gradually absorbed. In adult bones where osteogenesis is slower or where it may fail to accomplish the desired result, the plastic use of bone, muscle, fat or skin may be desirable.

During the course of the disease, joint contractures are prone to occur, and the protective and mechanical treatment to prevent these are of utmost importance. Where the sequestrum involves a large part of the shaft, fracture of the involucrum may also occur if protection is not sufficient.

DISCUSSION.

It

DR. SAMUEL J. MIXTER, Boston, Mass.: seems to me, there is only one fault in this paper, and that is, the author did not have X-rays taken of the humerus at shorter intervals and show them as a movie, because this is certainly a most remarkable series of pictures that one can imagine from the beginning to the end of the process, and if he had had them taken a little oftener and put them in a machine, it would have shown the whole thing.

There is one type of case that is important, and that is, where we have in the adult a sudden, very acute infection. Perhaps it has been opened and insufficient drainage established; but the whole shaft is involved to the tibia. Nearly the whole shaft is involved. The man is very sick. You can cure that man if you amputate his leg. If you open up that bone, and do a real, thorough operation, a conservative operation, he is going to die. I have seen them die in from three to twenty-four hours after such an operation. On the other hand, amputation will save them, while a conservative operation will kill them. There are certain of these cases which we meet with very seldom, but when we do they must be recognized.

DR. JAMES E. MOORE, Minneapolis:

It is with

a great deal of pleasure that I respond to the request of the Chairman to discuss this paper, because after teaching surgery for thirty-five years I feel that if there is any field in which I have accomplished some good it has been in teaching osteomyelitis to students,-how to diagnose the condition and how to treat patients with this disease, which, in earlier days, was neglected.

I do not think it would be amiss to dwell briefly upon the diagnosis, because in the University Hospital where we have cases coming in from all over the state, and from other states, we find many that have been neglected. We have found many cases of osteomyelitis that have not been recognized, and have been usually sent in with a diagnosis of rheumatism. All sorts of diagnoses have been made in these cases.

I want to call your attention to one important point, one in which you might be misled by these skiagraphs which you have seen today, and that is, that the skiagraph will not show infection in the

medullary cavity of bone at a very early stage. You may have a pronounced abscess at the end of the diaphysis of the long bone, you may take a beautiful skiagraph which will show all the trabeculae of the bone, but it will give you no evidence whatever of an abscess. You may cut in and discover the abscess. That is something you must guard against. The history in these cases is so complete that, it seems to me, there is no longer any excuse for a mistake in diagnosis, or neglect to make the diagnosis. Last summer a little child was brought into the University Hospital with an infection of the neck of the femur. The child had a temperature of 104°, and yet these boys, interns of mine, made a diagnosis of osteomyelitis beginning in the neck of the femur in the growing bone.

He

A child is brought in after playing probably all day, particularly when that child has been going in swimming, or has been skating, complaining of the knee joint. Perhaps the knee hurts terribly. Pretty soon the mother finds the child's cheeks red, and shortly thereafter the child will have a severe chill. A doctor is sent for. Already flexion has begun to take place, and the old-fashioned doctor will say rheumatism and apply a poultice, and so on. No modern practitioner will make a mistake there. will examine this child who says that his knee hurts, and he will find the seat of pain is not exactly in the joint. If he carefully manipulates the extremity he will find that the excruciating point of tenderness is always a little above the knee joint or a little below. In other words, you have an infection in the center of one of these bones in the medullary cavity and a sensitive point at the beginning of periostitis. Periostitis is not the original lesion, but secondary lesion. Periostitis, with the exception of a few cases in typhoid fever, is secondary to osteomyelitis, to the central infection.

Dr. Colvin called attention to one very important point in the treatment on which I want to lay stress. As soon as you make a diagnosis in one of these cases, put the limb in a position in which it will be the most useful should ankylosis occur. Too frequently we have children brought into the University Hospital with ruined knees because the doctor had neglected to put the limb in proper position. We try to do what we can for these children, but invariably we find the knee flexed at a right angle, making it useless. That is malpractice. Given this acute train of symptoms,-chill, high temperature, and a tender spot near a joint,-it cannot be anything else but acute osteomyelitis.

The diagnosis having been made, there is only one treatment, and that is, to cut down into the center of the bone. Do not be content to stop after you have cut down through the soft parts to empty the abscess; you have only reached the secondary complication, as it were; you have not reached the original seat of infection. You must chisel down into the medullary cavity and establish drainage. The most difficult part of treatment of osteomyelitis is in

A. W. ADSON, M. D., Mayo Clinic, Rochester, Minnesota.

The essayist has suggested the most modern way of treating these cases, and that is, to get these cavities cleaned out and fill them with the Moorhof bone wax. I have had gratifying results from such treatment based on surgical principles. Nature will displace that bone wax and replace it with bone, and you will get the cavity filled up; otherwise, you must resort to the old method of packing, which is a long, tedious process. The most difficult part, as I have said, in the treatment, is the curing of these old cases with sinuses. In those in which the sequestrum has been removed, with the proper appliIcation of the bone wax you can get highly satisfactory results.

DR. ALEXANDER R. COLVIN (closing the discussion): While agreeing with every word Dr. Moore has said, I am nevertheless much impressed with the difficutly of an accurate pathological diagnosis in acute infections of bones and joints, and I have a fellow-feeling for my medical brethren under certain trying conditions. However, there should be no hesitation as to what should be done as soon as the diagnosis is made.

I have under my care at the City Hospital at present, a child of six years who was admitted with a temperature of 104° and a decided hip limp with muscular spasm on attempted passive movement. The condition was suspicious of osteomyelitis of the upper end of the femur. If one's suspicions were correct, it was imperative to attack the bone, but because of doubt nothing was done and the condition gradually cleared up; this was certainly an acute infection of either the bone or joint.

There is no doubt that very stormy infections of joints clear up without suppurating, whether, especially in the young, an acute infection of bone may pursue the same course is questionable but I think it probably does. The very great variability of the clinical and pathological manifestations of acute infections by the same micro-organism, in the same organism, and at the same time, is a most interesting phenomenon. For instance, in a case under observation having an initial suppurating infection of a tendon sheath with metastatic suppurating foci in the calf muscles and at the same time a severe nonsuppurating arthritis of a shoulder and hip joint.

The symptoms of an acute infection of the joint end of a bone are practically those of joint inflammation.

Progressive ulnar paralysis is a clinical condition which has long been recognized but has rarely been treated surgically. It has been diagnosed as a progressive muscular atrophy and as a form of muscular distrophy. A number of patients have been examined in the Mayo Clinic who have had a single progressive ulnar paralysis and no other form of paralysis or atrophy. The operative findings in these cases verified the clinical condition and presented a marked interstitial neuritis with a diffuse thickening of the nerve as well as nodular masses like neuromas.

Symptomatology. The patients who have been under observation in the Mayo Clinic present similar symptomatology: First, the complaint of various forms of slow, progressive sensory changes, such as paresthesias and anesthesias, that is, tingling, hypersensitive areas of the skin, and numbness along the course of the ulnar nerve. Second, trophic disturbances, atrophy of the small muscles of the hands, of the flexor carpi ulnaris and of part of the flexor profundus digitorum which are supplied by the ulnar nerve; the atrophy of the hand is most

prominent in the hypothenar region, and there is marked depression between the base of the thumb and the second metacarpal bone. Third, a progressive motor paralysis, first noticed as a definite weakness, and then a gradual loss of motor control of the muscles involved. This phase also presents a peculiar contracted condition of the two outer fingers. (Fig. 1). Recently we have operated on the ulnar nerve in three cases in which there were very definite pathologic findings. The nerve was found to be very much enlarged and to present one or more so-called "neuromas" (intraneural fibrous tissue). The enlargement was of the fusiform type with definite thickening and hardening of the nerve itself and the neuromas were quite definitely circumscribed, though more or less diffuse throughout the nerve tis-. sue. The ulnar groove between the internal condyle and olecranon was found to be very shallow, owing, in two cases which were end results of old fractures, to an overgrowth of bone from the olecranon. In one instance a very definite bony spur of the ulna was present, without a history of fracture. It appears that the diffuse thickening of the nerve is due to frequent or constant but very slight trauma, such as bruising, or to the stretching of the nerve over some of the bony prominences. Small hemorrhages in the perineurium and in the endoneurium result, causing inflammatory reactions and the deposit of scar tissue. As the scar tissue tends to contract, many of the fibers become strangulated and eventually are destroyed, resulting in a gradual and progressive atrophy of the ulnar nerve.

Reports of Three Cases

Case 1 (82214).-R. L. K., a male, 31 years of age. The chief complaints were numbness, atrophy and weakness of the muscles supplied by the right ulnar nerve. The patient fractured his elbow in 1892, displacing the internal condyle downward and inward, and giving the elbow a broadened appearance. The displacement of the internal condyle carried the ulnar nerve with it, leaving it in a very much exposed position on the apex of the displaced fragments, thus causing its frequent injury. Two months previously the patient received a very hard blow on the elbow. Following this he noticed marked numbness, slight loss of tactile sensation, and beginning atrophy of the small muscles of the hand, associated with corresponding weakness. The weakness of the hand was progressive and surgical relief was advised and decided on (Fig. 2).

Operation, Jan. 17, 1918.-The ulnar nerve was exposed in its extremely shallow groove, and the nerve was brought up over a portion of the internal condyle. For a distance of about 3 cm. the nerve was considerably thickened and presented a neuroma of about one-eighth the size of the normal nerve, situated over the most prominent portion of the internal condyle. The nerve was freed from the surrounding structures and transferred to a position internal to the condyle.

Case 2 (220582).-J. A. L., a farmer, aged 42 years. There was no history of fracture or bony disturbance of the elbow. There was numbness, and a tingling sensation in the right hand, with atrophy and weakness of the mus

cles supplied by the right ulnar nerve. Four years previously the patient had first noticed. numbness and tingling sensation in the right little finger and on the ulnar side of the ring finger. Afterwards he noticed that those two fingers became cold sooner than other parts of the hand; a little later he noticed that the hypothenar surface of the hand became very thin and flabby; then a marked depression appeared between the base of the thumb and the second metacarpal bone, together with atrophy of the muscles of the outer part of the right fore-arm. About six months previously the patient had noticed that when he flexed the fore-arm on the brachial region, the numbness and tingling sensations were increased, with associated pain above the right clavicle. At the time of examination he complained of more or less constant numbness and of a tingling sensation along the course of the ulnar nerve. There was marked atrophy of the small muscles of the hand; the flexor carpi ulnaris and part of the flexer profundus digitorum presented a decidedly thickened and nodular nerve in the ulnar groove (Fig. 3).

Operation, Feb. 9, 1918.-There was a fusiform thickening of the ulnar nerve for about 4 cm. over the prominent portion of the elbow. In addition there were many adhesions about the nerve, with three neuromas which were about one-fourth the size of the normal nerve, the latter situated so that each came in contact with the other in the thickened portion of the nerve. The ulnar groove between the

condyle and the olecranon process was normal in its depth when the arm was extended, but on flexion of the fore-arm a bony prominence, a spur from the ulna, presented itself, which exposed the ulnar nerve and produced a constant irritation.

Case 3 (222410).-Mrs. J. S. D., age 32 years. The patient complained of numbness and a tingling sensation on the outer surface of the hand and fore-arm. There were atrophy and weakness of the muscles. Twenty-three years previously the patient had had a fall which resulted in the epiphyseal separation of the humerus at its lower extremity. Two years after the first fracture she had had a similar experience, but at that time there was no ulnar disturbance. Five years previous to our examination the patient first noticed numbness, more or less constant, in the little finger of the left hand, and three years later she noticed a beginning contraction of the two outer fingers of the left hand, which was associated with a thinning of the hand and a gradual loss of strength. During the last ten months she had noticed that the numbness was gradually increasing, extending from the hand to the forearm, and that in the last three of four months there had been a constant dull ache in the region of the elbow and shoulder. On coming to the Clinic the patient presented a picture. of paresthesia and anesthesia, of atrophy, and motor weakness, which followed the course of the ulnar nerve (Fig. 4).

Technic of the Operation.

Because of a tendency to overgrowth of callus which results in a condition similar to that for which the patient seeks relief, we have chosen as a surgical procedure, the transference of the nerve to a position anterior to the internal condyle in preference to removing bony prominences or creating a new bony groove as has been done by several other surgeons.

The nerve is freed for a distance of about three inches above the internal condyle as well as for three inches below it, and is then raised from its old ulnar groove to a position internal to the condyle. The tendons and a few of the muscle-fibers of the inner head of the flexor carpi ulnaris as well as a few of the tendonous fibers of the common flexor tendon are divided in order to bury the nerve underneath the tendonous fibers, rather than to leave it exposed on the surface of the internal head of the flexor carpi ulnaris, which would tend to expose it to slight trauma. The nerve is held up in