In these multiple forms of osteomyelitis the toxaemic symptoms predominate; the patient is dull and listless, or he may be restless and talkative, or actually delirious.  The tongue is dry and coated, the lips and teeth are covered with sordes, the motions are loose and offensive, and may be passed involuntarily.  The temperature is remittent and irregular, the pulse small and rapid, and the urine may contain blood and albumen.  Sometimes the skin shows erythematous and purpuric rashes, and the patient may cry out as in meningitis.  The post-mortem appearances are those of pyaemia.

Differential Diagnosis.—­Acute osteomyelitis is to be diagnosed from infections of the soft parts, such as erysipelas and cellulitis, and, in the case of the tibia, from erythema nodosum.  Tenderness localised to the ossifying junction is the most valuable diagnostic sign of osteomyelitis.

When there is early and pronounced general intoxication, there is likely to be confusion with other acute febrile illnesses, such as scarlet fever.  In all febrile conditions in children and adolescents, the ossifying junctions of the long bones should be examined for areas of pain and tenderness.

Osteomyelitis has many features in common with acute articular rheumatism, and some authorities believe them to be different forms of the same disease (Kocher).  In acute rheumatism, however, the joint symptoms predominate, there is an absence of suppuration, and the pains and temperature yield to salicylates.

The prognosis varies with the type of the disease, with its location—­the vertebrae, skull, pelvis, and lower jaw being specially unfavourable—­with the multiplicity of the lesions, and with the development of endocarditis and internal metastases.

Treatment.—­This is carried out on the same lines as in other pyogenic infections.

In the earliest stages of the disease, the induction of hyperaemia is indicated, and should be employed until the diagnosis is definitely established, and in the meantime preparations for operation should be made.  An incision is made down to and through the periosteum, and whether pus is found or not, the bone should be opened in the vicinity of the ossifying junction by means of a drill, gouge, or trephine.  If pus is found, the opening in the bone is extended along the shaft as far as the periosteum has been separated, and the infected marrow is removed with the spoon.  The cavity is then lightly packed with rubber dam, or, as recommended by Bier, the skin edges are brought together by sutures which are loosely tied to afford sufficient space between them for the exit of discharge, and the hyperaemic treatment is continued.

When there is widespread suppuration in the marrow, and the shaft is extensively bared of periosteum and appears likely to die, it may be resected straight away or after an interval of a day or two.  Early resection of the shaft is also indicated if the opening of the medullary canal is not followed by relief of symptoms.  In the leg and forearm, the unaffected bone maintains the length and contour of the limb; in the case of the femur and humerus, extension with weight and pulley along with some form of moulded gutter splint is employed with a similar object.