if the contusion has been considerable, 
the disturbances of sense are first noted, and then 
graver disorders appear, such as sensory or motor 
paralysis, due in most likelihood to an intercurrent 
neuritis. The immediate and consecutive motor 
disturbances are very variable and are in intensity 
in direct relation to the amount of damage done to 
the nerve. They rarely produce an absolute muscular 
impotency, but occasionally they are the cause of 
spasms or temporary or permanent contraction. 
Now, if an electrical examination of the muscles be 
made at various times, the following phenomena will 
be remarked. At the beginning and during the first 
few days following the nervous lesions, the muscles 
lose their contractility to the faradic current little 
by little ; at the end of about eighteen or twenty days, 
the limb no longer reacts to the interrupted current. 
The reaction occasioned by the galvanic current dur- 
ing the first ten days is a diminution, then an increase 
and they reach their height at the time when reaction 
to the faradic current has become nil. If the nerve 22 
does not return to its normal condition, the galvanic 
curve will descend to the normal, and then the reac- 
tion will descend little by little until it is no longer 
present, and when this occurs muscular contraction 
is lost forever. If, on the contrary, the nerve goes 
back to its normal condition, the reaction to the 
faradic current progressively returns. 
Besides these functional muscular troubles pro- 
duced by lesions of the nervous trunks, I must also 
mention the nutritive troubles, which especially take 
place in the skin, the hair, the nails and the subcuta- 
neous cellular tissue. The skin may present several 
conditions; sometimes it is red, smooth and dense 
and may feel scaly and rough to the touch. The 
epidermis becomes detached and remains adherent in 
more or less necrosed patches. Sometimes the layer 
of papillae situated under the altered skin may be 
seen, from which results an atonic ulceration which 
is very difficult to heal. 
The hair splits up and falls in many cases, but 
sometimes it becomes hypertrophied, especially when 
there is a purulent focus in the neighborhood. The 
nails become hard, brittle and cracked, blackish in 
color and rough. As to the cellular tissue, it is some- 
times infiltrated, at others indurated. 
The nerves may become inflamed when they have 
been in contact for some time with a purulent focus. 
The nerve-trunk becomes increased in size, while 
the vessels which go from its surface and penetrate 
into its depth are dilated and may even rupture. The 
nerve loses its glossy aspect and becomes a bloody 
yellow, while sometimes small ecchymoses may be 
seen on its surface. It is considerably altered in its 
anatomic structure, while the nerve bundles are 
usually dissociated. This dissociation may bring 
about a degeneration of the nerve-trunks, and by a 
different mechanism this may produce the same dis- 
turbances in immobility and sensibility that have 
already been mentioned. 
The arteries may become ulcerated from contact 
with the purulent focus. Monod mentions 37 cases 
of arteritis produced by the contact of pus, and in 6 
of these the ulceration occurred during the course of 23 
an osteomyelitis. The same author has also reported 
an interesting, case of a young man of 28 who for 15 
years had had an osteomyelitis of the femur. At 
three different times, on account of ulceration of the 
popliteal artery and its collaterals, there was serious 
hemorrhage. The bad general condition of the leg 
prevented the surgeon from applying a ligature, and 
amputation of the thigh was performed, but the 
patient died in the evening. 
The other cases of ulcerated arteries occurred at 
the same spot, and, if you will recollect that this is 
one of the most common seats of osteomyelitis, and 
that the presence of the cellular tissue in the popliteal 
region favors the secretion of pus, you will easily 
understand that a probe pushed down in this region 
in order to make an opening to give issue to pus, may 
strike against the walls of the popliteal artery which 
is in a condition of ulceration and thus produce a very 
alarming hemorrhage. Monod explains the process 
as follows : The artery becomes inflamed by the con- 
tact with pus, and this inflammation causes the middle 
tunic of the vessel to disappear, whose elastic and 
muscular fibers give place to connective tissue, which 
becomes intermingled with that of the external tunic. 
The wall is thus weakened, and if the arterial tension 
is considerable or even slightly modified in intensity, 
and if, during a dressing a forceps or a sound hits 
against the artery with any force, the vessel may 
rupture, especially when there is a poor general con- 
dition, as is usually the case when a patient has been 
the victim of a prolonged suppuration, and conse- 
quently the formation of a clot in the internal mem- 
brane, which is irregular and soft, and on the external 
membrane of protective sheath, due to the prolifera- 
tion of connective tissue of this tunic, which is in- 
flamed and in contact with pus. 
These changes in the arterial structures are fre- 
quent during the course of an abscess in chronic 
osteomyelitis; usually they are not noticed, because 
they give rise to no symptoms. They are only dis- 
covered unexpectedly, as during the introduction of a 
drain into the infectious focus, or during a resection, 
and then the surgeon unexpectedly comes down on 24 
an artery, which is destroyed and may rupture at the 
slightest shock. The inflammation may extend to the 
veins by a similar mechanism. Cornil and Ranvier 
admit that a periphlebitis and endophlebitis occur 
simultaneously. In periphlebitis the vasa vasorum 
become dilated and the leukocytes go out in large 
numbers among the meshes of the connective tissue, 
whose fixed cells proliferate. By their passage through 
the external tunic of the vessel they distend it and 
favor the formation of small purulent collections, 
which are really nothing but abscesses. These 
troubles reach the middle tunic of the vessel and a 
destruction of the muscular fibers takes place, which 
are replaced by embryonal cells, and are supplied 
with many vessels, which with the capillaries of all 
the three tunics lead to the formation of sinuses, lined 
with endothelium, and situated between the middle 
and internal tunics. The latter tunic becomes altered 
in its turn ; its endothelium proliferates and masses 
of embryonal elements are formed, which are supplied 
by the capillaries starting off from the neighboring 
sinuses. These vegetations make the walls rough 
and produce the precipitation of fibrine, and some- 
times a kind of false membrane lines the vessel, with- 
out, however, obliterating it, but in the majority of 
cases a clot obstructs the vein. 
This clot varies in length ; sometimes it occupies 
quite a long segment of the vessel and may enter into 
the capillaries. Its central end is usually thin and 
pointed, and continually being moved about by the 
flow from the collateral vessels, and it may be broken 
off and thus produce a distant embolus. Sometimes 
the clot may become absorbed, and the caliber of the 
vessel returns to its normal condition ; and the blood 
circulates normally but, on the contrary, the vessel 
may become completely blocked up, and become trans- 
formed into a fibrous band, in which case we have 
what is called a plastic phlebitis. This condition is 
not so serious as a suppurative phlebitis, in which we 
have an abscess distending the walls of the vessel, 
which become ulcerated, and the clot is destroyed by 
suppuration ; the debris are carried along through the 
blood into various viscera, where they form an infarct. 25 
When a patient has a phlebitis, he complains of 
pain along the entire course of the vein, and the limb 
becomes heavy and edematous, on account of the in- 
terruption of the circulation, which is then effected 
by the small vessels which become dilated, in order 
to allow the passage of blood, which can no longer 
pass through the large veins. Small subcutaneous 
vessels will soon appear in patches, and produce blis- 
ters filled with a reddish or transparent serous fluid. 
This edema may remain stationary for a certain time, 
and then little by little disappear, but unfortunately 
the ultimate recovery of the limb is far from always 
being obtained, and suppuration occurs. The skin 
becomes raised up along the course of the vein, and one 
or several collections of pus are formed. These ab- 
scesses ulcerate the integuments, and the pus burrows 
its way outwards, with or without hemorrhage. Occa- 
sionally, the abscess opens into the vein, and, if a re- 
sisting clot does not obstruct the canal, the pus mixes 
with the blood, and pyemia is the result. Although 
this termination is rather infrequent in the chronic 
form of osteomyelitis, it will occur, especially when 
the patient has had a suppurating focus for a long 
time. 
We now come, gentlemen, to the consideration of 
the general complications of chronic osteomyelitis, 
and foremost among them we should place the lesions 
of the kidneys, which occur in the form of nephrites. 
According to Mouret, it has usually been found that 
a nephritis may occur during any of the stages of the 
disease. It often occurs at the beginning of the acute 
stage, ceases during a certain time, and then reap- 
pears as soon as the first relapse has occurred. Ver- 
neuil has seen nephritis occur two, three or often more 
years after the acute symptoms of an osteomyelitis, at 
the time when there was an elimination of the se- 
questrum, or when the focus of suppuration was 
cleaned out. The symptoms produced by a nephri- 
tis during an osteomyelitis are to be particularly looked 
for in the quantity, color, and composition of the urine. 
In.the first place, there is usually a marked decrease 
in the quantity of urine voided in the twenty-four 
hours. It may go as low as 700 or even 600 cc., and 26 
this decrease may be explained by the accumulation 
of the epithelial casts in the tubuli contorti, which 
prevents the flow of the urine. During the first days 
the urine is colored a dark red, on account of the 
presence of more or less large amount of red blood cor- 
puscles, which have transuded with the albumin, and 
which show that there has occurred a capillary hem- 
orrhage from the vessels of the kidney. After two 
or three days, this hemorrhage ceases, and the urine 
becomes clear and limpid. The composition of the 
urine is extremely changed, and when it is heated or 
treated by the usual reagents, we usually obtain an 
abundant precipitate. The quantity of albumin is 
considerable in the beginning, and lasts for a long 
time in serious cases, while in lighter ones, and those 
having a more favorable outcome, it diminishes 
There are always a certain number of bacteria in the 
urine, either in the form of rods or cocci. We also 
find granular, colloid, or mucous casts at the same 
time. They are sometimes covered with epithelial 
cells, in the center of which will be perceived the 
microorganisms, after they have been stained by 
the various processes, such as osmic acid or hema- 
toxylin. Generally speaking, the nephritis of an os- 
teo-periostitis is only temporary, and has a tendency 
to get well. As it is the product of an infectious agent, 
it naturally disappears as soon as the organism is free 
from the cause. There are two ways of eliminating 
the bacteria; either rapidly, without producing very 
much damage, or, on the contrary, producing lesions 
capable in themselves of putting a patient’s life in 
danger. In favorable cases, this complication lasts 
from eight to fifteen days, while, in serious ones which 
have a fatal issue, the duration is longer, and the 
albumin is present up to the last. This nephritis is 
subject to relapses which are almost impossible to 
foresee. 
Among other complications which may occur dur- 
ing a chronic osteomyelitis, I may mention amyloid 
degeneration of the liver, which occurs after any pro- 
longed suppuration ; septic embolus, which may take 
place in the lungs; purulent infection, with multiple 
abscess occurring in the pericardium or the pleura ; 27 
but these lesions are infrequent during an acute 
affection, and are still more so during the chronic 
period, and consequently I only mention them in 
passing. 
Now, considering the progress of chronic osteo- 
myelitis, I may say that it rarely gets well- without 
medical aid, and when it is left to itself, and even if 
it does get well, it takes a very long period, perhaps 
as much as two years, for the slow and progressive 
elimination of one or several pieces of necrosed 
bone from the diseased limb; and still more it is 
necessary that the sequestrum be small, in order 
to make a passage through a cutaneous opening. 
Usually the patient is obliged to go to the surgeon, 
who, if he operates properly by performing a large 
resection or amputation of the limb, will place the 
patient in all the necessary conditions for avoiding a 
relapse. Perfect antisepsis is necessary, and the in- 
fected region should be very carefully cleaned out, 
but in spite of that, although the surgeon has placed 
the patient in the best conditions possible for a favor- 
able result, it may happen that the recurrence of the 
trouble occurs in some other bone, for the simple 
reason that the organism is not free from the microbes 
producing an osteomyelitis. 
The duration of chronic osteomyelitis is very varia- 
ble, and in the beginning in some cases, on account 
of the general appearance the condition may be con- 
sidered as not very serious. Many osteomyelites 
which have been considered chronic from the begin- 
ning, and which have commenced 'without fever, 
characterized by the elimination of sequestrums from 
time to time, have only had a fatal result 15 or even 
25 years later. The age of the subject and the 
duration of the trouble does not prevent him from 
death at a distant period. 
Chronic osteomyelitis may end by complete recov- 
ery or by death. In the first case the return to health 
may be either complete or simply relative, and the 
limb may recover all its functions. This result is, 
however, infrequent, and, in order that this shall oc- 
cur, the organism must have been only very lightly 
infected, and the operation performed in the diseased 28 
parts must also have been extremely free. In a rel- 
ative recovery the limb may still be good to a certain 
extent, but its functions are not sufficiently carried 
out. Atrophy of the muscles will cause a weakening, 
and it is always either shortened or lengthened. The 
joint is in a state of ankylosis, and from this a bad 
position of the limb will be produced. 
A large number of the patients with chronic osteo- 
myelitis die, and death may occur in several ways. 
Usually the fatal cases are those which have waited 
too long before seeking surgical treatment, or else it 
is the fault of the attending physician who is too 
conservative and who hopes to finally pull the patient 
through. Little by little the strength of a patient 
will decrease, and his organism will struggle in vain 
against the constant suppuration which' is going on. 
They are finally obliged to remain in bed, hectic fever 
appears, and the patient looks like a person in the last 
stages of tuberculosis, and, if a full history of the case 
is not obtained, one is very liable to be led into error. 
At other times the ulcerated arteries, or the contact 
of a purulent focus, or the introduction of a drainage 
tnbe will produce the fatal outcome, on account of 
the serious hemorrhage which will take place. A 
number of troubles have resulted from renal insuffi- 
ciency, because the toxic products are not properly 
eliminated, and the patient dies from a toxemia. Al- 
bumin occurs, and later on there is uremia. Another 
fatal issue is that by metastatic abscess, which may 
become localized in the various viscera, such as the 
liver or the kidneys. 
Regarding the diagnosis, I would say that it pre- 
sents considerable difficulty. Generally the patients 
who ask for help, will say that they have been smitten 
by their disease when quite young, and that ever 
since they have been more or less troubled by the 
condition, although some will not be able to give any 
data as to the primary disease. In the latter case 
one would be liable to attribute the trouble to every 
other cause excepting the true one. Very often the 
only remnant of the old trouble will be a small cica- 
trix that will have become covered by a growth of 
hair, which has occurred since they have become 29 
adults. Then, afterwards, this cicatrix will no longer 
be in exactly the same position as was the primary 
focus, and it will be found higher up, and, if it be 
incised, nothing but normal tissue is found. The 
affection is disguised by symptoms which take on a 
considerable importance. The patient often will have 
considerable fever and may be found in a state of 
torpor from which it will be difficult to rouse him, 
and under such circumstances it is easy to mistake 
the condition for typhoid. But, if the patient be very 
carefully examined, if we determine the actual com- 
mencement of the disease, if we will notice that this 
febrile condition, which is extremely marked, has not 
been preceded by constipation, diarrhea, or any other 
symptoms, as is the case in typhoid, and if there is a 
tumefaction in the joint or in its neighborhood, we 
will be able to avoid making a mistake. And still 
more, if the limb of the patient be grasped and 
movements given it, it will be noticed that they will 
be perfectly free in typhoid fever, and no pain will be 
complained of by the patient, while in osteomyelitis 
the pain is extremely severe, and the forced move- 
ments that are given the limb or the joint, cause him 
to cry out. The disease may also be rendered less 
apparent if the patient has an infectious disease 
which has started up a latent osteomyelitis. In other 
cases we have an infectious disease such as smallpox, 
typhoid, gonorrhea or syphilis, and a fresh attack of 
the former affection will occur. Others, after a trau- 
matism or gunshot wound, will certainly lay greater 
stress on the details of the accident, which they con- 
sider as the principal cause of their trouble, when in 
reality it is only a secondary one. 
The pains in the joints may lead one to believe 
that there is rheumatism, but a detailed examination 
carried over all the bones, and pressure made with 
the hand on the principal regions in which osteomy- 
elitis develops, will lead to the discovery of the true 
disease. For that matter, a negative result in medical 
treatment, particularly with the exhibition of sali- 
cylate of sodium or antipyrine, is a very important 
indication, as these medicines are extremely effica- 
cious in rheumatism, and only slightly modify the 30 
condition of affairs in osteomyelitis, and only have a 
calmative effect over the pain and the temperature 
in the latter disease. Nearly always a careful and 
detailed examination of the region will show that 
the pains are more intense and follow the articular 
surface than in the synovial membrane itself, and 
consequently shows that the trouble is either in the 
bone or in its juxtaepiphyseal region. 
Regarding the differential diagnosis of osteomye- 
litis with tuberculosis, I would point out that in the 
latter disease the affection is insidious, and the pain 
is always the first symptom complained of by the pa- 
tient. This pain, contrary to that produced by an 
osteomyelitis, is only trifling, and not durable for any 
length of time, and never presents the intensity of 
those met with in osteomyelitis. Then in tuberculosis, 
tumefaction develops over some part of the bone, and 
after a certain time it becomes softened, and fluctua- 
tion may be detected in its center. The abscess which 
follows may evolute in the spot, or, on the contrary, 
it may burrow through the tissues in such a way that 
it occasionally opens at a very distant part from the 
origin of the disease. Its progress, which is different 
in each region, depends on the position of the apo- 
neurotic layers as well as the vascular and nervous 
tracks, which serve as conductors along which the 
pus travels. 
A tuberculous abscess is contained in a pocket; the 
contents is a serous and badly mixed pus, in which 
cheesy lumps and occasionally very small sequestrums 
in the form of lamellae or particles of bone are found. 
Sometimes the contact of small vessels with the pur- 
ulent pocket and their consecutive ulceration, may 
change the color of the pus, which becomes brownish 
or a very dark purple. The size of these abscesses 
is very variable, and is largely dependent on the 
length of time in which the disease has been present, 
as well as its location, and the type of the tuberculo- 
sis. These abscesses may sometimes only contain 
fungosities, and all trace of pus is lacking. These 
fungosities are soft, whitish in aspect and are easily 
removed by the sharp curet. They are most always 
found on the subcutaneous cellular fascia, as well as in the intermuscular tissues. They perforate the 
periosteum and invade the tissues of the bone, and 
thus form a new fungous pocket, which may reach 
very large dimensions. The skin becomes very much 
distended by these abscesses, and sometimes one can 
evacuate liters of pus; after a variable lapse of time 
the skin will end by becoming thin over a certain 
point, and after taking on a highly reddish color, it 
becomes perforated, and the pus makes its exit. 
If the abscess has not been well irrigated and dis- 
infected the suppuration will continue, although it 
may not increase. The cutaneous opening does not 
close up, but becomes filled with fungous material, 
and from time to time some pus escapes, as well as a 
small sequestrum, although the latter does not occur 
often. If a sound is introduced into the fistula, and, 
if we are dealing with a sessile abscess, the instru- 
ment will come down on a denuded bony surface, 
which will be recognized by its characteristic grating 
feel. Sometimes the sound will come against a hard, 
irregular surface; while at others we will be able to 
push it into a soft rarified bony tissue, and the lamellae 
of the bone can be broken easily. This latter sign, 
which is called fine crepitation, is due to the tearing 
of the bone lamellae by the probe, and has always been 
regarded as pathognomonic of caries. 
Tuberculous lesions of the bones are not often ac- 
companied by a rise in temperature, except when 
the disease is present in some other viscera. When 
there is a hyperostosis, which is infrequent, the lesion 
will occupy the entire bone. Now one way in which 
we can distinguish tuberculous osteitis from a chronic 
osteomyelitis, is the more considerable length of time 
that the latter has been present, that it has presented 
a peculiar condition of exacerbation, which has espe- 
cially manifested itself during the period of growth; 
the sequestra are far more extensive, and the look of 
the pus is not the same. We do not have fungous 
material as in tuberculosis, and the general condition 
of the patient is far better for a long time in chronic 
osteomyelitis, and also in this disease one will not be 
able to elicit any hereditary history from the patient. 
The diagnosis is more difficult when tuberculosis has 32 
occurred in a patient who is still growing; often the 
lesions of tuberculosis and osteomyelitis evolute 
together, and in this case it is only by the aid of the 
microscope that one will be able to decide with which 
disease he is dealing. 
Syphilitic osteitis has very distinct characteristics, 
and its diagnosis is consequently far easier. The 
bones most usually attacked by syphilis are those of 
the head and the face, and we should always be 
careful to look at the head of the patient for syphilitic 
lesions when in presence of a case which presents 
certain difficulties. The tibia is, of the long bones, 
the one the most usually attacked by syphilis, and in 
this case we find its sharp border pointing outwards, 
and the patient will complain of osteocopic pains, 
which usually'coincide with the existence of a chancre 
whose traces will usually be found on the patient. 
A means which will permit to settle the diagnosis is 
the mercurial treatment. The exhibition of mercury 
protiodid has a very potent influence on the syphilitic 
diathesis. The diagnosis is more difficult when deal- 
ing with gummas, and at the same time the patient 
may present other lesions which are not due to the 
specific diathesis; such are, necrosis, suppuration due 
to sequestrums, sclerosis and hyperostosis, which 
are in no way controled by potassium iodid and mer- 
cury. In this case, gentlemen, we must remove all 
doubt; the sequestrums have as characters to be cut 
out cleanly and are of a golden yellow color, and 
when once these sequestrums are removed, mercurial 
treatment will act wonders. 
If a careful inquiry into the antecedents of the 
patient has been made, and if we attentively examine 
the diseased parts, we will not usually mistake a 
lesion due to chronic osteomyelitis with a tubercular 
or syphilitic osteitis. The joint lesions in osteomy- 
elitis are usually those which are more likely to lead 
to an erroneous conclusion, because in the beginning 
of the disease they closely resemble hydarthrosis 
and, later on in the affection, a white swelling. A 
symptom which will permit us to avoid a mistake 
with the first mentioned disease, is the appearance 
of pain, which usually is very pronounced, the con- 33 
trary to what occurs in hydrarthrosis, which is pain- 
less, and which usually manifests itself by a disorder 
in the movements of the joints and functional im- 
potency. Contrary to what occurs in hydarthrosis 
the tumefaction will usually be found in the periar- 
ticular tissues, and its maximum is not found in the 
synovial culs-de sac. One can easily feel the bony 
projections in an osteomyelitic osteoarthritis. Later 
on the atrophy of the quadriceps and the abnormal 
attitude of the limb, such as subdislocation of the 
tibia, etc., will give the clue to a diagnosis, because 
these joint troubles are peculiar to chronic osteomy- 
elitis. When the pathologic process is very exten- 
sive, so much so that the patient has been obliged 
to keep absolutely quiet, and the joint is riddled with 
fistulas, giving issue to pus, the question of tubercu- 
losis presents itself. The skin, as in tuberculous 
arthritis, is a violet color and ulcerated, while the limb 
has a yellowish color, and the patient is incapable of 
moving it in the slightest degree. 
The fact that the lesion has begun in the bone and 
has secondarily attacked the joint would at once lead 
to a diagnosis of an osteoarthritis due to a chronic 
osteomyelitis, because in tubercular arthritis the 
lesion commences in most cases in the synovial mem- 
brane, which is in a fungous condition, and gives a 
pasty feel to the joint. The aspect of the purulent 
foci is not the same in the two diseases; in white 
swelling the pus which comes away contains fungous 
masses or cheesy concretions and is often mixed 
with blood, while in osteomyelitis it is a laudable 
pus. The cultures from the former will show the 
presence of the bacillus of tuberculosis, while in 
osteomyelitis the infectious agent of the disease is 
grown, which is usually the streptococcus. 
The prognosis of these cases should always be 
guarded as relapses are frequent. It will be all the 
more favorable when an operation has been performed 
soon after the first attack, or, if necrosed tissue has 
been removed, in which case the patient will be less 
likely to have a new outbreak. There are cases in 
which surgical interference is prevented on account 
of the bad general condition of the patient due to 34 
autointoxication. As I have said, some of these 
patients die from the mere fact of a prolonged sup- 
puration, while there are others who die because 
their kidneys no longer eliminate the toxic products. 
Others die from epithelial transformation of the pri- 
mary focus of osteomyelitis, and, although this end is 
very infrequent, it should be recalled to mind when 
giving a prognosis. 
The manner in which one may suppose that a 
malignant change is going on is by the transforma- 
tion of the granulations in the neighborhood of the 
fistula into epitheliomatous granulations. The secre- 
tion in the latter case will be extremely fetid, in spite 
of irrigation and antisepsis. The sequestra that are 
removed from the focus are often as black as coal 
and give forth a purulent odor. Epithelioma has a 
tendency to extend into the focus instead of out- 
wardly, and in this case the most radical operation is 
amputation of the limb as far up as possible. If this 
malignant transformation has already given rise to in- 
filtration of the glands, they should also be removed. 
Regarding the treatment of chronic osteomyelitis, 
it naturally varies according to the length of time 
the patient has been afflicted, as well as to his 
age and general condition. If we are dealing with a 
subject who has had one or two relapses of osteomye- 
litis, incisions into the periosteum with drainage will 
probably not be sufficient, and a more radical opera- 
tion is necessary. A radical operation, even if it 
will not entirely cure, will at least prevent another 
relapse. 
A long incision through the skin over the focus, 
should be practised, the bone exposed by the free use 
of the chisel and hammer, and the necrosed bony tissue 
and sequestra must be carefully removed. It often 
happens that the cause which made the disase con- 
tinue will be discovered, which is often a small purulent 
focus hidden in the bone itself near one of the ep- 
iphyses. If this condition of affairs is found, the focus 
should be thoroughly disinfected and packed with 
oxyiodid of bismuth gauze or xeroform gauze, in order 
to secure good drainage. An excellent method is to 
trephine both ends of the bone and pass a drain 35 
through its entire length, and this should only be 
removed when all trace of secretion has stopped. 
It often happens that the bone will be destroyed to 
a considerable extent, as well as around its entire 
circumference, in which case the necrosed parts are 
to be cut out, which, if left in place, would certainly 
compromise the ultimate result of the operation. The 
segments of the bone are united by a silver suture, 
and, after an antiseptic dressing has been applied, the 
limb is placed in a plaster dressing. After a certain 
time the bone will become consolidated, but it will be 
shortened and all the more so according to the size 
of the piece of bone removed. In order to prevent 
this shortening, decalcified bone has been placed 
between the two fragments, or bone grafts may be 
made. The results that have been obtained are ex 
cellent, and this method may be employed in young 
and adult subjects who are not too much undermined 
by the disease. 
Now, when dealing with cases in which too much 
damage has been wrought, so that definitive cure 
cannot be brought about by a conservative opera- 
tion, we must sacrifice the limb, but on this point 
I would say that surgeons are not all of the same 
idea; some advise amputation, and others, dis- 
articulation. Now, regarding these two operations, I 
believe it is better to choose between them when con- 
sidering a given case, but, as we are obliged to ex- 
plain to the patient the nature of the operation, one 
must always have it understood beforehand that he 
will do the best he can for him, and he must leave it 
to the surgeon to use his judgment. 
When damage has been considerable, amputate, and 
do this high up and as far away from the primary 
focus of the disease as is possible. When dealing 
with a weak and septic patient, I should advise always 
to choose amputation, because less blood is lost, and 
at the same time it is usually quicker to execute. 
It is not the same when dealing with an osteomye- 
litis which has invaded the upper epiphysis of the 
limb and has extended deeply into it. In this case I 
would advise disarticulation, in order to prevent a 
relapse. 36 
As to the localizations of osteomyelitis in the joints, 
a resection gives very excellent results and should be 
performed in this class of patients. 
Like all other diseases in the domain of surgery, 
the general condition of the patient must be attended 
to by medical treatment, and, on account of the infec- 
tious condition and the debility of these patients, inter- 
nal antisepsis and the free use of properly selected 
tonics, such as iron, kola, etc., are indicated. 
As soon as is practical, the patient should be allowed 
to take the fresh air and, if possible, when well 
enough, should be sent to the seashore for two or 
three months.