ACUTE INFECTIOUS EPIPHYSITIS. 
BY 
W. M. L. COLLIN; M.D., 
ADJUNCT PROFESSOR OF HYGIENE AND DEMONSTRATOR OF PATHOLOGY IN 
JEFFERSON MEDICAL COLLEGE, 
AND' 
D. BEVAN, M.D., 
ASSISTANT IN DEPARTMENT OF HYGIENE, JEFFERSON MEDICAL COLLEGE, 
OF PHILADELPHIA, 
FROM 
THE MEDICAL NEWS, 
August 13, 1892. [Reprinted from The Medical News, August 13, 1892.] 
ACUTE INFECTIOUS EPIPHYSITIS. 
By W. M. L. COLLIN, M.D., 
ADJUNCT PROFESSOR OF HYGIENE AND DEMONSTRATOR OF 
PATHOLOGY IN JEFFERSON MEDICAL COLLEGE, 
AND 
D. BEVAN, M.D., 
ASSISTANT IN DEPARTMENT OF HYGIENE, JEFFERSON MEDICAL 
COLLEGE, OF PHILADELPHIA. 
Definition.-Acute infectious epiphysitis is a 
disease peculiar to infancy and adolescence, and is 
due to the specific pathogenic action of one or more 
of the microbes of suppuration. It is a disease the 
etiology of which modern bacteriologic research 
has revealed, and which for more than a century 
and a half had baffled the most diligent inquiry of 
able scientific observers. 
Synonyms.1-The disease is best known in the 
United States by the names of acute infectious osteo- 
myelitis and acute infectious periostitis. Acute 
infectious arthritis is also applied to a special form 
of epiphysitis. 
History.-In 1805 J. L. Petit described an acute 
affection of bone, which we now recognize as acute 
osteomyelitis. This is the first distinct mention 
that we have of this disease. Allusions were made 
1 The various synonyms used will be fully discussed in consider- 
ing the history. 2 
COPLIN AND BEVAN, 
to it also by Gooch, Pott, Cheselden, Hay, and 
Abernethy. 
Bearing on this subject, M. Renaud, in 1831, pub- 
lished a paper "On Inflammation of the Medullary 
Tissue of Long Bones," and reported five cases 
occurring after amputation, all of which terminated 
fatally. 
Cruveilhier refers to it as "phlebitis of bones," 
when suppuration supervened on amputation, and 
attributes to it the formation of visceral abscesses. 
Jules Teilhard La Terrisse first employed the 
designation acute arthritis of infants in 1831, in 
his thesis submitted for the degree of Doctor of 
Medicine, to the Faculty of Medicine in Paris, in 
which he reported three cases in children, aged 
respectively three, six, and nine days. At the 
necropsy pus was found in each case in several of 
the joints, and in one case a number of abscesses 
were found in the lung. 
Nelaton is credited by Roux as having devised 
the term osteomyelitis in 1834; in 1844 he pub- 
lished a brief account of it under the title of " Sup- 
puration of Bone." 
Mr. Stanley, in 1849, in h's monograph on " Dis- 
eases of Bone," gives an accurate description of the 
kryptogenetic, or the then so-called spontaneous 
variety. Schultzenberger directed attention, in 
1853, to this disease as "Rheumatoid Periostitis." 
Chassaignac, having studied it in the same year, 
and recognizing its infectious character, gave to it 
the name of "Acute Infectious Osteomyelitis," 
and, for the first time, applied to the spontaneous 
variety, in 1855, name " Osteomyelitis," and ACUTE INFECTIOUS EPIPHYSITIS. 
3 
detailed four cases that came under his own ob- 
servation. 
In 1855 the affection was described by Becker 
as "Phlegmonous Periostitis." Almost at the 
same time Klose published an account of thirteen 
cases under the term " Meningo-osteo-Phlebitis." 
In each case there was epiphyseal separation. 
"Epiphyseal Ostitis of Adolescence" was the term 
applied to it by Gosselin, at about this time. 
Garnet's thesis on this affection appeared in 1862. 
He entitled it " Juxta-epiphyseal Osteo-periostitis. " 
Geraldes designated it "Phlegmonous Periostitis." 
V. Roser bestowed upon it the name of "Pseudo- 
rheumatism," on account of the number of bones 
involved and the frequency with which the joints 
were implicated. Luecke is given credit with hav- 
ing first called attention to its infectious character. 
Lannelongue gave a description of it in 1878, 
under the heading of " Acute Osteomyelitis of 
Adolescence." 
Mr. T. Smith, a surgeon in St. Bartholomew's 
Hospital, has reported two cases of "Acute Arthri- 
tis of Infants." In his treatise on the Disease of 
Joints, Barwell describes the affection as "Peracute 
Articular Ostitis;" he also uses the term epiphysitis, 
taking his definition from Stromeyer's memoirs on 
Ostitis Articular Peracute. 
From the frequent occurrence of the separation 
of the epiphysis from the diaphysis, Klose describes 
it as " Epiphysentrennung," also as " Meningo- 
osteo-Phlebitis." Krause called it "Acute Puru- 
lent Synovitis in Infants."' 
MacNamara, in the first edition of his work, 4 
COPLIN AND BEVAN, 
speaks of " Acute Epiphysitis "; but, exception being 
taken to this term as applied to this disease, in the 
third edition he refers to it as " Suppurative Ostitis." 
In the work of Thomas Jones on Diseases of 
Bone, he discusses it under the subject of " Acute 
Osteo-myelitis and Necrosis of the Epiphyses and 
Articular Extremities of Bone." 
Normal Histology of Bone.-Before consider- 
ing the etiology or the pathology of acute infectious 
epiphysitis it is necessary to form a clear and com- 
prehensive idea of this subject, that we should recog- 
nize and differentiate between the conditions existing 
at, and previous to, the completion of ossification, 
the arrangement of the vascular system, and other 
special anatomic and histologic peculiarities of the 
bones, all of which exercise a potent influence in 
determining pathologic conditions in these struc- 
tures. 
Bone is produced by a temporary cartilaginous 
substance being converted into medulla. This 
change is induced by the cartilage becoming pierced 
by channels or bloodvessels with but an imperfectly 
developed coat of soft connective tissue, as it is 
necessary that actual contact should take place 
between the blood and the cartilage-cells before 
further development can occur. The cartilage-cells, 
thus receiving an additional amount of nutriment, 
are stimulated to increased activity. With the 
further development of the bone, the periosteum 
and endosteum are produced, and then we have the 
bone growing from the cells contained in the 
medulla, the endosteum, and the periosteum. 
The periosteum is developed by the outer layer ACUTE INFECTIOUS EPIPHYSITIS. 
5 
of cartilage assuming a reticulated fibroid character, 
in the meshes of which are contained osteo genetic 
cells, and it is by their further and continued de- 
velopment that the bone is increased in thickness. 
The bone receives its nourishment not only from 
the nutrient artery, but also from innumerable small 
arteries that penetrate into the bone from the peri- 
osteum, being derived from arteries of adjacent 
structures. The arteries are distributed throughout 
the compact portion of the bone by the system of 
Haversian canals. In the cancellated structures 
some vessels follow along the trabeculae, while others 
span across the space occupied by the soft marrow. 
In this situation they bear a strong resemblance to 
the blood-sinuses in the spleen. The sinuses are 
larger than the arteries that empty into them. In ad- 
dition to the veins accompanying the nutrient artery, 
those arising in the compact tissue and those making 
their exit through the articular cartilage, there is a 
venous plexus surrounding the bone at the junction 
of the epiphyseal cartilage with the diaphysis, 
greatly facilitating the flow of the blood from this 
situation. The epiphyseal cartilages receive their 
blood-supply from the arteries of the medulla. 
Continuous with the endosteum in the medullary 
cavity is a network of adenoid tissue, which is also 
found accompanying the bloodvessels in the 
Haversian canals. This is regarded by many author- 
ities as the commencement of the lymphatic system 
in the bone. In the meshes of this structure are 
numerous cells both morphologically and function- 
ally resembling the corpuscles in the spleen. The 
subcartilaginous layer of bone is a dense plate of 6 
COPLIN AND BEVAN, 
compact osseous tissue, situated between the epiphy- 
sis and diaphysis. It is pierced by numerous 
vessels entering the epiphyseal cartilage from the 
shaft. From its peculiar structure it possesses great 
resistance to all inflammatory processes. In it there 
is no definite Haversian system. 
The medullary substance occupies the central 
cavity of tubular bones, and is also continuous with 
the soft tissues contained between the trabeculae in 
the cancellated portion of the bone. At the ex- 
tremity of the diaphysis it terminates in bulbous 
processes, and from these numerous other processes 
are given off, which penetrate the subcartilaginous 
disc, and, uniting with one another, form arches. 
Etiology.-The specific cause of acute infectious 
epiphysitis is not a special organism, as Becker at 
one time supposed, but-as determined by Krause, 
Garr6, and Rosenbach, whose researches and 
observations have been substantiated by many 
of the more able bacteriologists of the day-this 
disease is produced by one or more of the vari- 
eties of pyogenic microbes the entrance of which 
into the circulation is usually effected through some 
abrasion of the skin, or, less frequently, through the 
mucous membrane of the respiratory or alimentary 
tracts ; a decayed tooth, or any suppurating inflam- 
matory focus, however small, may be a portio inva- 
sionis. The organisms have, apparently, a predilec- 
tion for the long bones, and more frequently attack 
the one extremity, that from which the development 
of the bone is principally accomplished, e. g. the 
lower epiphysis of the femur and the upper epiphysis 
of the tibia. ACUTE INFECTIOUS EPIPHYSITIS. 
7 
The short and flat bones are not exempt from the 
process, and that they are not frequently involved 
may be ascribed to the fact that their position and 
function render them less liable to injury, and that 
the evolving changes in their development are not 
of such an active character as we have observed in 
the long bones. 
The selective affinity of the microbes for one or 
the other extremity of a bone, or for any particular 
class of bones, is not incomprehensible when we 
study the anatomic structures. We discover that 
in the medullary tissue, in proximity to the epiphy- 
seal cartilage, where the transitional changes and 
the vascular supply attain their maximum, and 
where the blood-pressure and velocity are at a 
minimum, where the capillaries are mere excava- 
tions, sinuses, or have but an imperfectly developed 
wall, we have all the conditions most favorable 
for the localization and multiplication of micro- 
organisms, the pathogenic action of which is in 
health counteracted by the inherent vital resistance 
of the cells. 
Roswell Park asserts that the marrow is " predis- 
posed to collect and retain germs, and that it is most 
sensitive in its reaction"; from its constitution it 
also affords a soil that is particularly adapted for 
their nourishment and proliferation. 
As early as 1874, Klebs, Recklinghausen, and 
others, discovered the presence of cocci in the bodies 
of patients dying of acute infectious epiphysitis, 
Pasteur found micrococci, and in 1881 Schuller 
amputated a limb, and found the same organisms 
in the bone, periosteum, and articular cartilages. 8 
COPLIN AND BEVAN, 
In the same year Rosenbach cultivated from one 
case the staphylococcus aureus and albus, from 
another the staphylococcus albus alone, and from 
a third the staphylococcus aureus and the strepto- 
coccus pyogenes. He also produced the disease in 
animals by injecting the pus from a furuncle, after 
subcutaneously fracturing the bone, and with the 
pus from osteomyelitis produced in the subcutaneous 
issues a furuncle. 
Becker, in 1883, made most careful and extended 
observations, and thought that he had discovered 
the specific microbe of osteomyelitis. Rodet has 
produced osteo-myelitis by the intravenous injec- 
tion of cultures of the staphylococci, and without 
fracturing or otherwise injuring the bones; this, 
however, was possible only by intravenous injection, 
never in his hands /by the mere introduction into 
the subcutaneous connective tissues. Krause, in 
1884, cultivated froip the pus the staphylococcus 
aureus and albus, and found the same organisms in 
effusions about the joints. 
Subsequently, he produced the disease in animals 
by injecting pure cultures of these cocci, and making 
subcutaneous fractures. Garre corroborated the 
experiments of Krause, and also discovered the 
staphylococcus in the blood. Krause observed 
lesions in the muscles, kidneys, and other organs 
identical with those found in pyemia. 
Kocher experimented by injecting foul and putrid 
material into animals, and was sometimes successful 
in producing the disease. His failure in the other 
cases was probably due to the fact, that the sub- ACUTE INFECTIOUS EPIPHYSITIS. 
9 
stances injected contained none of the pyogenic 
organisms. 
In children that have inherited constitutional 
taints, as those of tuberculous and syphilitic parents, 
the resistance to the action of pyogenic organisms 
is much diminished, so that we find that they are pre- 
disposed to osteomyelitis, as also are those that have, 
or are convalescing from, any of the acute infectious 
or exanthematous diseases. Thus, T. Holmes, in 
The Surgical Treatment of Diseases of Infancy and 
Childhood, reports the case of an infant but seven 
months old, in which suppuration of the hip-joint 
succeeded an attack of chicken-pox. 
Dr. K. McLeod's case of epiphysitis, reported in 
the Indian Medical Gazette for 1883, was attributed 
to variola. Leucke, Keen, and Renne have demon- 
strated, and as experience and history of the cases 
confirm their conclusion, it may be received as a 
truth, that the specific poisons of diphtheria, typhoid 
fever, scarlatina, measles, rubeola, and variola, pre- 
pare the medullary tissues for the reception of the 
pyogenic germs. 
An influential role is assigned to exposure to cold 
and damp as a predisposing factor, and as the exceed- 
ing activity of the tissue-changes in growing bone 
involves an instability, any sudden change tending 
to disturb the equilibrium of the circulation will 
create the conditions necessary for the inception of 
osteomyelitis. Professor Senn avers to have repeat- 
edly observed cases of osteomyelitis in boys, who, 
after active and exciting exercise, have plunged in 
cold water or have stretched themselves out upon 
the cold ground to rest. 10 
COPLIN AND BEVAN, 
Pathology.-There are three situations that, 
according to Howard Marsh, furnish a ready nidus 
for the localization of microbes, as follows: 
" Immediately subjacent to the cartilaginous 
disc ; in the vicinity of the ossifying center; in 
the line of union between the epiphysis and dia- 
physis." 
Their localization in the diaphyseal side of the 
epiphyseal cartilage, as in the soft tissues, determines 
an inflammation in which we may observe the same 
tissue changes that occur in other structures sub- 
jected to the action of these organisms. 
There is at first an increased supply of nutrient, 
quickly followed by a rapid multiplication of the 
nuclei of the fixed cells. 
These cells surround themselves with a layer of 
granular material, and the whole is encased within 
a shell of earthy matter, supposed to be elaborated 
by the nucleus. A poor and lowly organized form of 
bone is thus produced. This is the analogue of the 
granulation-tissue found in other structures of the 
body. The cells, as a result of their rapid prolifera- 
tion and the unyielding character of the osseous 
tissue, are crowded together to such an extent that 
their development is materially interfered with; 
consequently they offer but feeble resistance to the 
action of the germs and their ptomaines. 
When the epiphyseal cartilage is primarilyaffected, 
the nuclei of the cells undergo rapid division and 
subdivision, forming masses of cells, and these con- 
glomerations, the progeny of the cartilage-cells, 
becoming permeated by bloodvessels, are converted 
into medulla, which may continue to develop until ACUTE INFECTIOUS EPIPHYSITIS. 
11 
it reaches the surface of the articular cartilage, and 
then we have what is frequently described as an 
articular ulcer. The process may also extend in 
the other direction, and communicate with the 
medullary cavity. Subsequently, we shall have a 
sinus formed, and an open passageway for the pus 
between the interior of the joint and the medullary 
canals. 
We perceive that the tissues adjacent to the in- 
flammatory focus are saturated with the transuded 
serum of the blood, and there are present numerous 
leukocytes that have migrated from the vessels. We 
discover, also, that the tissues are stained. This is 
attributable, not to the presence of serum and leu- 
kocytes, but to the hematin that is liberated as the 
result- of the injury sustained by the capillaries, 
diapedesis supervening, and the red corpuscles 
having undergone disintegration. 
The compact portion does not escape, for we find 
that the lacunar corpuscles undergo a granular 
degeneration, and the bone, dependent upon the 
corpuscles for nutrition and repair, degenerates. 
Several of the spaces coalescing, a cavity is formed, 
which ultimately opens into an adjoining medullary 
space. The shape of this cavity corresponds with 
the original growth of the lacunar system, thus 
assuming a more or less circular form. The canal- 
iculi are also filled with this granular material, as are 
the Haversian canals. This granular substance 
resembles highly vascularized granulation-tissue. 
Absorption of the walls of the Haversian canals is 
the natural sequence of this process. The canals 
are in consequence greatly increased in diameter, 12 
COPLIN AND BEVAN, 
and rarefaction of the bone is effected. The vessels, 
not being permitted to contract, remain patulous, 
thereby facilitating the entrance of microorganisms 
and their toxines into the circulation. 
The veins also participate in the inflammatory 
process, and we have established a phlebitis, with 
the formation of infected thrombi. Subsequently, 
portions of these thrombi become detached and 
washed into the circulation, and are arrested in 
some of the viscera. At the site of these infected 
embolic infarcts we have founded new foci of 
inflammation, and metastatic abscesses are thus 
engendered. 
One of the peculiar features of osteomyelitis is the 
local or pyemic condition in the bone, and this is 
beautifully illustrated in the case here reported (see 
illustration), in which there were several meta- 
static abscesses in the medullary substance. 
Diastasis is the result of localization of the germs 
at the juncture of the diaphysis and the epiphysis, 
or when the integrity of the bone is destroyed by 
extension of the inflammation. 
History of the Case.-In reporting the history of 
this case, it has not been deemed necessary to go fully 
into the symptoms, but only to bring out the more 
important features, which make it differ slightly 
from other cases reported in the current literature 
on this subject. The symptoms of this disease have 
been so fully gone into by the various writers who 
have considered it, that it is not deemed at all 
necessary to present an elaborate history, which 
would, in many points, be but a repetition of well- 
known and well-established facts. ACUTE INFECTIOUS EPIPHYSITIS. 
13 
In the first place, the case was rather peculiar in 
that the child was thirteen years of age, and that the 
symptoms had never been active in early life. From 
the time when she began to walk she had complained 
of pains in the tibia, occurring more frequently at 
night, and often preventing sleep. There had been 
slight swelling, at about four years of age, situated 
just externally to the tubercle of the tibia, but this 
had subsided, and had given rise to no symptoms. 
About one year previously to the time when first seen 
she had received an injury, caused by a flat-iron fall- 
ing on the metatarsal bone of the great toe. This 
had been, followed by severe inflammation and the 
development of a small abscess, which was opened at 
the time. Some small fragments of bone were re- 
moved, and the cavity was freely drained. The 
wound healed without any apparent difficulty. The 
pain in the tibia, which had annoyed her for years, 
became more intense; her general health failed ; 
she lost flesh ; her appetite disappeared ; and, from 
a bright, cheerful child, she became morose, disin- 
clined to play, and showed other well-marked 
symptoms of diminished physical activity. Six 
weeks before the time when she was first seen there 
developed points of intense tenderness, situated 
immediately above and below the knee-joint, and 
the family states that these points were slightly soft. 
This was followed in about ten days by symptoms of 
active inflammation in the knee-joint. 
The entire crest of the tibia was painful and 
tender to the touch; there was some enlargement 
of the lower extremity of the bone ; there was fever; 
several distinct chills occurred, followed by sweats Fig. i. 
I 
A. 
B- 
H 
C. 
D. 
E. 
F, 
G ACUTE INFECTIOUS EPIPHYSITIS. 
15 
A. Patella turned backward and to one side, showing its 
lower surface. 
B. The lower extremity of the femur, showing the line of the 
epiphysis and a distinct border of fatty degeneration just where the 
epiphysis joins the shaft. In the lower extremity of the femur 
are several small round or irregular dots that mark the position of 
metastatic abscesses in the bone. The periosteum of the femur 
is slightly thickened just above the epiphyseal line. The 
epiphysis is normal. 
C. D, E. Sawn section of the tibia, showing the condition of its 
medullary canal; at the upper extremity of the tibia the shaft ter- 
minates in a jagged, irregular extremity that has been in apposition 
with the epiphysis. The epiphysis is placed over on one side at 
H, with a view of the upper surface, while at I the view is that 
of its under surface. Just above the line that leads from C are 
two metastatic abscesses of considerable size; below this line, 
and extending to the line D, is to be noted the detachment 
of the periosteum. The periosteum is much thickened, the 
thickening fading off as the line E is approached. At C 
the bone-marrow was intensely red and congested, and 
there were no less than a dozen small abscess-cavities not 
quite as large as split peas. The external compact por- 
tion of the bone is much thickened, and just opposite the 
pointer there is considerable swelling along the line of the peri- 
osteum. The lower epiphysis of the tibia does not show well; 
at the lower extremity of the shaft, however, can be seen several 
small abscess-cavities. The point G is the seat of the original 
injury. F marks the metatarso-phalangeal articulation, the 
lower extremity of which should be placed to the upper extremity, 
as that represents the sawn section of the bone of the great toe. 
The great toe is also shown. 
H is a view of the superior surface of the epiphysis of the tibia, 
the articular surface. In it there will be observed not less than 
five or six small openings that communicate with the abscess 
below and with the joint above. In some of them small fragments 
of necrotic bone are to be observed. Th e cartilaginous structures o f 
the joint are also entirely destroyed, and the articular margins of 
the epiphysis show a slight fragment of the two semi-lunar 
cartilages. 
I is the same as H, except that it is a view of the inferior sur- 
face where it came in contact with the tibia. It will be observed 
that in the epiphysis there is nothing more or less than an abscess- 
cavity, the wall of which is formed by a hard cancellated layer of 
bone and by the articular disc. There was no periosteum con- 
tinuous with the shaft and epiphysis, and .hence the epiphysis 
moved freely upon the end of the shaft, thus giving the well- 
known " flail joint" so characteristic of epiphysitis. The interior 
of the knee contained a considerable quantity of pus, and the 
synovial structures were also disorganized. 16 
COPLIN AND BEVAN, 
and extreme weakness. The emaciation increased ; 
sleep became impossible, except after the adminis- 
tration of opiates to lull the pain in the infected 
joint and quiet the nervous system. The symptoms 
did not seem to respond to any local or systematic 
treatment, and six weeks after their beginning she 
first came under our observation. 
The physician who had attended the case diag- 
nosticated the condition as one of white swelling, 
and had so treated it. She was seen by Dr. Allis, 
Dr. Hearn, and Dr. Coplin, and after a careful 
study of the case the diagnosis of infectious epiphy- 
sitis was made, and an exploratory operation was 
decided upon. When the knee-joint was opened, 
the enormous extent of the pathologic process seemed 
to demand the amputation of the limb, and after gain- 
ing the consent of the parents this was done. The 
accompanying illustration shows the extensive infil- 
tration of the bones affected. There was the "flail 
joint," and the development of other well-marked 
symptoms which are usually associated with the 
disease. 
After amputation the girl rapidly recovered. 
Laboratory.-The tubes inoculated from the pus 
immediately surrounding the joint were, by plating 
and carrying the cultures rapidly through several 
generations, proven to contain the following organ- 
isms : The staphylococcus pyogenes aureus; the 
staphylococcus pyogenes albus; the bacillus pyo- 
genes fetidus; the proteus mirabilis. 
Experimental Pathology.-Rabbit No. i was 
injected at 5 p.m. with a culture of the staphy- 
lococcus aureus of the first generation. It remained ACUTE INFECTIOUS EPIPHYSITIS. 
17 
apparently perfectly well until the day following, 
when it appeared rather weaker than usual. Its 
eyes were dull; it ate but little food; and it 
seemed inclined to doze a greater portion of the 
time. When seen later in the day, it was extremely 
Fig. 2. 
Micrococcus (staphylococcus) aureus-from agar-agar culture; 
Beck's homogeneous immersion; Oc. 2. 
restless ; prostration was marked ; and there was an 
inability to coordinate muscular movements. Res- 
piration was shallow, quickened, and irregular; 
the heart was quick, weak, and the rhythm altered. 
During the latter part of the day it had refused to 18 
COPLIN AND BEVAN, 
eat and associate with other rabbits. It sought a 
corner of the cage, where it remained, and was 
found on the next morning, dead. On post-mortem 
examination, no microscopic lesions were observed. 
Death had resulted from septicemia ; tubes culti- 
Fig. 3. 
Bacillus pyogenes fetidus-from agar-agar culture; Beck's 
homogeneous immersion ; Oc. 2. 
vated from the blood showed growths of the staphy- 
lococcus aureus. This was confirmed by micro- 
scopic examination. 
Rabbit No. 2 was injected at 8 a.m., June 17th, ACUTE INFECTIOUS EPIPHYSITIS. 
19 
with the staphylococcus albus of the first generation. 
The first symptoms noted manifested selves on them 
the following day, at 2 o'clock. When offered food, 
the animal refused to eat, and the same symptoms 
Fig. 4. 
Proteus mirabilis-from agar-agar culture ; Beck's 
homogeneous immersion ; Oc. 2. 
succeeded that were observed in the preceding case, 
although the animal did not so readily yield to the 
influence of the microbes, not dying until the even- 
ing of the 20th. Cultures of the blood and urine 
showed growths of staphylococcus albus. 20 
COPLIN AND BEVAN, 
Rabbit No. 3 was inoculated on the evening of 
June 24th with a mixture of the aureus and albus. 
It died on June 26th, at 3 o'clock, with the symp- 
toms of an intense septic infection. In tubes 
inoculated a growth of the two cocci developed, as 
was proven by plating, staining, and microscopic 
examination. 
On June 26th, two rabbits were inoculuted, small 
quantities of the organisms being employed ; one, 
No. 4, with proteus, and the other, No. 5, with the 
bacillus pyogenes fetidus. No lesions were observed 
at the seat of inoculation. The animals were killed 
ten days later. There were no internal lesions. 
The organisms had probably been destroyed by the 
phagocytes and eliminated by the emunctories; 
their absence from the blood being proved by cul- 
ture-experiments with the intra-cardiac blood and 
with blood from the kidneys, liver, and spleen. 
On Monday, January 12th, rabbit No. 6 was 
inoculated with staphylococcus aureus, just above 
the ankle-joint, on the right side. The injury was 
inflicted by means of a small sterilized gimlet, an 
attempt being made to puncture the bone, but on 
account of the dulness of the instrument, and the 
extreme hardness of the bone, the periosteum alone 
was injured, the seat of the injury being as near to 
the epiphyseal line as could be made, without hav- 
ing previously ascertained its location. The injury 
to the bone, as well as the injection of the micro- 
organisms, was effected with the strictest antiseptic 
precautions, care being taken that the point of the 
puncture through the skin should not be located im- 
mediately above the point of injury of the bone, the ACUTE INFECTIOUS EPIPHYSITIS. 
21 
point of inoculation being fully one inch below the 
point of injury. 
On the day following the treatment, the rabbit 
was dull; it did not eat. At the seat of inocula- 
tion was a small point of tenderness, with a distinct 
area of inflammatory redness. This small point of 
redness developed slowly into an abscess, requiring 
nearly a whole week to attain sufficient size to 
render the diagnosis positive. At this time there 
were well-marked constitutional symptoms, such as 
severe rigors, emaciation, weakness, staggering gait, 
and inability to stand. This condition continued 
for about five days, when it was noted that the in- 
jured limb had rotated directly backward, the 
plantar surface of the foot being upward ; there 
was well-developed "flail joint"; the limb was 
considerably swollen, the abscess having evidently 
extended up the middle third of the femur. The 
rabbit at this time seemed to have improved in its 
physical condition ; it evinced a desire to eat, and 
would also run around the cage in which it was con- 
fined. The emaciation did not seem to lessen; 
neither did the rigors entirely cease. The abscess 
seemed to have diminished in size, but the general 
usefulness of the limb did not seem to improve in 
the least; it was limp and useless to the animal. 
The animal died on February 12th, and the follow- 
ing post-mortem notes were made: It was evidently 
emaciated to the last degree. Before any incisions 
were made in the skin, the condition of the limb was 
noted as follows: Instead of any well-marked artic- 
ulation at the knee-joint, the limb was found to 
move in all possible directions, and crepitus could 22 
COPLIN AND BEVAN, 
readily be obtained. What had been the abscess 
now seemed doughy and firm, and pitted on 
pressure. The skin was very carefully dissected 
from over the seat of the abscess, after which this was 
opened. The cavity was filled with a cheesy mate- 
rial, which emitted a sweetish odor. It was too thick 
to flow, and contained large flocculi, evidently 
necrotic tissue. The knee-joint was entirely dis- 
organized ; its capsule was destroyed ; the articular 
cartilages were necrotic; the epiphysis of the 
femur was separated, and divided into minute 
fragments, the extremity of the bone being eroded, 
irregular, and the periosteum removed from its sur- 
face as far as the middle third. The abscess had 
infiltrated the muscle to a slight extent, and in the 
inguinal region there was an enlarged lymphatic 
gland, about the size of a shell-bark. The other 
joints were found perfectly healthy. 
The heart was the seat of a slight pericarditis, as 
shown by the small quantity of flocculent lymph 
found in the pericardium, also attached to the vis- 
ceral and parietal layers. This all washed off, and 
did not seem adherent. The pleura was normal, 
the lungs thoroughly collapsed, and the seat of 
several spots of petechial redness; they did not 
seem to be the seat of any abscesses, and crepitated 
at all points. 
The liver showed marked swelling ; its borders were 
not so sharp and smooth as usual; upon its surface 
were several distinct creamy white spots, about 
as large as the head of an ordinary pin; these 
seemed at first to be on the surface of the liver, but 
closer examination showed that they were beneath ACUTE INFECTIOUS EPIPHYSITIS. 
23 
the capsule, and in the liver-tissue itself. The liver 
was very friable, and granular in appearance; it 
also seemed to lack the usual intensely red color 
found in most rabbits. On section, several spots, 
identical with those beneath the capsule, could be 
seen ; some of these were removed for microscopic 
examination. The bile was light in color, and did 
not stain. 
The kidneys were apparently swollen, and their 
capsule tense; after section, the cut surface 
could not be placed smoothly together. Along the 
cortex there were striated lines of congestion, many 
of them extending far down toward the pelvis of 
the organ. There were several distinctly white 
spots of extremely small size, which it was thought 
might be minute abscesses. To ascertain this, 
small pieces of the organ were removed for micro- 
scopic examination. The organ had no urinary 
odor, and the urine in the bladder seemed normal. 
The other abdominal organs were healthy, except 
that the spleen was swollen and friable ; the peri- 
toneum seemed dryer than usual, and its surface did 
not look glistening, although no other evidence of 
inflammation could be detected. There was no 
apparent enlargement of the mesenteric glands; the 
retroperitoneal glands were enlarged, and a few had 
undergone suppuration and caseous formation in 
their interstices. The general muscular system and 
joints, other than already noted, were carefully 
examined, but no evidence of infection could be 
found. 
A microscopic examination of the liver and 
kidney is appended. 24 
COPLIN AND BEVAN, 
The liver showed numerous thrombotic blood- 
vessels, and into the perivascular structures and 
the intercellular spaces rhexis had taken place; 
the leukocytes had emigrated, and were present in 
large number. The vessels radiating from the 
hepatic veins showed stasis, and in points the entire 
vascular apparatus of the lobule was plugged. The 
liver cells were granular, their nuclei not staining. 
Many of the thrombi were the seat of beginning 
abscess-formation, as indicated by the young-cell 
exudate and mycotic invasion. The liver-cells 
showed the usual changes due to hyperpyrexia; 
they were granular, stained poorly, and in no 
small number neither nuclei nor nucleoli were 
visible; the epithelium of the bile-ducts was not 
altered. 
After staining, so as to bring into relief the organ- 
isms, if any were present, the examination was con- 
tinued with high powers: everywhere in the blood- 
vessels, perivascular and intercellular spaces, were 
hosts of microbes; and, what was peculiarly char- 
acteristic, mural implantation had occurred and 
colonies of organisms could be demonstrated within 
the walls of the hepatic vessels. There appeared to 
be present bacilli, for which we could not account; 
but Professor Longstreth expressed an opinion that 
they were refraction lines. Staphylococci were pres- 
ent in abundance, and even a casual observer could 
not fail to note how thoroughly disseminated through 
the textures they were. 
The kidneys, with low powers, showed infarcts 
with areas of hemorrhagic extravasation. Small 
round cells were present in abundance in and about ACUTE INFECTIOUS EPIPHYSITIS. 
25 
these areas, indicating inflammation and beginning 
abscess-formation. The epithelium of the tubes was 
granular, and degenerating in the highest degree. 
Indeed, few points were visible in which any of the 
histologic structures were normal. Many of these 
changes, like those in the liver, might be attributed 
to the high temperature. Many of the vasa recta 
were thrombotic. 
With high powers, organisms were found in all 
portions of the kidney, and especially in and around 
the thrombi. Some of these microbes could be 
observed in the interior of the round cellular ele- 
ments. There were also present rod-shaped bodies, 
resembling those found in the liver, for which the 
same explanation is offered as that already given. 
It is also to be remembered that cocci situated in 
the interstices of tissues may be stained, and look 
very much like rod-shaped bodies. This observation 
is borne out by the fact that by no amount of plat- 
ing could aught but cocci be cultivated. 
Remarks.-There is no specific microbe of 
epiphysitis or osteomyelitis. The two are prac- 
tically the same disease-that is, when the latter 
occurs in adolescence, due to the same organisms, 
and differing only in the primary site of localization 
of the germs. 
The order of frequency with which the germs are 
found is as follows: Staphylococcus aureus, staphy- 
lococcus albus, staphylococcus citreus, and rarely 
the streptococcus pyogenes. Unless dependent 
upon some anomalous condition, epiphysitis never 
occurs after the completion of ossification, the 
peculiar construction of the parts and the dis- 26 
COPLIN AND BEVAN, 
tribution of the vessels being necessary and essen- 
tial elements in its causation. 
It is of interest to note, that in the effusion into 
the tissues, the advance-line of mycotic invasion, 
saprophytes were not present; neither could they be 
found in the metastatic abscess in the tibia, nor 
could any effect be observed by injecting them into 
healthy tissues of rabbits in quantities insufficient 
to produce death. 
In considering the foregoing fact, it may be con- 
fidently asserted that the coexistence of the bacillus 
pyogenes fetidus and proteus in the pus, was due 
not to primary, but to secondary infection. The 
staphylocci constitute the essential exciting cause 
of this affection, and they prepare the tissues for the 
reception of saprophytes. The toxines produced 
by the saphrophytes increase the danger of septic 
poisoning. 
The staphylococcus aureus excites a more active 
inflammation than does the staphylococcus albus, 
and the staphylococcus albus is more active than 
the staphylococcus citreus, and a mixed infection, 
especially of the staphylococcus aureus and staphy- 
lococcus albus, is the most virulent of all. These 
facts may be explained by attributing to each 
variety of microbe the capability of engendering 
a ptomaine peculiar to itself. As the result of 
chemical action from the presence of two such 
compounds in the tissue, another compound is 
formed, which, though not differing essentially in 
its action, acts upon the cell-protoplasm with greater 
intensity; or the hypothesis may be advanced that 
the amount of ptomaines generated by an organism ACUTE INFECTIOUS EPIPHYSITIS. 
27 
is not dependent upon the number, but upon the 
quantity of the material supplied that it can utilize 
as food. Hence, it may be assumed that there are 
present in a part substances that are unaffected or 
cannot be assimilated by one organism, which to 
another will serve as an excellent pabulum, and from 
which the organism will elaborate its peculiar pto- 
maine. Therefore, it is evident that if this be the 
case, we shall have in a given amount of material 
a greater production of ptomaines in mixed in- 
fection. 
Localization of the organisms is determined by 
any condition that lowers the inherent vitality or 
physiologic resistance of the cells, or by any circum- 
stances that disturb the equilibrium of the circula- 
tion, as pointed out in considering the etiology. 
In the case reported by Rosenbach, in which a child 
was born suffering with infectious epiphysitis, the 
mother showed no sign of disease ; and in a similar 
case, personally related by Dr. Joseph Hearn, 
in which he operated upon a child but three weeks 
of age, suffering with a peri-articular abscess, the 
little patient, with the exception of a small sinus, 
which occasionally discharges a little pus, is ap- 
parently perfectly healthy. 
A pyemic condition of the bone is a constant 
attendant upon acute infectious epiphysitis, and if 
the disease is allowed to progress unchecked, a 
general pyemia invariably ensues. 
In the illustration the number of apertures com- 
municating through the epiphyseal cartilage with 
the cavity of the abscess, and with that of the joint, 
will be noted. 28 
COPLIN AND BEVAN, 
BIBLIOGRAPHY. 
Annual of the Universal Medical Sciences, 1890, 
vol. iv, L. 
Ashhurst: International Encyclopedia of Surgery. 
Billroth's Surgical Pathology. 
Macnamara, C. : Diseases of Bone. 
Cornil and Ranvier's Pathological Histology. 
Crookshank: Manual of Bacteriology, 1891. 
Practical Bacteriology, 1886. 
Flugge: Microorganisms. (Sydenham.) 
Frey : Histology and Histo chemistry of Man. 
Friedlander: Use of the Microscope in Clinical and 
Pathological Examinations. 
Gray: Anatomy. 
Green : Pathology and Morbid Anatomy. 
Griffiths : Microorganisms. 
Gross : System of Surgery, vol. i. 
Heitzmann: Microscopical Morphology of the Ani- 
mal Body. 
Hueppe: Methods of Bacteriological Investigations. 
Marsh : Diseases of Joints. 
Keating: Cyclopedia of Diseases of Children, vol. iii. 
Klein : Microorganisms and Disease. 
Leidy: Anatomy. 
MacAllister: Text-book of Human Anatomy. 
The Medical News, vol. xlv, p. 290. 
Miller: Practical Microscopy. 
Ranney : Lectures on Nervous Diseases. 
Park, Roswell: "A Study of Acute Infectious Pro- 
cesses in Bone,'' Am. Journ.of Med. Sci., July, 1889. 
Seiler: Microscopical Technology. 
Senn : Principles of Surgery. 
Surgical Bacteriology, 
Salonionsen : Bacteriological Technology. 
Stricker : A Manual of Histology. 
Treves : A Manual of Surgery, vol. ii. ACUTE INFECTIOUS EPIPHYSITIS. 
29 
Woodhead and Hare : Pathological Mycology. 
Townsend: "Acute Arthritis of Infants,'' American 
Journal of the Medical Sciences, January, 1890. 
Ziegler: Text-book of Pathological Anatomy and 
Pathogenesis. MacAllister's translation. German edi- 
tion, 1890. The Medical News. 
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