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Osteitis Pubis
THE JOURNAL OF UROLOGY
Vol. 66, No. 3, September 1951 Printed in U.S.A.
OSTEITIS PUBIS HENRY MORTENSEN From the Urological Department St. Vincent's Hospital, Melbourne, Australia
Beer who first recorded in the English language (1924) the condition now referred to as osteitis pubis, stated: "During the last dozen years following suprapubic operations on the bladder we have repeatedly observed a curious and painful complication of periostitis" and again, "It is surely a rare complication although we have seen every year one or more cases during the past twelve years." I have believed for some time that this complication of lower urinary tract surgery is far more common than one would be led to believe by the literature. My reason for presenting this paper to you today is to record a large series of cases presenting this distressing complication. As a result of a questionnaire addressed to my urological colleagues in Australia and New Zealand, some forty-four cases have been collected from the practices of 16 out of 37 urologists who answered the questionnaire. Of these, 7 cases occurred in my own practice. Prior to 1947, practically all cases were reported as occurring after the second stage of a two-stage suprapubic prostatectomy. Since that date the cases presenting this complication have become more protean in their nature. In the cases here recorded, 5 occurred after cystectomy either partial or total, 29 after retropubic prostatectomy, 5 after suprapubic prostatectomy, 3 after transurethral prostatectomy, 1 after external urethrotomy and 1 after rupture of the posterior urethra, both these last 2 cases in association with suprapubic cystotomy (table 1). Perhaps the main interest lies in the occurrence of osteitis pubis after the use of the retropubic route of approach to the prostate as elaborated in recent years by Terence Millin. Though comparatively rare in the experience of the originator of the operation, his latest statistics being 9 cases in 1,100 retropubic prostatectomies, its incidence in a high percentage of prostatectomies performed by this route has led various urologists to view the procedure with concern and in some instances to abandon it. Moore reports 8 cases occurring in the first 65 prostatectomies done by this method and in the cases here presented it is noted that 65 per cent followed on this operation, one urologist reporting the occurrence of 7 cases of osteitis pubis following on 200 cases of retropubic prostatectomy. In this series, apart from one case diagnosed in 1934, no case was seen prior to 1944. The clinical picture may be mild or severe, symptoms beginning from 4 to 28 days after the relative operation. The onset may be delayed for upwards of 4 months as in 1 case in this series. The severe cases appear to predominate in numbers. The clinical and radiological features of the disease have been adequately dealt with in previous reports. To summarize however, pain is the outstanding Read at annual meeting, American Urological Association, Washington, D. C., May 30, 1950.
412
413
OSTEITIS PUBIS
symptom beginning in the midline and associated ,Yith great tenderness on pressure over the symphyseal region. With extension to the rami of the pubes, pain is complained of in the inguinal regions, on both sides and the upper medial aspect of the thigh. Later the ischia become involved with pain in the perineum and the buttocks. The mm,des attached to the affected bones become spasmodic, any movement of the pelvis causing contractions 1Yhich are excruciatingly painful. Micturition becomes painful particularly at the end of the act and because of the eontractiou of the levatores ani musc:les and the use of the bedpan, defecation beromes a misery. The most obvious spasm is that of the adductor musc:les and the patient lies in bed in gross fear of any movement. This is a pathognomic picture hardly comparable with that seen with any other condition in the body. The dramatic symptom complex may persist for many weeks or some months, and in practically all cases little alleviation is produced by any therapeutic measure. ,vith the passage of the hyperacute stage the act of walking or sitting may be painful as long as 12 months. In the milder cases the symptoms are far less severe and their duration shorter. TABLE ]
----·~-~-------Cases
Cystectomy, partial or complete. Retropubic j)rostatectomy. Suprapubic prostatectomc·. Transurethral prostatectomy. Exterrrnl urethrotomy Rupture of the prostatic urethra.
5 cases
29 cases 5 cases 3 cases 1 case 1 case 44 cases
The earliest radiological changes may be seen about the third ,rnek. They occur in the symphysis pubis where a motheaten appearance of the cartilage and the adjacent portions of the pubes may be seen. The brunt of the disease at this stage affects this joint, the cartilage disappearing and the pubic bones being splayed out up to 1.5 cm. With the progress of the disease areas of rarefaction are seen in both rami of the pubes on each side and in the severe cases similar changes are noted in the ischia. Evidence of lifting and fraying of the periosteum is seen particularly in relationship to the muscular attachments. vVith retrogression recalcification takes place, even though symptoms may be still present, and after a period of months complete bony restitution will occur. In the symphyseal region bony ankylosis ensues, while in the region of their attachments large masses of bone ,Yill extend into the muscles particularly the adductor group. No sequestrae have been reported. Abscess formation has been noted on occasion, but each of the recorded collections of pus has been very small, 5~ 10 cm. Ko abscess formation occurred in these 44 cases. Ko treatment offers any certainty of either cure or amelioration of the symptoms. In the cases here recorded some relief of symptoms ,Yas obtained by chemotherapy in two cases, and in one rapid relief follmYed the exhibition of vitamin B. In all the other cases the routine measures of chemotherapy, vitamin therapy, radiotherapy, diathermy and radiant heat were tried without significant result.
414
HENRY MORTENSEN ETIOLOGY AND PATHOLOGY
The greatest interest of osteitis pubis lies in its pathological nature and the relationship of this to its etiology. Various features of this unusual disease require adequate explanation. 1) Osteitis follows on operations involving the opening of the bladder. Exceptions are recorded as following transurethral resection. In the two cases mentioned by Bruskewitz and Ewell, both gave a history of severe bleeding in the anterior region of the bladder neck requiring an excessive degree of coagulation for hemostasis. In a female these observers record a further unusual case following on the removal of a stone from the lower end of the ureter. In this present series all 3 of the cases of transurethral resection which were followed by osteitis pubis required cystotomy in their aftercare, because of hemorrhage, extravasation or perivesical abscess respectively. That the condition is related to the opening of the prevesical space is strongly suggested by the great number of cases following on retropubic prostatectomy. It is difficult to reconcile this with the earlier occurrence of the complication after the second stage of a twostage supropubic prostatectomy. One would expect that the prevesical space would be sealed off after the preliminary cystotomy and that with a correctly placed abdominal incision and a tube inserted into the highest point of the bladder that there would be little chance in the second stage, of trauma to the pubes or opening up of the prevesical space. An odd case has been reported where there was no drainage of urine involved, such as the case after confinement, of Soderlund (cited by Wilensky), and that on a similar basis mentioned by Millin, but available details are insufficient for comment to be made. 2) Osteitis pubis is a comparatively new disease. Twenty-six cases had been recorded in the literature up to 1941, twelve of them by Edwin Beer. That the condition could have passed unobserved prior to this is most unlikely since most cases follow the severe pattern and the pain and disability are such that radiological investigation would inevitably have been carried out and the obvious changes discovered. My own experience has followed closely on that of most other observers. In consultation with a surgical colleague in 1944, I had seen 1 case following on suprapubic prostatectomy. It was not until January 1948, that I suffered this complication in my own surgical practice and within a month 6 cases had been diagnosed. It is remarkable that many urologists with an experience of thousands of cases of pelvic surgery involving the opening of the bladder have gone through their urological life without seeing one case, while others with similar experience are now confronted with a spate of them. In the search for an explanation for this recent occurrence it was early suggested that the use of chemotherapeutic powders in the wound (a procedure of recent origin) might provide the cause. From a theoretical point of view this could produce rapid healing of the superficial layers of the wound and cause infection to be pent up in the depths. This theory is disproved by the fact that in this series osteitis pubis occurred in 50 per cent of the cases in the practice of surgeons who do not use any powder in their postoperative toilet of wounds.
OSTEITIS PUBIS
415
3) The third factor still unsatisfactorily explained is the delay of onset from 15 days to very much longer periods, the onset being associated with a mild degree of pyrexia but with no gross fever or constitutional signs. The intensity of pain and disability is not comparable to similar lesions in other parts of the bony skeleton. The degree of pain is characteristic of cartilaginous involvement in joints. In an acute gonorrheal joint the pain is pathognomically intense and here the brunt of the pathological changes falls on the cartilage. 4) The fourth unusual feature is the evidence of bony changes with a primary affection of the symphysis, a tendency to bilateral involvement of the other bones of the pelvis associated with gross rarefaction and complete reconstitution of the bony structure following on cure of this self-limited disease. 5) The almost complete lack of response to all therapeutic procedures in a disease that proceeds to resolution is anomalous and rarely seen in other conditions. Approaching the problem from the appearances presented radiologically the characteristic early finding is that of rarefaction. The rapid onset of decalcification in a bone demands the presence of marked hyperemia. This may rise from three main causes: a) infection within the bone, b) infection adjacent to the bone, and c) interference with the nervous supply of the blood vessels to the bone. Rarely is it possible for vitamin or hormonal upsets to produce a similar condition. The suggestion of Beach that all of these cases occur as a result of a "septic spill of urine" is an obvious one considering the operative factors preceding the complication. He envisages a gross infection of the prevesical space, stating "this clinical entity is dependent on an accumulation of urine or septic material behind the pubes overspreading the nutrient foramen." It is hard to believe that infection could be present in soft tissues and yet no clinical evidence of such be consistently present. In a very few cases in my series was there any record of soft tissue involvement. He further suggests closure of the bladder and lack of adequate drainage as predominant factors, but surely again infection in the prevesical space with its abdominal cellulitis and constitutional disturbance would be recorded prior to the 15-28 days that osteitis generally takes to evidence itself. In most of the cases osteitis pubis appeared in the presence of a soundly healed abdominal wall. That an inflammatory origin for the lesion is suggested by the intensity of the pain and the amount of destruction of tissue is not denied. One would however, expect as in other bony infections associated with marked pain a gross amount of constitutional disturbance with greater temperature rise. Further, one queries why an inflammatory lesion should be predominantly bilateral and slowly and symmetrically progressive. Many writers have suggested trauma as the main etiological factor. Beer suggested that direct trauma by the pressure of retractors or drainage tubes or periosteal injury from avulsion of the fibres of attachment of the rectus muscle may provide the cause. Kirz (1947) described three factors which may be responsible: 1) The deliberate opening of the prevesical space; 2) avulsion of the' fibres of the rectus muscle or of the two layers of the transversalis fascia attached to the pubic bone; 3) rupture of the puboprostatic ligaments in the process of enucleation of the prostate.
416
HENRY YIOR'l'ENSE:'<
Added to these with the increase in popularity of the retropubic operation, the possibility of a needle prick of the periosteum has been suggested. This complication, however, has occurred in the practice of surgeons who never use anterior retractors in the ,vound, who always insert their drainage tubes in the upper angle of the wound, who feel certain that gentleness in handling of the rectus muscle or transversalis fascia precludes any damage to these structures and who do not tear the prostate out of its capsule. It has been suggested that perhaps this condition arises from damage to the nutrient vessel of the pubis. Pathologically this tenet is insecure since necrosis and sclerosis of bone would result with few or none of the clinical signs and symptoms of osteitis pubis. Wheeler (1941) rejected the inflammatory theory as a result of his failure in a series of experiments on animals to infect the pubis or periosteum with overinfected urine. He preferred to ally the condition with that interesting complication of trauma to the extremities known as Sudeck's post-traumatic atrophy. Bruske,vitz and E,vell (1949) also favor this explanation. At a varying period of time after even a slight injury the patient presents a typical syndrome. Complaint is made of marked pain out of all proportion to that suffered with the original injury and unrelieved by immobilization. With this are associated trophic changes in the limb distal to the injury: edema and blueness of the hand and foot. The bones in the vicinity showed marked spotty osteoporosis. Following on this there is gradual destruction of cartilage which may eventually lead to a fusion of joints and a useless extremity when recalcification eventually occurs. The cause of this condition is accepted as being due to interference with the nerve supply to the blood vessels of the part producing gross hyperemia and a consequent ,rnshing out of the calcium of the bones. Improvement has been achieved from the operation of periarterial sympathectomy. The inexplicable onset, the prominence of pain as a clinical feature and the gross osteoporosis suggest a similarity between it and osteitis pubis. However, the brn conditions do not correspond accurately. The pain of Sudeck's atrophy is not relieved by rest, rather any form of fixation increases it. On the other hand, in osteitis pu,bis the emphasis is on acute distress on attempt at movement, and avoidance of tihis appears to produce amelioration of the pain. Secondly no trophic changes ari) seen over the pubes in the soft tissues. This may of course be relative to the thickness of the tissues and the distribution of the arterial supply. Further the pain of Sudeck's atrophy is relieved by radiotherapy even though this treatment bears no relation to the course of the disease. Two cases of Millin's series have exhibited similar radiological changes in the vertebral column to those in the pubes. This has led him to suggest that the condition develops in some way through the pelvic veins associated as they are with the vertebral series. Batson (1940) demonstrated in his work on the venous system of the pelvis and its relationship to metastases in prostatic carcinoma that if a thin medium were injected into the dorsal vein of the penis a spread was seen to the ilium, to the veins of the pelvic girdle, to the veins of the vertebral system even to the sinuses of the skull. Millin has suggested a venous spread of infection by this route as an explanation of this occurrence.
417
OSTEITIS PUBIS
In conclusion, it is stressed that osteitis puhis is an increasingly common complication of operations on the lmver urinary tract. It is believed that the actual pathology remains unsolved, all the various theories evolved heing inadequate in their explanation. As the condition, in the vast majority of cases, appears in association Yvith the opening of the bladder early care should be taken to avoid any of the possible factors that have been mentioned as causative elements until the exact etiology is understood. 33 Collins
A.ustralia REFERENCES
BA'rSON, 0. V.: Ann. Surg., 112: 138, 1940. BEER, K: J. 1.Jrol., 20: 233, 1928. BEACH, E.W.: Grol. & Cutan. Rev., 53: 577, 1949. BRuSKEWITZ, H. W. AND EwELL, G. H.: Arch. Surg.,
Krnz, _K: Brit . .J. Surg., 34: 272, 1947. 1\/lrLLIN, T.: Personal communication. WILENSKY, A. 0.: Arch. Surg., 37: 371, 1938.
77: 705, 1949"
Vol. 66, No. 3, September 1951 Printed in U.S.A.
OSTEITIS PUBIS HENRY MORTENSEN From the Urological Department St. Vincent's Hospital, Melbourne, Australia
Beer who first recorded in the English language (1924) the condition now referred to as osteitis pubis, stated: "During the last dozen years following suprapubic operations on the bladder we have repeatedly observed a curious and painful complication of periostitis" and again, "It is surely a rare complication although we have seen every year one or more cases during the past twelve years." I have believed for some time that this complication of lower urinary tract surgery is far more common than one would be led to believe by the literature. My reason for presenting this paper to you today is to record a large series of cases presenting this distressing complication. As a result of a questionnaire addressed to my urological colleagues in Australia and New Zealand, some forty-four cases have been collected from the practices of 16 out of 37 urologists who answered the questionnaire. Of these, 7 cases occurred in my own practice. Prior to 1947, practically all cases were reported as occurring after the second stage of a two-stage suprapubic prostatectomy. Since that date the cases presenting this complication have become more protean in their nature. In the cases here recorded, 5 occurred after cystectomy either partial or total, 29 after retropubic prostatectomy, 5 after suprapubic prostatectomy, 3 after transurethral prostatectomy, 1 after external urethrotomy and 1 after rupture of the posterior urethra, both these last 2 cases in association with suprapubic cystotomy (table 1). Perhaps the main interest lies in the occurrence of osteitis pubis after the use of the retropubic route of approach to the prostate as elaborated in recent years by Terence Millin. Though comparatively rare in the experience of the originator of the operation, his latest statistics being 9 cases in 1,100 retropubic prostatectomies, its incidence in a high percentage of prostatectomies performed by this route has led various urologists to view the procedure with concern and in some instances to abandon it. Moore reports 8 cases occurring in the first 65 prostatectomies done by this method and in the cases here presented it is noted that 65 per cent followed on this operation, one urologist reporting the occurrence of 7 cases of osteitis pubis following on 200 cases of retropubic prostatectomy. In this series, apart from one case diagnosed in 1934, no case was seen prior to 1944. The clinical picture may be mild or severe, symptoms beginning from 4 to 28 days after the relative operation. The onset may be delayed for upwards of 4 months as in 1 case in this series. The severe cases appear to predominate in numbers. The clinical and radiological features of the disease have been adequately dealt with in previous reports. To summarize however, pain is the outstanding Read at annual meeting, American Urological Association, Washington, D. C., May 30, 1950.
412
413
OSTEITIS PUBIS
symptom beginning in the midline and associated ,Yith great tenderness on pressure over the symphyseal region. With extension to the rami of the pubes, pain is complained of in the inguinal regions, on both sides and the upper medial aspect of the thigh. Later the ischia become involved with pain in the perineum and the buttocks. The mm,des attached to the affected bones become spasmodic, any movement of the pelvis causing contractions 1Yhich are excruciatingly painful. Micturition becomes painful particularly at the end of the act and because of the eontractiou of the levatores ani musc:les and the use of the bedpan, defecation beromes a misery. The most obvious spasm is that of the adductor musc:les and the patient lies in bed in gross fear of any movement. This is a pathognomic picture hardly comparable with that seen with any other condition in the body. The dramatic symptom complex may persist for many weeks or some months, and in practically all cases little alleviation is produced by any therapeutic measure. ,vith the passage of the hyperacute stage the act of walking or sitting may be painful as long as 12 months. In the milder cases the symptoms are far less severe and their duration shorter. TABLE ]
----·~-~-------Cases
Cystectomy, partial or complete. Retropubic j)rostatectomy. Suprapubic prostatectomc·. Transurethral prostatectomy. Exterrrnl urethrotomy Rupture of the prostatic urethra.
5 cases
29 cases 5 cases 3 cases 1 case 1 case 44 cases
The earliest radiological changes may be seen about the third ,rnek. They occur in the symphysis pubis where a motheaten appearance of the cartilage and the adjacent portions of the pubes may be seen. The brunt of the disease at this stage affects this joint, the cartilage disappearing and the pubic bones being splayed out up to 1.5 cm. With the progress of the disease areas of rarefaction are seen in both rami of the pubes on each side and in the severe cases similar changes are noted in the ischia. Evidence of lifting and fraying of the periosteum is seen particularly in relationship to the muscular attachments. vVith retrogression recalcification takes place, even though symptoms may be still present, and after a period of months complete bony restitution will occur. In the symphyseal region bony ankylosis ensues, while in the region of their attachments large masses of bone ,Yill extend into the muscles particularly the adductor group. No sequestrae have been reported. Abscess formation has been noted on occasion, but each of the recorded collections of pus has been very small, 5~ 10 cm. Ko abscess formation occurred in these 44 cases. Ko treatment offers any certainty of either cure or amelioration of the symptoms. In the cases here recorded some relief of symptoms ,Yas obtained by chemotherapy in two cases, and in one rapid relief follmYed the exhibition of vitamin B. In all the other cases the routine measures of chemotherapy, vitamin therapy, radiotherapy, diathermy and radiant heat were tried without significant result.
414
HENRY MORTENSEN ETIOLOGY AND PATHOLOGY
The greatest interest of osteitis pubis lies in its pathological nature and the relationship of this to its etiology. Various features of this unusual disease require adequate explanation. 1) Osteitis follows on operations involving the opening of the bladder. Exceptions are recorded as following transurethral resection. In the two cases mentioned by Bruskewitz and Ewell, both gave a history of severe bleeding in the anterior region of the bladder neck requiring an excessive degree of coagulation for hemostasis. In a female these observers record a further unusual case following on the removal of a stone from the lower end of the ureter. In this present series all 3 of the cases of transurethral resection which were followed by osteitis pubis required cystotomy in their aftercare, because of hemorrhage, extravasation or perivesical abscess respectively. That the condition is related to the opening of the prevesical space is strongly suggested by the great number of cases following on retropubic prostatectomy. It is difficult to reconcile this with the earlier occurrence of the complication after the second stage of a twostage supropubic prostatectomy. One would expect that the prevesical space would be sealed off after the preliminary cystotomy and that with a correctly placed abdominal incision and a tube inserted into the highest point of the bladder that there would be little chance in the second stage, of trauma to the pubes or opening up of the prevesical space. An odd case has been reported where there was no drainage of urine involved, such as the case after confinement, of Soderlund (cited by Wilensky), and that on a similar basis mentioned by Millin, but available details are insufficient for comment to be made. 2) Osteitis pubis is a comparatively new disease. Twenty-six cases had been recorded in the literature up to 1941, twelve of them by Edwin Beer. That the condition could have passed unobserved prior to this is most unlikely since most cases follow the severe pattern and the pain and disability are such that radiological investigation would inevitably have been carried out and the obvious changes discovered. My own experience has followed closely on that of most other observers. In consultation with a surgical colleague in 1944, I had seen 1 case following on suprapubic prostatectomy. It was not until January 1948, that I suffered this complication in my own surgical practice and within a month 6 cases had been diagnosed. It is remarkable that many urologists with an experience of thousands of cases of pelvic surgery involving the opening of the bladder have gone through their urological life without seeing one case, while others with similar experience are now confronted with a spate of them. In the search for an explanation for this recent occurrence it was early suggested that the use of chemotherapeutic powders in the wound (a procedure of recent origin) might provide the cause. From a theoretical point of view this could produce rapid healing of the superficial layers of the wound and cause infection to be pent up in the depths. This theory is disproved by the fact that in this series osteitis pubis occurred in 50 per cent of the cases in the practice of surgeons who do not use any powder in their postoperative toilet of wounds.
OSTEITIS PUBIS
415
3) The third factor still unsatisfactorily explained is the delay of onset from 15 days to very much longer periods, the onset being associated with a mild degree of pyrexia but with no gross fever or constitutional signs. The intensity of pain and disability is not comparable to similar lesions in other parts of the bony skeleton. The degree of pain is characteristic of cartilaginous involvement in joints. In an acute gonorrheal joint the pain is pathognomically intense and here the brunt of the pathological changes falls on the cartilage. 4) The fourth unusual feature is the evidence of bony changes with a primary affection of the symphysis, a tendency to bilateral involvement of the other bones of the pelvis associated with gross rarefaction and complete reconstitution of the bony structure following on cure of this self-limited disease. 5) The almost complete lack of response to all therapeutic procedures in a disease that proceeds to resolution is anomalous and rarely seen in other conditions. Approaching the problem from the appearances presented radiologically the characteristic early finding is that of rarefaction. The rapid onset of decalcification in a bone demands the presence of marked hyperemia. This may rise from three main causes: a) infection within the bone, b) infection adjacent to the bone, and c) interference with the nervous supply of the blood vessels to the bone. Rarely is it possible for vitamin or hormonal upsets to produce a similar condition. The suggestion of Beach that all of these cases occur as a result of a "septic spill of urine" is an obvious one considering the operative factors preceding the complication. He envisages a gross infection of the prevesical space, stating "this clinical entity is dependent on an accumulation of urine or septic material behind the pubes overspreading the nutrient foramen." It is hard to believe that infection could be present in soft tissues and yet no clinical evidence of such be consistently present. In a very few cases in my series was there any record of soft tissue involvement. He further suggests closure of the bladder and lack of adequate drainage as predominant factors, but surely again infection in the prevesical space with its abdominal cellulitis and constitutional disturbance would be recorded prior to the 15-28 days that osteitis generally takes to evidence itself. In most of the cases osteitis pubis appeared in the presence of a soundly healed abdominal wall. That an inflammatory origin for the lesion is suggested by the intensity of the pain and the amount of destruction of tissue is not denied. One would however, expect as in other bony infections associated with marked pain a gross amount of constitutional disturbance with greater temperature rise. Further, one queries why an inflammatory lesion should be predominantly bilateral and slowly and symmetrically progressive. Many writers have suggested trauma as the main etiological factor. Beer suggested that direct trauma by the pressure of retractors or drainage tubes or periosteal injury from avulsion of the fibres of attachment of the rectus muscle may provide the cause. Kirz (1947) described three factors which may be responsible: 1) The deliberate opening of the prevesical space; 2) avulsion of the' fibres of the rectus muscle or of the two layers of the transversalis fascia attached to the pubic bone; 3) rupture of the puboprostatic ligaments in the process of enucleation of the prostate.
416
HENRY YIOR'l'ENSE:'<
Added to these with the increase in popularity of the retropubic operation, the possibility of a needle prick of the periosteum has been suggested. This complication, however, has occurred in the practice of surgeons who never use anterior retractors in the ,vound, who always insert their drainage tubes in the upper angle of the wound, who feel certain that gentleness in handling of the rectus muscle or transversalis fascia precludes any damage to these structures and who do not tear the prostate out of its capsule. It has been suggested that perhaps this condition arises from damage to the nutrient vessel of the pubis. Pathologically this tenet is insecure since necrosis and sclerosis of bone would result with few or none of the clinical signs and symptoms of osteitis pubis. Wheeler (1941) rejected the inflammatory theory as a result of his failure in a series of experiments on animals to infect the pubis or periosteum with overinfected urine. He preferred to ally the condition with that interesting complication of trauma to the extremities known as Sudeck's post-traumatic atrophy. Bruske,vitz and E,vell (1949) also favor this explanation. At a varying period of time after even a slight injury the patient presents a typical syndrome. Complaint is made of marked pain out of all proportion to that suffered with the original injury and unrelieved by immobilization. With this are associated trophic changes in the limb distal to the injury: edema and blueness of the hand and foot. The bones in the vicinity showed marked spotty osteoporosis. Following on this there is gradual destruction of cartilage which may eventually lead to a fusion of joints and a useless extremity when recalcification eventually occurs. The cause of this condition is accepted as being due to interference with the nerve supply to the blood vessels of the part producing gross hyperemia and a consequent ,rnshing out of the calcium of the bones. Improvement has been achieved from the operation of periarterial sympathectomy. The inexplicable onset, the prominence of pain as a clinical feature and the gross osteoporosis suggest a similarity between it and osteitis pubis. However, the brn conditions do not correspond accurately. The pain of Sudeck's atrophy is not relieved by rest, rather any form of fixation increases it. On the other hand, in osteitis pu,bis the emphasis is on acute distress on attempt at movement, and avoidance of tihis appears to produce amelioration of the pain. Secondly no trophic changes ari) seen over the pubes in the soft tissues. This may of course be relative to the thickness of the tissues and the distribution of the arterial supply. Further the pain of Sudeck's atrophy is relieved by radiotherapy even though this treatment bears no relation to the course of the disease. Two cases of Millin's series have exhibited similar radiological changes in the vertebral column to those in the pubes. This has led him to suggest that the condition develops in some way through the pelvic veins associated as they are with the vertebral series. Batson (1940) demonstrated in his work on the venous system of the pelvis and its relationship to metastases in prostatic carcinoma that if a thin medium were injected into the dorsal vein of the penis a spread was seen to the ilium, to the veins of the pelvic girdle, to the veins of the vertebral system even to the sinuses of the skull. Millin has suggested a venous spread of infection by this route as an explanation of this occurrence.
417
OSTEITIS PUBIS
In conclusion, it is stressed that osteitis puhis is an increasingly common complication of operations on the lmver urinary tract. It is believed that the actual pathology remains unsolved, all the various theories evolved heing inadequate in their explanation. As the condition, in the vast majority of cases, appears in association Yvith the opening of the bladder early care should be taken to avoid any of the possible factors that have been mentioned as causative elements until the exact etiology is understood. 33 Collins
A.ustralia REFERENCES
BA'rSON, 0. V.: Ann. Surg., 112: 138, 1940. BEER, K: J. 1.Jrol., 20: 233, 1928. BEACH, E.W.: Grol. & Cutan. Rev., 53: 577, 1949. BRuSKEWITZ, H. W. AND EwELL, G. H.: Arch. Surg.,
Krnz, _K: Brit . .J. Surg., 34: 272, 1947. 1\/lrLLIN, T.: Personal communication. WILENSKY, A. 0.: Arch. Surg., 37: 371, 1938.
77: 705, 1949"