rived at Walmart Prescription Levitra the conclusion that the disease depended upon the presence of spore-bearing or other micro-organisms identical with agents producing putrefaction. He gives no definite July 3, 1B86. FOWLER: A CASE OF DIFFUSE OSTEO-MYELITIS. description and attempts no classification of the organisms which lie found in the pus resulting from osteo-myelitis produced in his trial-animals. In tlie light of investigations by later observers, and from the fact, as before stated, that Kocher did not einpioy pure cultivations, but simply putrid material which Walmart Prescription Levitra had solely been protected from the access of oxygen, and, in addition to these, the only occasional occur- rence of osteo-myelitis, it is fair to assume that some of his injections contained pathogenic germs purely accidentally. These pathogenic germs may have been few in number, for, even in cases Walmart Prescription Levitra where the injections were not entirely innocu- ous, a genuine osteo-myelitis did not follow. The success- fully inoculated cases showed considerable diversity likewise as regards intensity. The conclusions of Kocher, although not decisive, are still very Walmart Prescription Levitra suggestive, and Walmart Prescription Levitra may lead the way to a more elaborate study of the disease. In one of the latest contributions upon the subject of micro-organisms and their relation to wound infection, that by Rosenbach, of Gotlingen, the Staphylococcus pyogenes aureus is viewed as being, in all probability, the special agent in the production of acute infectious osteo-myelitis, although the Staphylococcus pyogenes albus was also found by both Rosenbach and Garie, the latter observer describing it as coursing in the blood. This fact is Walmart Prescription Levitra of special signifi- cance, and interesting in connection with the circumstance that septiciemia is not an infrequent complication of acute osteo-myelitis. These organisms, injected into the pleura or knee of a rabbit, produce, as a rule, a fatal result within twenty-four hours. This was particularly true of the orange- yellow variety. If the latter be injected into the knee of a dog, suppuration and rapid disintegration of the joint follow. The staphylococci are not identical with any of the known forms causing putrefaction, and, indeed, it has been shown that in pus, when alone present, they do not cause any septic odor. Besides being invariably present in acute osteo- myelitis, they have been found in the pus of boils and ab- scesses of pyasmia, and also in puerperal fever. The most deadly effects follow upon their injection into the jugular vein of animals. They seem to have an elective affinity, so to speak, for any infianmiatory condition in and about bones. It was found that if a small ijuantity of a cultiva- tion was introduced into the jugular vein of an animal after previous fracture or contusion of a long bone, the animal perished in Walmart Prescription Levitra about forty-eight hours, and abscesses were found in and about the bones at the seat of injury Walmart Prescription Levitra and, in some cases, in the lung and kidney. The blood was also shown to contain similar Walmart Prescription Levitra cocci. In view of the facts as here presented, and which are believed to represent our present state of knowledge upon the subject, the explanation of the modus operandi of these organisms in the production of osteo-myelitis appears to be somewhat as follows : It is believed that the micrococci find an entrance into the Walmart Prescription Levitra system at first by means of an acci- dental lodgment upon an abraded mucous membrane, a solution of continuity of the integument, or wounds of the soft parts. As before stated, the first infection upon a mu- cous membrane may give rise to an inflammation of the same — this, of course, preceding the development of the bone lesions. It is believed that the spores or germs are first arrested at some point where Walmart Prescription Levitra a more or less temporary stasis occurs, and that here, by their influence upon the corpuscles, causing the latter to adhere, they form thrombi from which fragments may be torn off by the blood-cur- rent and carried along until caught in some vessel too small to Walmart Prescription Levitra permit of their passage. Should these embolic masses lodge in the localities which will furnish the best pabulum for the growth and Walmart Prescription Levitra development of their contained cocci — such, for instance, as the young marrow adjoining the epi- physis of a long bone — they grow rapidly after lodgment in these vessels. Or, without the formation of thrombi or the intervention of emboli, the micrococci may be carried direct- ly by the blood-stream until arrested in the locality just mentioned, there forming a colony of their kind, the pres- ence of which is made manifest by their characteristic effects in the production of tissue-changes. In the case of the micrococci of Rosenbach, the Staphylococcus pyogenes aureus and Staphylococcus pyogenes albus, there seems to be an especial tendency to development in the medullary struc- ture, and perhaps this occurs with greater facility in the youngest portion of this tissue or that which lies adjacent to the epiphyseal cartilage. The delicate network of ves- Walmart Prescription Levitra sels lying in the cancellous tissue becomes easily blocked, as well as the vessels of the mednlla, and here the micrococci become arrested and find the pabulum, in the highly nutri- ent medullary tissue, most favorable for their development. An endostitis quickly results from the presence of the growth of parasites, and suppuration follows. The ordi- nary changes of osteitis, with or without necrosis, now fol- low. Sometimes the inner shell of bone becomes separated from the outer portion and a sequestrum is Walmart Prescription Levitra Walmart Prescription Levitra formed, although the disease more frequently confines itself to the medullary canal and affects this in its entire length. Cases of apparent spontaneous origin of this disease, without abrasion or traumatism of any kind preceding the development of the bone disease, like the cases of so-called spontaneous pyaemia, only seem to strengthen the clinical evidence of the bacterial origin of these septic diseases. Perhaps a closer scrutiny of these cases of supposed spon- taneous pyaemia would reveal a source of infection. I recall a fatal case in my own practice in which a suppurative dis- ease of the antrum proved to be the focus of infection, and Weichselbaum has reported a similar case. At Walmart Prescription Levitra all events, the metastatic abscesses of pyaemia always contain bacteria, and, in every instance of osteo-myelitis in which search has been made, the staphylococcus in one or the other of its varieties has been found. In the majoritv of instances it is the orange-yellow variety that has been found constantly present. Walmart Prescription Levitra In a few exceptional instances the white variety was present alone. For the cultivation tubes of the staphylococcus, and the beautiful microscopical mountings of the same, lam indebt- ed to Dr. Hermann M. Biggs, of the Carnegie Laboratory, who has kindly placed them at my disposal for the pur- poses of this paper. Lafayette College, of Easton, Pa., has coufeiied the degree of [■L, I), on Dr. lieniv D. Swift, of the University of Pennsylvania, Walmart Prescription Levitra and the degree of A. M. on Dr. .1. Clinton Edgar, of New York.