The Report of Five Cases of Subacute Osteomyelitis of the Femur Resembling Sarcoma

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WHILE osteomyelitis in the majority of cases is a disease of childhood, there is a slow subacute type which may appear at any age. In this type the process may go on for a long time, the result being an osseous formation quite difficult to differentiate from sarcoma. The causative agent in practically all the cases is an attenuated organism of low virulence, which has been present in the system for a long period of time. The patient gains a certain amount of resistance against this organism, the result being a subacute rather than an acute type of osteomyelitis. Because of the great difficulty in reaching a correct diagnosis and because the treatment depends so entirely upon the correct diagnosis, every means at one's disposal must be used to arrive at this important decision. A few days' delay will not affect the results. As in all bone lesions, the burden of proof should be to demonstrate the malignancy of the condition. A very careful history should be taken, a careful search made for a history of injury or of any acute infection, and above all an exhaustive examination must be carried out to locate any possible foci, however slight. A number of cases have entered the clinic in which a differential diagnosis has been exceedingly difficult. Some patients with an initial diagnosis of sarcoma are well today without radical treatment of any kind. In this group of cases, which is being reported as a group for the first time, there is a history of injury in two, bad teeth in one, a carbuncle in one, and osteomyelitis ten years before admission in another. In all these cases pain in and an enlargement of the part affected were the symptoms of the onset, and in all cases the femur has been involved. A leukocytosis in all but one case has been present, while the Wassermann was negative in all. Case 1.—Three months before entering the clinic the patient had an attack of “sciatica,” affecting the right leg. Five teeth were extracted and the back was strapped. A few weeks later he noticed soreness and swelling of the right thigh. Two weeks later he had more pain and swelling. The diagnosis of osteogenic sarcoma was made by an outside doctor. Examination.—The right thigh is much larger than the left and there seems to be a thickness of the femur at the upper and middle third. This thickness almost surrounds the entire femur. It is not tender. Tonsils infected and sinuses cloudy. White blood count 14,000. Wassermann negative. X-ray examination of chest negative. X-ray film shows a thickening of the periosteum but no real breaking through. There is a slight shadow in the medullary cavity and a tiny calcified spot about one and a half inches from the femur. This does not impress one as a malignant lesion, but, rather, as a benign infective process of osteomyelitis. The patient was kept at rest. The tonsils were removed and a submucous resection of the septum done. Three months after we saw him, a sequestrum about 8 by 3 mm. was removed from the thigh.