the bone is unaccompanied by any absorption of the articular cartilage
of its head. A section of another well marked specimen may be here
added. This bone also exhibits approximation of the head to the shaft,
from absorption of the neck. The head is somewhat flattened and
expanded, but the articular cartilage is entire, and of its natural
thickness. The acetabalum was diminished in depth, but enlarged
laterally, so as to correspond with the alteration of shape in the head
of the thigh-bone. The preparation was obtained from a man at 32, who
died at the General Hospital at Chatham of pulmonary consumption, after
a confinement of two years in hospital. Previously to his admission,
he had regularly performed his duty as a light infantry soldier, from
which it is plain that his limbs were then of equal length, although,
when the body was examined, the affected femur was upwards of one inch
and a half shorter than the other. From a careful inquiry after his
death, it appeared that he had, five years previously, fallen on the
trochanter, in consequence of which he often complained of pain in
the hip, but continued to do his duty long after, never having been
confined on account of the accident. It therefore results, that morbid
change had taken place during his long confinement in hospital, a
circumstance not very favourable to the recommendation by some surgeons
of the horizontal posture, as a remedy in such cases, and equally
adverse to the opinion of certain continental pathologists, who inform
us, that shortening of the neck of the femur is to be attributed to the
gradual operation of the superincumbent weight of the body.
[Illustration]
In old subjects, particularly in fat women, the neck of the femur is
often shortened, and becomes more transverse and brittle than natural,
from a true interstitial absorption or atrophy of the osseous tissue.
This has sometimes been described as a natural effect of age, but it
is undoubtedly disease, for in the greater number of old people the
neck of the thigh-bone presents its usual length and obliquity. The
affection is obviously a very serious one, as predisposing to fracture
of the part, under circumstances which render its reunion almost
hopeless.
_Treatment of Affections of the Joints._—After the infliction of
a wound, accidental or not, in order to prevent inflammation of a
joint from becoming violent, it is of the utmost importance to bring
the edges of the wound into close apposition. Sometimes neither
local action, nor disturbance of the constitution, supervene on an
opening, even of considerable size, being made into a joint, while the
slightest puncture often gives rise to the most dreadful symptoms,
both local and general. An incised wound, of no great extent, will be
sufficiently closed by the careful application of adhesive plaster,
and attention to the position of the limb; but if it is extensive
stitches become indispensable. The parts must be kept in a state of
complete relaxation and rest; cold cloths or iced water, allowed to
drop or run over the surface by capillary attraction, should be
assiduously applied. The patient’s bowels must be freely opened, and
he is to be kept on low diet. If inflammatory action occur, bleeding,
locally and generally, must be had recourse to energetically,
accompanied with warm fomentations to the parts; and, at the same
time, preparations of antimony, and other saline medicines, are to be
administered internally. If there be reason, from the symptoms, to
suspect the formation of matter, the parts ought to be attentively
examined, in order to detect its presence; and, when discovered to
exist, it must be evacuated without delay. In chronic cases, even local
bleeding to any great extent is inadmissible. In some a few leeches
may be applied, followed by counter-irritation, with advantage. The
employment of counter-irritation is, perhaps, chiefly to be trusted
to in the treatment of those more chronic affections of the joints in
which, from the painful feelings, there is reason to dread disease
of cartilage or bone. Of these, blisters are most in use; though,
from my own experience, I cannot much recommend them. Their constant
repetition is exceedingly annoying, and the slow progress which is
made towards a cure under their use is far from encouraging. Tartrate
of antimony, applied in the form either of ointment or of plaster,
is generally productive of much advantage, in the first instance, by
causing a great degree of superficial irritation, and relieving the
internal parts. After the pustules have been fully developed, its
use is to be discontinued till the surface be nearly whole, when it
is again to be resumed, if the recurrence of painful feelings should
demand it. Caustic issues have been much praised, and are occasionally
beneficial. An eschar is made by the caustic potass applied to the
skin, or by rubbing the bichloride of mercury, or any other caustic,
into scarifications made by the lancet: the slough separates, and pus
is discharged. Instead of promoting a continuation of the discharge, by
applying savine ointment, and inserting foreign bodies, or employing
other irritating dressings, it is better, when the sore begins to heal,
to repeat the application of the caustic to another part; or, when the
issue begins to dry up, to apply for a few hours a pledget of strong
antimonial ointment.
The employment of the bichloride of mercury, though a most efficient
escharotic, appears not to be unattended with danger, as in many
instances violent purging, with tenesmus and bloody stools, follow its
application. When swelling exists without pain, considerable advantage
may be derived from frictions and liniments of various kinds, with
careful bandaging. No applications can be of the least avail unless the
joint be kept completely at rest.
When there is no pain in the joint, when swelling exists, with or
without fluctuation, and there is every reason to believe that the
extremities of the bones are not much diseased, a cure may be, in
general, obtained by the employment of rest, support, and slight
superficial excitement. A practice which has been extensively and
rather indiscriminately pursued in diseases of joints and of other
parts, in affections of synovial membrane, ulceration of cartilage,
disease of bone, and even in cases of necrosis, is here detailed. It
is useful in proper cases, very hurtful in others. The joint is well
washed with soap and water, and afterwards rubbed with camphorated
spirits of wine: it is then covered with an ointment spread on lint,
and composed of equal parts of the unguentum hydrargyri cum camphora
and the ceratum saponis—in the majority of cases the mercurial ointment
would be better omitted—strips of lead, soap, or adhesive plaster are
then applied with a moderate degree of tightness round, from two or
three inches below the joint to the same distance above it: these are
covered with soap-plaster spread on thick leather, and the whole is
surrounded with a bandage, which extends from the extremity of the
limb. The bandage should be put on as far as the joint, before the
plasters are applied. The irritation produced on the surface tends
to check the deep-seated action, whilst the compression excites the
action of the absorbents to remove the effused fluids, and thus to
reduce the swelling: by the joint being kept completely motionless,
not the least salutary indication of the treatment, the cartilage and
bones, if ulcerated, are placed in a condition tending much to expedite
their restoration to a natural state. If they are diseased to such an
extent that the process of cicatrisation cannot be expected, a cure by
anchylosis is, by these means, much more likely to occur. The dressings
may be left undisturbed for the space of a week or two; at which
period, and, in many cases, sooner, they will be found much slackened,
in consequence of the swelling being greatly reduced. By repetition
of the application at intervals, the disease will, in a great many
instances, rapidly cease, and the joint resume almost its natural
appearance; but the period at which this takes place will be found
to vary much according to circumstances. If, however, the plasters
produce such irritation as to cause a return of inflammatory action,
their use must be discontinued till such action has been subdued by
the usual means. If the thickening of the external parts has occurred
to such an extent as to cause immobility of the joint, or if partial
anchylosis has ensued, the limb may be brought to the most convenient
position, the knee nearly, but not quite, straight, the elbow half
bent, and so on, by the cautious use of a jointed splint, fitted with
an extending screw. The practitioner is not to be deterred from having
recourse to the above practice, even when matter has collected and
burst externally, for sometimes under its employment the cavities of
abscesses contract rapidly. After the swelling and other symptoms of
disease have subsided, the joint is to be slightly moved, but with
great care; and, by a gradual increase of the movement, the natural
motion of the part may be ultimately restored. The great object in
treating chronic affections of joints must be to give them support, and
prevent motion as much as possible. This is effected pretty well in the
articulations, removed from the trunk, by the process above described,
modified according to circumstances. The filth and smell arising from
the plasters often becomes annoying, and, above all, the eruptions and
excoriations produced by them prove so troublesome that the application
requires to be discontinued. The principal and most essential
indication, that of securing repose to the affected parts, is fully
as well obtained by the application of well-adjusted splints. These
may be formed of lint soaked in a mucilage of gum acacia, as described
in the _Practical Surgery_, p. 150, or coarse linen may be smeared
over thickly with a coating of mucilage mixed with common whiting,
and another layer of linen spread over that. This is laid out smooth
and allowed to dry; portions of this sheet are cut to the form of the
affected joint, and, after being moistened, are applied and retained
by a roller. A firm case is thus formed, which may be afterwards lined
with lint or cotton wadding, and so reapplied. The most suitable
splints of all are made of leather, prepared without oil, softened
in warm water, and put on as above described. They are, when they
have become dry, pared and well fitted, then lined with wash-leather,
and padded as may be required. The employment of these splints gives
great relief in cases where further excited action has been lighted
up in the joint in consequence of the surface of the articulating
cartilage having become ulcerated from its free or attached surfaces,
or in consequence of matter finding its way into the synovial cavity
from the cancelli in the head of the bone. In cases, also, where the
painful sensations have existed from the first, and even before any
great alteration in the external form of the joint has taken place,
indicating primary ulceration of cartilage, this practice affords
immediate relief. These splints are easily applicable to the shoulder
or hip-joints; and, in the majority of instances, nothing further
requires to be done. It appears that Dr. Physick of Philadelphia had
been for many years in the habit of confining the motions of the
hip-joint by means of hollowed wooden splints, and his practice was
marked by very favourable results.[9]
It is seldom that local abstraction of blood is at all required, and
its employment in cases of morbus coxarius in weak constitutions,
which it generally seizes upon, is very questionable. Neither is
counter-irritation called for; and it is only in extreme cases, when
the suffering is intense, that small blisters over the fore part of the
joint, or a slight drain in that situation, or behind the trochanter,
is admissible. The nitrate of silver rubbed on the surface causes
vesication and discharge; and its early repetition is often followed
by good effects. The tincture of iodine, or a liniment containing
sulphuric acid, may sometimes be applied with the same view. There
is no doubt whatever, that much of the benefit that attends upon
counter-irritation, both in the human body and in the lower animals,
is to be attributed to the rest that is at the same time enjoined,
and often indispensable. It is thus that the firing and blistering
of horses does good in the majority of the diseases of tendons,
bursæ, bones, and joints. In some instances, it may be necessary to
have recourse to soothing applications, as fomentations to affected
joints, and to employ general antiphlogistic means suited to the age,
strength, and constitution of the patient. In the greater number of
cases in young subjects, after the stomach and bowels are unloaded, the
system must be supported by tonics and nutritious food; none are more
beneficial than the preparations of iron.
When the occurrence of anchylosis affords the only hope, this process
ought to be encouraged by rest, and the limb at the same time kept in
that position which will be most useful in after life; this will be
effected here also by the employment of splints.
In cases of disease of the knee, ankle, elbow, or wrist joints,
notwithstanding everything that can be done, the disease often runs its
course, abscesses form and give way, the patient’s health declines,
and he becomes emaciated and hectic. In such cases amputation, when
not contraindicated by internal disease, must be had recourse to, as
the only remedy. In some few instances, the excision of the diseased
extremities of the bones may supersede this operation; but this will
be discussed in a future part of the work. Every circumstance must be
well weighed before mutilation be resorted to; and there can be little
doubt that thousands of limbs have been saved by the employment of
the means above mentioned, which would have been otherwise doomed to
amputation.
Hydrops articuli will in general be got rid of by the use of friction,
either dry or with liniments; by stimulating plasters or by blisters;
and by the proper application of bandages. Mercurial ointments are used
in this affection, and often with very great benefit. Electricity has
been recommended.[10]
In neuralgic affections of joints, it is clear that the symptoms are
to be combated by general and not by local means, at least of a severe
nature. The patient must be amused and occupied, exercise in the open
air must be enjoined, and attention paid to diet. The state of the
digestive organs and secretions should be looked to, and corrected if
need be. Medicines directed to the regulation of the functions of the
uterus are essential in the majority of cases. When there is reason to
suspect the lodgement of sordes or worms in the intestinal canal of
children so affected, the balsam of copaiba, in doses of Ʒss., or
more, on an empty stomach, followed, if need be, by brisk purgatives,
will be found to answer admirably. Tonics, such as preparations of
iron, of quina, &c., are then given with advantage: many apparently bad
cases yield at once to such treatment.
As local applications, anodynes, fomentations, or cold lotions are
employed, according to circumstances. Frictions with gently stimulating
liniments, belladonna, veratria, &c., may be used as occasion
demands. The patient must be encouraged to use the affected limb as
much as possible; and the use of all severe and heroic remedies, as
bleeding, blistering, counter-irritation, setons, issues, or moxas,
discountenanced.
OF INFLAMMATION OF BONE, AND DISEASES THENCE ARISING.
Bones grow and are nourished by the same means, and are subject to
the same laws, with other parts of the system. Like all the tissues
of a white colour, particularly when their growth is completed, they
are less freely supplied with bloodvessels and nerves than other
parts. When incited action of the bloodvessels occurs in the harder
textures, sensibility is roused to an exquisite degree, and the healthy
and perverted processes often advance with great vigour and amazing
rapidity.
Inflammation of bone often arises from external injury, and in some
constitutions from very slight causes. Its occurrence is supposed to
be favoured by a syphilitic taint, but the inflammatory disposition
is much more frequently produced in a system vitiated by the abuse of
mercury. From the unyielding nature of the tissue, the pain attendant
on inflammatory action is dreadfully excruciating; it is also most
violent during the night, even in chronic cases, a circumstance which
does not admit of satisfactory explanation. The integuments over the
inflamed bone are swollen, and the tumour is œdematous; whilst a hard
and solid tumefaction exists in the more deeply-seated parts, caused
partly by enlargement of the osseous tissue and partly by effusion of
lymph into the cellular substance. The bone is imbedded in a gelatinous
or lymphatic effusion, situated mostly beneath the periosteum. This
membrane is more vascular than in its natural condition, thickened,
and at the same time opened out in texture. The bloodvessels of the
affected bone are much increased, both in activity and in size; and,
in consequence of enlargement of the vessels, and thickening of the
naturally delicate membrane on which the vessels ramify, the bone is
swollen and increased in size; its texture, as shown in the annexed
cut, is loose, somewhat resembling the cancellated structure, and
its surface is occupied by numerous foramina, which are enlarged in
proportion to the size of the vessels which they contain. The limb is
often enormously swollen and indurated. The gelatinous effusion beneath
the periosteum speedily becomes organised, nodules of osseous matter
project into it, and adhere to the surface of the bone frequently by
a narrow neck; these increase in number, gradually assume a solid
appearance: the bone is thus thickened, often to a very great extent.
[Illustration]
It has been supposed that the new osseous matter is deposited by the
vessels of the soft parts and of the periosteum; but there can be
little doubt but that it is secreted principally by the vessels which
ramify within the substance of the bone, and by the vessels of the
periosteum after they have entered the osseous tissue. Thus, in the
case of fracture, the new osseous particles lie between the periosteum
and bone at a distance from the broken ends, where the vessels are
enlarged and increased in activity, or adhere to fragments which have
been detached in part and retain their vitality, but not to the under
surface of the periosteum. There is no doubt that thin laminæ of bone
are now and then found attached to the periosteum, or impacted within
its substance; but this is to be attributed to that morbid action of
the tissue, to which this as well as several other membranes is subject.
When bone is extensively affected with inflammation, motion is
impaired; the muscles being displaced and retarded in their action by
the swelling and irregularity of the bone, by effusion of lymph into
their tissue and intermuscular spaces, and, perhaps, also, by their
partaking, in some measure, of the inflammatory action. Any attempt
to move the parts very much aggravates the patient’s suffering.
Occasionally inflammation attacks almost all the bones in the body,
and causes great constitutional disturbance, by exhausting the powers
of life: it sometimes terminates fatally. Bones become inflamed from
various causes. However it originates, the action ends, as in the other
tissues, in resolution, suppuration, or mortification. The effusion
by which the diseased vessels naturally relieve themselves in softer
textures cannot here take place so readily, or to such an extent as
to prove beneficial: the intensity of the action is with difficulty
subdued, and, consequently, resolution is comparatively rare. When it
does occur, the parts do not soon regain their natural condition, but
often remain considerably swollen and indurated, as is seen in nodes,
which continue during the life of the patient, without causing pain or
much inconvenience.
Suppuration on the surface, or in the centre, and partial or total
death of a portion of bone are the most frequent consequences of
external injury and incited vascular action; but suppuration in the
cancellated texture frequently follows very slight incited action
in those of a scrofulous habit. Tubercular matter exists, in all
probability, previously, and it leads very often to long continued
disease, curable only by operation. The matter may find its way to the
surface after long suffering and great constitutional disturbance.
Again, it may be confined for months, or even years, the patient
suffering from time to time the most excruciating agony. The bone
becomes thickened towards the surface by new deposit, as the cavity
is increased by ulcerative absorption, and relief is only afforded, a
correct diagnosis having been formed, by artificial evacuation of the
matter. In many cases small sequestra lie in the cavity; and though
the matter escapes naturally, or is evacuated, the patient’s strength
becomes worn out, and he perishes, unless the limb is removed. So
long as dead portions of bone remain, the discharge cannot cease
permanently. Fresh collections are apt to form in the soft parts if
the original openings close. It is no easy matter to discover or
remove sequestra from deeply seated bones. A section of the femur is
represented on the next page, showing a cloaca leading to the cavity
of an abscess in the medullary canal. The bone is very dense in
consistence, and irregular on its surface.
[Illustration]
Suppuration in bones is necessarily connected with loss of substance,
and condensation of the surrounding parts; and purulent collections
exteriorly, if allowed to press long, or if bound down by unyielding
sheaths, will sooner or later produce a breach of continuity, by
causing absorption of the outer lamella and the subjacent cancellated
texture. A similar effect is produced by aneurismal and some other
tumours. Such loss of substance is, in some instances, speedily
repaired, after removal of the cause, by effusion of new matter
from the surrounding bloodvessels of the bone; thus, in disease in
consequence of pressure from large aneurism, there is reason to suppose
that the healing process commences as soon as the aneurismal sac begins
to diminish, as after operation. But, as has been already observed,
the healthy actions are more vigorous in the softer tissues than in
bone; and when ulceration has occurred in the latter, it is generally
attended with weak action, and presents the same general characters
as an ulcer in the soft parts, connected with a feeble action of the
bloodvessels; the discharge is thin and fetid, absorption gradually
proceeds, and there is little or no effort towards reparation.
Cavities in bones are necessarily slower in healing than those in
the soft parts; the vitality and power of reparation are lower; and
there being no elasticity in the parts, the walls cannot come rapidly
together, contract and coalesce. It may tend to prevent confusion of
the two different morbid states, if we confine the term ulceration to
suppuration in, and absorption of, bone, whilst the vessels retain
a considerable power of action, throw out new matter, and procure a
reparation of the breach; and this condition of the osseous tissue
exists when the disease is situated in the surface of the bone, and
when it has been produced by an external cause. On the contrary, the
term caries will denote that peculiar kind of ulceration in which
reparation is hardly attempted by nature, and is with difficulty
obtained by the most active interference; and this disease will most
generally be found to affect the cancellated structure. The comparative
frequency of one or other of the terminations of inflammation depends
much on the kind of bone implicated.