SPONTANEOUS 
Osteo-Myelitis of the Long Bones. 
BY 
nsr. smnsrn\r, im: _id., 
OF MILWAUKEE, 
CHAIRMAN OF COMMITTEE ON SURGERY'. 
Head, before lire Hook Hirer Medical Society of Wisconsin, at its meeting held in West Bend, \or. 8, 
1879, and published by request of the Society. 
ItKI’ltl NTKI) FROM TIIK CHICAGO MIC DIG AH JOURNAL AND .EXAMINER 
Foit January, 1880. 
Chicago : 
Bulletin Print, 113 Madison Street. 
1*80. ERRATA. 
Page 5, 3rd line from top, read “ Llicke ” for “ Durcke.” 
“ o, 8th “ “ “ “ “ “ 
“ 5, 5th “ “ below, read “tissue” for “tissues.” 
P, 2nd “ “ top, omit “ their.” 
“ 9,10th “ “ below, read “inner ” for “ minor.” 
“ 12,13t’h “ “ top, read “ time ” for “ end. ” 
“ 14,11th “ “ “ insert “in some cases ” after the word “operation.” 
“ 16, 7th “ “ “ read “ Langhans ” for “Langhaus.” 
“ 18, 7th “ “ below, read “Senator ” for “Lenator.” 
“ 19, 3rd “ “ top, read “40°-41°” for “40,41°.” 
“ 20,10th “ “ “ read “fluctuation” for “fluctuations.” 
“ 26, 6th “ “ below, read “ 1,100 to 1—2” for “1.100—1.200.” 
“ 27, 2nd “ “ “ read “ thin ” for “this.” 
“ 33, 9th “ “ top, omit one “ the.” 
“ 35,12th “ “ “ read “ parosteal’’ for “parostral.” 
“ 39,16th “ “ below, read “Petrequin ” for “Petregrin.” 
“ 39, 6th “ “ “ read “epiphysary ” for “epipysary.” SPONTANEOUS 
Osteo-Myelitis of the Long Bones. 
BY 
u- 
nsr. siEnsrisr, jml.jd., 
OF MILWAUKEE, 
CHAIRMAN OF COMMITTEE ON SURGERY. 
Read before the Rock River Medical Society of Wisconsin, at its meeting held in West Bend, Nov. 8, 
1879, and published by request of the Society. 
REPRINTED FROM TIIE CHICAGO MEDICAL JOURNAL AND EXAMINER 
For January, 1880. 
Chicago : 
Bulletin Print, 113 Madison Street. 
1879. SZF’OZKTT.A.ICTIEOTTS 
OSTEOMYELITIS OE THE LONG BONES. 
Since the appointment of your committee, no great innovations 
■or improvements have been made in the department of medicine 
assigned to your committee, hence I ask your indulgence if in 
the selection of the subject for my report, I have disregarded the 
letter of our by-laws. I shall invite your attention to a consider- 
ation of “ Spontaneous Osteo-myelitis of the Long Bones.” 
While traumatic osteo-myelitis was carefully studied by our sur- 
geons during the late war of the rebellion, the spontaneous vari- 
ety has attracted but little attention, and is entirely ignored by 
most of our text-books. As this affection is quite prevalent in 
this section of country, and is at present but imperfectly under- 
stood by the majority of the profession, I trust a discussion of 
this topic on this occasion may prove to be interesting and profit- 
able to us all. 
Definition.—Spontaneous osteo-myelitis is an infectious inflam- 
mation of the marrow of bone. All inflammatory diseases of 
the bones involve, to a greater or less extent, the medullary tissue; 
practically the surgeon understands by this term an affection 
where the inflammatory process begins primarily in this substance 
by localization of the infectious poison. 
Synonyms.—A great variety of terms have been applied to 
this disease at different times and by different authorities, as, 4 
endostitis, medullitis, ostitis, ostitis acutissima, osteo-myelitis 
diffusa, diffuse suppuration of bone, periostitis rheumatica, (diffusa, 
acutissima,) osteo-phlebitis, typhus des os, typhus des membres, 
pseudo-rheumatic inflammation of joints and bones. These differ- 
ent terms have served to convey the ideas entertained by different 
authors in regard to the location, nature or aetiology of this 
affection. Although every bone in the body containing marrow 
may become the seat of osteo-myelitis, the following remarks will 
apply to the disease only as it occurs in the long bones. 
History.—Although this affection must have had an existence 
almost as early as disease itself, we find no mention of it until 
1705, when J. L. Petit described an affection of the bones 
which was identical with what we now understand by osteo-mye- 
litis. Similar allusions have been made to it by Gooch, Pott, 
Cheselden, Hey and Abernethy, some of their descriptions being 
sufficiently accurate to enable us to recognize the character of 
the lesion. The traumatic form was studied with more care and 
assiduity than the spontaneous variety. In 1831, M. Renaud 
published a paper “ On Inflammation of the Medullary Tissue of 
the Long Bones,” in which he gives a report of five cases occur- 
ring after amputation, all having terminated fatally. Cruveil- 
hier alludes to this affection when he says, “ The phlebitis of the 
bones is one of the most frequent causes of visceral abscesses 
following wounds or surgical operations in which the bones are 
involved. Roux credits Ndlaton with having devised the term 
osteo-myelitis in 1834, and having published a brief account of 
it in 1844. In 1849, Mr. Stanley, in his excellent work “ On 
Diseases of the Bones,” gave an accurate description of the 
spontaneous variety under the title “ Suppuration in Bone.” In 
1855, Chessaignac applied the term osteo-myelitis for the first 
time to the spontaneous form, reporting four cases. Traumatic 
osteo-myelitis has always been of frequent occurrence in military 
practice and in infected and badly ventilated hospitals. Among 
the military surgeons who have advanced our knowledge of this 
form of the affection, Yallette, M. Roux, Jules Roux, Larrey, 
Pirogoff, Lidell and Allen deserve prominent mention. In 1865, 
W. Roser gave a complete resumd in thirty propositions, of what 
was then known concerning the spontaneous variety. While the 5 
traumatic form was generally admitted to be of an infectious 
origin, the spontaneous type was considered purely inflammatory 
until Durcke ascertained its infectious character. Demme, Volk- 
mann, Schede and Hueter have added valuable contributions to 
our knowledge of this disease by their pathological investigations 
and clinical observations. Eosenbach and Kocher, by numerous 
experiments on animals, have established many facts corrobora- 
ting the theory advanced by Durcke. From the history of this 
disease, it will be seen that our knowledge pertaining to it is of 
comparatively recent date. Before pathological anatomy estab- 
lished the fact that the marrow is always the primary seat of 
inflammation, this affection was confounded with ostitis or peri- 
ostitis. Before osteo-myelitis was recognized as a distinct affec- 
tion, ostitis was regarded as a frequent disease of bone. At 
present osteo-myelitis must be considered the most frequent of 
all inflammatory diseases of bone, wThile ostitis is of very rare 
occurrence. 
In opposition to the generally received opinion that the disease 
originates primarily in the medullary tissue, are the views of M. 
Gosselin and M. Gudrin who attribute the suppuration in the 
marrow to an antecedent subperiosteal suppuration, occurring 
especially where the matter has not been evacuated by an early 
incision. They regard osteo-myelitis as a lesion secondary to 
inflammation of the substance of the bone proper, or its fibrous 
envelope, and seek to prevent it by free and early incisions, even 
to the extent of penetrating into the interior of the bone. M. 
Panas has found the myeloid tissue not only in the central canal 
of the long bones, but likewise in the deeper layer of the perios- 
teum and the Haversian canals ; it is therefore not necessary for 
the disease to originate in the central medullary canal, but it may, 
and very frequently does, commence at any point where myeloid 
cells are found. This view is substantiated by the clinical fact 
that this disease affects with greater frequency individuals during 
a time in their lives when the medullary tissue! exist in greatest 
abundance, and by its manifesting a strong predilection for those 
portions of the bones containing the greater amount of marrow. 
From the peculiar relation of the structures it is easy to under- 
stand that inflammation of bone or periosteum will affect the 6 
medullary substance by contiguity, but the surgeon applies the 
term osteo-myelitis exclusively to those cases where the marrow is 
the primary focus of the inflammatory process. 
*Structure and Function of Marrow.—Periosteum, osseous 
tissues proper, and medullary tissue are anatomically distinct, 
but in a physiological sense combined, being supplied by the same 
nerves and blood vessels. Any one or more of these substances 
may disappear during pathological changes, and may, by meta- 
morphosis of their histological elements, be converted into each 
other. A similar metamorphosis of those tissues constitutes a 
well established fact in physiology. By sympathy and contiguity 
a pathological or physiological process in one structure is very apt 
to involve others to a greater or less extent. The appearance 
and structure of marrow varies according to age and locality in 
which it may be found. In the foetus and in the cancellated 
structure of bone it is red and contains only a trace of fat, while 
in the central medullary cavity of the long bones in the adult, it 
presents a yellowish color, and is composed almost entirely of fat. 
The difference in color depends on the presence or absence of 
fat. The red or embryonic marrow contains about 86 per cent, 
of myeloid cells. These are round simple embryonal elements 
measuring from 0.0129 to 0.0257 m. m. and containing one or two 
nuclei and granular matter. Some of these cells assume a spindle- 
shaped form and are transformed into connective tissue cells, 
others are changed into fat cells, while the rest preserve their 
lymphoid character. An important physiological function has 
been lately assigned to these bodies by Neumann and Bizzozero, 
viz.: the production of red and white blood globules which enter 
the circulation by immigration, a process opposite to the one 
described by Cohnheim. Neumann and Eales have observed a 
pecularity of the capillaries in the medullary tissue, their caliber 
being four times greater than that of the arterial branches that 
immediately supply them. This dilatation of the capillaries 
diminishes the rapidity of the blood current and favors the 
accumulation of the white globules of the blood and may pos- 
sibly undergo here a transition from white to red corpuscles. The 
process of hsemato-genesis in the medulla may therefore be intra- 
vascular and extra-vascular, in the former case depending on a metamorphosis of the white corpuscles, in the latter instance on 
a transformation of myeloid cells into blood corpuscles. To ex- 
plain the possibility of the red corpuscles entering the capillary 
vessels from without, Dr. H. C. Hand, of St. Paul, suggests 
that during the formation of lacunae the vascular walls may suffer 
a slight loss of continuity, affording thus an ingress to these 
bodies. The blood-producing function of the myeloid tissue has 
also received attention in this country through the investigations 
of Dr. H. C. Hand, Prof. H. C. Wood and Prof. Wm. Pepper, 
and in the light of experiment, microscopical examination and 
clinical observation, must now be considered an established fact in 
physiology. 
The yellow marrow found in the central canal of long bones is 
composed of 96 per cent, of fat. The fat vesicles are lodged in 
a nidus of delicate fibers of connective tissue, interlacing freely 
in every direction, and becoming more abundant towards the 
outer portions of the marrow. In a healthy bone there is no such 
thing as an endosteum; this had only ati existence in the 
imagination of the older anatomists. Bundles of connective 
tissue fibers are arranged longitudinally with the bone, but no 
complete membrane is formed, and the medulla is in direct con- 
tact with the bone tissue. 
The principal source of blood-supply is the nutrient artery, 
branches of which form a delicate network, with meshes of poly- 
gonal shape. Free anastomosis exists between the vessels in the 
central canal and the reticulated tissue. 
The nerves are derived in greater part from the cerebro-spinal 
system, and enter the bone with the vessels, through the foramina 
nutritia and the Haversian canals. 
The presence of lymphatics has been demonstrated by fine 
injections by Bichat, in the substance of bone, if not in the 
central medulla. During early foetal life, marrow does not exist; 
it is formed by transformation of osseous into medullary tissue, 
so that during the development of bone, not only bone but 
medullary tissue is formed. The most important anatomical 
properties to be remembered in connection with our subject are : 
the softness, vascularity and exuberance of the cellular elements 
of the medulla, as well as the unyielding character of the walls 8 
surrounding it, all important factors in the production of inflam- 
mation and infection. 
JEtiology.—Infection is the essential cause of traumatic, as 
well as idiopathic osteo-myelitis, the difference consisting in the 
manner in which infection is produced. In the traumatic form 
the infecting element is brought in direct contact with the marrow 
through a wound after compound fracture, amputation or resec- 
tion ; in the spontaneous form the poison enters the circulation, 
and is carried with the blood to the medulla, where it becomes 
localized. 
The influence in preventing traumatic osteo-myelitis in con- 
taminated hospitals has been strikingly illustrated in the general 
hospital in Munich. Before Lister’s treatment of wounds was 
adopted, almost every patient who was brought to the hospital 
with a compound fracture, or had submitted to an amputation or 
resection, became affected with this disease, and the majority of 
them died of pyaemia. Since the introduction of the antiseptic 
treatment, this dreadful scourge has been unknown in that institu- 
tion. The spontaneous variety is met with in a large proportion 
of cases in individuals under 25 years of age, before ossification 
of the epiphyseal cartilage has taken place. The period of 
growth and development of bone constitutes the most important 
predisposing cause. * Perhaps 90 per cent, of the whole number 
attacked are between five and fifteen years of age. I have seen 
at least three cases where the patients were more than thirty 
years of age. 
Case I. Osteo-myelitis of femur, with secondary suppurative 
synovitis of knee-joint ; pyaemia ; death.—Joseph S.. aged 38, a 
laborer by occupation, in previous good health, received a slight 
injury of the lower part of his right thigh by a fall during the 
month of September, 1872. The injury was soon forgotten, but 
in a few days the patient experienced severe pain in the lower 
part of the thigh, attended by febrile disturbances, followed by a 
diffuse swelling. Three weeks from the beginning of the attack, 
the knee-joint became swollen, and the general symptoms assumed 
a more serious aspect. I saw him about five weeks from the time 
the first symptoms had developed themselves, and found him very 
much emaciated and suffering from hectic fever. Several open- 9 
ings existed over and above the knee-joint, discharging profusely 
sanious pus ; a probe could be passed readily into the joint 
and into the interior of the femur, coming everywhere in contact 
with denuded bone. Amputation of the thigh was advised as the 
only means to save the patient’s life, but was not acceded to, and 
the patient died two weeks subsequently, with symptoms of 
pyaemia. Cough, rapid breathing, chills and a jaundiced hue of 
the conjunctiva and skin made their appearance a few days before 
the fatal termination. 
In this case the morbid process commenced undoubtedly in the 
lower and interior part of the femur. After suppuration had 
taken place, pus infiltrated the spongy portion of the condyles, 
and invaded the knee-joint through a perforation in the articular 
cartilage of the joint, exciting there a suppurative synovitis. 
An early incision, with perforation of the compact layer, 
affording an outlet for the pus, might have been the means of 
saving the patient’s life and limb. 
Case II. Osteo-myelitis of lower extremity of tibia ; necrosis; 
operation; recovery.—August Musach, aged 35, laborer, with a 
scrofulous hereditary taint, came under observation in the fall of 
1872. When he was about 12 years of age he received an injury 
to the lower portion of the right tibia, acute inflammation fol- 
lowed, resulting in suppuration and spontaneous evacuation above 
the internal malleolus. The opening discharged pus for a long 
time, when it finally closed, leaving the bone enlarged but caus- 
ing no further inconvience. About a year ago he injured the 
same place with the blunt edge of an ax. Soon after the acci- 
dent the part became very painful and in a few days swollen; in 
about five weeks a physician opened an abscess over the minor 
and lower aspect of the tibia. The pain and fever subsided but 
a thin and extremely offensive pus continued to escape until 
I saw him. At that time several openings existed above the 
internal malleolus; the lower end of the tibia was enlarged to 
more than twice its normal size. A probe passed readily through 
one of the cloacae and came in contact with loose, dead bone. 
The soft tissues were very much indurated. The patient 
appeared to be well nourished but very anaemic. He was ether- 
ized and the bone exposed by an incision. The cloaca was 10 
enlarged with the trephine and chisel and a sequestrum of cancel- 
lated bone infiltrated with foetid pus was removed. The involu- 
crum was fully an inch (in thickness and almost as dense as ivory. 
The abscess cavity was lined throughout with large, whitish-grey 
granulations; only a very thin shell of bone seemed to separate 
the abscess from the anklejoint. The patient made a slow but 
permanent recovery. In this case the disease during childhood 
affected the lower epiphyseal cartilage and the spongy tissue on 
both sides of it and its results undoubtedly furnished a predis- 
posing element for the second attack. 
Case III. Suppurative synovitis of knee-joint; osteo-myelitis 
of femur; death.—John Schulz, aged 32, laborer, with a heredi- 
tary tubercular taint suffered during his childhood from a syno- 
vitis of the left knee-joint, which terminated in false anchylosis 
and partial dislocation of tibia without suppuration. While at 
work during the spring of 1878 he injured the affected knee by 
a fall. In a few days severe pain and swelling supervened, 
accompanied by fever. A number of weeks afterwards an abscess 
appeared on the inner side of the knee, which was opened by a 
physician. When I saw him, about eight months from the com- 
mencement of the disease, I found the patient very much 
emaciated, an opening on the inner side of the knee discharged 
freely a sanious pus and permitted the passage of a probe into the 
joint when denuded bone was distinctly felt. The joint was swollen, 
tender and extremely painful on the slightest attempt to move it. 
I proposed to make a free incision on both sides of the joint, and, 
with a sharp spoon scrape away the carious articular ends under 
antiseptic precautions. I failed, however, to obtain the consent 
of the patient and his friends, and lost track of the case until 
about four months afterward, when I was again called to see him. 
I then learned that the whole thigh became swollen and extremely 
painful about three weeks previous to my visit. Several open- 
ings existed over the inner and outer aspect of the thigh, through 
which a probe could be passed down to the femur, which was 
found denuded of periosteum. The patient was suffering from 
chills and presented a jaundiced appearance. The spleen was 
considerably enlarged and over the posterior and inferior part of 
the chest numerous r&les could be heard. As internal metastatic 11 
deposits had evidently taken place, only a palliative treatment 
was adopted. The patient succumbed rapidly to the general 
invasion and in a few days death terminated his sufferings. In 
this case osteo-myelitis occurred as a secondary affection following 
destructive suppurative synovitis. The disease in the joint had 
destroyed the articular cartilage, and, from imperfect drainage, 
the pus in the joint infiltrated the reticulated structure of the 
condyles of the femur, causing finally a diffuse and fatal osteo- 
myelitis. It is evident that the establishment of free drainage, 
combined perhaps with Svidement under antiseptic precautions, 
might have prevented the extension of the disease to the femur. 
Location and climate appear to exert an influence in the causa- 
tion of this disease. According to Yolkmann it is frequently met 
with in Berne, Marburg, and Halle, but seldom in Zurich and 
Berlin. From the great number of patients suffering from 
necrosis and from the number of recent cases that have come 
under my observation, I am inclined to believe that this disease 
is quite prevalent in our section of country, more particularly 
along the lake shore. The frequent and sudden changes in the 
temperature, incident to this region, are a fertile cause in the pro- 
duction of internal congestions. 
“ Mr. Savory reports a case in which the exposure of a limb 
to sudden extremes of heat and cold by plunging it into ice cold 
or very warm water, caused acute osteo-myelitis and McNamara, 
of Westminster Hospital, cites the case of a boy in perfect health 
who fell through the ice Dec. 20th and on Feb. 15th suffered 
amputation at the knee-joint in order to prevent further absorp- 
tion by extension of evident septicaemia. Dissection of the limb 
showed that the cancellated tissue and medullary canal of the 
tibia were entirely destroyed and that the outer shell (compact 
tissue) of the bone was more healthy than any other part; the 
myelitis being evidently not due to extension of inflammation 
from the periosteum to the medulla through the Haversian canals, 
as might naturally be supposed.” 
I have seen a number of cases where the exciting cause could 
be clearly traced to a sudden chilling of the cutaneous surface. 
Case IY. Osteo-myelitis of humerus; necrosis; operation; 
recovery.—Henry R., aged 18, farmer, previously in perfect 12 
health, was attacked early in the spring of 1865, with severe 
pain in the upper portion of his humerus, almost immediately 
after bathing in cold water. He had over-heated himself by a 
long and rapid walk before he went into the water. The fever 
and general disturbance were severe from the beginning. After 
three days a diffuse swelling took place, extending over the whole 
arm and part of the forearm. In about three weeks, after the 
most terrible suffering, an abscess formed and discharged itself 
near the insertion of the deltoid muscle. Several other open- 
ings formed subsequently, through which several small pieces of 
bone escaped. The movements of the shoulder-joint became 
impaired and the muscles in its neighborhood became atrophied. 
At the end of the operation, June, 1871, several cloacae existed, 
through which a loose sequestrum could be distinctly felt with a 
probe. The involucrum was found exceedingly dense and meas- 
ured over an inch in thickness. The sequestrum was rough on 
all sides and had evidently a central origin. The primary dis- 
ease involved the interior of the bone, and had extended from or 
over the upper epiphyseal cartilage to the middle of the humerus. 
Judging from the impaired motion in the shoulder-joint, the pre- 
vious synovitis must have been quite severe. In about four 
months the wound had entirely healed, and the usefulness of the 
arm had materially improved. 
Case V. Osteo-myelitis of tibia and radius; recovery.— 
Reinhold Stolz, aged 12 years, a healthy boy, after over-heating 
himself in a game of ball, rested himself by lying on the cold 
ground until he became thoroughly chilled. When he came 
home he complained of a severe pain in his left leg, and the next 
day he was unable to walk. On my visit at this time (Oct. 30, 
1877), his pulse was 140, temperature, 40°. The lower part 
of the tibia was tender, but no swelling could be detected. The 
least attempt to move the limb caused intense pain. In a few 
days a diffuse phlegmonous swelling appeared and an incision 
gave exit to a considerable quantity of reddish brown fluid, in 
which free oil globules were found floating on the surface. The 
tibia was found denuded of periosteum over several inches of its 
extent. The pain continued after the incision, and the general 
symptoms assumed a more serious aspect. During the second 13 
week of the disease the lower part of the radius on the right 
side became swollen and tender ; suppuration did not take place; 
the pain and swelling yielded in a few weeks to the persistent 
local use of tincture of iodine. 
After a few months the general symptoms improved, and when 
last seen, the patient was able to walk, but the lower end of the 
tibia was found to be the seat of extensive central necrosis. 
Over-heating of the t)ody diminishes its power to resist the 
deleterious influences of cold. The internal congestion resulting 
from a sudden abstraction of heat from the cutaneous surface pro- 
duces a stasis in the capillaries of the medullary tissue which 
favors the localization of the infectious germs which may exist 
in the blood. The influence of temperature is further apparent 
from the fact that, according to Luecke and Schede, the dis- 
ease seldom occurs during the summer months. My observa 
tions would tend to corroborate this assertion. Most of my 
patients contracted the disease during the months from October 
to May. 
Among the general predisposing causes may be enumerated, 
the period of youth, the male sex, occupation, a damp and 
changeable climate, scrofula, syphilis, and the period of conva- 
lescence after acute infectious diseases. Crowded school-rooms, 
badly ventilated sleeping apartments, damp dwelling houses, and 
other unfavorable hygienic surroundings, are potent agencies to 
render the system susceptible to infection. Among the local 
causes may be mentioned fractures, contusions and concussions, 
but traumatism in every form can only be viewed in the light of 
exciting causes. No amount of local mechanical, physical or 
chemical irritation is sufficient to produce the disease independent 
of the essential cause—infection. Rosenbach has even gone so 
far as to assert that the infection is one sui generis, a specific 
infection, while Kocher and most of the modern pathologists 
regard the infection analogous in charater to that producing 
other forms of inflammation. Both of these observers have made 
numerous and ingenious experiments on animals to prove the 
infectious nature of this disease. Rosenbach found that contu- 
sions, fractures and crushing of bone, as well as destruction of 14 
marrow by cauterization, artificially produced under antiseptic 
precautions, were insufficient to produce osteo-myelitis. 
In eleven cases of cauterization of the central medulla with a 
galvano-caustic wire, under the antiseptic treatment; in eight no 
suppuration took place; in three, where the burning was severe, 
necrosis occurred; the general symptoms were not severe, and 
suppuration very slight. In three cases where the marrow was 
operated upon by electrolysis, the resulfs were negative. Injec- 
tions of mercury, amalgamate of sodium, caustic potassa and sul- 
phuric acid, directly into the medullary cavity, caused instant 
death during the operation^from the entrance of the irritants 
into the veins, but osteo-myelitis failed to be produced in any of 
them. Injection of a mixture of equal parts of croton oil and 
fat, previously heated to 100° C., produced intense inflammation 
of the soft parts, destruction of medulla and complete necrosis of 
the shaft of the bone. Two drops of pyaemic fluid, injected into 
the interior of the tibia of a rabbit, caused death in three days. 
An examination of the bone showed that extensive osteo-myelitis 
and necrosis had taken place. Rancid butter injected into the 
medulla excited a severe phlegmonous osteo-myelitis which came 
near proving fatal. On killing the animal some time afterwards, 
the entire diaphysis was found necrosed and separated from both 
epiphyses. In three cases where pus from an osteo-myelitic 
patient was injected into the medulla, well-marked, typical osteo- 
myelitis followed. These experiments were made on dogs and 
rabbits. 
From the results of these experiments, Rosenbach concludes 
that mechanical, physical or chemical irritants applied to the 
marrow, with the exclusion of infection, cause simply death of its 
substance and the subsequent removal or absorption of the dead 
tissues. Injections of infectious matter excite a diffuse, purulent, 
phlegmonous, septic inflammation, followed in some instances by 
general infection and death. Osteo-myelitis, traumatic and spon- 
taneous, can only occur after infection has taken place, no matter 
how severe and extensive the local destruction may have been. 
In spontaneous cases the infectious material circulates in the 
blood, and localizes itself in the medulla, where it reproduces 
itself, causing septic inflammation. Localization of the poison in 15 
many instances is determined by local causes in individuals labor- 
ing under general infection. 
Luecke assumes that a stagnation in the capillaries of the 
marrow, from any cause, may arrest the infectious germs at the 
point of obstruction where they find a fertile soil for their repro- 
duction. Intense infection may lead to a fatal termination with- 
out localization. In most cases the poison remains latent or 
innocuous in the system until some local cause or causes deter- 
mine its localization. 
Kocher, who does not believe in the specific nature of the 
infection, was unable to produce, artificially, osteo-myelitis in 
animals by injecting into the marrow pus obtained from patients 
suffering from this disease. He regards osteo-myelitis, not as a 
specific infectious disease in the same sense as typhus, scarlatina 
and diphtheria, but simply infectious in the same sense as every 
other acute inflammation. 
His experiments on dogs, by applying directly to the marrow 
chemical or mechanical irritants, resulted in ostitis circumscripta 
hyperplastica; osteo-myelitis did not occur in a single instance, 
provided infection was prevented. Injections of septic fluids 
containing bacteria produced the disease promptly. Injections of 
pure pus, with micrococci, was followed by sclerosis of the bone. 
Injections of caustic ammonia, and feeding the animal afterwards 
with decomposed blood, mixed with Pasteur’s solution, resulted in 
osteo-myelitis, with grave constitutional symptoms. He believes 
also that traumatic influences are insufficient to produce osteo- 
myelitis without the aid of local or general infection. In external 
wounds communicating with the marrow, the septic germs in the 
air are brought in direct contact with the marrow; where no 
such direct entrance is possible, the septic bacteria enter the 
circulation through the gastro-intestinal or broncho-pulmonary 
mucous membrane, and with the blood-current reach the medulla. 
Schueller succeeded in producing osteo-myelitis in animals by 
subcutaneous injections of decomposed blood. Mikulicz has 
ascertained that the presence of living micro-organisms in the 
septic fluid is essential for the production of progressive sepsis 
after injection ; only slight reaction took place if the germs were 
destroyed by the addition of glycerine. S. Hasse found that a 16 
much smaller quantity of osteo-myelitic pus would produce a 
more intense effect on the same dog if it was allowed to undergo 
decomposition for six days. When the circulation of the blood 
in the marrow is impeded, or extravasation has taken place, the 
septic organisms circulating in the blood are readily arrested, and 
find there a fertile soil for their development and reproduction. 
Klebs, Recklinghausen and have found micro- 
organisms in osteo-myelitic patients, in the inflamed medulla, in 
the secondary deposits, the thrombi and fat emboli, in the fibrous 
exudations on serous membranes, and in the lymphatic vessels. 
In not rare instances, according to Billroth, diplo-cocci and 
strepto-cocci were also found. In some cases the micrococci were 
so numerous as to constitute the principal bulk of the products 
of inflammation, imparting to the fluid a reddish-brown, emul- 
sion-like appearance. The following cases may be of interest in 
this connection : 
Case VI. Osteo-myelitis of femur ; suppurative synovitis of 
knee-joint; micrococci found in pus.—Albert P., aged eight 
years, had been in his usual health until September 10, 1879. 
While at school, he was attacked almost suddenly with a severe 
pain in the lower part of the thigh, which was attended by sev- 
eral chills and fever. On the second day the pulse was 140, 
temperature 40° ; tongue coated; total loss of appetite; great 
thirst. The pain was very severe. Great tenderness, but 
no swelling over the lower epiphyseal cartilage of right femur, 
lie was very restless and soon became delirious. Salicylate of 
soda in large doses was administered and tr. iod. and ice ap- 
plied over the lower part of thigh. On the fourth day the knee 
and lower part of thigh commenced to swell. On the tenth day 
deep fluctuation could be felt; the swelling appeared to terminate 
somewhat abruptly about the middle of the thigh, the surface 
pitted on pressure, and the superficial veins were enlarged. 
Chloroform was administered and a free incision was made on the 
outer aspect of the thigh between the quadriceps extensor femo- 
ris and biceps muscles; after dividing the skin and fascia, the 
handle of the scalpel was used to separate the muscles until the 
periosteum was reached. This membrane presented a dark 
brown almost black color; fluctuation was distinct underneath 17 
it; it was incised freely, and about two ounces of a thick brown- 
ish red matter escaped. On introducing the finger the femur 
was found completely denuded of its periosteum from the lower 
epiphyseal line upwards to the extent of about six inches. The 
epiphyseal line was marked by a deep groove indicating begin- 
ning epiphyseolysis. The operation was performed under anti- 
septic precautions. 
A microscopical examination of the matter removed, made 
immediately after the incision, showed the presence of red and 
white blood corpuscles, pus globules, fat globules and numerous 
living cocci. After the incision the pain and fever became less; 
both re-appeared with increased violence after swelling of knee took 
place. A large aspirator needle was introduced into the joint, 
and a small quantity of pus removed; on injecting a five per 
cent, solution of carbolic acid, it was found that the fluid escaped 
through the incision above, demonstrating the fact that the knee- 
joint was in direct communication with the primary seat of osteo- 
myelitis in the femur. Marked improvement followed this 
procedure. A splint was applied to support the parts and prevent 
if possible, a complete separation of the lower epiphysis. In 
this case the morbid process began near the cartilage of aggluti- 
nation and became arrested at the middle of the femur above; 
below, the pus escaped at the partially separated epiphyseal junc- 
tion, but subsequently infiltrated the epiphysis and reached the 
joint through a perforation of the articular cartilage. The most 
favorable result that can be hoped for in this case, will be exten- 
sive necrosis of the lower portion of the shaft of femur and par- 
tial or complete anchylosis of the knee-joint. 
The femur is most frequently affected. Seventy-three per 
cent, of all of Demme’s cases involved the femur. In this bone 
* 
the disease manifests a special preference for the lower epiphy- 
sary region, while in the tibia the order of frequency, is reversed. 
The great frequency wTith which the extremities of the shaft of 
the long bones are affected, receives a plausible explanation 
from the activity of the physiological changes during the growth 
of bone, and perhaps to a lesser extent by the greater fre- 
quency of traumatism in these localities. 
English claimed that the extremity of the shaft and epiphysis 18 
toward which the nutrient artery is directed, is always primarily 
affected, on account of the greater blood pressure in that locality. 
Clinical experience has proved the contrary. 
Volkmann has called attention to embolism as a cause of osteo- 
myelitis and necrosis. 
Ritter reports a case of spontaneous fracture of clavicle fol- 
lowing osteo-myelitis, which was caused by embolism of the 
principal vessel supplying the bone. The patient was a woman 
34 years of age, who, four days after an abortion, suffered from a 
periosteal abscess over the middle of the clavicle, which ,was 
opened by incision and closed in four weeks. A painful spot 
remained over the seat of the abscess. At this point a spon- 
taneous fracture took place after which the pain disappeared. 
Union with deformity took place in the usual length of time. 
Azam reports a case where osteo-myelitis followed tumor albus 
of the knee in a patient 32 years of age. 
Case III affords a similar illustration. 
Billroth has seen several cases of osteo-myelitis follow acute 
articular rheumatism of the knee-joint. 
Stanley has observed several cases of suppuration of bone near 
the articular ends W'ith implication of the adjacent joint, caused 
by tubercular deposits in the cancellae, as tubercular matter was 
found in the purulent discharges. 
Symptomatology.—The symptoms attending osteo-myelitis al- 
ways indicate a grave affection. They vary in intensity according 
to the location and extent of the disease and later in the disease 
they are modified by the complications that may arise. In severe 
cases a chill or succession of chills followed by high temperature 
initiates the disease. The febrile state sometimes obscures the 
local symptoms to such an extent as to lead the physician to sup- 
pose that the patient is suffering from an attack of typhoid fever. 
If we recollect that Lenator entertains the opinion that osteo- 
myelitis may occur during an attack of typhus fever, the diffi- 
culty in diagnosis must be very great in some instances as the 
latter would obscure the local manifestations. Goltdammer 
reported a case of acute osteo-myelitis of the tibia to the Medical 
Society of Berlin, where the general symptoms simulated typhoid 
fever to such an extent that the patient, after an illness of ten 19 
days, was sent to the medical wards as a severe case of typhus 
fever. 
The patient had a pulse of 110-120, temp., 40.41° C., tym- 
panitis, furred tongue, enlargement of the spleen, bronchitis, 
rapid respiration and delirium. On close examination, a slight 
swelling was found over the lower*part of the right tibia with 
tenderness on pressure which led to the diagnosis of acute osteo- 
myelitis. During the progress of the case, pleuritis, parotitis 
duplex and synovitis of the right shoulder-joint made their 
appearance. The patient died 8 days after admission, or 18 days 
from the beginning of the disease. A post mortem examination 
revealed the existence of acute osteo-myelitis of the tibia and 
pyaemia. Chassaignac believes that diarrhoea is present in 
almost all cases in the beginning, but it is a more constant symp- 
tom after septicaemia or pyaemia have made their appearance. 
Usually the first symptom is the pain. This is generally severe, 
deep-seated, constant, boring, tearing or throbbing and referred to 
the primary center of the disease, usually in the vicinity of an 
epiphysary cartilage. Patients old enough to describe their sen- 
sation, complain of a feeling as if the bone was being broken. 
The patient objects to moving or handling the limb on account of 
an aggravation of this distressing sensation. In some instances 
where the disease begins insidiously the patient may continue to 
walk for several days, but is lame on account of the pain, which 
is increased by the weight of the body making pressure upon the 
cartilage of agglutination. This aggravation of pain, by bring- 
ing the epiphysis and diaphysis in forcible contact, is an early, 
prominent and important symptom. Impairment or entire loss 
of function of the nearest joint and the entire limb is one of the 
first symptoms. Swelling seldom takes place before the third 
day, but tenderness is present from the beginning and is usually 
located at the junction of the diaphysis and the epiphysis, and, 
from the close proximity of this point to the joint, disease of the 
latter is generally suspected by the patient and not unfrequently 
also by the physicians. In chronic cases, swelling may not take 
place for weeks or months ; when it does, it is due to an extension 
of the morbid process to the periosteum or the neighboring soft 
parts. After it has once made its appearance it increases with 20 
great rapidity, including usually one joint and extending over a 
surface corresponding to the extent of bone involved. The 
swelling is oedematous and terminates abruptly at a point where 
the disease in the interior of the bone has become limited. 
Chassaignac was the first one to call attention to this peculiar 
clinical fact and place great stress upon its diagnostic significance. 
The superficial veins as a rule are enlarged and if the obstruction 
in the deep-seated veins from thrombosis or pressure becomes 
great, oedema of the entire limb may take place. In regard to 
fluctuations, Ed. V. Wahl says that it is circumscribed at first in 
phlegmonous inflammations of the soft parts, while it is diffuse 
from the beginning in osteo-myelitis. I regard this distinction 
as a good one. 
From the anatomical location of the primary seat of the lesion 
it is easy to conceive that the products of inflammation are evacu- 
ated spontaneously only after extensive destruction of bone 
and soft tissues. On account of the resistance offered by 
the unyielding walls of the compact tissues many of the products 
of inflammation are forced into the circulation through the veins, 
producing in the first instance high temperature, and, later, fat 
embolism and pyaemia. Numerous experiments made with injec- 
tions of chemical and medicinal substances directly into the mar- 
row, have proven the possibility of thus forcing the substances 
directly into the veins. It is therefore logical to assume that 
affections of veins in cases of osteo-myelitis must be of frequent 
occurrence. In most of the fatal cases where post mortem exami- 
nations have been made, the veins were found affected, their inte- 
rior being filled with thrombi in different pathological conditions. 
These necessarily lead to metastatic deposits in various internal 
organs. Fat embolism and pysemia take place in a similar man- 
ner ; both are attended with difficulty of respiration, cough and 
an aggravation of the general symptoms. In many severe cases 
the morbid process is not limited to a part or an entire bone, but 
appears simultaneously or in rapid succession in different bones 
of the body. Cases of this description have induced Roser to 
apply the term pseudo-rheumatism, and Simon used the term 
necrosial fever from their resemblance to acute articular rheuma- 
tism. Volkmann regards this form as a rare affection and applies to 21 
it the term osteomyelitis spontanea multiplex. A number of 
cases of this, the severest form of osteo-myelitis, have come 
under my observation. 
Case VII. Helen M., aged 18, not affected with any consti- 
tutional taint, was in good health until Nov. 12, 1872, when 
after a supposed exposure to cold she was taken suddenly ill 
with a chill, followed by high temperature (40.5°), and pain 
in the right knee and left shoulder-joint. The pulse varied 
between 120-140, and the fever was continuous ; the morning 
and evening temperature ranging between 40°—40.5°. The 
general symptoms, and especially the low muttering delirium 
simulated typhoid fever, and almost obscured the local symptoms. 
Diarrhoea, slight cough, and rapid breathing were early and con- 
spicuous symptoms. The pain in the localities mentioned, was 
at first severe but soon subsided after the appearance of a diffuse 
oedematous swelling. Well-marked tenderness existed over the 
upper epiphysary region of the tibia and humerus. New points 
of inflammation made their appearance during the progress of 
the case, at the middle of the clavicle on right side ; lower end of 
femur, left side; third and fourth rib, left side; lower end of 
radius on right side. At the end of the first week deep fluctua- 
tions could be detected at most of these places, but the patient’s 
general condition had assumed such a serious aspect that no 
incisions were made. Notwithstanding the early and persistent 
use of stimulants and tonics, the patient died on the 10th day 
of the disease, with symptoms indicating serious lung complica- 
tions from metastatic deposits. 
Case VIII. Multiple osteo-myelitis; pyaemia; death.— 
Joseph E., aged 14 years, a healthy boy, was taken Dec. 31, 
1878, with a severe pain in the middle of the right thigh, which 
rendered him at once unable to walk. The thigh did not 
become swollen for three days. Chilliness and fever were pres- 
ent from the beginning. When first seen the thigh was swollen 
and oedematous from the lower third upward, measuring two 
inches more than the opposite one; superficial veins enlarged; 
pulse 120 ; temperature 40°. The patient was very restless and 
delirious most of the time; great thirst and total loss of appetite. 
On the ninth day the lower part of the right fore-arm, on radial 22 
side and wrist was found swollen, as well as the right parotid 
region, the latter occurrence rendering deglutition difficult. lie 
remained in about the same condition, the pulse ranging from 116 
to 130, and the temperature from 38.5° to 40° until the 21st 
when the left knee commenced to swell; December 30th, a swell- 
ing appeared over the left clavicle; January 15, 1879, fluctuation 
being present, an incision was made on the outer aspect of the 
thigh, lower part of radius and middle of clavicle, giving exit to 
a thin sanious fluid. The femur and radius were found exten- 
sively denuded and the clavicle had suffered spontaneous fracture 
about its middle. The abscess cavities were kept open by drain- 
age tubes and were washed out daily with a 3 per cent, solution of 
carbolic acid. Toward the final termination the patient became 
sallow and suffered from a dry hacking cough, symptoms plainly 
indicating the presence of pyaemia. The patient died on the 
27th of January, eight wTeeks from the beginning of the disease. 
Case IX. Multiple osteo-myelitis ; necrosis; recovery.—John 
S., aged 14, with an hereditary strumous diathesis, was attacked 
suddenly during the month of November, 1872, with a severe 
pain in the upper part of the right thigh and the lower part of 
the left tibia almost simultaneously, attended by violent constitu- 
tional disturbance, fever and delirium. In a few days a rapid and 
diffuse swelling appeared in both localities, in the thigh it evi- 
dently involved the hip-joint. About two weeks afterward, the 
patient failing rapidly, chloroform was administered and an incis- 
ion made on the right side, extending into the hip-joint, which 
gave exit to a large quantity of a thick brownish red fluid, mixed 
with laudable pus. The upper portion of the femur was denuded 
of periosteum and the hip joint affected with suppurative synovitis. 
The incision over the lower portion of the left tibia liberated a 
moderate amount of a thin sanious fluid, mixed with numerous 
fat globules. From the epiphysary junction upward, the tibia was 
separated from the periosteum for a space of more than five inches. 
The abscess cavities were washed out daily with carbolized water, 
and nutritious food was freely administered as well as tonics and 
stimulants. The pain diminished after the incisions, but the gen- 
eral condition did not improve for several months. Profuse sup- 
puration continued for several months until the upper epiphysis 23 
of the femur and a number of spiculae of bone escaped sponta- 
neously from the hip-joint as well as a sequestrum from the tibia 
when it almost ceased and the patient regained his former health. 
In about one year the wounds had closed completely. The left 
leg was perfect; the right showed nearly two inches of shorten- 
ing, but a movable false joint with slight flexion of the thigh upon 
the pelvis. 
In some cases the disease appears in another, perhaps distant 
bone in a sub-acute form several weeks after the first invasion, 
and fails to develop itself fully because the original infection 
appears, as it were, to have expended its force at the primary seat 
of localization. In such cases the process terminates with an 
increased production of bone instead of suppuration. To sub- 
stantiate this assertion I will report the following cases : 
Case X. Osteo-myelitis of femur; spontaneous fracture; 
hyperplastic osteo-myelitis of radius ; recovery.—August Schulz, 
aged 13, son of healthy parents, after an alleged fall, was taken 
with severe pain in the left thigh during the winter of 1874, 
which soon rendered walking impossible. I saw him two weeks 
afterwards, and found the whole thigh and knee enormously 
swollen and oedematous. The superficial veins were enlarged. 
Fluctuation was perceptible around the whole circumference of 
the thigh, and was well-marked on the outer aspect of the limb, 
at the junction of the lower with the middle third of the femur. 
The patient was emaciated and very anaemic. An incision was 
made between the biceps and quadriceps extensor femoris, about 
5 ctm. above the knee-joint, which gave exit to a large quantity 
of a mixture of a thick, brownish-red emulsion, with pus. The 
lower end of the femur, from the epiphysary junction upwards, 
to the extent of 20 ctm., was found completely denuded of peri- 
osteum. Drainage tubes were inserted, and the cavity well 
washed out daily with carbolized water. About two weeks later 
I found, during one of my visits, that the femur had fractured 
spontaneously at, a point near its middle. This occurrence added 
greatly to the perplexities in the management of the case, and 
increased my apprehensions in regard to the prospects of the 
future usefulness of the limb, and not less concerning the possi- 
bilities of saving the life of the patient. The limb was placed 24 
as nearly as possible in its natural position, with the knee slightly 
flexed, and a fenestrated plaster of Paris splint applied from the 
toes to the hip-joint. Soon after this unfortunate complication 
had taken place, the patient complained of a pain in the lower 
part of the right radius, and in a few days a circumscribed hard 
swelling made its appearance in that locality. Tincture of iodine 
was freely applied, which soon arrested the further progress of 
the disease and subdued the pain. About three months after the 
application of the first plaster splint, the new bone had become 
sufficiently firm to retain the position of the limb. The swelling 
above the wrist gradually disappeared, and the patient began to 
improve in his general health, so that during the following 
summer he was able to go to school with the aid of one crutch, a 
fistulous opening at the point of incision discharging a moderate 
quantity of pus. Three years afterwards I removed by seques- 
trotomy a large, rough, central sequestrum 17.5 ctm. in length, 
after which a permanent recovery took place, with a good, 
moveable knee-joint. Notwithstanding a slight curvature of the 
femur, with the concavity inwards, it is about 1.8 ctm. longer 
than the opposite one. 
Case Y may also serve as an illustration in this connection. 
Diagnosis.—Mr. Holmes has Avell said that the disease under 
consideration is more frequently recognized at post mortem ex- 
aminations than at the bedside of the sick. I am well satisfied 
that it is often mistaken and treated for other affections, as peri- 
ostitis, ostitis, inflammation of joints, rheumatism, typhoid fever 
and even phlegmonous inflammation of the soft parts. When 
we remember that periostitis, ostitis, synovitis and cellulitis are 
secondary lesions intimately associated in the clinical history of 
every case of osteo-myelitis, and furthermore, that the fever 
attending it assumes such close resemblance to typhoid fever, 
it is not surprising at all that many cases are not correctly 
interpreted during life. A careful consideration of every feature 
of the clinical picture presented by each case, can only enable us 
to arrive at correct conclusions. There is no single pathogno- 
monic symptom that would infallibly lead us to a correct diagno- 
sis. The presence of fat globules in the products of inflammation 
was regarded as diagnostic by Chassaignac and lloser. Although 25 
this symptom is present in some of the cases, it is absent in a 
larger number, and it may also be present during the course of 
other suppurative processes, as 1 have repeatedly observed. Fat is 
almost always present in the purulent discharges from gangren- 
ous inflammation of the cellular tissue. In a diagnostic point of 
view, the pus derived from the primary seat of the disease pre- 
sents the following elements for examination : 1. Blood cor- 
puscles, red and white, their number depending upon the acute- 
ness of the attack. 2. Pus globules. 3. A thick, brown, 
emulsion-like fluid containing fat globules and micro-cocci. 
One of the most important symptoms for differential diagnosis 
is the absence of swelling for the first few days regardless of the 
severity of other symptoms, also its rapid diffusion after it has 
once made its appearance. In phlegmonous inflam- 
mation of the cellular tissue, swelling is one of the earliest symp- 
toms. In osteo-myelitis the swelling is at first oedematous, 
extends symmetrically around the entire bone and terminates 
abruptly at a point where the morbid process in the interior of 
the bone has become arrested. Fluctuation in acute cases 
appears about the end of the first or during the second week. 
The superficial veins are usually enlarged. A consecutive affec- 
tion of one or more joints in close proximity usually makes its 
appearance about from the end of the first to the fourth week. 
The time of its appearance as well as its character depends 
largely upon its causation. While joint affections are almost 
constant in osteo-myelitis, they are seldom associated with perios- 
titis. Early incisions are of great diagnostic value; besides 
affording an opportunity of examining the condition of the bone, 
the subsequent history is of importance in arriving at a correct 
conclusion. If the pain and fever subside after the incision, we 
have to deal, in all probability, with a case of cellulitis or periosti- 
tis ; if they are only diminished or continue unabated, it may be 
safely concluded that the disease is located in the interior of the 
bone. The frequency with which pyaemia occurs during the 
progress of this disease, must also be remembered in rendering a 
final diagnosis. A very interesting case was reported by M. 
Auger at a meeting of the Socidtd de Chirurgie, on January 8, 
1879, which well illustrates the obscurity of diagnosis in some 26 
cases, as well as the liability of neighboring joints to become 
involved if the disease occurs in an adult. The patient, a man 
54 years of age, after having been out hunting, felt on the fol- 
lowing day a violent pain in the right leg. The pain was most 
severe in the calf of the leg, the ankle and along the course of 
anterior tibial nerve, and came on in paroxysms Avithout any 
regular intermittence. For a month the tibia was not swollen, 
when in a few days a purulent discharge took place on the upper 
third of the bone. Soon after this time the knee began to swell 
and the medullary canal was found filled with pus. An incision 
wras made into the knee-joint on both sides under antiseptic pre- 
cautions, and free drainage established. In three months the 
patient died of pyaemia. 
Prognosis.—The mortality attending osteo-myelitis appears to 
be greater in hospital than private practice. Demme lost 4 out 
of 17 cases; Luecke, 11 out of 24; Kocher, 9 out of 26; and 
Schede 3 out of 23 cases. 
Uncomplicated cases do not prove fatal very often. Roser 
says a fatal issue may take place Avithout localization, and 
attributes death in such cases to an acute dyscrasia. Acute fatal 
cases can usually be traced to pyaemia, the result of phlebothrombo- 
sis. The organs most frequently affected by metastatic deposits, 
are the lungs, and next in frequency, the kidneys; in the former 
causing pleuritis,, pneumonia or abscesses; in the latter, diffuse 
nephritis and anasarca. Fat embolism of the lungs has already 
been referred to as a cause of death. Great enlargement of the 
spleen is one of the gravest prognostic symptoms. Where the 
marroAV is severely and extensively affected leucaemia is some- 
times produced as a consequence, and of course leads to a fatal 
termination. 
Schede has found the proportion of the white to red corpuscles 
of the blood change from 1.100 to 1.200. 
I have invariably observed early and marked anaemia in all of 
my cases. 
The thermometer furnishes us with an important prognostic 
aid in this as well as in many other acute affections. 
If the morning and evening temperature remain constantly 27 
high, that is to say, range between 40°-40.5° during the first 
week, it indicates a severe case. 
The more the general symptoms resemble typhoid, the graver 
the case. Chronic pyaemia is sometimes the cause of death. 
After incision secondary infection may take place, which may 
result in death by septic or pyo-septic infection. This result is 
more likely to follow in this than most other alfections, as the 
cavities in the bone are reached and disinfected with the greatest 
difficulty. 
In regard to the function of the limb after osteo-myelitis, a 
few words are necessary. Necrosis to a greater or less extent is 
the rule. Joint affections and partial or complete separation of 
epiphysis are frequent complications. If the effusion into the 
joint is passive from phlebothrombosis, or catarrhal, it is generally 
absorbed, and the function of the joint is restored completely. 
If the effusion is sero-purulent and the cartillage remains intact, 
aspiration and washing out the joint with a five per cent, solution 
of carbolic acid may be sufficient to restore the usefulness of the 
limb. Stiffness of the joint to a greater or less extent as well 
as mal-position of the articular ends of the bones, are events 
that cannot be avoided in all cases, even by the most skillful and 
attentive treatment. If the cartilage of the joint has become 
destroyed by suppurative synovitis, false or complete anchylosis 
anti more or less deformity cannot be prevented. Separation of 
the epiphysis may be repaired completely, as will be seen from 
the following cases : 
Case XI. Osteo-myelitis of both tibiae; sero-purulent effu- 
sion in knee-joints; separation of epiphyses ; recovery.—Carl 
Schulz, aged 14, after exposure to cold was taken suddenly with 
severe pain in the upper part of both legs during the winter of 
1874. No swelling could be discovered the first four days ; after 
this time the upper part of both legs became rapidly swollen and 
oedematous. The patient was treated for rheumatism for lour 
weeks. When I saw him, about this time, I found him very 
much emaciated and extremely pale; pulse very rapid ; profuse 
perspiration, etc. A fistulous opening existed on both sides 
about three inches below the knee-joint, discharging freely this 
sanious pus. The legs were oedematous and the superficial veins 28 
enlarged. The shaft of the tibia was completely separated from 
the epiphysis on both sides. A probe could be passed through 
the opening between the diaphysis and epiphysis. The shaft of 
the tibia was denuded of periosteum over a considerable extent. 
Both of the legs were flexed and the slightest attempt to move 
them was attended by great pain. Both knee-joints were swollen. 
The patient was placed under the influence of chloroform and the 
existence of epiphyseolisis verified by the existence of preter- 
natural mobility and crepitus at the epiphyseal junction. To 
ascertain the character of the effusion into the joints, aspiration 
was performed and a sero-purulent fluid removed. Both joints 
were thoroughly washed out with a five per cent, solution of car- 
bolic acid and a plaster of Paris dressing applied from the toes 
to the middle of the thighs, with fenestrated openings over the 
anterior aspect of the leg. The abscess cavities were washed 
out daily with carbolized water and the wounds covered with 
cotton saturated in carbolized oil. Tonics and stimulants wrere 
given freely to support the patient’s strength. 
With the knowledge I then had of this disease, I must freely 
confess that I should have been tempted to advise amputation 
had the disease been limited to one side. As it was, I had but 
little hope of saving the patient’s life. Contrary to all expecta- 
tion, however, slow but uninterrupted improvement began to take 
place. A slight effusion reappeared in a few days but was 
absorbed without further treatment after several weeks. A num- 
ber of months subsequently, several rough pieces of bone escaped 
through the openings, after which suppuration ceased and the 
wounds closed. About a year after the beginning of the disease 
the patient was able to walk with the aid of a cane, the joints 
being .somewhat stiff. At present the upper extremities of both 
tibiae are enlarged, the mobility of the joints is completely 
restored, the patient is a strong, healthy young man, nothing in 
his gait indicating the extent of his previous disease. 
Case XII. Osteo-myelitis of tibia; partial > separation of 
lower epiphysis; operation; recovery.—August Scholtke, aged 
11 years, a previously healthy boy, was taken with a severe pain 
in his right leg, accompanied by grave constitutional symptoms 
during the month of January, 1879. In a number of weeks an 29 
abscess opened spontaneously above the ankle-joint after which 
the pain diminished but the patient remained in bed in a feeble 
condition for several months. He was admitted to the Milwaukee 
Hospital, August 15, 1879. On admission the lower part of the 
tibia was very much enlarged from the ankle-joint to the juncture 
of the middle with the upper third. Three fistulous openings 
existed, as follows: over the middle of the shaft, above the 
internal malleolus, and above and internal to the external mall- 
eolus. With a probe a loose piece of bone was discovered, 
surrounded by a strong involucrum. After placing the patient 
under the influence of ether and applying Esmarch’s bandage,, 
an operation under antiseptic precautions was performed for the 
removal of the sequestrum. With a chisel the cloacae were suf- 
ficiently enlarged to permit the extraction of the sequestrum, 
which measured 18 ctm. in length and was rough on all sides, 
indicating its central origin. A partial separation of the lower 
epiphysis was found; a probe could be passed freely in every 
direction between it and what remained of the shaft. 
The granulations were scraped out with a sharp spoon and the 
cavity disinfected with an 8 per cent, solution of chloride of zinc 
and carbolized water. Lister’s dressing was applied. No fever 
followed the operation and only a trace of suppuration. The 
process of repair was initiated at once and in a few weeks the 
wound had entirely healed. The new tibia is 1 ctm. longer than 
the opposite one, giving to the foot a slight varus appearance. 
Case XIII. Osteo-myelitis of the tibia ; separation of upper 
epiphysis; recovery.—John M., aged 12 years, during the month 
of March, 1871, while engaged playing ball, was suddenly siezed 
with an intense pain in the head of the right tibia, which soon 
became so severe that he was unable to stand on the affected limb. 
Slight fever was present from the beginning, and a diffuse swel- 
ling appeared below the knee in a few days. In about three 
weeks an abscess was opened below the knee which gave exit to 
a considerable quantity of osteo-myelitic pus. Antiseptic injec- 
tions were made daily and the wound covered with a gauze com- 
press kept saturated with carbolized water. About two weeks 
after the incision was made, complete epiphyseolysis and swelling: 
of the knee-joint took place, but as the fever had almost entirely 30 
subsided, the effusion was supposed to be of a serous nature. A 
plaster of Paris bandage was applied from the toes to the groin 
with a fenestrum over the incision. Profuse suppuration for a 
while threatened to prostrate the patient but diminished after the 
removal of a rough, thick but short sequestrum. The effusion 
into the joint disappeared without special treatment and the 
patient regained his usual health and almost perfect use of the 
limb in a little over a year. Soon after the separation of the 
epiphysis the the patient was seen by an old surgeon, who ad- 
vised amputation as the only means of saving his life; having, 
however, observed the wonderful restorative power of the vis medi- 
catrix natures in similar cases, I insisted on pursuing a conserva- 
tive course and was amply rewarded by obtaining such a 
satisfactory result. 
From anatomico-pathological reasons the result is less fortunate 
if separation of the upper epiphysis of the femur or humerus 
takes place during an attack of osteo-myelitis. In these cases 
the head of the bone, deprived of its principal blood supply and 
surrounded by the products of inflammation, becomes necrosed 
and acts as a foreign body, exciting, not unfrequently, serious 
disorganization of the remaining joint structures, as was the case 
in the following instance : 
Case XIY. Osteo-myelitis of femur; separation of upper 
epiphysis; operation; recovery.—L. C., aged 10 years; the 
youngest member of a healthy family of children, fell from a 
haystack during the summer of 1870, and, as was thought at the 
time, sprained his hip. He was soon able to leave his bed, but 
walked quite lame ; a few weeks later the knee on the same side 
began to pain him ; the hip and upper part of the thigh became 
swollen and tender; violent constitutional symptoms followed, 
with hectic fever and rapid emaciation. In about three months 
an abscess formed in front of the upper part of the thigh, 
which soon opened spontaneously and discharged a large quan- 
tity of pus. The patient remained in a very feeble condition for 
several months, when gradual improvement commenced to take 
place, so that in the spring he was able to walk on crutches. 
About eighteen months later I performed excision of the hip- 
joint. The head of the bone was found loose in the joint; on 31 
making a section through the bone below the great trachanter, 
the bone was found very soft and the cancellse infiltrated with 
pus, the sawed ends presenting a greenish or gray color; conse- 
quently two more sections were made lower down until healthy 
bone was reached, removing in all the head and four inches of 
the shaft. The periosteum was thickened, and was carefully 
separated and preserved. The wound closed in a short time, but 
reopened on several occasions during the next two years, dis- 
charging several small spiculae of bone, when it finally closed 
permanently, and the patient recovered with a very useful limb— 
motion in the false joint and two inches of shortening. 
Case XV. Osteo-myelits of femur; separation of upper 
epiphysis; operation; recovery.—George Muehlhauser, aged 15 
years, of a strumous diathesis, has been in delicate health for a 
number of years. Without any obvioys cause, he began to suffer 
from symptoms of acute coxitis in the fall of 1875. For several 
weeks he was treated on general principles, rest, extension, fixa- 
tion, tr. iod., fomentations, etc., when the general symptoms 
became so grave that excision of the head of femur was con- 
sidered the only chance to save the patient’s life. On opening 
the joint, the head of the femur was found necrosed and com- 
pletely detached, the upper portion of the femur was soft and 
infiltrated with pus. On a level with the trochanter minor the 
bone was porous, otherwise healthy. In about a year the patient 
recovered completely, the limb being about 4 ctm. shorter. 
In both of these cases the disease originated evidently in the cancel- 
lous tissue near the cartilage of agglutination and involved the 
joint secondarily. In the last case the upper and posterior por- 
tion of the acetabulum was denuded of cartilage, the affected 
tissues were scraped out with a sharp spoon. The prognosis in 
regard to the usefulness of a limb after an attack of osteo-myelitis 
depends less upon the extent of bone involved than the presence 
and severity of joint complications. 
Pathology.—Simple non-infectious inflammation of the medulla 
is a physiological reparative process. According to Virchow, the 
medulla of infants resembles granulation tissue chemically and 
microscopically. The restorative function of myeloid tissue is 
studied most advantageously in cases of fracture and around osteo- 32 
myelitic foci; in these instances its cells are transformed directly into 
bone cells, uniting the fragments in the former case and limiting the 
extension of the latter. In osteo-myelitis the inflammatory process 
extends beyond the process of repair, its tendency being in an 
opposite direction—to suppuration and necrosis. The inflamma- 
tion is a specific one, and depends upon the presence of septic 
germs which are either brought in direct contact with the medulla 
or have gained entrance from without into the circulation through 
the respiratory or gastro-intestinal tract, and are conveyed with 
the blood to the marrow where localization takes place. Many 
causes which have been previously enumerated may determine 
localization, but the sine qud non factor in calling into existence 
this destructive process, is the presence of living septic bacteria. 
Morbid Anatomy.—Lidell describes three stages or morbid 
conditions in which the marrow may be found: 1. Carnification, 
2. Suppuration, 3. Gangrene. In the first stage the substance 
of the marrow appears congested and has become abnormally 
firm. Fat globules are set free and are removed and the myeloid 
cells are generated with great rapidity. The sclerosis of the 
ipedulla is owing to a production of new connective tissue and 
partly to a hardening of the existing fibrous network. Only in 
exceptional cases is the disease arrested in this stage, but usually 
passes into the stage of suppuration. Acute oedema of the cellular 
tissue around the bone indicates that suppuration has taken place 
in its interior. Generally multiple deposits are disseminated 
over a greater or less area of marrow, but two or more of these 
purulent collections may coalesce and form large suppurating 
cavities. Pus globules are produced from leucocytes, connective 
tissue or myeloid cells, or all of them. In the cancellated tissue 
the cancellae are either removed by pressure and absorption, form- 
ing abscess cavities, or a certain district loses its vitality and is 
separated from the surrounding living tissue as a sequestrum. 
The most intense form of infection may terminate in gangrene of 
the marrow. This form is extremely rare, and when it does 
occur, it is in traumatic cases, after amputations, in infected and 
over crowded hospitals. As a direct extension of the morbid pro- 
cess to adjacent tissues by continuity or contiguity of structure, 33 
we have present in every case, ostitis, osteo-chondritis, periostitis 
and in most cases participation of neighboring joints. 
The bone substance, from the intensity of the inflammatory 
process, or from arrest of circulation, undergoes necrosis, and if 
the life of the patient is preserved, is sooner or later detached 
from the living tissues. Instances have been reported where an 
entire bone, including both articular ends, has lost its vitality, 
constituting a large sequestrum. Usually only a part of the 
shaft, and in preference that near one of the ends of the diaphysis, 
becomes necrosed. In the lower part of the femur, necrosis 
takes place most frequently on the posterior aspect of the bone, 
and in the upper extremity of the humerus on the outer surface. 
If the vitality of the bone is not destroyed, its substance is soft- 
ened by liquefaction and absorption of the inorganic matter, and 
from increased histogenesis of the marrow and bone cells which 
subsequently produce sclerosis. Osteo-chondritis may exist as a 
distinct affection, but more frequently it constitutes an important 
element in the history of osteo-myelitis. It may result in a par- 
tial or complete separation of the epiphysis from the diaphysis. 
I have no doubt that the disk of temporary cartilage placed 
between the shaft and epiphysis, serves a useful purpose in pro- 
tecting the joint from the invasion of disease. The cartilage 
interrupts completely the continuity of the medullary tissue in 
the epiphysis and diaphysis, and to a less extent also the vascular 
connections. If the disease originates in the diaphysis, the 
cartilage must be destroyed to a greater or less extent before it 
can invade the epiphysis. Mr. Hutchinson, in his “ Illustrations 
of Clinical Surgery,” gives a beautiful illustration to support 
this view. The femur was amputated at its upper third. The 
patient died of pyaemia. The marrow and cancellated tissue of 
the bone were infiltrated with pus and presented a greenish color 
from the end of the bone to the cartilage of the great trochanter 
and head of bone. The bone above the cartilages was perfectly 
normal. I believe it is also a well-established fact that adults 
are more liable than children to suffer from destructive suppura- 
tive synovitis of joints, if the disease is located near the articular 
ends of the bones. 
The softening of the cartilage usually commences at its mar- 34 
gins. After complete or partial destruction of its substance, if the 
disease has not expended its force, the epiphysis is in danger of 
becoming infiltrated with the infectious products of inflammation, 
and the joint is placed in great jeopardy. Joint affections 
usually make their appearance from the 15th-19th day (Chassaig- 
nac), but may occur as early as the third day, or be delayed for 
months in chronic cases. The swelling of the joint appears slowly 
and insidiously, without any additional severe local or general 
symptoms. The joint becomes affected either by the establish- 
ment of a direct communication with the osteo myelitic center 
through a perforation of the articular cartilage, or by an exten- 
sion of the periosteal inflammation to the structures of the joint. 
In some instances a chronic osteo-myelitis in an epiphysis leads 
to caseous degeneration of the products of inflammation (phthisis 
of bone) which may remain latent for a long time, but when it 
begins to break down and suppuration takes place, perforation 
into the'joint is a frequent occurrence. If the joint communicates 
directly with the disease in epiphysis, the result is necessarily a 
suppurative synovitis with extensive disorganization of the artic- 
ular and peri-articular tissues, and may produce infection of the 
opposite bone. Mr. Hutchinson, in his work quoted above, 
reports a very interesting case of this kind. A boy who had 
suffered a contusion of the hip, died of pyaemia two weeks after 
the injury. A post mortem examination revealed the existence 
of dirty pus in the hip-joint. The iliac bone and head of femur 
showed signs of recent inflammation. The affected portions of 
bone were discolored, being yellow in some parts, dusky purple 
or green in others. The discoloration in the head of femur was 
abruptly limited by the line of the epiphyseal cartilage. 
If the joint inflames by contiguity, the process extending from 
the periosteum to the ligaments and synovial membrane, the pro- 
duct of inflammation is more likely to be serous, or sero-purulent, 
and the function of the joint is less apt to suffer permanent injury. 
Entrance of pus into a joint between the periosteum and bone 
must be a rare accident, as this membrane, with the ligaments 
is very firmly attached to the surface of the epiphysis. The 
periosteum participates, to a greater or less degree, in all cases. 
The periostitis must be purulent, fibrous, haemorrhagic or osteo- plastic, according to the character of the exudations. The 
disease extends to the periosteum from the primary seat 
through the Haversian canals or at the epiphysary junc- 
tion. The irritation may not exceed the physiological limits 
and production of bone is the result. In severe and acute cases 
suppuration is always the result. The haemorrhagic form is 
invariably fatal. If an incision is made before perforation of this 
membrane has taken place, its outer surface is recognized by its 
very dark brown, purple or almost black color. In typical cases 
the pus underneath it has a brown, bluish, emulsion-like aspect. 
After perforation of the periosteum, pus escapes into the paros- 
tral tissues and produces the well-known phlegmonous inflamma- 
tion of the connective tissue. If the entire marrow has been 
destroyed and the periosteum completely separated, circulation 
in the bone is arrested and necrosis of the entire diaphysis is the 
inevitable result. After the acute symptoms have subsided, the 
reparative process is at once inaugurated. New bone is formed 
on the inner surface of the periosteum, which forms a case or 
involucrum around the dead bone until the latter is detached and 
removed as a sequestrum, either by spontaneous expulsion or 
through the interference of art. The cloacae which lead to the 
dead bone indicate deficiencies in the periosteum, caused by spon- 
taneous perforation, incision or destruction of the membrane. 
Osteo-sclerosis follows osteo-myelitis, but in exceptional cases the 
new bone remains porous and soft (osteo-porotic), a condition 
described by Volkmann and Schede, which may become the cause 
of various degrees of deformity from bending of the shaft. The 
veins of the marrow, bone and periosteum in inflammation of 
these structures are most always affected ; the exceptions to this 
rule are few. Coagulation of the blood in the veins leads to 
phlebo-thrombosis. If the clot fails to undergo organization, it 
breaks down and small particles enter the circulation and are 
carried to distant organs where they are arrested as embola, 
causing metastatic deposits so characteristic of pyaemia. The 
same result may follow phlebitis and periphlebitis. 
Hr. Woodward attributes the frequency with which pyaemia 
occurs in this disease to a septic infection which is propagated by 
continuity from the putrefied marrow to coagula in the veins. 36 
Hutchinson believes that the particles of organic matter not 
only produce embolism and thrombosis but that they serve at the 
same time as carriers of living matter capable of infecting the 
tissues around the plugs. 
Treatment.—The indications to be fulfilled in the treatment of 
a case of osteo-myelitis are: 
1. To neutralize, if possible, the infectious element by local 
and general use of antiseptics. 2. To subdue inflammatory 
action. 8. To establish, under antiseptic precautions, an early 
and efficient outlet for the products of inflammation. 4. To 
prevent deformity. 5. To sustain the patient’s strength by 
procuring the best hygienic surroundings and by the early admin- 
istration of stimulants and tonics. 
An early diagnosis is of paramount importance. An uncer- 
tainty in this regard often prevents the adoption of timely and 
positive measures to prevent or combat the progress of the disease. 
The deep-seated location of the malady offers the greatest obstacle 
to a correct diagnosis and successful treatment. Taking it for 
granted that in the spontaneous variety the septic germs enter the 
system through the gastro-intestinal tract it would be rational to 
assume that a brisk cathartic administered soon after the appear- 
ance of the first symptoms would be an efficient remedy to cut 
off any further supply of these noxious agents. In many 
instances nature makes an attempt in this direction by establish- 
ing a copious diarrhoea. A large dose of calomel administered 
for the same purpose and in the same manner as advised during 
the early stage of typhoid fever, could not fail to produce a bene- 
ficial effect. Salicylate of soda given in large doses from 6.0—24.0 
grms. during 24 hours has been advised by Kocher with a view 
to neutralize the poison. In such doses this remedy would also 
promptly reduce the temperature, which is constantly high in all 
acute cases. If the medicine is rejected by the stomach it can 
be administered by enema. Opium must be given in sufficient 
doses to alleviate pain. The limb should be placed in an elevated 
position and the strong tr. iodine applied daily until vesication 
is produced. Demme, Billroth and Yolkmann speak very highly 
in favor of iodine applications. If there is reason to believe that 
the first stage has not passed, ice should be applied over the part affected for the purpose of diminishing congestion, provided such 
applications are agreeable to the patients. As soon as swelling 
takes place it is a sign that suppuration has taken place when 
warm fomentations should be substituted. 
In regard to incisions, great diversity of opinion still prevails. 
Previous to the researches of Demme, early and free incisions 
were practiced. As the results in most cases were disastrous, he 
was led to adopt a more conservative treatment. He resorted to 
an expectant course of treatment until the poison had exhausted 
itself in the system, as indicated by reduction of temperature 
and cessation of local inflammation, and then made large incisions. 
For the purpose of affording an outlet to the products of inflam- 
mation, Klose made early and small incisions over the epiphysary 
junction. 
Most all authorities agree that early and free incisions expose 
the patient to additional risks of septicaemia and pyaemia, while 
at the same time the primary seat of suppuration is not reached 
unless trephining is also performed. 
M. Ollier is an advocate of early incision combined with tre- 
phining. In a communication read before the Academy of 
Sciences of Paris, he claims that trephining is applicable to all 
forms of osteo-myelitis with severe general symptoms. He says 
the most painful variety is usually found near the extremities of 
long bones. Trephining, even in the most diffuse form, will 
arrest the intense pain by reliving pressure ; where the disease is 
circumscribed it affords prompt and decided relief. In the acute 
form, trephining will often prevent the grave and fatal symptoms, 
while in the sub-acute and chronic form it removes the most dis- 
tressing symptom—pain. In eight out of nineteen cases of pain- 
ful osteo-myelitis he found pus; and in ten cases the marrow 
presented different diverse morbid appearances, while in the last 
case, a case of acute osteo-myelitis of femur, a large quantity of 
fluid blood escaped. Two of the nineteen cases died of pyaemia. 
After pus has appeared beneath the periosteum or in the paros- 
teal tissues, no time should be lost to remove it promptly. If it 
is permitted to accumulate, it may seriously compromise the 
integrity of neighboring tissues and organs and in addition 
serve as a source of infection. It can be removed safely with the aspirator and the abscess cavity thoroughly washed out 
with carbolized water for the purpose of neutralizing the local 
infection, or by making one or more incisions under antiseptic cau- 
tels. Lister has found that no less than a five per cent, solution of 
carbolic acid is necessary to destroy bacteria, or their products. 
Hueter has employed parenchymatous injections of carbolic acid 
with decided benefit in other inflammatory affections of bones 
and soft tissues. Koclier suggests injections of carbolized water 
into the tissues around the bone, made with a hypodermic 
syringe, several syringes full to be injected at different points 
twice daily. It seems to me the safest plan would be, after fluc- 
tuation can be detected, to remove the fluid with an aspirator, 
using a large needle and subsequently washing out the cavity 
with a five per cent, solution of carbolic acid. This simple pro- 
cedure should be repeated as soon as the fluid reappears and 
until the acute local and general symptoms have subsided, when 
a permanent opening can be made without much risk of sec- 
ondary infection, Kocher also suggests the propriety of making 
intra-osseous injections by penetrating the bone with a small per- 
forator, and injecting carbolized water, thus reaching the 
primary focus of the disease. Theoretically the suggestion ap- 
pears valuable, practically it would be uncertain and difficult of 
execution. Incisions, especially if practiced during the acute 
stage, should be made only under the antiseptic treatment. 
They should be made,-if possible, at a point out of reach of any 
important vessels and nerves and over some well marked inter- 
muscular septum. The limb should be shaved, cleaned and dis- 
infected around its entire circumference and over a considerable 
space. To prevent hgemorrhage the knife should be used as 
little as possible; after dividing the skin and fascia the handle 
of scalpel and finger should be used to separate the muscles 
until the pus escapes, or if the periosteum remains intact it is 
incised with the knife. The opening should be sufficiently large 
to permit the introduction of the index finger for the purpose of 
ascertaining the condition of the bone. If necessary one or 
more counter openings must be made, with a view of securing 
free drainage. Large drainage tubes should be inserted, the 
cavity thoroughly washed out with a weak solution of chloride 39 
of zinc or a five per cent, solution of carbolic acid and the anti- 
septic dressing applied. 
No special benefit can accrue from making the incisions 12-30 
ctm. in length as recommended and practiced by Demme. 
The antiseptic treatment of wounds justifies operative interfer- 
ence, which would heretofore have been considered unsafe and 
imprudent. It prevents decomposition of the products of inflam- 
mation and its result—septicaemia. Should putrefaction take 
place, then an attempt should be made to render the abscess 
cavity aseptic by applying thoroughly an eight per cent, solu- 
tion of chloride of zinc, followed by a five per cent, solution of 
carbolic acid. Should an opening exist before the patient comes 
under treatment, free drainage must be established by enlarging 
the opening or making new incisions. Where the greater por- 
tion or the entire diaphysis of a bone has become necrosed and 
has become separated at one or both epiphysary junctions, it may 
become necessary to remove it during the acute stage to avert 
exhaustion of the patient from the profuse discharges and hectic 
irritation incident to such a condition. It has been argued 
against this operation, that the bone would not be sufficiently 
regenerated after its removal. This fear is however not sup- 
ported by facts. Duplay, Holmes, McDougal, Lefort, Giraldes, 
Spence, Petregrin, Philzky, Wilms, Cheever, Ropes, and Gay, 
have each reported cases where almost complete reproduction fol- 
lowed the removal of the entire shaft. It is very important, 
especially in young persons, to preserve both epiphyses to pre- 
vent subsequent shortening and deformity of the limb. 
I will report one case, where, after excision of two thirds of 
the shaft of the tibia, complete reproduction took place. 
Case XYI. Osteo-myelitis of tibia ; excision of two-thirds of 
the shaft; recovery.—John Endlich, aged 12 years, of healthy 
parents, was the subject of osteo-myelitis of the right tibia which 
resulted, after four weeks, in separation of the upper epipysary 
junction; the knee-joint was considerably swollen at the time. 
The temperature was continuously high, delirium, rapid emacia- 
tion, etc. An incision was made three inches below the knee, 
after the.second week, which gave exit to a large quantity of thin 
sanious pus on which floated numerous fat globules. Six weeks 40 
from the commencement of the attack the constant fever and pro- 
fuse suppuration threatened fatal exhaustion unless the source of 
irritation could be removed; it was consequently decided to per- 
form excision of the shaft. After the patient was placed under 
the influence of chloroform an incision was made along the inner 
surface of the tibia, extending along the entire length of the dia- 
physis. The upper epiphysis was found detached, and the upper 
two-thirds of the shaft denuded of its periosteum ; the bone was 
divided with a chain saw, about two inches above the ankle-joint. 
Immediately above the section the lines of demarcation between 
the dead and living bone could be distinctly seen. The medullary 
canal of the portion of bone removed was infiltrated with pus. The 
inner surface of the periosteum showed, at some points, deposits 
of new bone. The limb was placed at first upon a posterior splint, 
and afterward a fenestrated plaster of Paris splint was applied 
from the toes to the knee, and the wound dressed with carbolized 
oil. The fever and discharge disappeared almost entirely after 
the operation, and the general health began to improve. New 
bone began to fill up the large gap and in four months complete 
regeneration had taken place. The tibia is now somewhat larger 
and longer than the opposite one and the function of the leg is 
perfect. When both epiphyses have become separated from the 
diaphysis, the operation for removing the shaft is an easy one ; all 
that is necessary is to make an incision sufficiently large to remove 
the sequestrum. Suitable mechanical support must be applied 
for a long time to prevent bending of the new bone. Should 
swelling of one or more joints arise, it is always well to make an 
exploratory puncture with a hypodermic syringe to ascertain the 
character of the effusion. If the effusion is serous no special 
treatment is necessary, unless the tension becomes great causing 
severe pain, when it can be removed by simple aspiration. If it 
is found sero-purulent, it should be removed with aspirator and 
the joint washed out with a 5 per cent, solution of carbolic acid, 
and the operation repeated as often as may become necessary. If 
the joint contains pus the same treatment is applicable, but if the 
effusion reappears in a short time then incisions and drainage, 
according to Lister’s directions, offer the best prospects for re- 
covery. This latter treatment is positively indicated if the joint 41 
communicates directly with the disease in the bone, as in such a 
case perforation of the articular eartilage and serious destruction 
of other joint tissues has taken place. During the septic stage 
of acute osteo-myelitis with suppurative synovitis, amputation 
may become to save the life of the patient. In excep- 
tional cases the same sad alternative may be required after the 
acute symptoms have subsided for the purpose of removing the 
source of exhausting suppurative discharges. Our present means 
of treating abscesses and diseases of joints are fortunately suffici- 
ently advanced so that even severe cases can be safely treated on 
a conservative plan, and'amputation must be reserved only as a 
dernier rassort in extreme cases. 
In chronic cases the articular extremities are usually the seat 
of disease, and as there is great danger that the joint may 
become involved directly by perforation of the cartilage, they 
should receive early attention and thorough treatment. If the 
bone is enlarged, softened, and no external opening exists, excel- 
lent results are obtained by ignipuncture, an operation introduced 
by Richet. The part affected, and considerable of the surface 
beyond, should be prepa/ed in a similar manner as for incision; 
while the field for operation is covered with a spray, the round, 
sharp platina point of Paquelin’s thermo-cautery, heated to a 
white heat, should be thrust into the interior of the bone at 
several points, and Lister’s dressing applied. If an opening 
exists, an incision should be made, the cloaca enlarged, and the 
diseased and infected tissues in the interior of the bone thoroughly 
removed with a sharp spoon. 
If the joint has become affected by suppurative synovitis, the 
choice can only be between resection and amputation. The special 
indications of each individual case must determine in favor of one 
or the other of these operations. 
From the frequency with which the joints become affected 
during the progress of this disease, our attention should be 
directed early towards proper management of this complication. 
Deformity should be prevented by appropriate mechanical sup- 
port by means of splints or plaster of Paris dressings. A reten- 
tive apparatus, combined with suspension, will not only prevent 
contractures, partial dislocations of joints, and bending of newly- 42 
formed bone, but will add materially to the comfort of the 
patient. 
Should signs of pyaemia arise, our main reliance must be 
placed on the administration of large doses of quinine and 
alcohol. Luecke has obtained the best results from the adminis- 
tration of large doses of alcohol. Instances have been reported 
where two bottles of cognac were given, with decided benefit, 
during twenty-four hours. The patient should be surrounded by 
the most favorable hygienic influences, as fresh air, equable 
temperature, light and an abundance of plain, nutritious food. 
As soon as the acute symptoms have subsided, iron, especially 
the tr. ferri chloridi, should be freely administered. Should any 
dyscrasia, as syphilis, scrofula, tuberculosis or scorbutus, exist, it 
should be corrected by appropriate medication. 
CONCLUSIONS. 
1. Spontaneous osteo-myelitis is an infectious disease. 
2. It is most prevalent in damp, changeable climates, and 
during the winter and spring months. 
3. It affects with preference individuals during the period of 
growth and development of bone. 
4. Traumatism and other agencies, which produce a retarda- 
tion or arrest of circulation in the vessels of the marrow, act 
only as determining causes. 
5. Its primary seat is usually in the marrow of the cancel- 
lated tissue, in close proximity to the epiphysary cartilage. 
6. Joint affections are frequent and prominent complications 
of this disease. 
7. Thrombosis and inflammation of the veins of the marrow, 
bone, periosteum and soft parts are of frequent occurrence, and 
are the direct cause of pyaemia. 
8. Swelling is absent for the first few days, and when it does 
occur, it becomes rapidly diffuse, and is attended by oedema and 
enlargement of the superficial veins. 
9. Fluctuation is diffuse as soon as its existence can be ascer- 
tained. 
10. A constant high temperature and typhoid symptoms indi- 
cate the gravest type of the disease. 43 
11. Death may result from the intensity of the primary 
infection, but is usually produced by some complication. 
12. Early removal of the products of inflammation, under 
strictest antiseptic precautions and local disinfection of the tissues, 
are of paramount importance for its successful treatment. 
18. Epiphyseolysis may become completely repaired. 
14. Excision of shaft may become necessary during the acute 
stage, to prevent exhaustion from profuse suppuration ; this rule 
is not applicable if the humerus or femur is affected, on account 
of the impossibility of keeping the limb in position until regenera- 
tion of bone has taken place. 
15. In most cases fixation of the limb is necessary for the 
purpose of procuring rest and to prevent deformity. 
AUTHORITIES REFERRED TO. 
Allen, American Jour. Med. Sciences, July, 1865. 
Auger, The Monthly Abstract of Med. Science, June, 1879. 
Azam, Schmidt's Jahrbuecher, Band 128, S. 204. 
Bardeleben, Lehrbuch der Chirurgie u. Operationslehre. Berlin, 
1871. 
Billroth, Surgical Pathology. New York, 1872. 
Demme, Schmidt's Jahrbuecher, Band 119, S. 204. 
Demme, Schmidt s Jahrbuecher, Band 124, S. 55. 
Emmert, Lehrbuch der Chirurgie. Stuttgart, 1850. 
English, Schmidt's Jahrbuecher, Band 149, S. 187. 
Erichsen, Science and Art of Surgery. Philadelphia, 1869. 
Frey, Histologie u. Histochemie des Menschen. Leipzig, 1874. 
Gay, Excision of the Diaphysis of Tibia. Transactions Ameri- 
can' Med. Association, 1878. 
Gosselin, Clinical Lectures on Surgery, 1878. 
Gosselin, The Monthly Abstract of Med. Science, August, 
1879. 
Goltdammer, Berliner Klinische Wochenschrift, May, 1877. 
Green, An Introduction to Pathology and Morbid Anatomy. 
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Woodward, Pyaemia. Transactions American Med. Ass., 1869. WE are glad to receive contributions from 
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