HISTORY OF ILLUSTRATIVE CASES.

Case I. Dates back to January, 1909 and is my earliest acquaintance with the condition. The patient, male, 10 years, in poor health and flesh, injured left upper arm several days ago. The injury was held to be a fracture by the attending physician. On examination a distinct lump was felt between the middle and upper third of humerus. This was thought to be due to overriding of fragments. The personal history related several injuries to the same arm previous to the present one; the last one about ten months ago. They were not, however, held to be fractures at the time. The X-ray revealed the lump to be an atrophic bone lesion, oval in shape and evidently cystic in nature, involving the medulla of the humerus. The appearance suggested a neoplasm which the history of the repeated injuries made likely. Exploratory operation was advised and done same month, the plan being. to be prepared to amputate should the gross appearance and fresh section examination show malignancy beyond doubt. At operation a cavity was found containing a blood-like mass and a hemorrhagic membrane. Specimens of these and bone chips from the wall of the cavity were taken for examination. There being no distinct sign of neoplasm the wound was closed after curettage and the arm splinted. The pathologic findings of Dr. Bartlett revealed no sign of malignant tumor formation but suggested a low grade chronic inflammation. A slow but apparently complete recovery took place. However, the arm was broken again, with little provocation, in the same place in October of the same year. It was treated by splinting, after union for some time by stimulating treatment such as heat and massage. The patient is well to-day, the arm has completely recovered and no further difficulties with it have been experienced.

Case 2. Connects the lesion directly with injury. Patient, female, 24 years, seen January 1920. In September 1919 she fell, striking the front of the tibia below the knee on the edge of a trolley rail. The bruise promptly healed but sometime after a swelling was noticed at the side of the former injury. At the time of the first examination this swelling was about the size of a

hen's egg, smooth to touch. The skin over it showed some pressure signs. The X-ray presented a cystic cavity with several compartments. The diagnosis of osteomyelitis hemorrhagica was made, and operation done. The cavity was filled with a gelatinous mass and lined by a hemorrhagic membrane. It was curetted and closed. A protective brace was worn for six months, a complete recovery was made, the patient is well and about.

Seen June, 1920, has also the history of trauma but whether the osteomyelitis found at the time of the first X-ray examination was cause or effect of the injury cannot be told. Patient male, five years, fell, breaking leg, June 1919. Since then the patient has been seen by quite a number of practitioners. He wears a protective brace but he limps with and without it considerably. The tibia is bent to an angle of one hundred and fifty degrees and there is a false point of motion. The X-ray shows an ununited fracture and bone cysts in the proximal fragment. The diagnosis: ununited fracture in presence of osteomyelitis hemorrhagica. At operation the lower fragment has its edges freshened. The upper fragment is found to have a cavity containing a bloody mass and a hemorrhagic membrane. This is curetted out. Apposition of fragments without suture, cast applied for six weeks, bony union promptly followed. A protective brace was worn, the patient is well and about and the union firm.

Case 4. Illustrative of the possibility of lesion being mistaken for a tubercular joint. Patient, female, six years, in fair health and flesh, has been lame in left leg for upward of six months. There has been occasional pain but not severe. There is no atrophy of the muscles of thigh or gluteofemoral region, only rotation in hip is limited. The X-ray shows a large cystic area involving the region in the neck, trochanter and upper part of shaft. Diagnosis of osteomyelitis hemorrhagica was made. This diagnosis is confirmed by operation, the lesion being entered through the trochanter. A large cavity filled with a bloody mass and lined by a hemorrhagic membrane is exposed. Curettage was done. A supporting brace is worn and should be worn for some

time for fear of fracture through the very thin bony shell remaining after curettage. The operation is followed by the cessation of pain and the limitation of movement. The lesion is filling in. The patient is well and about though still, for above cited reason, on a supporting brace.

DISCUSSION.

DR. E. A. CODMAN (Boston): I am very much interested in this subject, but cannot add anything to the paper. This presentation of the subject has been excellent. I was inquiring whether the reader had been a teacher, for it is so well done that I am sure he has been a teacher of students. He did not confuse us with the other words which have been applied to this disease; he called the condition hemorrhagic osteomyelitis. It is also called osteitis fibrosa by many and bone cyst, and it is on the border line of the giant cell tumor, about which Bloodgood and Barrie have written so much. The important thing is to distinguish these lesions from malignant tumors for undoubtedly many such cases are being amputated for

sarcoma.

I have been interested in what we call the Registry of Bone Sarcoma, in which we register cases of bone sarcoma as we would register a pedigreed animal, so that the case will be definitely on record, if it is cured by radium, Coley's serum, amputation or by any other method. Dr. Bloodgood of Baltimore, Dr. Ewing of New York, and myself are trying to do this, and if you have any such cases we hope you will register them with us and supply us with a bit of the tissue.

It is extremely important to spread what the reader has said about these cases of hemorrhagic osteomyelitis over the country, for undoubtedly such cases are being observed and having excisions or amputations done, when they are quite curable by the means he has adopted, and others. No doubt radium therapy and crushing the bone so as to drive the outer part into the center of the cyst will cure them. Probably the best and safest way is as Dr. Arnold has done.

You have in Hartford one of the few cases of true sarcoma, reported by Wells, some ten years ago. I have been able to find less than a dozen cases of true bone sarcoma now living after a period of five years. When we have looked at the specimens which have been sent to us many have proved to be this hemorrhagic osteomyelitis which Dr. Arnold has described.

DR. ARNOLD (Closing): I will confess to being a teacher; it is one of my side lines and has been my profession. The importance lies just where Dr. Codman said,-in preventing the mistaken diagnosis of malignancy. I know of some cases where amputation has been done for this con

dition, and where a better knowledge of the condition would have prevented it. The recognition of it, though, may not be as easy as I represent it, but it is possible to make a differential diagnosis by the behavior of the conditions that come in for consideration. As to name I especially like to call a condition by a name which describes it; I think that osteomyelitis and hemorrhagica defines it; osteofibrosis does not describe it exactly. It describes a rather later stage of it. After cutting into quite a number I have been struck by the hemorrhagic nature of the condition. They all stop bleeding after the membrane is removed.