and the displacement of
the head of the bone is readily shown in a skiagram.

_General Complications._--In some cases a _multiplicity of lesions_ in
the bones and joints imparts to the disease the features of pyaemia. The
occurrence of endocarditis, as indicated by alterations in the heart
sounds and the development of murmurs, may cause widespread infective
embolism, and metastatic suppurations in the kidneys, heart-wall, and
lungs, as well as in other bones and joints than those primarily
affected. The secondary suppurations are liable to be overlooked unless
sought for, as they are rarely attended with much pain.

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.