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Some observations on osteomyelitis
SOME OBSERVATIONS
ON
OSTEOMYELITIS* ISIDORE COHN, NEW
ESPITE
* Read before the South Mississippi
F.A.C.S.
ORLEANS
the great number of papers which have been written on the subject of osteomyeIitis with reference to earIy diagnosis, it is rareIy diagnosed earIy. AI1 authors reiterate the formuIa by which a diagnosis can be made, yet few have the good fortune to present many personaIIy observed rea1 acute cases which they have treated. This sad commentary is responsibIe for the presentation of this coIIection of persona1 experiences for consideration here. Didactic teaching and textbooks must of necessity be dogmatic in a measure based on ideaIs not yet attained. This is with reference to the especiaIIy true disease under consideration. In this discussion an effort wiI1 be made to present the state of the deveIopment of the disease process when the individua1 cases first came under my observation. In one instance to be cited the patient was under the observation of a competent physician for two weeks. During that time a discussion of the x-ray finding delayed surgica1 intervention unti1 a positive bIood cuIture was obtained. In another instance a pathoIogica1 fracture, secondary to osteomyeIitis, prevented earIy recognition and proper handIing. The diagnosis of pIeurisy, pneumonia and of tonsiIIitis in other instances deIayed earIy recognition of the disease. I think a11 wiI1 agree that this evidence indicates that effIcientIy earIy diagnosis is the exception rather than the ruIe. I believe that the evidence indicates that operative procedures which are at times resorted to are incompIete, and that dangerous operative methods of approach which increase the risk to important vesseIs are too often adopted.
D
M.D.,
I am sure, when one considers treatment, that it is not necessary to adopt one of the recent idea1 methods of treatment in order to obtain good end-resuIts. I do not hoId as true-once osteomyeIitis, aIways 0steomyeIitis. In order to deveIop the thesis onIy certain phases of the broad subject under discussion can be presented. Diagnosis in very young chiIdren is at times greatIy deIayed. This is accounted for by the fact that painfu1 extremities are often considered to be due to rickets, scurvy or syphiIis, and many times the x-ray findings confuse rather than aid the attending physician. Of course it must not be overIooked that any one of the diseases mentioned may be coexistent with an acute 0steomyeIitis. The foIIowing summary of 2 cases wiI1 serve to iIIustrate the point in question: CASE I. R. M. T., aged two months. The chiId had been iII for ten days before the mother noticed the sweIIing of the wrist. There was marked tenderness about the wrist, and the chiId did not use the arm with as much ease as she did the other extremity. The doctor in charge of the patient had x-ray pictures taken. These showed a destructive Iesion associated with some productive changes. The pictures were variousIy interpreted; syphiIis, scurvy, OsteomyeIitis and maIignancy tubercuIosis, were considered. The radioIogist suggested that there was a we11 defined Iuetic process, and probabIy a mixed infection producing an osteomyelitis. SeveraI days Iater I was asked to see the chiId. At the time of my first examination, JuIy 12 “the Ieft forearm was Iarger than the right. The skin wa.s sIightIy gIossy, and red. Supination was Iimited. There was some i&Itration of the soft tissues, both on the dorsa1 and voIar surfaces of the forearm, and I got
MedicaI Societies. Submitted 237
for publication
June
24,
193 I.
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of Surgery
Cohn-Osteomyelitis
the impression that there was an irreguIar enIa.rgcment of the radius. There was no Iimitation of motion in the wrist, eIhow or shouIder.
FEBRUARY, 1932
diseased and a pure cuIture of Staphylococcus aureus was obtained from the pus. This chiId made an uneventfu1 recovery.
FIG. I. R. (M. T., July 12, 1929. RadioIogic diagnosis Iuetic ostitis and probably a mixed infection producing osteomyehis. No. 84939.
There was no gIanduIar enIargement. I wouId be incIined to believe, because of the destructive reaction of Iesion and infIItration, that we are deaIing with an acute infection producing a destruction of bone. I beheve that at Ieast an expIoration of the radius is indicated and advise that an exploratory operation be done.” The doctor, whose patient the child was, beIieving that the entire condition was due to syphiIis, ordered antiIuetic medication and orange juice. SurgicaI intervention was not accepted. A bIood count, ten days after the chiId was first seen, was 13,000. The Wassermann reaction was three PIUS. The chiId’s fever persisted. Subsequent x-ray pictures showed marked increase in the destructive process. Tweltle days after the chiId was first observed a blood culture showed a positive hemolytic staph.ylococcus. Twenty days after the jkst observation we were permitted to operate upon
the child. We found the radius on both sides
FIG. 2. R. M. T., JuIy 22, 1929. Picture progress of disease. No. 85 I 20.
indicates
The x-ray pictures (Figs. 1-4) which are here presented show the marked improvement which foIIowed. The chiId was Iast seen one week ago (May 28). The condition is exceIIent. CASE II. H. H., aged three months. Breastfed baby. The foIIowing history was obtained. The mother noticed that the baby cried when the right Ieg was handIed, and that the baby heId the right Ieg and thigh ffexed. Temperature was 102&F. Examination of the right Ieg showed a marked sweIIing causing the leg to have a fusiform shape between the knee and the ankIe. The skin over this area was tense and shiny. There was no ffuctuation. Movement of the Ieg caused pain. The other leg and arms were free from evidence of deformity or invoIvement. The x-ray findings were reported as foIIows: “There is a fracture of the tibia in the upper
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third. There is a marked periostea1 reaction which is characteristic of Iues.” The doctor who f&t examined the baby
FIG. 3. R. M. T. August operation.
13, 1929. Two 85549,
American
Journal
of Surgcrg
239
The cortex of the tibia was removed for 3i inch. Pus was found in the meduIIary canal. Prior to operation an x-ray picture was taken
weeks after
No.
FIG. 4. R. M. T. May IO, 1931. One year and nine months after operation. No. 103950.
specifically stated that he did not think it a case of OsteomyeIitis. Anti-Iuetic treatment was ordered for the patient. Four days Iater, when I first saw the child, the following notes were made. “The right thigh is flexed on the abdomen, and the knee flexed at a right angIe. ExternaI rotation and abduction of the entire Iower extremity. The leg and thigh on the right side are larger than on the Ieft. There is some gIossiness of the skin of the Ieg and foot. PaIpation over the leg causes the baby to scream. There is an apparent thickening of the inner side of the shaft of the tibia. I believe that there is a sIight fluctuation in the center of the mass. There is some edema of the thigh. The head of the femur rotates with the shaft. The deep femora1 gIands are enIarged. I beIieve that this is a case of osteomyeIitis and accordingIy advise operation.” Immediate operation was done. A subperiosteal abscess was incised and drained.
and an osteomyelitis was reported as being present. A coincidental Iuetic change was considered to exist. S-ray pictures taken May 31, 1931 show a progressive improvement of the previousIy shown disease of the bone. There is aImost a compIete return to the norma appearance. Comment: In these cases the cIinica1 findings suggested osteomyehtis, the x-ray findings were variousIy interpreted. Syphilis was suspected and the idea persisted for over two weeks before surgica1 intervention was aHowed. It is true that from the radioIogica1 standpoint there was good reason to state that the patient had congenital syphilis. In view of the recent observations made by MacLean, February 193 I, the confusion in such a case wouId certainIy
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be increased for he states there is aImost a unanimous opinion that in infants during the first weeks of Iife a deepening in the
FIG.
5. D. T. OsteomyeIitic
focus in lower portion of diaphysis.
IongitudinaI axis of the provisiona zone of caIcification of the Iong bones is indicative of syphilitic invoIvement. He aIso states that there is usuaIIy a rarefaction near the metaphysis; further that syphiIitic OsteomyeIitis can be definitely diagnosed “ roentgenoIogicaIIy ” if the osteomyeIitic Iesions are symmetrica1, and further that Iesions are usuaIIy punched out areas with thickened contiguous supportive periostitis. In Case I of this series the x-ray pictures presented a11 of these evidences. The patient did have congenita1 Iues, but the
patient did not improve unti1 the osteomyeIitic foci, which were proved to contain StaphyIococcus aureus, were surgicaIIy drained. Moreover, the patient did have a positive bIood culture prior to operation. In both instances the diagnosis of osteomyeIitis was confirmed at operation. The rapidIy progressive destructive nature of the Iesion indicated an acute bone infection. Much vaIuabIe time was Iost in both cases because the cIassic picture was not present. It must be remembered that ,an infant cannot Iocate his pain for us, that gross differences in the size of the affected Iimbs may not be found and that syphiIis, scurvy and rickets may be present in association with osteomyelitis. A pathoIogica1 fracture such as was found in the case described here may coexist with OsteomyeIitis. If we are to prevent proIonged iIIness, great destructive changes and crippIing deformities, we must not wait in the case of infants. EarIy operation is comparativeIy easy, takes but a short time and the period of after care is greatIy shortened. Can we agree that too much has aIready been said on OsteomyeIitis and the need for earIy diagnosis when one sees cases such as the foIIowing : CASE III. Master D. T., aged nine years. When the chiId came under my observation about two weeks after the onset of the disease the foIIowing history was obtained. The chiId had deveIoped pneumonia three days after having pIayed footbaI1 on a wet Iot. He had high fever and pain in his chest and abdomen. After the chiId had been sick for about fortyeight hours a doctor was caIIed and a diagnosis of pneumonia was made. Three days Iater the patient had sudden severe pain in the right thigh and Ieg. X-ray pictures were taken and an operation was done on the Ieg under IocaI anesthesia. Some pus was evacuated and the crisis of the pneumonia safely passed. A few days Iater the doctor toId the mother that he wouId have to open the Ieg and scrape the bone. At this time the chiId came under my observation. The chiId presented the appearance of one exhausted by sepsis (marked emaciation, anxious expression, hot dry skin, rapid
Cohn-OsteomyeIitis
NEW SERIES VOL. XV, No. +
shaIIow
respiration
pulse). We found
a marked
and
a
sweIIing
rapid
thready
of the
FIG. 6. D. T. Before operation,
entire
Journal
of Surgery
241
marked regeneration of the tibia which has taken pIace. A year Iater the chiId returned with pain over
showing destruction
right Ieg from the ankIe up to above the knee. X-ray pictures at this time (Figs. 3, 6) showed a marked destructive process invoIving the upper third of the diaphysis of the tibia. Immediate operation was done. We found that the upper 234 inches of the diaphysis of the tibia was so honeycombed that we feIt that the best thing to do was to remove that portion of the tibia at once. With a motor driven circuIar saw section was made about 2 34 inches beIow the upper Iimit of the diaphysis. The cavity was packed. We aIso found that there was an osteomyeIitic focus in the Iower portion of the diaphysis of the tibia on the same side. With a motor driI1 we entered the meduIIary cana and there found evidence of diseased bone and a smaII quantity of pus. DichIoramine--r pack was introduced and a pIaster cast appIied. The chiId’s condition was so precarious that it was necessary after a few days to give him a transfusion. His convaIescence was stormy, but his eventua1 recovery was excellent as evidenced by the pictures which show the
American
of the upper portion of the diaphysis.
the wrist. We found evidence of an osteomyelitis or capitate. The entire of the OS magnum, diseased bone was removed. The child made an uneventfu1 recovery. He has not had to have, so far as I know, any subsequent operative procedure. CASE IV. Master J. T., aged nine years. The chiId was first seen on the JuIy 17, 1930. His iIIness began in November 1929, with an acute febriIe reaction and pain in both Iower extremities. For two months he was kept under observation because his tonsiIs were diseased. At the end of that time the tonsiIs were removed. The chiId continued to run temperature and this had been considered to be due to rheumatic fever. In June 1930 the family insisted on having x-ray pictures of the extremities because the chiId continued to compIain of pain. The picture showed evidence of disease of the neck of the right femur and the lower portion of the Ieft femur. The doctor who was in charge at the time operated on the chiId, making a drill hoIe in the shaft of the femur beIow the great trochanter. At this time
2-P
hnrericall
.iourllal
“(‘
an incision was made the Ieft thigh, about temperature persisted.
surgery
Cohn-Osteomyelitis
on the inner aspect of the middle third. His
FEBRUARY. 1932
X-ray pictures were taken, bIood count, and Mood culture. The pictures demonstrated a progressive destruction of bone, invoIving the
FIG. 8. D. T. June 14, 1928. Eight months after operation. Showing bone regeneration. No. 76210. neck
7. D. T. January 12, 1928. OsteomyeIitis of OS magnum (capitate) which was removed. Patient has been perfectIy well since. No. 8395.
FIG.
On JuIy 17 the chiId was brought to New Orleans and was referred to Dr. Butterworth through whose courtesy I had the opportunity to see the patient. We found a tiIting of the peIvis. The right thigh was much larger than the left. The right lower extremity was apparentIy Ionger than the left. We found an incision on the inner side of the Ieft thigh above the knee in which we found a pack.
of the right femur with a prohferative osteitis. Just above the great trochanter the cortex had been broken through. There was evidence of a driI1 hoIe beIow the great trochanter. The white cell count was 19,400. It became necessary, because of the destruction of the trochanter and neck, eventuaIIy to remove a11 of the trochanter, neck and head of the femur. It was aIso necessary to operate upon the Ieft femur where there was an osteomyehtic focus in the Iower portion of the shaft. The subsequent course of this case which is stiI1 not a cured case by any means, has been stormy. During his stay in the hospital the
NEW
child
SERIES VOL.. XV,
developed
No. 2
an acute appendicitis
Cohn-Osteomyelitis for which
it was necessary to operate upon him. Later the retroperitonea1 gIands became invoIved, he
This chiId wiI1 be, if he survives, An earIy diagnosis, a terribIe crippIe. and proper surgica1 intervention probabIy wouId have cured this chiId in a very short whiIe. Instead he represents one of the human wrecks which stand as a monument to Iate diagnosis, and as mute evidence of the great destruction that can be produced by osteomyeIitis. In summary then we see two tragic results which foIIowed a diagnosis of pneumonia, and of tonsiIIitis. We witness, by the examination of these two patients, the ravages that septic processes wiI1
JuurnaI
OF Sorgrry
213
In both instances the profound anemia and the sepsis did Iook as though there wouId be a tragic end. It is true
produce.
FIG. 9. Air. 0. B. Showing extensive osteomyeIitic invoIvement of practicaIly diaphysis. September 13, 1929.
deveIoped a septic endocarditis, and at the present time is stiI1 running temperature as his temperature high as IOI OF. For months Several ran as high as 103-104’~. daily. transfusions were given.
Arneri~xn
entire radius except lower third of
they gave us an opportunity to see the beneficent effects of operation and transfusions. It aIso caused a great amount of undue anguish to the parents. FortunateIy the first chiId has recovered and is we11 today. EarIy diagnosis and prompt surgica1 intervention would have cured both of these cases in a short while. EarIy diagnosis wouId have avoided extensive mutiIating operations, and transfusions wouId not have been needed. The resuIt in the first case indicates that regenerative processes wiI1 restore form and function. The next case adds further evidence of the rea1 need for earIy diagnosis. CASE v. Mr. 0. B. This patient was first seen September 17, 1929. FoIIowing is a brief summary of the history as I obtained it from the patient. Patient had pIeurisy five weeks
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before. Four weeks previous the Ieft forearm began to sweI1. At this time an x-ray was taken of the eIbow because of pain and some
FIG. IO. Mr. O,,B.
FEBRUARY,193~
the radius except the Iower 1>4 inches. The operative record which foIIows is incIuded because of the method of approach to the
One year and eight months after operation showing great amount of regeneration foIIowed. Patient has never had a second operation. No. 104068.
sweIIing of the forearm. The picture showed no evidence of bone disease. After the first few days he was not confined to bed. 17, a diagnosis On examination, September of osteomyeIitis was made. The patient was admitted to Touro Infirmary for operation. Prior to operation the median, radia1 and uInar nerves were tested for their gaIvanic response. It was found that there was very IittIe deIay in the response. Prior to operation pictures were also taken. These indicated a destruction of aImost the entire radius down to within about 136 inches of the styloid process. Operation was done and this consisted in a subperiostea1 remova of the entire shaft of
which has
radius for a compIete subperiostea1 remova of the radius. “Operation: A subtota1 excision of the radius. Position of forearm, eIbow flexed at right angIes; forearm midway between pronation and supination. Incision made beginning at the IeveI of the head of the radius, and at a point posterior to the insertion of the supinator Iongus, extending foreward obIiqueIy across the forearm, and to the middIe of the forearm and then continued downward to the styIoid of the radius. MuscIes were separated. IntermuscuIar pIanes found, radius exposed subperiosteaIIy, bisected about the middIe and with a Iion-jaw forceps the upper fragment inchIding the head was removed. Pack intro-
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Cohn--OsteomyeIitis
duced. Lion-jaw forceps appIied to the Iower fragment. It was decided, however, not to remove the entire Iower fragment, hut to leave the base of the radius with the hope that in that way, a usefu1 wrist might be obtained. When the fragment was removed, the periosteum had attached to it, a Iong invoIucrum, about $4 inch in thickness in some pIaces and tapering down to about 352 inch. DichIoramine-T pack was introduced and interrupted sutures were appIied over the pack. Skin was cIosed with interrupted dermo1 sutures. PIaster cast appIied, eIbow at right angIe, the hand was incIuded, wrist in a cock-up position, or dorsiff exion.” The convaIescence in this case was unusuaIIy smooth and the picture (Fig. IO) shows an amount of regeneration which had taken pIace up to the Iast time that the patient was seen. June 3, 193 r. Since Iast seen his arm has given him no troubIe. The onIy thing he has noticed is that the arm has become stronger. He is abIe to drive an automobiIe. There has been no pain whatsoever. Examination on this day reveaIed the Ieft forearm to be smaIIer than the right. There is a sIight bowing on the radiaI side. There is a scar which extends from the IeveI of the externa1 condyIe obIiqueIy downward to the styIoid of the radius. The scar is about ?,$ inch wide. The patient is able to ffex to sIightIy beyond a right angIe and extend it about 150 degrees. Pronation is compIete, supination to about 60 degrees. There is no Iimitation of motion about the wrist. The grip is exceIIent. Comment: In this instance the patient was treated for a pIeurisy. One week after the onset of the fever pain and sweIIing of the forearm attracted attention to the forearm, but since the x-ray picture did not reveaI any evidence of disease nothing further was done. After another three weeks had eIapsed a second picture was taken. It was then that I had the priviIege of seeing him. A radica1 operation had to be done. The entire radius, with the exception of the Lower 135 inches, was removed superiosteaIIy. Regeneration progressed very rapidIy. No subsequent operations have had to be done.
American Journal of Surgery
245
Mention shouId be made of the method of approach. It has been my poIicy to foIIow the suggestions of the Iate James E. Thompson in the approach to a11 Iong bones. In this instance the forearm was kept midway between pronation and supination with the eIbow fIexed at right angles. The incision began at the IeveI of the head of the radius, and at a point posterior to the supinator Iongus, extending obIiqueIy forward across the forearm and then continuing down to the styIoid of the radius, where we were thus abIe to get in the intermuscuIar pIanes. The radius was exposed subperiosteaIIy. In order to avoid a great dea1 of dissection and damage to the soft tissues thk radius was bisected about its middIe, then with a Iion-jaw forceps it was easy to remove the upper incIuding the head. The refragment, mainder of the operation has been aIready described. In the method utiIized we were abIe to avoid extensive damage to muscIes and important nerves, particuIarIy the radia1 nerve. In the postoperative management of the case we were abIe to give the patient considerabIe comfort by having a mouIded Ieather jacket made for the Iower third of the arm and the entire forearm. I believe that a11 wiI1 agree with me that deIay in diagnosis resuIted in extension of the disease and necessitated an unnecessariIy radica1 operation at a Iater date. EarIy diagnosis wouId have caused Iess disability, Iess pain, and Iess expense to the patient. We taIk of reducing mortaIity and morbidity in cancer, appendicitis, and osteomyeIitis, and yet such caIamities as these are mute evidence that our progress toward the goa is sIow if at a11 sure. Too much dependence is stiI1 pIaced on x-ray pictures. In the two preceding cases attention has been caIIed to the regeneration which has taken pIace in these patients. RecentIy it has been my good fortune to see a patient on whom I did a compIete superiostea1 resection of the diaphysis of the tibia fifteen years ago. At the present time
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Cohn-OsteomyeIitis
there has been not onIy a compIete regeneration, but the form of the tibia has been restored. This case presents so many
FIG. I I. Miss H. V. Fifteen years after subperiostea1 excision of entire diaphysis of tibia. Patient has never had any further operative procedure. No. 102211.
interesting features regeneration, that be incIuded.
besides the satisfactory a brief summary wiII
CASE VI. Miss H. V. White femaIe, aged eIeven years? Patient originaIIy presented herseIf to a surgeon who drained a subperiostea1 abscess about her ankIe. Five weeks Iater the patient came under my observation. At that time there were a number of draining sinuses on the inner side of the Ieg. X-ray pictures taken at this time reveaIed the fact that the
FEBRUARY,1932
tibia was honey-combed from one end of the diaphysis to the other. A subperiostea1 resection of the entire diaphysis was done. This patient has not needed another operation. The original operation was done fifteen years ago. At the present time an x-ray picture (Fig. I I) shows a fuIIy regenerated tibia. A synostosis has formed between the tibia and the astraguIus, but in spite of this the patient dances, walks and carries on generaIly without discomfort. AI1 of her ankIe movements are accompIished through the astragaIocaIcanean articuIation. The method of treatment utihzed for the past eighteen years has been consistent. In the few cases in which a rea1 acute condition has been found, at the time that the patient has come under observation, the foIIowing method has been utiIized. A diagnosis is made in those cases which present a history of an acute febriIe onset with pain as a ruIe IocaIized over the shaft of one of the Iong bones. There is usuaIIy a marked Ieucocytosis. X-ray is not depended upon for diagnosis. The x-ray can be of service onIy when the disease has existed Iong enough for destructive changes to have taken pIace. Under no condition can the x-ray give definite information unIess there is a difference in the density of the various portions of the bone invoIved. I believe that it is better to err when no osteomyeIitis exists, rather than to deIay and wait for definite x-ray changes. Under genera1 anesthesia an incision is made through the periosteum and a number of driI1 hoIes are made through the cortex, and if the disease is in that portion of the bone above the canceIIous end of the diaphysis, into the meduIIary cana1. Two points which I shouId Iike to emphasize right here are (I) that the presence of pus under the periosteum indicates that the operation shouId be extended to incIude drainage of either the canceIIous portion or the meduIIary portion of the bone, depending upon the Location. It cannot be emphasized too often that a11 pus outside of the cortex must have gotten there in a centrifuga1 manner. Drainage is the essen-
NEW SERIES VOL.XV, No. 2
Cohn-Osteomyelitis
I.
DE CHAULIAC, GUY. On Wounds 1363.
2.
CABAN&.
247
The Orr method of treatment does not seem to me to meet surgica1 principles. WhiIe many are wiIIing to accept the method, it does not appea1 to me. The secretions which do accumuIate irritate the skin and after a time the odor which emanates from the dressing is nauseating. With more frequent change of dressings there is Iess IikeIihood of conceaIed damage occurring. It is not my intention to enter into a controversy with those who prefer putrefactive odors due to unchanged dressing, or with those who stand by and expect heaIing processes to be promoted by Iiving scavangers in the form of repuIsive maggots as advocated by the Iate Dr. Baer. Let me hasten to add that Bear did obtain good end-resuIts by the use of sterilized we11 bred maggots; so do the foIIowers of Orr, and so have we. The resuIts are dependent more on the factor of prompt drainage of the infected and devitaIized bone, than on anything eIse. The amount of destructive change is directIy proportionate to the Iocation of the emboIus, and to the promptness with which drainage is instituted.
tia1 thing. The type of drug appIied which is used is almost immaterial. With free drainage it matters IittIe whether dichIoramine T or vaseIine, or anything else is used. The advantage of an oiIy substance on the gauze is that it does not become adherent to the endosteum. By way of digression I shouId Iike to insist that in acute osteomyelitis a curette shouId never be used because with the curette you destroy the very ceIIs on which YOU are depending for regeneration. There is aIso a grave danger of injuring the nutrient artery, and if a cIot is formed you are IikeIy to have the entire diaphysis of a pIaster sequestrate. Th e appIication cast has been our practice. In Iater cases the amount of bone to be removed is dependent on the amount of evident disease. After the cavity has been Ioosely packed with dichIoramine T (since 1917) the pack is usuaIIy aIIowed to remain for five days, after which it is removed. If the pack is not removed the suppIy of dichIoramine T has been repIenished.
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American Journal of Surgery
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8. D’HERELLE, F. The Bacteriophage
and its Behavior. Bait., WiIkins and WiIIiams, 1921. PARS, AMBROISE. La methode de traicter Ies * Continued
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ALBEE*
pIayes faictes par hacqvebvtes et avItres bastosn B feu. g. ALBEE, F. H. The principIes of the bacteriophage applied to OsteomyeIitis. Internat. J. Med. H SW&,
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IO. ALBEE, F. H. The bacteriophage in wound treatment. Internat. J. Med. CYSurg., 42: 658, 1929. II. ALBEE, F. H., and PAITERSON, M. B. The bacteriophage in surgery. Ann. Surg., gr : 855, 1930. 12. ALBEE, F. H. The bacteriophage in surgery. Internat. J. Med. Ed Surg., 43: 461, 1930. 13. ALBEE, F. H. The bacteriophage in surgery. Rebabilitation Rev., Aug., 1931, 5, Ig5-201. 14. HUXLEY, J. BioIogy and our future worId. Harper’s, Sept., 1931. from p. 236.
ON
OSTEOMYELITIS* ISIDORE COHN, NEW
ESPITE
* Read before the South Mississippi
F.A.C.S.
ORLEANS
the great number of papers which have been written on the subject of osteomyeIitis with reference to earIy diagnosis, it is rareIy diagnosed earIy. AI1 authors reiterate the formuIa by which a diagnosis can be made, yet few have the good fortune to present many personaIIy observed rea1 acute cases which they have treated. This sad commentary is responsibIe for the presentation of this coIIection of persona1 experiences for consideration here. Didactic teaching and textbooks must of necessity be dogmatic in a measure based on ideaIs not yet attained. This is with reference to the especiaIIy true disease under consideration. In this discussion an effort wiI1 be made to present the state of the deveIopment of the disease process when the individua1 cases first came under my observation. In one instance to be cited the patient was under the observation of a competent physician for two weeks. During that time a discussion of the x-ray finding delayed surgica1 intervention unti1 a positive bIood cuIture was obtained. In another instance a pathoIogica1 fracture, secondary to osteomyeIitis, prevented earIy recognition and proper handIing. The diagnosis of pIeurisy, pneumonia and of tonsiIIitis in other instances deIayed earIy recognition of the disease. I think a11 wiI1 agree that this evidence indicates that effIcientIy earIy diagnosis is the exception rather than the ruIe. I believe that the evidence indicates that operative procedures which are at times resorted to are incompIete, and that dangerous operative methods of approach which increase the risk to important vesseIs are too often adopted.
D
M.D.,
I am sure, when one considers treatment, that it is not necessary to adopt one of the recent idea1 methods of treatment in order to obtain good end-resuIts. I do not hoId as true-once osteomyeIitis, aIways 0steomyeIitis. In order to deveIop the thesis onIy certain phases of the broad subject under discussion can be presented. Diagnosis in very young chiIdren is at times greatIy deIayed. This is accounted for by the fact that painfu1 extremities are often considered to be due to rickets, scurvy or syphiIis, and many times the x-ray findings confuse rather than aid the attending physician. Of course it must not be overIooked that any one of the diseases mentioned may be coexistent with an acute 0steomyeIitis. The foIIowing summary of 2 cases wiI1 serve to iIIustrate the point in question: CASE I. R. M. T., aged two months. The chiId had been iII for ten days before the mother noticed the sweIIing of the wrist. There was marked tenderness about the wrist, and the chiId did not use the arm with as much ease as she did the other extremity. The doctor in charge of the patient had x-ray pictures taken. These showed a destructive Iesion associated with some productive changes. The pictures were variousIy interpreted; syphiIis, scurvy, OsteomyeIitis and maIignancy tubercuIosis, were considered. The radioIogist suggested that there was a we11 defined Iuetic process, and probabIy a mixed infection producing an osteomyelitis. SeveraI days Iater I was asked to see the chiId. At the time of my first examination, JuIy 12 “the Ieft forearm was Iarger than the right. The skin wa.s sIightIy gIossy, and red. Supination was Iimited. There was some i&Itration of the soft tissues, both on the dorsa1 and voIar surfaces of the forearm, and I got
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for publication
June
24,
193 I.
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Cohn-Osteomyelitis
the impression that there was an irreguIar enIa.rgcment of the radius. There was no Iimitation of motion in the wrist, eIhow or shouIder.
FEBRUARY, 1932
diseased and a pure cuIture of Staphylococcus aureus was obtained from the pus. This chiId made an uneventfu1 recovery.
FIG. I. R. (M. T., July 12, 1929. RadioIogic diagnosis Iuetic ostitis and probably a mixed infection producing osteomyehis. No. 84939.
There was no gIanduIar enIargement. I wouId be incIined to believe, because of the destructive reaction of Iesion and infIItration, that we are deaIing with an acute infection producing a destruction of bone. I beheve that at Ieast an expIoration of the radius is indicated and advise that an exploratory operation be done.” The doctor, whose patient the child was, beIieving that the entire condition was due to syphiIis, ordered antiIuetic medication and orange juice. SurgicaI intervention was not accepted. A bIood count, ten days after the chiId was first seen, was 13,000. The Wassermann reaction was three PIUS. The chiId’s fever persisted. Subsequent x-ray pictures showed marked increase in the destructive process. Tweltle days after the chiId was first observed a blood culture showed a positive hemolytic staph.ylococcus. Twenty days after the jkst observation we were permitted to operate upon
the child. We found the radius on both sides
FIG. 2. R. M. T., JuIy 22, 1929. Picture progress of disease. No. 85 I 20.
indicates
The x-ray pictures (Figs. 1-4) which are here presented show the marked improvement which foIIowed. The chiId was Iast seen one week ago (May 28). The condition is exceIIent. CASE II. H. H., aged three months. Breastfed baby. The foIIowing history was obtained. The mother noticed that the baby cried when the right Ieg was handIed, and that the baby heId the right Ieg and thigh ffexed. Temperature was 102&F. Examination of the right Ieg showed a marked sweIIing causing the leg to have a fusiform shape between the knee and the ankIe. The skin over this area was tense and shiny. There was no ffuctuation. Movement of the Ieg caused pain. The other leg and arms were free from evidence of deformity or invoIvement. The x-ray findings were reported as foIIows: “There is a fracture of the tibia in the upper
Cohn-Osteomyelitis
NEW SERVESVOL. XV, No. z
third. There is a marked periostea1 reaction which is characteristic of Iues.” The doctor who f&t examined the baby
FIG. 3. R. M. T. August operation.
13, 1929. Two 85549,
American
Journal
of Surgcrg
239
The cortex of the tibia was removed for 3i inch. Pus was found in the meduIIary canal. Prior to operation an x-ray picture was taken
weeks after
No.
FIG. 4. R. M. T. May IO, 1931. One year and nine months after operation. No. 103950.
specifically stated that he did not think it a case of OsteomyeIitis. Anti-Iuetic treatment was ordered for the patient. Four days Iater, when I first saw the child, the following notes were made. “The right thigh is flexed on the abdomen, and the knee flexed at a right angIe. ExternaI rotation and abduction of the entire Iower extremity. The leg and thigh on the right side are larger than on the Ieft. There is some gIossiness of the skin of the Ieg and foot. PaIpation over the leg causes the baby to scream. There is an apparent thickening of the inner side of the shaft of the tibia. I believe that there is a sIight fluctuation in the center of the mass. There is some edema of the thigh. The head of the femur rotates with the shaft. The deep femora1 gIands are enIarged. I beIieve that this is a case of osteomyeIitis and accordingIy advise operation.” Immediate operation was done. A subperiosteal abscess was incised and drained.
and an osteomyelitis was reported as being present. A coincidental Iuetic change was considered to exist. S-ray pictures taken May 31, 1931 show a progressive improvement of the previousIy shown disease of the bone. There is aImost a compIete return to the norma appearance. Comment: In these cases the cIinica1 findings suggested osteomyehtis, the x-ray findings were variousIy interpreted. Syphilis was suspected and the idea persisted for over two weeks before surgica1 intervention was aHowed. It is true that from the radioIogica1 standpoint there was good reason to state that the patient had congenital syphilis. In view of the recent observations made by MacLean, February 193 I, the confusion in such a case wouId certainIy
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be increased for he states there is aImost a unanimous opinion that in infants during the first weeks of Iife a deepening in the
FIG.
5. D. T. OsteomyeIitic
focus in lower portion of diaphysis.
IongitudinaI axis of the provisiona zone of caIcification of the Iong bones is indicative of syphilitic invoIvement. He aIso states that there is usuaIIy a rarefaction near the metaphysis; further that syphiIitic OsteomyeIitis can be definitely diagnosed “ roentgenoIogicaIIy ” if the osteomyeIitic Iesions are symmetrica1, and further that Iesions are usuaIIy punched out areas with thickened contiguous supportive periostitis. In Case I of this series the x-ray pictures presented a11 of these evidences. The patient did have congenita1 Iues, but the
patient did not improve unti1 the osteomyeIitic foci, which were proved to contain StaphyIococcus aureus, were surgicaIIy drained. Moreover, the patient did have a positive bIood culture prior to operation. In both instances the diagnosis of osteomyeIitis was confirmed at operation. The rapidIy progressive destructive nature of the Iesion indicated an acute bone infection. Much vaIuabIe time was Iost in both cases because the cIassic picture was not present. It must be remembered that ,an infant cannot Iocate his pain for us, that gross differences in the size of the affected Iimbs may not be found and that syphiIis, scurvy and rickets may be present in association with osteomyelitis. A pathoIogica1 fracture such as was found in the case described here may coexist with OsteomyeIitis. If we are to prevent proIonged iIIness, great destructive changes and crippIing deformities, we must not wait in the case of infants. EarIy operation is comparativeIy easy, takes but a short time and the period of after care is greatIy shortened. Can we agree that too much has aIready been said on OsteomyeIitis and the need for earIy diagnosis when one sees cases such as the foIIowing : CASE III. Master D. T., aged nine years. When the chiId came under my observation about two weeks after the onset of the disease the foIIowing history was obtained. The chiId had deveIoped pneumonia three days after having pIayed footbaI1 on a wet Iot. He had high fever and pain in his chest and abdomen. After the chiId had been sick for about fortyeight hours a doctor was caIIed and a diagnosis of pneumonia was made. Three days Iater the patient had sudden severe pain in the right thigh and Ieg. X-ray pictures were taken and an operation was done on the Ieg under IocaI anesthesia. Some pus was evacuated and the crisis of the pneumonia safely passed. A few days Iater the doctor toId the mother that he wouId have to open the Ieg and scrape the bone. At this time the chiId came under my observation. The chiId presented the appearance of one exhausted by sepsis (marked emaciation, anxious expression, hot dry skin, rapid
Cohn-OsteomyeIitis
NEW SERIES VOL. XV, No. +
shaIIow
respiration
pulse). We found
a marked
and
a
sweIIing
rapid
thready
of the
FIG. 6. D. T. Before operation,
entire
Journal
of Surgery
241
marked regeneration of the tibia which has taken pIace. A year Iater the chiId returned with pain over
showing destruction
right Ieg from the ankIe up to above the knee. X-ray pictures at this time (Figs. 3, 6) showed a marked destructive process invoIving the upper third of the diaphysis of the tibia. Immediate operation was done. We found that the upper 234 inches of the diaphysis of the tibia was so honeycombed that we feIt that the best thing to do was to remove that portion of the tibia at once. With a motor driven circuIar saw section was made about 2 34 inches beIow the upper Iimit of the diaphysis. The cavity was packed. We aIso found that there was an osteomyeIitic focus in the Iower portion of the diaphysis of the tibia on the same side. With a motor driI1 we entered the meduIIary cana and there found evidence of diseased bone and a smaII quantity of pus. DichIoramine--r pack was introduced and a pIaster cast appIied. The chiId’s condition was so precarious that it was necessary after a few days to give him a transfusion. His convaIescence was stormy, but his eventua1 recovery was excellent as evidenced by the pictures which show the
American
of the upper portion of the diaphysis.
the wrist. We found evidence of an osteomyelitis or capitate. The entire of the OS magnum, diseased bone was removed. The child made an uneventfu1 recovery. He has not had to have, so far as I know, any subsequent operative procedure. CASE IV. Master J. T., aged nine years. The chiId was first seen on the JuIy 17, 1930. His iIIness began in November 1929, with an acute febriIe reaction and pain in both Iower extremities. For two months he was kept under observation because his tonsiIs were diseased. At the end of that time the tonsiIs were removed. The chiId continued to run temperature and this had been considered to be due to rheumatic fever. In June 1930 the family insisted on having x-ray pictures of the extremities because the chiId continued to compIain of pain. The picture showed evidence of disease of the neck of the right femur and the lower portion of the Ieft femur. The doctor who was in charge at the time operated on the chiId, making a drill hoIe in the shaft of the femur beIow the great trochanter. At this time
2-P
hnrericall
.iourllal
“(‘
an incision was made the Ieft thigh, about temperature persisted.
surgery
Cohn-Osteomyelitis
on the inner aspect of the middle third. His
FEBRUARY. 1932
X-ray pictures were taken, bIood count, and Mood culture. The pictures demonstrated a progressive destruction of bone, invoIving the
FIG. 8. D. T. June 14, 1928. Eight months after operation. Showing bone regeneration. No. 76210. neck
7. D. T. January 12, 1928. OsteomyeIitis of OS magnum (capitate) which was removed. Patient has been perfectIy well since. No. 8395.
FIG.
On JuIy 17 the chiId was brought to New Orleans and was referred to Dr. Butterworth through whose courtesy I had the opportunity to see the patient. We found a tiIting of the peIvis. The right thigh was much larger than the left. The right lower extremity was apparentIy Ionger than the left. We found an incision on the inner side of the Ieft thigh above the knee in which we found a pack.
of the right femur with a prohferative osteitis. Just above the great trochanter the cortex had been broken through. There was evidence of a driI1 hoIe beIow the great trochanter. The white cell count was 19,400. It became necessary, because of the destruction of the trochanter and neck, eventuaIIy to remove a11 of the trochanter, neck and head of the femur. It was aIso necessary to operate upon the Ieft femur where there was an osteomyehtic focus in the Iower portion of the shaft. The subsequent course of this case which is stiI1 not a cured case by any means, has been stormy. During his stay in the hospital the
NEW
child
SERIES VOL.. XV,
developed
No. 2
an acute appendicitis
Cohn-Osteomyelitis for which
it was necessary to operate upon him. Later the retroperitonea1 gIands became invoIved, he
This chiId wiI1 be, if he survives, An earIy diagnosis, a terribIe crippIe. and proper surgica1 intervention probabIy wouId have cured this chiId in a very short whiIe. Instead he represents one of the human wrecks which stand as a monument to Iate diagnosis, and as mute evidence of the great destruction that can be produced by osteomyeIitis. In summary then we see two tragic results which foIIowed a diagnosis of pneumonia, and of tonsiIIitis. We witness, by the examination of these two patients, the ravages that septic processes wiI1
JuurnaI
OF Sorgrry
213
In both instances the profound anemia and the sepsis did Iook as though there wouId be a tragic end. It is true
produce.
FIG. 9. Air. 0. B. Showing extensive osteomyeIitic invoIvement of practicaIly diaphysis. September 13, 1929.
deveIoped a septic endocarditis, and at the present time is stiI1 running temperature as his temperature high as IOI OF. For months Several ran as high as 103-104’~. daily. transfusions were given.
Arneri~xn
entire radius except lower third of
they gave us an opportunity to see the beneficent effects of operation and transfusions. It aIso caused a great amount of undue anguish to the parents. FortunateIy the first chiId has recovered and is we11 today. EarIy diagnosis and prompt surgica1 intervention would have cured both of these cases in a short while. EarIy diagnosis wouId have avoided extensive mutiIating operations, and transfusions wouId not have been needed. The resuIt in the first case indicates that regenerative processes wiI1 restore form and function. The next case adds further evidence of the rea1 need for earIy diagnosis. CASE v. Mr. 0. B. This patient was first seen September 17, 1929. FoIIowing is a brief summary of the history as I obtained it from the patient. Patient had pIeurisy five weeks
244
American Journal of Surgery
Cohn-OsteomyeIitis
before. Four weeks previous the Ieft forearm began to sweI1. At this time an x-ray was taken of the eIbow because of pain and some
FIG. IO. Mr. O,,B.
FEBRUARY,193~
the radius except the Iower 1>4 inches. The operative record which foIIows is incIuded because of the method of approach to the
One year and eight months after operation showing great amount of regeneration foIIowed. Patient has never had a second operation. No. 104068.
sweIIing of the forearm. The picture showed no evidence of bone disease. After the first few days he was not confined to bed. 17, a diagnosis On examination, September of osteomyeIitis was made. The patient was admitted to Touro Infirmary for operation. Prior to operation the median, radia1 and uInar nerves were tested for their gaIvanic response. It was found that there was very IittIe deIay in the response. Prior to operation pictures were also taken. These indicated a destruction of aImost the entire radius down to within about 136 inches of the styloid process. Operation was done and this consisted in a subperiostea1 remova of the entire shaft of
which has
radius for a compIete subperiostea1 remova of the radius. “Operation: A subtota1 excision of the radius. Position of forearm, eIbow flexed at right angIes; forearm midway between pronation and supination. Incision made beginning at the IeveI of the head of the radius, and at a point posterior to the insertion of the supinator Iongus, extending foreward obIiqueIy across the forearm, and to the middIe of the forearm and then continued downward to the styIoid of the radius. MuscIes were separated. IntermuscuIar pIanes found, radius exposed subperiosteaIIy, bisected about the middIe and with a Iion-jaw forceps the upper fragment inchIding the head was removed. Pack intro-
NEW SERIES VOL. XV, No. z
Cohn--OsteomyeIitis
duced. Lion-jaw forceps appIied to the Iower fragment. It was decided, however, not to remove the entire Iower fragment, hut to leave the base of the radius with the hope that in that way, a usefu1 wrist might be obtained. When the fragment was removed, the periosteum had attached to it, a Iong invoIucrum, about $4 inch in thickness in some pIaces and tapering down to about 352 inch. DichIoramine-T pack was introduced and interrupted sutures were appIied over the pack. Skin was cIosed with interrupted dermo1 sutures. PIaster cast appIied, eIbow at right angIe, the hand was incIuded, wrist in a cock-up position, or dorsiff exion.” The convaIescence in this case was unusuaIIy smooth and the picture (Fig. IO) shows an amount of regeneration which had taken pIace up to the Iast time that the patient was seen. June 3, 193 r. Since Iast seen his arm has given him no troubIe. The onIy thing he has noticed is that the arm has become stronger. He is abIe to drive an automobiIe. There has been no pain whatsoever. Examination on this day reveaIed the Ieft forearm to be smaIIer than the right. There is a sIight bowing on the radiaI side. There is a scar which extends from the IeveI of the externa1 condyIe obIiqueIy downward to the styIoid of the radius. The scar is about ?,$ inch wide. The patient is able to ffex to sIightIy beyond a right angIe and extend it about 150 degrees. Pronation is compIete, supination to about 60 degrees. There is no Iimitation of motion about the wrist. The grip is exceIIent. Comment: In this instance the patient was treated for a pIeurisy. One week after the onset of the fever pain and sweIIing of the forearm attracted attention to the forearm, but since the x-ray picture did not reveaI any evidence of disease nothing further was done. After another three weeks had eIapsed a second picture was taken. It was then that I had the priviIege of seeing him. A radica1 operation had to be done. The entire radius, with the exception of the Lower 135 inches, was removed superiosteaIIy. Regeneration progressed very rapidIy. No subsequent operations have had to be done.
American Journal of Surgery
245
Mention shouId be made of the method of approach. It has been my poIicy to foIIow the suggestions of the Iate James E. Thompson in the approach to a11 Iong bones. In this instance the forearm was kept midway between pronation and supination with the eIbow fIexed at right angles. The incision began at the IeveI of the head of the radius, and at a point posterior to the supinator Iongus, extending obIiqueIy forward across the forearm and then continuing down to the styIoid of the radius, where we were thus abIe to get in the intermuscuIar pIanes. The radius was exposed subperiosteaIIy. In order to avoid a great dea1 of dissection and damage to the soft tissues thk radius was bisected about its middIe, then with a Iion-jaw forceps it was easy to remove the upper incIuding the head. The refragment, mainder of the operation has been aIready described. In the method utiIized we were abIe to avoid extensive damage to muscIes and important nerves, particuIarIy the radia1 nerve. In the postoperative management of the case we were abIe to give the patient considerabIe comfort by having a mouIded Ieather jacket made for the Iower third of the arm and the entire forearm. I believe that a11 wiI1 agree with me that deIay in diagnosis resuIted in extension of the disease and necessitated an unnecessariIy radica1 operation at a Iater date. EarIy diagnosis wouId have caused Iess disability, Iess pain, and Iess expense to the patient. We taIk of reducing mortaIity and morbidity in cancer, appendicitis, and osteomyeIitis, and yet such caIamities as these are mute evidence that our progress toward the goa is sIow if at a11 sure. Too much dependence is stiI1 pIaced on x-ray pictures. In the two preceding cases attention has been caIIed to the regeneration which has taken pIace in these patients. RecentIy it has been my good fortune to see a patient on whom I did a compIete superiostea1 resection of the diaphysis of the tibia fifteen years ago. At the present time
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Cohn-OsteomyeIitis
there has been not onIy a compIete regeneration, but the form of the tibia has been restored. This case presents so many
FIG. I I. Miss H. V. Fifteen years after subperiostea1 excision of entire diaphysis of tibia. Patient has never had any further operative procedure. No. 102211.
interesting features regeneration, that be incIuded.
besides the satisfactory a brief summary wiII
CASE VI. Miss H. V. White femaIe, aged eIeven years? Patient originaIIy presented herseIf to a surgeon who drained a subperiostea1 abscess about her ankIe. Five weeks Iater the patient came under my observation. At that time there were a number of draining sinuses on the inner side of the Ieg. X-ray pictures taken at this time reveaIed the fact that the
FEBRUARY,1932
tibia was honey-combed from one end of the diaphysis to the other. A subperiostea1 resection of the entire diaphysis was done. This patient has not needed another operation. The original operation was done fifteen years ago. At the present time an x-ray picture (Fig. I I) shows a fuIIy regenerated tibia. A synostosis has formed between the tibia and the astraguIus, but in spite of this the patient dances, walks and carries on generaIly without discomfort. AI1 of her ankIe movements are accompIished through the astragaIocaIcanean articuIation. The method of treatment utihzed for the past eighteen years has been consistent. In the few cases in which a rea1 acute condition has been found, at the time that the patient has come under observation, the foIIowing method has been utiIized. A diagnosis is made in those cases which present a history of an acute febriIe onset with pain as a ruIe IocaIized over the shaft of one of the Iong bones. There is usuaIIy a marked Ieucocytosis. X-ray is not depended upon for diagnosis. The x-ray can be of service onIy when the disease has existed Iong enough for destructive changes to have taken pIace. Under no condition can the x-ray give definite information unIess there is a difference in the density of the various portions of the bone invoIved. I believe that it is better to err when no osteomyeIitis exists, rather than to deIay and wait for definite x-ray changes. Under genera1 anesthesia an incision is made through the periosteum and a number of driI1 hoIes are made through the cortex, and if the disease is in that portion of the bone above the canceIIous end of the diaphysis, into the meduIIary cana1. Two points which I shouId Iike to emphasize right here are (I) that the presence of pus under the periosteum indicates that the operation shouId be extended to incIude drainage of either the canceIIous portion or the meduIIary portion of the bone, depending upon the Location. It cannot be emphasized too often that a11 pus outside of the cortex must have gotten there in a centrifuga1 manner. Drainage is the essen-
NEW SERIES VOL.XV, No. 2
Cohn-Osteomyelitis
I.
DE CHAULIAC, GUY. On Wounds 1363.
2.
CABAN&.
247
The Orr method of treatment does not seem to me to meet surgica1 principles. WhiIe many are wiIIing to accept the method, it does not appea1 to me. The secretions which do accumuIate irritate the skin and after a time the odor which emanates from the dressing is nauseating. With more frequent change of dressings there is Iess IikeIihood of conceaIed damage occurring. It is not my intention to enter into a controversy with those who prefer putrefactive odors due to unchanged dressing, or with those who stand by and expect heaIing processes to be promoted by Iiving scavangers in the form of repuIsive maggots as advocated by the Iate Dr. Baer. Let me hasten to add that Bear did obtain good end-resuIts by the use of sterilized we11 bred maggots; so do the foIIowers of Orr, and so have we. The resuIts are dependent more on the factor of prompt drainage of the infected and devitaIized bone, than on anything eIse. The amount of destructive change is directIy proportionate to the Iocation of the emboIus, and to the promptness with which drainage is instituted.
tia1 thing. The type of drug appIied which is used is almost immaterial. With free drainage it matters IittIe whether dichIoramine T or vaseIine, or anything else is used. The advantage of an oiIy substance on the gauze is that it does not become adherent to the endosteum. By way of digression I shouId Iike to insist that in acute osteomyelitis a curette shouId never be used because with the curette you destroy the very ceIIs on which YOU are depending for regeneration. There is aIso a grave danger of injuring the nutrient artery, and if a cIot is formed you are IikeIy to have the entire diaphysis of a pIaster sequestrate. Th e appIication cast has been our practice. In Iater cases the amount of bone to be removed is dependent on the amount of evident disease. After the cavity has been Ioosely packed with dichIoramine T (since 1917) the pack is usuaIIy aIIowed to remain for five days, after which it is removed. If the pack is not removed the suppIy of dichIoramine T has been repIenished.
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American Journal of Surgery
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8. D’HERELLE, F. The Bacteriophage
and its Behavior. Bait., WiIkins and WiIIiams, 1921. PARS, AMBROISE. La methode de traicter Ies * Continued
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ALBEE*
pIayes faictes par hacqvebvtes et avItres bastosn B feu. g. ALBEE, F. H. The principIes of the bacteriophage applied to OsteomyeIitis. Internat. J. Med. H SW&,
42: I, 1929.
IO. ALBEE, F. H. The bacteriophage in wound treatment. Internat. J. Med. CYSurg., 42: 658, 1929. II. ALBEE, F. H., and PAITERSON, M. B. The bacteriophage in surgery. Ann. Surg., gr : 855, 1930. 12. ALBEE, F. H. The bacteriophage in surgery. Internat. J. Med. Ed Surg., 43: 461, 1930. 13. ALBEE, F. H. The bacteriophage in surgery. Rebabilitation Rev., Aug., 1931, 5, Ig5-201. 14. HUXLEY, J. BioIogy and our future worId. Harper’s, Sept., 1931. from p. 236.