Osteomyelitis among children

O S T E O M Y E L I T I S AMONG C H I L D R E N SAMUEL AMBEI~G, M.D., AND RALPIr K. GHOaMnEY, !V[.D. ROCHESTER, M I N N .

T I S agreed that osteomyelitis is essentially a disease of childhood a n d so c o m m a n d s the interest of the pediatrician in conjunction with r of the surgeon. B y the term " o s t c o m y e l i t i s " we mean usually those infections of bo~le due to the p y o g e n i c organisms, staphylococci and streptococci. Often in discussions, as well as in publications on this subject, it is to be noted t h a t relatively few illustrative cases are cited, and recommendations for t r e a t m e n t do not seem to be based on a sufficiently b r o a d foundation, a n d not always on cases observed for a sufficiently long time. The necessity f o r further w o r k seems obvious.

I

The r e p o r t we are submitting is based on a total of 394 patients, who were less t h a n fifteen years of age. I n t h i r t y - f o u r cases, the lesions were confined to the head, but mastoiditis a n d its sequelae were excluded. The bead presealts r a t h e r special problems; therefore, some parts of our r e p o r t are limited to the 360 r e m a i n i n g cases. The patients came u n d e r observation during the: period from 1921 to 1933. I n m a n y cases the time of observation was v e r y limited. Some patients r e t u r n e d several times. We were able, to keep in touch with the condition of others b y correspondence with the f a m i l y or the a t t e n d i n g p h y s i c i a n ; concerning still others we were unable to obtain follow-up information. I n a n u m b e r of cases the disease had lasted months or years before the patients came to our attention, and at times it was impossible to get either detailed or reliable histories. Concerning an illness which can extend over m a a y years, with long periods of quiescence, exact statistical data are not easily obtained. Realizing the difficulties, of gathering exact d a t a on the subject, as well as those due to our p a r t i c u l a r situation, we can offer only r a t h e r tentative figures. The distribution according to age of onset has been given somewhat differently b y various authors. F o r instance, S c b u c h a r d t 11 placed the onset in the m a j o r i t y of cases in the period f r o m eight to seventeen years o.f age. S t a r t 12 placed it at from two to ten years, and Phemister 6 stated t h a t in more t h a n half of the cases the onset occurred between the ages of ten and sixteen years. Treade118 assigned R e a d before the A m e r i c a n P e d i a t r i c Society, Asheville, N o r t h Carolina, May 4, 1934. ~ r o m the Sections on P e d i a t r i c s a n d Orthopedic Surgery, ti,.e Ma yo Clinic. 177

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the onset to the first decade of life i n 28.6 p e r cent, to the second decade i n 60.8 p e r cent, a n d to t h e t h i r d d e c a d e i n 7 per' c e n t of 1,051 cases ( f r o m n o n e to five y e a r s i n 8.6 p e r c e n t ; f r o m six to t e n y e a r s i n 20 p e r c e n t ; f r o m e l e v e n to f i f t e e n y e a r s i n 33.9 p e r c e n t ; f r o m s i x t e e n to t w e n t y y e a r s i n 26.9 p e r cent, a n d f r o m t h i r t e e n to s e v e n t e e n y e a r s i n 38.7 p e r c e n t of all). T h e d i s t r i b u t i o n b y age i n o u r eases is g i v e n i n T a b l e I, but. it is to be. n o t e d t h a t w e are c o n s i d e r i n g o n l y p a t i e n t s less t h a n f i f t e e n y e a r s of age. I t is r e m a r k a b l e t h a t t h e o n s e t i n o n l y t h i r t e e n of T r e n d e l ' s 1,051 eases o c c u r r e d i n the. f i r s t y e a r of l i f e , w h e r e a s t h e c o r r e s p o n d i n g n u m b e r i n o u r smaller' series w a s s i x t e e n . O s t e o m y e l i t i s c a n o c c u r v e r y e a r l y i n l i f e ; i n d e e d it h a s b e e n r e p o r t e d as of c o n g e n i t a l occurr e n e e , a~ The e a r l i e s t o n s e t i n our series of eases w a s a t t h r e e w e e k s TABLE I DISTRIBUTION BY AGE IN 394 CASES OF OSTEOMYELITIS 01~ CHILDR.EN A,G~ YEARS 0 to 1 1 to 2 2 to 3 3 to 4 4 to 5 5 to 6 6 to 7 7 to 8 8 to 9 9 to 10

C'ASES

PEg CENT

16 8 t6 15 23 16 23 43 30 43 42 35 37 28 18

2.3 4.1 3.8 5.8 4.1 5.8 10.9 7.6 10.9 10.7 8.9 9.4 7.1 4.6

I0 to 11 II to 12

12 to 13 13 to 14 14 to 15 of age.

78 cases ~ 22.3 per cent ] 155 cases ~ 39.3 per cent

160 cases ~___40.6 per cent

T h e i n f a n t h a d boils on t h e h e a d a n d neck, s w e l l i n g of t h e

r i g h t t h i g h , a n d o s t e o m y e l i t i s of t h e u p p e r p a r t of t h e f e m u r . I n f o u r eases, i n w h i c h t h e disease s t a r t e d i n t h e first y e a r of life, t h e o s t e o m y e l i t i s i n v o l v e d b o n e s of t h e h e a d . I n o n l y one case w a s s e p a r a t i o n of a n e p i p h y s i s n o t e d , a n d i n t h a t ease t h e f e m u r w a s t h e b o n e involved. T h e d i s t r i b u t i o n b y sex is g i v e n d i f f e r e n t l y b y d i f f e r e n t i n v e s t i g a tors, a l t h o u g h m o r e of t h e p a t i e n t s a r e s a i d to be m a l e s tha.n f e m a l e s i n such p r o p o r t i o n s as 4 : 1 or 3:1, or p e r h a p s m a l e s are s t a t e d to be o n l y s l i g h t l y p r e p o n d e r a n t . I n o u r series, m a l e s m a d e u p a b o u t twot h i r d s of t h e total. A l l a u t h o r s a g r e e t h a t p e c u l i a r i t i e s of g r o w i n g b o n e e n t e r i n t o cons i d e r a t i o n , a n d this v i e w is s u p p o r t e d b y e x p e r i m e n t s on a n i m a l s ; i n s u c h e x p e r i m e n t s i t w a s f o u n d n e c e s s a r y to use y o u n g a n i m a l s i n

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o r d e r to obtain results. I n e x p e r i m e n t s in which microorganisms' were injected, an i n j u r y to the bone d e t e r m i n e d the localization of the osteomyelitis. An infection following an i n j u r y such as a compound f r a c t u r e is r e a d i l y u n d e r s t o o d ; this h a p p e n e d in six of our cases. In one ease the disease followed a g u n s h o t wound. Several times blisters on the foot, caused b y w e a r i n g new shoes, s t a r t e d the infection. Falls, accidents incident to play amt participation in sport, such as twisting, wrenching, a n d so forth, can give rise to the infection. At times such injuries seem to be insignificant; at times there is delay of a w e e k or more before the o u t b r e a k of the disease, and in one, at least, of our cases the i n j u r y h a p p e n e d to one leg whereas the disease appeared in the other. A r a t h e r definite history of i n j u r y was obtained in 109 of our 360 eases. Sometimes an i n j u r y is combined with an infection; f o r instance, a blister on the heel becomes infected, or an infection of the skin m a y p r e c e d e the injury. In one of our eases, the condition s t a r t e d with a boil on the knee, which was hit twice with a baseball. I n t h i r t y - f o u r cases, boils w e r e present at the time of onset of the osteomyelitis, or s h o r t l y before. I t h a s b e e n s t a t e d t h a t osteomyelitis can follow exposure, sore throat, or infectious diseases, and a m o n g our eases are some examples of this. E x p o s u r e alone, or exposure with tonsillitis, was especially m e n t i o n e d as. preeedLng the. illness in five instances ; influenza, in four ; measles, in t h r e e ; scarlet fever, G e r m a n measles, pneumonia, chickenpox, and whooping" cough eaeh in one, and in one, special significance was a t t a c h e d to bilateral eonjunetivitis. In one ease measles, and in a n o t h e r ease exposure, p r e c e d e d an exacerbation. These are not all the eases in which i~feetior diseases preceded, or oceulTed in the course of the illness, b u t in these eases the onset of the osteomyoelitis fell within, a t the m o s t , two weeks of the occurrence of the infections disease. I n these eases the lesions were o f t e a limited to one bone. Judging" f r o m the e x p e r i m e n t s of Lexer, s one m i g h t have expected t h a t p r e c e d i n g infections m i g h t f a v o r more extensive osteomye]itis. His i m p o r t a n t e x p e r i m e n t s well deserve to be recalled here although t h e y were p u b l i s h e d thirty=eight years a g o . . H e was able to r e p r o d u c e osteomyelitis in y o u n g r a b b i t s b y i n t r a v e n o u s injection of a t t e n u a t e d Staphylococcus c~ureus and a~tenuated Sta.phylococcus albus, without first i ~ j u r i n g t h e bone. The, lesions r e m a i n e d limited to one bone. I n f e c t i o n b y bacillus of Sehimme]buseh, followed b y the staphylococcus, p r o d u c e d m u c h m o r e extensive lesions t h a n those p r o d u c e d b y the staphylococcus alone. The bacillus alone p r o d u c e d only h y p e r e m i a of the bone m a r r o w . The m i x e d infection, f u r t h e r m o r e , resulted also in periostea] and p a r o s t e a l s u p p u r a t i o n . W i t h streptococci it was

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m u c h m o r e difficult to p r o d u c e a s u p p u r a t i v e disease of bone. W h e n such disease occurred, it was similar to the. disease caused b y staphylococci. As in the cases of others, so in t h e g r e a t m a j o r i t y of our cases in which cultures were made, staphylococci w e r e grown, v e r y r a r e l y with staphylococci and streptococci, but sometimes streptococci alone, either h e m o l y t i c or green-producing, and in one ease, both. The p a r t i t i o n of the disease a m o n g various bones is given in Table II. I t is c o m p a r e d w i t h the d i s t r i b u t i o n given b y S c h u e h a r d t and also w i t h t h a t given b y Trendel. B o t h S c h u c h a r d t ' s and T r e n d e l ' s tabulations come f r o m the surgical clinic of Tiibingen, and the latter includes the former. As g e n e r a l l y accepted, numerically, i n v o l v e m e n t of f e m u r a n d tibia t o g e t h e r are p r e p o n d e r a n t . But the distribution of i n v o l v e m e n t of f e m u r and of tibia t a k e n s e p a r a t e l y does .not seem to be settled. I n the first 440' cases, the distribution of i n v o l v e m e n t of femur' and of tibia w a s equal, but to r e a c h a p e r c e n t a g e of 45 f o r the femur, and of 34 f o r the tibia, in the t o t a l of 1,110 eases, means t h a t of the remaining 670 cases, in 50 p e r cent the f e m u r m u s t h a v e been involved. T A B L E II ~ONES

UASES

Femur Tibia ttumerus Radius Fibula Ulna

AFFECTED

IN CASES

AJv[BERG AND GnORBILEY 36O :PER C E N T 38.9 39.4 13.6 7.5 6.4 3.0

0F

OSTEO~IYELITIS

OF

SCEUCHARDT 440 PER

CENT 38.5 38.5 11.1 5.1 3.4 3.4

CHILDREN

TREI',TDEL 1110 :PER CENT 45.8 34.8 9.2 3.9 3.2 3.2

The p a r t i c i p a t i o n of other bones i.n our cases was as follows: pelvic bones, 8.3 per cent; small bones of h a n d s and feet (with the exception of the ealcaneus a n d talus), 7.3 p e r cent; calcaneus, 5.8 p e r c e n t ; clavicle, 4.4 p e r c e n t ; scapula, 3.3 p e r cent, and talus, 2.5 p e r cent. The ribs were i n v o l v e d in f o u r cases, the spinal column also in f o u r cases, a n d the p a t e l l a in two Gases. N o t included in this list are six cases in which osteomye]itis of the ribs, a f t e r resection of ribs f o r p o s t p n e u m o a i c e m p y e m a , k e p t the e m p y e m a active. The e m p y e m a was cured a f t e r r e m o v a l of the osteomyelitic tissue. Bones of t h e h e a d were involved in 9 p e r cent of the t o t a l of 394 cases. I t is of interest to note t h a t of the l a r g e r series of eases r e p o r t e d b y Trendel, in 2.8 p e r cent the bones of t h e h e a d w e r e involved. A r a t h e r distinct difference is seen in the n u m b e r of cases in which the disease is limited to one bone a n d t h a t in which more t h a n one

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bone is a t t a c k e d . W i t h this in mind, Trendel r e p o r t e d t h a t of the series of 1,058 cases, in 84=.3 per cent the disease was limited to one bone, whereas in 15.7 p e r cent m o r e t h a n one bone was involved. In our series of 360 cases, in 68 p e r cent one bone was involved, and in 32 p e r cent i n v o l v e m e n t was multiple. The f r e q u e n c y of i n v o l v e m e n t of various p a r t s of the long bones is given d i f f e r e n t l y b y different investigators. The distinction is not a h v a y s easy, so we r e f r a i n e d f r o m t a b u l a t i n g our eases. Trendel, utilizing 1,299 eases f o r this purpose, g a v e the figures s h o w n in Table III. TABLE III INVOLVElVfENT Ot0 VARIOUS PARTS Ole LONG BONES IN OSTEOMYELITIS OF CtIILDREN (TI~ENDEL)

]~'emur Tibia Humerus Radius :Pibula

Ulna,

UPPER PORTION CASES

LOWER pOI~TION CASES

I~IDDLE PORTION GASES

157 114 52 1 3

275 115 22 16 21

138 264 38 28 15

11

19

10

The onset of the disease, s0 f a r as could be d e t e r m i n e d was m o r e or less acute in a b o u t 60 p e r cent of our cases; not i n f r e q u e n t l y an exact date w a s given. I n these cases, the h i s t o r y is one of a severe, sudden pain, often o c c u r r i n g at night, followed within a f e w d a y s b y swelling, redness, tenderness, and r a p i d l y i n c r e a s i n g b o d y t e m p e r a t u r e , :reaching often 10.5~ F. and more. Often chills a n d s w e a t i n g occur. A t times, a l t h o u g h not often, the onset is t h a t of an acute infectious disease, while pain, swelling a n d t e n d e r n e s s come to the f o r e within two d a y s or so. W i t h sudden paixt a n d swelling, and tenderness in the region of a j o i n t and fever, the first diagnosis m a y readi'ly be a c u t e r h e u m a t i s m . Indeed, Sehuchardt, in his excellent m o n o g r a p h on diseases of bones and joints r e m a r k e d t h a t i n f l a m m a t i o n of the joint, in its e a r l y stages, m a y be s t r i k i n g l y similar to t h a t of acute r h e u m a t i c arthritis. This m a y lead to error, axtd the e r r o r is the more easily made w h e n the p a t i e n t complains about p a i n in a n m n b e r of joints f o r a d a y or so. W h e n the lesion r e m a i n s limited to one joint f o r several days, the e r r o r is soon corrected, p r o v i d e d t h a t a single bone is involved. I n v o l v e m e n t of m o r e tha.n one bone m a y extend the period of d o u b t as to diagnosis. I n two cases, peteehiae o c c u r r e d ; in tw% a b d o m i n a l s y m p t o m s were at first p r o m i n e n t , a n d peritonitis was suspected. I n one ease a p p e n d e c t o m y h a d been p e r f o r m e d before the p a t i e n t ' s admission, and, a l t h o u g h the a p p e n d i x was normal, there was pus a r o u n d it. I n this case the s y m p h y s i s w a s involved.

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I n other eases the onset is more insidious, the pain is not severe, and the other local symptoms are less pronounced. The t e m p e r a t u r e of the body m a y be raised little or not at all. Our mildest ease was t h a t of a boy who was five years old (m admission. F o r one and a half y e a r s he had complai,ned, intermittently, of pain in the right knee, that was a g g r a v a t e d when r u n n i n g a r o u n d much. IIis general eonditio~ was good. Neither swelling noT" tenderness was present. The r o e n t g e n o g r a m gave evidence of a r e g i o n of decreased density i~ the distal end of the shaft of the r i g h t femur. Such patients m a y never require surgical help, and can get well w i t h o u t f u r t h e r destruction or s u p p u r a t i o n t a k i n g place, but a focus of infection m a y remain. In two other cases, a rather mild infection occurred in the course of osteomyelitis involving other bones. The first of these two cases was t h a t of a boy, a y e a r and a half old, who h a d m u l t i p l e abscesses involving the left femur, and some periostitis of the r i g h t f e m u r and of both tibias. Another boy, ten years of age, h a d complained of more or less pain in the r i g h t leg for two or three years. A n acute exacerbation a p p e a r e d for no de~monstrable cause. Culture of the blood yielded s~aphyloeoeei. Six y e a r s later he had some mild s y m p t o m s referable to the other leg a n d arm, where small lumps had formed. Both these lumps, excised completely, consisted of g r a n u l a t i o n tissue a p p a r e n t l y not connected with the bone. But both tibia and humerus, p r o v e d on roentgenologie examination, to be the seat of osteitis. I n another r a t h e r p r o t r a c t e d case, in which there was involvement of r a t h e r low intensity, the patient was a boy, who was seven years old on admission. He h a d complained of h a v i n g some pain in his left ankle for most of his life, in a t t a c k s of two or three d a y s ' duration. Lately, the pain h a d become worse, m a k i n g walking difficult, and some swelling aaad reddening h a d been noted. In the lower t h i r d of the tibia an area of destruction of bone could be made out. This yielded a small amount of pus, which on culture gave a g r o w t h of staphylococci. The surgeon made a note that the conditiol~ was of t h a t chronic t y p e which m i g h t lead to f o r m a t i o n of cysts. Six years later the boy returned, h a v i n g had pain in the r i g h t hip for about three months. A region which gave rise to a suspicion of destruction of bone was seen at the junettwe of the neck and head of the femur. The tibia was normal. Such relatively mild eases m a y not be so rare as it m i g h t a p p e a r f r o m our experience, if the data of Trendel can serve as an i.ndiealion. Of 1,299 cases, in fifty-four there was no f o r m a t i o n of p u s ; t h a t is, about 4.0 per cent. F'ormation of pus without necrosis of bone occurred in 15 per cent of eases. I n sharp contrast to these milder eases are the quickly f a t a l eases. Of these we h a d four, t h a t is, about 1 per cent. Two of the four patients concerned were boys, aged respectively five and thirteen

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OSTEOMYELITIS

years, and two were girls, aged respectively two and four years. Death o c c u r r e d f r o m the f o u r t h to the eighth d a y a f t e r tile acute onset. These cases need not be considered in detail; clinically t h e y were cases of o v e r w h e l m i n g infection of which osteomye]itis was a part. The localizing s y m p t o m s were confined to one bone, either the f e m u r or the tibia. The s t r i k i n g ]esio.ns in these cases were embolie processes in the lungs, kidneys, h e a r t muscle, and brain. The h e a r t valves were also affected. Pur~llent pericarditis, meningitis, phlebitis, g a n g r e n e of the finger tips of one hand, iritis, and b r o n c h o p n e u m o n i a were .noted. One boy, eleven years: of age, who h a d osteomyelitis of the frontal and p a r i e t a l bones, died in shock. Other p a t i e n t s died a f t e r leaving tile clinic. The illness of a boy nine y e a r s old, s t a r t e d w i t h acute osteomyelitis of the pelvic bones a n d r i g h t f e m u r . Four' y e a r s l a t e r the osteomyelitis p r o g r e s s e d to involve a clavicle a n d the left femur. L a t e r in t h a t year, osteomyelitis of the skull, a n d cerebellar abscess, developed. These were cared for successfully. The b o y was getting along well, when, n e a r l y one aa~d a h a l f years a f t e r this operation, or more t h a n six y e a r s f r o m the onset, he died f r o m r a p i d l y developing meningitis. A n o t h e r boy, nine years old, w h e n seen, h a d b e e n acutely ill with multiple involvement. t i e died eighteen m o n t h s a f t e r leaving the clinic, and we were unable to obtain f u r t h e r data. A girl, five yea.rs old, came u n d e r our care with extensive osteomyelitis of the ]eft tibia and talus. E x t e n s i v e surgical p r o c e d u r e s were necessary, w i t h a p r o s p e c t of long treatment. The p a r e n t s p r e f e r r e d to have this done at home. The child died a few m o n t h s later, and again we could not secure f u r t h e r information. A girl, t w e n t y - t w o months old, h a d to be t a k e n f r o m the clinic shortly a f t e r a cavity in the u p p e r end of the l e f t f e m u r had been opened. The onset of t h e i]lness d a t e d b a c k t h i r t e e n mo.nths, w i t h swe]ling of t h e thigh. The osteomyelitis was chronic. All we h e a r d about h e r was t h a t she died one m o n t h a f t e r she was t a k e n away. A girl, nine y e a r s of age, when she was seen f o r extensive osteomyelitis of both sides of the lower jaw, had pus. in the urine and a large, hard spleen. Twe.nty-two m o n t h s ] a t e r she died r a t h e r s u d d e n l y in a state of uremia. The case of a boy, three y e a r s of age, is of p e c u l i a r interest. t i e was b r o u g h t to us f o u r weeks a f t e r d e v e l o p m e n t of extensive osteomyelitis of the entire left. tibia w i t h a small central bone. abscess, a n d p r o n o u n c e d periosteal thickening. A d e q u a t e d r a i n a g e was provided. L e u c o c y t e s n u m b e r e d 12,400 per cubic m i l l i m e t e r of blood. iV'or the week he spent in the hospital he was afebrile. S h o r t l y a f t e r he was t a k e n home, the l y m p h nodes ea~larged r a p i d l y and greatly. The spleen became enormous. He died f o r t y - s i x days a f t e r he had been t a k e n home, f r o m acute l y m p h a t i c leueemia.

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A s s u m i n g t h a t the osteomyelitis was in some w a y o r other concerned in the f a t a l outcome in all these eleven cases, we would have. a m o r t a l i t y of 2.8 p e r cent. E v i d e n t l y t h a t is a v e r y u n c e r t a i n figure. Some of our other p a t i e n t s m a y h a v e died w i t h o u t our' knowledge, and it is u n l i k e l y t h a t the acute leucemia is c h a r g e a b l e to the osteomyelitis. S t r a n g e to say, m o r t a l i t y statistics of osteomyelitis do n o t seem readily available. Even Trendel limited his mortality statistics to the first five y e a r s of life. On this basis, of sixty-six patients, t h r e e died, a m o r t a l i t y r a t e of 4.5 p e r cent. The g r e a t m a j o r i t y of p a t i e n t s a r e in need of some surgical treatmerit, which f a c t will be discussed later. However, an abscess m a y b r e a k s p o n t a n e o u s l y a n d sequestrums m a y be cleared out in this ma~her. W e h a d only ten cases w i t h o u t surgical intervention. I n some of these ten cases operation m a y h a v e been p e r f o r m e d later. In one of t h e cases in which o p e r a t i o n was ~ot p e r f o r m e d , an abscess due to osteomyelitis of the pelvic bones b r o k e t h r o u g h the v a g i n a of an eleven-year-old girl. She w a s well for a y e a r and a h a l f b u t t h e n had t r o u b l e again. I n a n o t h e r case in w h i c h there was i n v o l v e m e n t of several bones, including a rib, the a c e t a b u l u m , the ilimn, a n d the left a n d r i g h t tibias, the disease h a d l a s t e d two y e a r s w h e n the b o y came to us. He w a s sent h o m e in a cast w i t h r e c o m m e n d a t i o n f o r conservative t r e a t m e n t ; healing w a s r e p o r t e d a f t e r five years, but details were not given. The condition of a n o t h e r boy, twelve y e a r s old, h a d s t a r t e d a c u t e l y with i n v o l v e m e n t of b o t h knees and ankles, and s p o n t a n e o u s drainage. H e a l i n g h a d t a k e n place in a b o u t two and a h a l f years, b u t shortly before his visit to the clinic he again h a d had p a i n following a fall. All t h a t could be f o u n d was a f u s i f o r m swelling of the u p p e r end of one tibia. I n a table, Trendel r e c o r d e d t h a t in a b o u t 8.9 p e r cent of the cases in which there was necrosis of the bone, o p e r a t i o n was not p e r f o r m e d . A s s u m i n g t h a t t h e r e w a s some necrosis in all of our ten cases in which operation was not p e r f o r m e d , and, a d d h l g the p r e v i o u s l y mentioned mildest case, we would h a v e in our list a b o u t 3 p e r cent of cases in which necrosis of bone was present, b u t operation was not p e r f o r m e d . This does not m e a n t h a t the p a t i e n t s can be r e g a r d e d as cured. A few w o r d s will suffice w i t h r e g a r d to diagnosis. As is well k n o w ~ in t h e early stages, roentgenologic e x a m i n a t i o n does not help. The diagnosis rests entirely on clinical examination, which now a n d t h e n m a y p e r h a p s be aided b y cultures of urine and blood. Localization of the lesion is not always easy. F o r instance, in one case acute swelling a n d tenderness p o i n t e d to i n v o l v e m e n t of the u p p e r end of the tibia, whereas the osteomyelitis p r o v e d l a t e r to i.nvolve the distal end.

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Sometimes, if rarely, the differential diagnosis between a bone tumor and osteomyelitis has to be left until exploration can be performed. Consideration of the differential diagnosis between tuberculous and pyogenic osteomyelitis is not in our province. I t is not ahvays easy. Osteomyelitis caused b y bacilli of t y p h o i d fever (Eberthdla typhi) seems to be as rare t o d a y as t h a t a c c o m p a n y i n g smallpox. The course of the disease n o w claims our interest, p a r t i c u l a r l y with r e g a r d to its n o n s u r g i c a l features. The average patient who has osteomyelitis, p a r t i c u l a r l y when only one bone is involved, does not suffer much in general health as soon as the a c u t e stage has passed. The p a t i e n t becomes afebrile, and it is r e m a r k a b l e how r a p i d l y the general well-being can be restored. I t is somewhat surprising that in only t h i r t y cases, or about 8.3 per cent, n o t e w o r t h y enlargement of regional l y m p h nodes was registered. Not infrequently, absence of this was especially noted, and at times e n l a r g e m e n t of cervical l y m p h nodes was w r i t t e n down without mention of the regional l y m p h nodes. E n l a r g e m e n t of the spleen, also, does not belong in the usual picture. I t was n o t e d only in four instances, in one of which the enlargement receded, with improvement in the condition. I n two cases enlargement of the liver was n o t e d ; in one case the liver was v e r y large, and ascites was noted. Moderate secondary anemia is not unusual, b u t more severe degrees usually are reserved f o r the more severe cases. D e p e n d i n g on the stage of the disease, a g r e a t e r or lesser degree of p o l y m o r p h o n u c l e a r leueocytosis can be prese.nt. I n none of our cases did the n u m b e r of leucocytes exceed 30,000 per cubic millimeter of blood. Filament counts and sedimentation rates, were determined in only a v e r y few cases. In some of our most severe cases, the n u m b e r of leucocytes was n o t increased at the s t a r t although we n e v e r had a case in ~which leucopenia was pronounced. The urine often presents febrile a]buminuria, but as soon as the febrile stage has passed, it clears. I n some cases, a few hyaline and g r a n u l a r casts are seen. B u t in ten cases, the urine contained, ben sides albmnin, pus cells, and in some cases t h e r e were significant numbers of e r y t h r o e y t e s in the urine. M a n y of our patients came to us 'long a f t e r the acute stage was over; our time of observation of other patients was limited. I n some cases which we could observe, pus a p p e a r e d at times but was not present at all times. This phase of the subject deserves more attention. Cultures of urine were made in Only seventeen cases.; in ten the result, was ~ e g a t i v e ; and in seven, positive. I n six of these seven eases, staphylococci were f o u n d either alone or in association with other organisms; in two eases with colon bacilli, and in two with streptococci. Only .kn one ease were colon

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bacilli found alone. It is not necessary that the urine that harbors microorganisms also contain pus. In one of our cases the culture of

urine w a s positive several days before pus appeared, and in one case staphylococci were p r e s e n t for a long time w i t h o u t pus cells being p r e s e n t in n o t e w o r t h y numbers. T h a t the presence of staphylococc~ in the urine m a y indicate a focus of infection is evident f r o m a v e r y interesti,ng experience. A boy, eleven y e a r s old, whose febrile p e r i o d s of a y e a r ' s d u r a t i o n were finally a t t r i b u t e d to I[odgki.n's disease, p e r s i s t e n t l y h a d staphylococci in his u r i n e until an infection a c c o m p a n y i n g i n g r o w n toe nails was treated. I n a few cases a positive culture of urine was associated with a positive blood culture. Of t w e n t y - f o u r cases in which blood culture w a s made, in six culture was positive, excluding the r a p i d l y f a t a l cases. These cultures, were m a d e o~nly in cases in which f e v e r was r a t h e r high. E v e n in the v e r y severe cases, of which we will give t w o examples later, the blood cultures b e c a m e n e g a t i v e a f t e r two to t h r e e weeks. Only staphylococci w e r e f o u n d in the blood. I n only one ease did we see amyloidosis. T h r e e girls, two nine y e a r s old, and one thirteen, years old, h a d chorea in the spring of the same year. One of these p a t i e n t s h a d multiple i n v o l v e m e n t of bone of two y e a r s ' duration. T h e talus of one only w a s diseased for two y e a r s ; the ilium of the o t h e r was affected f o r a b o u t two months. Only in the first case did a h e a r t m u r m u r develop. In two cases severe bed sores developed in spite of all possible care. I n all severer cases certainly, in the m i l d e r cases p r e f e r a b l y , there should be some s u p e r v i s i o n b y a pediatrician. His f u n c t i o n is the recognitio.n, of a n d care of some of the complications which m a y arise; he should h a v e a vote in the d e t e r m i n a t i o n of the risk of c o n t e m p l a t e d o p e r a t i o n and, p e r h a p s m o s t i m p o r t a n t , he is to look out f o r a d e q u a t e m a i n t e n a n c e of nutrition, which at times is no easy task. T h e disease m a y end i~ complete healing, w i t h no impairmea~t of function, or i m p a i r m e n t m a y result. T h e most i m p o r t a n t f o r m s of i m p a i r m e n t result f r o m i n v o l v e m e n t of joints, w i t h limitation of motion, to complete ankylosis a n d changes in the le.ngth of the extremities. I n fifteen of our cases, the diseased e x t r e m i t y was shortened, a n d in nine, lengthened. T r e n d e l f o u n d f o r t y - t h r e e cases in which ]engthea~ing occurred a n d t h i r t y - t h r e e in which shortening occurred. I n v o l v e m e n t of joints, aside f r o m secondary, traaasitory involvement, was seen in sixty-seven cases, or 18.6 p e r cent. T r e n d e l ' s corresponding figure w a s about 45 per cent. These lesions resulted in more or less limitation of motion. The special corrective measures d e m a n d e d b y these lesions are not within the scope of our discussion.

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I t is not u n c o m m o n for osteemyelitis to drain for long periods; drainage for f o r t y reported. Of cases concerning which we we h a d nineteen in which drai.nage lasted and of these, eleven were cases in which a

give rise to sinuses which years and more has been could obtain information, from four to nine years, single bone was involved.

W i t h r e g a r d to healing, it must be kept in mind that after months, and even years, a flare-up m a y occur, sometimes f o r no determinable cause, often a f t e r some injury. The flare-up may involve the original site, a n o t h e r p a r t of the same bone, or another bone. The m a j o r i t y of observers are of the opinion that no new infection takes place, but t h a t an old "sleeping" infection, becomes active. But if bacteriologic examinations, c o m p a r i n g microorganisms f o u n d in earlier and in later attacks, have been made, reports of them have escaped o u r notice. F o r instance, a lesion of osteomyelitis of the radius seemed to be healed for eighteen months, when it broke open again. A lesion of osteomyelitis of the tibia was healed f o r sixteen months, but about three years later the f e m u r became involved. I n one ease of acute osteomyelitis of the humerus healing occurred, but the patient ret u r n e d after five years with acute osteomyelitis of the tibia ; this also was r e p o r t e d to h a v e healed when the patient was h e a r d from after more t h a n three a n d a half years. I n one case a radical operation on the tibia became necessary a f t e r four and a half years of drainage ; healing was r e p o r t e d f o u r and a half years after the 9Peration. iaa a n o t h e r case, in which a lesion of osteomyelitis of the tibia had not healed after ten years, complete healing was r e p o r t e d after a total of twelve and a half years. TABLE I V ] [ E A L I N G O~~ L E S I O N S Ol~ OST~OMYELITIS INVOLVING ~INGLE B O N E S O~~ ~HILDP~EN IN :[~ELATION TO EARLY AND L A T E STJRGICAL OPERAT'ION OPEKATION B.EFOR~ END OF THREE ~NEEKS I~I~OM ONSET

OPERATION AFTER THIRD WEEK FRO~ ONSET

(71 CASES) CASES

Healed Not healed

42 29

_ _ PER CENT

59.2 40.8

(26 CASES) CASES

PEK CENT

:15 11

57.6 38.2

I n Table I V we recorded cases in which healing occurred and cases in which there was no healing, so far as we could obtain sufficient i n f o r m a t i o n f o r tabulation. The aim was to determine the relationship of healing to early surgical interference, and we considered operation before the end of three weeks to be early interference. This sort of t a b u l a t i o n could be made only f o r eases in which a single bone was involved. I n Table V, also, we recorded eases in which healing occurred and eases in which it did not occur, but, ill this table, we paid attention to the relationshi p of healing to i n v o l v e m e n t of a single

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Ol~ OSTEOI~iYELITIS OF CHILDI%EN IN ]~ELATION TO I N V O L V E M E N T 0!~ O N E B O N E 01% 1V[0RE TIIAN O N E

INVOLVE1Vs Ol~ A SINGLE BON~ (97 CASES) CASES l PER, CENT Healed N o t healed

57 40

t

58.7 41.3

INVOLVEMF~NT Ol~ M:OI%ETHAN ONF~ BONE, (26 eASES) CASES FEE CENT 10 16

38.5 61,5

bone or of several bones. The result was rather astonishLng; early operations did not seem to have given v e r y m u c h b e t t e r results t h a n late operations. W e do not lay m u c h stress on these figures. The o p e r a t i v e p r o c e d u r e s often h a d been c a r r i e d out long b e f o r e the patients came to us, and the n u m b e r of cases we could utilize f o r tabula. tion was m u c h too small to allow definite conclusions to be reached. B u t we do wish to emphasize t h e necessity f o r f u r t h e r information. The chances of healing in cases of multiple i n v o l v e m e n t seem to be smaller t h a n w h e n i n v o l v e m e n t is of a single bone, b u t how g r e a t is the difference m u s t also be left f o r f u r t h e r s t u d y to determine. I f there is one thing which is o u t s t a n d i n g in our study, :we t h i n k it is t h a t t r e a t m e n t in a l a r g e n u m b e r of cases of osteomyelitis is unsatisfactory, a n d t h a t t h e r e are p r o b l e m s in this field well w o r t h y of the combined s t u d y of surgeon a n d pediatrician. SURGICAL TREATMENT

Surgical operation p r o b a b l y is indicated at some stage in n e a r l y A l t h o u g h in a few cases the process m a y go on to s p o n t a n e o u s healing, w i t h o u t operation, the f a c t remains t h a t the g r e a t m a j o r i t y of all cases of osteomyelitis m u s t be r e g a r d e d as surgical. I n the l i t e r a t u r e of the p a s t few y e a r s the surgical treatm e n t has been s o m e w h a t o v e r s h a d o w e d b y the use of accessory substances such as maggots, b a c t e r i o p h a g e , and so f o r t h - - t h i s in spite, of t h e f a c t t h a t n e a r l y all well-qualified observers h a v e stressed the imp o r t a n c e of a d e q u a t e operation no m a t t e r w h a t sort of a d j u n c t is used. every case, of osteomyetitis.

P r o b a b l y no a u t h o r on this contine=t has received such w i d e s p r e a d recognition of his a t t i t u d e t o w a r d t r e a t m e n t of acute osteomyelitis as has Starr, ~2 p a r t i c u l a r l y in cases in which the lesion p r o b a b l y is localized in the m e t a p h y s i s of the long bones. H e expressed the belief t h a t t r e a t m e n t should consist of an incision over the region of greatest t e n d e r n e s s and t h a t the incision should be continued t h r o u g h the skin, s u b c u t a n e o u s tissue, a n d periosteum. Care should be taken, he said, to p r e s e r v e the periosteal a t t a c h m e n t to the epiphyseal line, and the incision should be m a d e on the d i a p h y s e a l side of the. epiphyseal line. I f f r a n k pus is e n c o u n t e r e d b e n e a t h the periosteum, the incision should be sufficient and a d r a i n inserted. I f no gross pus is found, the

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p e r i o s t e u m should be s t r i p p e d f o r a short distance on each side of the incision a n d a series of drill holes m a d e t o w a r d , b u t not into, the epiphysis. S t a r r did not open the m e d u l l a r y c a v i t y and considered opening it to be a d a n g e r o u s procedure. W h e n a p a t i e n t is seen in the l a t e r stages of the disease, efficient d r a i n a g e should be established, but until a s e q u e s t r u m can be r e m o v e d no e x t e n s i v e decortication should be done. A f t e r a s e q u e s t r u m has formed, it should be r e m o v e d t h r o u g h an o p e n i n g t h a t p e n e t r a t e s t h e involucrum, a n d t h a t is of sufficient size to allow the s e q u e s t r u m to be removed. T h e c a v i t y should be cleaned of d i r t y granulations, sponged w i t h iodine, and p a c k e d t i g h t l y w i t h i o d o f o r m gauze f o r f o r t y - e i g h t hours. A f t e r the p a c k i n g and drains h a v e been removed, if the remakning c a v i t y is too large to fill easily w i t h granulation, the edges should be m a d e saucershaped, a n d should be allowed to fall in and o b l i t e r a t e the cavity. The f o r e g o i n g is t a k e n almost w o r d f o r w o r d f r o m the nineteenth r e p o r t of Progress of Orthopedic Surgery. The editors at t h a t time a g r e e d with S t a r t . The same ideas h a v e been e x p r e s s e d b y Robertson, 9 Platt, 7 and Rest. 1~ The last f r a n k l y ss t h a t he t h o u g h t opening the bone in the presence of a subperiosteal abscess would be dangerous. K r a s n o b a e w r e v i e w e d 600 eases, 428 of which were acute. F r o m s t u d y of these, he concluded t h a t a m o n g other things it is of g r e a t e s t i m p o r t a n c e to consider t h e general condition of the p a t i e n t a n d t h a t too radical t r e a t m e n t in the firsS s t a g e is n o t only useless b u t dangerous. These and other observations w e r e more or less along the s a m e line as those of S t a r r and seem to b e a r out the opinion held b y m o s t physicians who h a v e successfully t r e a t e d the disease; namely, t h a t a h a p p y m e d i u m should b e s t r u c k between the m o r e r a d i c a l a n d the m o r e conservative practices. B y and l a r g e it should be pointed out that. in the presence of an acute, f u h n i n a t i n g t y p e of disease, a n d infection of the blood stream, operation should be r e s o r t e d to only w h e n the indications a r e clearcut and precise. W h e n the p a i n and tenderness are definitely localized, incision is i n d i c a t e d ; and if pus is c~leountered b e n e a t h the periosteum, opening of the bone is not n e c e s s a r y at once. I t m a y be f o u n d necessary, in two or three days, to open the bone, but little h a r m can come f r o m the delay in most eases, a n d kn m a n y eases the m a r r o w c a v i t y will be s p a r e d almost certain infection. Roentgcnog r a m s m u s t not be relied on at all for aid in acute eases. I n the more chronic stages, r o e ~ t g e n o g r a m s are of the u t m o s t i m p o r t a n c e . I n m a n y eases, hope cannot be e n t e r t a i n e d of opening up the entire infected r e g i o n ; s u b s e q u e n t r o e n t g e n o g r a m s will r e v e a l a m u c h more extensive change in the bone t h a n is suspected aS first sight. Opening the m a r r o w c a v i t y is indicated only w h e n pus is not eJaeountered b e n e a t h the periosteum, b u t a drill hole reveals pus. W e believe t h a t m o r e t h a n a. drill hole should be m a d e in case p u s is encountered.

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Surgical t r e a t m e n t for the later stages consists of three procedures, as t h e y m a y be indicated. 1. Sequestri~ms should be r e m o v e d if this is indicated, and the indications are t w o : first, persistence of symptoms with or without a draini.ng sinus, and second, the presence of a s e q u e s t r m n as d e m o n s t r a t e d b y r o e n t g e n o g r a m s . 2. Sinuses of soft p a r t s should be cur etted in cases in which, otherwise, n o t h i n g of importa.nce can be d e m o n s t r a t e d . Occasionally, on examination, these e u r e t t i n g s will be f o u n d to consist, of tuberculous tissue, a n d occas i o n a l l y . a small spicule of s e q u e s t r u m m a y be f o u n d to be keeping' u p the drainage. 3. 1Kore or less extensive e x c a v a t i o n of the bone shaft, in the f o r m of a saucer, should be carried out in cases of wides p r e a d infection of eancellous and cortical bone. This p r o c e d u r e is one t h a t has been a d v o c a t e d f o r years, a~ld when carefully done and followed up, in m a n y eases is of value. However, its abuse is p r o b a b l y as f r e q u e n t as its p r o p e r use. The choice of p r o p e r dressings a f t e r operatiop, is i m p o r t a n t . Of late years, advocates of various substances, such as vaseline gauze, maggots, m a g g o t extract, and so f o r t h h a v e r e p o r t e d v a r y i n g results. As to the relative merits of all of these substances we have little to say f r o m personal experience. Our own m e t h o d has been t h o r o u g h cleansing' of the: bone c a v i t y w i t h iodine and p a c k i n g with vaseline gauze, according to Orr. 5 This p a c k i n g is changed at intervals of a p p r o x i m a t e l y one w e e k to avoid the d i s t u r b i n g m a l o d o r t h a t always is p r e s e n t in these eases. Only kn eases in which extensive involvem e n t of bone has t h r e a t e n e d to result in pathologic fracture, have we used plaster-of-Paris casts. The use of maggots, as a d v o c a t e d b y Baer, ~ has had enough trial to h a v e p r o d u c e d something in the w a y of definite conclusions reg'ardin g its value. There seems to be a p r e t t y well-established opinion t h a t good s u r g e r y must precede their use, a n d t h a t m a g g o t s do not destroy dead bone or bacteria. The successful p r o p a g a t i o n a n d s u p p l y of m a g g o t s are a t t e n d e d with difficulty, a n d their use on m a n y p a t i e n t s is objectionable to the p a t i e n t s themselves and to other p a t i e n t s in the ward. The use of b a c t e r i o p h a g e has been r e c o m m e n d e d by some, b u t m a n y h a v e tried it a n d have failed to be coavinced of its value in osteomyelitis. D a k i n ' s solution was so widely used during the W o r l d W a r t h a t its f u t u r e seemed assured. H o w e v e r , it is c o m p a r a t i v e l y r a r e l y used now, and m a i n l y because of the difficult and elaborate technic necess a r y to c a r r y on its use, not to m e n t i o n the discomfort to the p a t i e n t of daily dressings. I n the m o r e severe infections of the blood s t r e a m , nothing is more useful t h a n blood transfusion. T r a n s f u s i o n s e v e r y day, or e v e r y other d a y d u r i n g the active infection, will do more to build up resistance

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on the p a r t of t h e p a t i e n t titan a n y other t y p e of t r e a t m e n t . Imm u n o t r a n s f u s i o n s and reeonvalescent s e r u m h a v e been r e c o m m e n d e d but h a v e not been tried sufficiently. The various dyes r e c o m m e n d e d h a v e been t r i e d f r o m time to t i m e w i t h o u t conclusive p r o o f t h a t they help. G e n t i a n violet, m e r e u r o e h r o m e , and m e t a p h e n all h a v e been used b y us w i t h o u t consistently good results. R6sum6s of f o u r eases are given to illustrate the necessity of close cooperation of internist and surgeon. REPORT OF CASES CASE 1 . - - A girl, n i n e m o n t h s old, h a d h a d a n i n f e c t i o n of tile u p p e r p a r t of t h e r e s p i r a t o r y t r a c t f o r two days, w i t h a t e m p e r a t u r e of 103 ~ F. T h e n swelling a n d t e n d e r n e s s of t h e r i g h t knee h a d appeared, a n d t h e t e m p e r a t u r e rose to 104 ~ F. On the f i f t h d a y a f t e r o n s e t of t h e condition a n incision was m a d e above t h e knee, p u s was seen, a n d the m e t a p h y s i s w a s drilled. O n t h e t w e l f t h d a y a f t e r operation, t h e t e m p e r a t u r e b e c a m e n o r m a l a n d t h e p a t i e n t w a s dismissed. She was b r o u g h t back a f t e r three d a y s w i t h swelling of t h e r i g h t t h i g h . T h i s w a s incised. F o u r days later, erysipelas s p r e a d over the entire body. She was i n h o s p i t a l s e v e n t y M x d a y s when she was t r e a t e d with erysipelas antistreptococci serum, t r a n s f u s i o n , u l t r a v i o l e t rays, r o e n t g e n rays, i n j e c t i o n s of glucose, a n d t u b e f e e d i n g . A t t i m e s t h e girl was e x t r e m e l y ill a n d was difficult to feed. D u r i n g her s t a y i n hospital b i l a t e r a l s u p p u r a t i v e otitis m e d i a developed; also, abscesses of t h e l e f t thigh, l e f t sacral region, region of t h e r i g h t knee, a n d d o r s u m of r i g h t f o o t developed, a n d bulbous i m p e t i g o a p p e a r e d on tile head. The only i n v o l v e m e n t of bone was in t h e middle of t h e l e f t f e m u r . T h e lowest value for h e m o g l o b i n was 40 per c e n t ; the n u m b e r of e r y t h r o c y t e s d r o p p e d to 2,500,000; a n d t h e n u m b e r of leucocytes v a r i e d f r o m 9~000 to 25,000 per cubic m i l l i m e t e r of blood. The p e r c e n t a g e of p o l y m o r p h o n u c l e a r cells was as h i g h as 89.5; t h e count of n o n f i l a m e n t e d cells exceeded t h e count of filamented cells somewhat. T h e m'ine r e m a i n e d p r a c t i c a l l y n e g a t i v e t h r o u g h o u t . F o r a short t i m e it c o n t a i n e d some bile p i g m e n t ( m e t h y l e n e blue t e s t ) . F r o m t h e pus f r o m t h e ears, staphylococci were grown) a n d f r o m tile incision in t h e l e f t thigh, hemolytic streptococci. CASE 2 . - - A girl, a g e d seven years, h a d h a d s u d d e n p a i n in t h e r i g h t ankle. I n the n e x t few days, t h e r e was swelling, redness, a n d t e n d e r n e s s , a n d the t e m p e r u t m ' e was f r o m 103 ~ to 104 ~ F. On t h e f o u r t h day, a a incision was m a d e over t h e lower p a r t of the t i b i a a n d p u r u l e n t m a t e r i a l d r a i n e d forth. Drill holes were m a d e in the lower p a r t of t h e tibia, b u t no pus a p p e a r e d . P u s was f o u n d i n the ankle joint. The t a l u s w a s exposed a n d w a s seen to be discolored. A c u l t u r e f r o m t h e w o u n d c o n t a i n e d staphylococci. Blood cultures were negative. E x t e n s i v e osteomyelitis of t h e talus w a s p r e s e n t . I n t h e n e x t year, several tlmes~ incision~ c u r e t t a g e , a n d s e q u e s t r e c t m n y were p e r f o r m e d . D r a i n a g e continued. T h e girl h a d chickenpox, measles, several a t t a c k s p r o b a b l y of s l i g h t appendicitis, a n d several a t t a c k s of p h a r y n g i t i s . A b o u t t h r e e y e a r s a f t e r o n s e t of the osteomyelitis she h a d chorea. H e r condition i m p r o v e d w i t h rest. T h o r o u g h c l e a n i n g of t h e whole s i n u s a n d c a v i t y of t h e t a l u s w a s decided on. The f o o t was p u t in good w a l k i n g position, casts were applied, a n d p r o v i s i o n for d r a i n a g e w a s made. She was sent to Florida. Complete cure resulted, w i t h a u k y l o s i s of the ankle. H a r d l y noticeable a t r o p h y a n d s h o r t e n i n g of t h e leg r e m a i n e d . The girl is active in sports.

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CASE 3.--A girl, seven years old, lind a temperature of 105 ~ ~L Some swelling of the upper part of the right arm appeared. The joints were free. Leucocytes numbered 6,600 per cubic millimeter of blood, with 83 per cent polymorphonuclear cells. On the third day after onset, the humerus was drilled at the upper metaphysis. Leucocytes ranged in number from 8,000 to 29~000 per cubic millimeter of blood. The temperature, for eight days, was up to 105 ~ F'., then it became more remittent, ranging up to 102 ~ F. and occasionally to 103.5 ~ F.~ and finally it became n o r m a l During her s t a y in hospital, there were superficial areas o f reddening and swelling of various parts of the skin, some with formation of pus, and healing with or without incision. Bilateral pleurisy and bronchopneumonia developed, together with pericarditis fibrinosa, pyelouephritls, oliguria, general edema, and ascites. Enlargement of the liver and questionable peritoneal involvement also appeared. Treatment consisted in blood transfusion, with and without gentian violet, and pericardeetomy. The right humerus, right and left metatarsals, and right fibula wore involved. I n cultures of blood and of urine and in some material from the pericardium, staphylococci were found. The last posltive blood culture was obtained about the seventeenth day after admission. For about a year, the p a t i e n t ' s general condition was very good. There was some drainage from the left foot and right ankle. During the year following this, abscesses os the right foot, right leg, and left foot were drained. Tonsillectmny and adenoidectomy were performed, and thick pus was obtained from the upper pole of the right tonsil. Chorea was present~ and a systolic murmur, transmitted to the axilla. The urine was negative, and during this year radical operation was performed on the right fibula. The year after the chorea had occurred, the systolic murmur had disappeared. Seven and a half years after the patient's admission, the right humerus, right fibula, metatarsals, right femur, right ilium, right acetabulum, neck of the left femur and left ilium were involved. The patient underwent various operations in all this time, mostly consisting of draining of abscesses and application of casts. The last renal flare-up was about six years after admission. The patient walks with a brace, and flexion deformity of the right hip is present. Two small sinuses are draining, and she limps. There is shortening of the leg of about 3 cm. The g~rl's general condition is very good. Observation has extended for eight years. CASE ~.--A boy, twelve years old, ten days before admission had a boil over his left patella. During the tea days, this region was struck twice with a baseball ; then he had severe pain in the left groin. H e had fever next day, and increasing malaise~ loss of appetite, vomiting, and delirium. Roentgenograms were negative, and on entrance the boy's temperature was 106 ~ F. lie was in hospital 194 days, and always was febrile. During this time, he had empyema of the right side of the thorax and fluid in the left side of the thorax. A roentgenogram gave evidence of multiple abscesses of both lungs. The left hip~ left femur, and right acetabulum were involved. Destructive arthritis of the lateral articulations of the fifth and sixth cervical vertebrae was present. The right clavicle, a rib, right ankle, right thumb, right elbow and left elbow were involved. Deep and extensive bed sores appeared. One time he had a convulsion, with a few minutes of unconsciousness, but he completely recovered frmn this. The kidneys became involved. When he was leaving the hospital the empyema still was under treatment. The co~dltlon of the skin improved. The left hip was regarded as the main site of the disease. During the first half month, staphylococci grew on blood culture. Incisions were made in the left hip, ankle, elbow, and right hip. Four transfusions of blood and one immunotransfusion were given. Gentian violet was injected. Staphylococci appeared in the urine before pus appeared. On the p a t i e n t ' s dismissal, the urine was clear; cultures were negative. The boy was seen several times at home after

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leaving hospital. About three years later amyloidosis appeared. Treatment with liver was not successful. The left hip became ankylosed. He had draining sinuses in the right thigh, left thigh, sacroiliac region, clavicle, elbow, and foot. There was extensive involvement in the region of the pelvic bones. Observation extended for four years. SUMMARY AND CONCLUSIONS T h e p r i m a r y o b j e c t of t h i s p a p e r is to i n v i t e f u r t h e r s t u d y i~ t h e field o f o s t e o m y e l i t i s . C u l t u r e s of b l o o d , u r i n e , a n d w o u n d s s h o u l d be m a d e w h e n e v e r p o s s i b l e . I n o r d e r to a r r i v e a t a b e t t e r e s t i m a t e of t h e p a t i e n t % g e n e r a ] c o n d i t i o n , cl o se c o o p e r a t i o n o f s u r g e o n a n d i n t e r n i s t is of a d v a n t a g e . T h i s is o f t e n n e c e s s a r y f o r a d e q u a t e t r e a t m e ~ t . I t is i m p e r a t i v e to o b t a i n b e t t e r d a t a w i t h r e g a r d to t h e u l t i m a t e r e s u l t s of v a r i o u s t h e r a p e u t i c p r o c e d u r e s . REFERENCES

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Baer, W. S.: J. Bone & Joint Surg. 13: 438, 1931. Krasnobaew, T.: Chir. d. org. di movlmento 10: 537, 1926. Lexer, E.: Arch. f. klin. Chir. 53: 266, 1896. Nineteenth Report of Progress of Orthopedic Surgery, Arch. Surg. 6: 195, 1923. err, tI. W.: Surg. Gynec. Obst. 45: 446, 1927. Phemister, D . B . : Pyogcnic Osteomyelitis. Abt, I. A.: System of Pediatrics, Vol. 5, pp. 40-67, Philadelphia, 1924, W. B. Saunders Co. P]att, Harry: Prec. Roy. Soc. lVied. 21: 1377, 1928. Reuss, August: Die Krankheiten des Neugeborenen, p. 340, Berlin, 1914, Julius Springer. Robertson, D . E . : J. Bone & Joint Surg. 9: 8, 1927. Rest, Franz: Miinchen. med. Wchnschr. 2: 1492, 1920. Schuchardt, Karl: Die Krankheiten der Knochen und Gelenke. In: Deutsche Chirurgie, pp. 158-202, Stuttgart, 1899, Ferdinand Enke. Starr, C . L . : Arch. Surg. 4: 567, 1922. Trendel: Beitr. z. klin. Chir. 41: 607, 1904.