cancellated structure of the short bones, as unhealthy suppuration most
frequently takes place in the loose, fatty, and cellular tissues of
the soft parts. The formation of abscess in the cancelli is generally
preceded by deposit of tubercular matter, isolated or collected in
masses, and by the softening of this cheesy substance. When pus has
formed in the substance of a bone, the outer lamella, in the end,
becomes absorbed, and the effusion undermines the periosteum, which,
from the distension, also ulcerates: the matter then spreads into the
neighbouring cellular tissue, or makes its way to the surface, and is
evacuated, or, what is still worse, it escapes into an articulation.
The discharge is often continued, as already stated, in consequence
of a dead portion of the cancellated structure being imbedded either
in the carious cavity, or in the soft parts, where they sometimes are
lodged for a long period.
[Illustration]
It was formerly remarked that bones become highly sensible from incited
action; hence, during the progress of this disease, which is attended
with more or less inflammation, the patient generally suffers most
excruciating agony—so great, in general, as to prevent him, perhaps
for weeks, from enjoying the least repose. The affected part is
considerably swollen, but the enlargement is seldom so general, or so
great as in the diseased state of the ligaments and other apparatus
of a joint. White swelling, however, may be the precursor of caries;
or, in other words, a disease commencing in the bursæ, ligaments,
synovial membrane, or cartilage, may extend to the bone; and breach
of continuity, attended with weak action, be the consequence. In
caries the affected portion appears neither to possess vitality enough
to enable it to repair the breach, nor to be sufficiently deprived
of vitality to be thrown off by the surrounding parts. Considerable
portions of dead bone are occasionally found in carious cavities, in
the heads of bones, and even in the vertebral column. Small portions
are also detached piecemeal in the progress of ulceration, and
discharged; but it is seldom that the whole surface is thrown off, so
as to give place to a healthy and reparative action. When the parietes
of the cavity have remained a considerable time in this inactive state,
the surrounding vessels become more active, and the surface of the
bone in the vicinity is studded with nodules of new osseous matter.
The disease here delineated affected only a small portion of the
cancellated texture of the condyle. An ashy looking substance fills the
cavity, and this again was concealed in the recent state by lardaceous
matter. The elbow joint is unaffected, excepting only that, from the
deposit of new bone in spiculæ and nodules, and the condensation of
the soft parts, almost complete anchylosis had taken place. This
deposit is not always limited to the affected bone, if one only be the
seat of the disease, but frequently extends to those articulated with
it. The soft parts are commonly more or less thickened, and rendered
exceedingly dense by effusion of lymph into the cellular texture; and
so great is this thickening sometimes, that the knife is resisted as
if by cartilage. The discharge which proceeds from the carious part is
generally highly fetid, very profuse, is often poured through several
openings, and the surrounding skin is excoriated and generally of a
livid colour. The ichorous discharge occasionally dries up for a short
period and again breaks out more violently. The surface of the ulcer
is, in some cases, occupied by soft unhealthy granulations; in others
the earthy part of the bone is most prominent. When the parts have been
macerated and dried, the disease is often found to have proceeded more
in width than in depth, and the absorption has not reduced all points
of the diseased surface to the same level, thin portions remaining
somewhat elevated, and giving the part a cancellated appearance; and
there often project numerous minute osseous fibrillæ of considerable
length, which intermix with one another, and form a most delicate
network. In other instances, the ulceration has extended more deeply
and uniformly, and a considerable cavity is formed, with irregular
margins and surface; not unfrequently it contains dead portions of the
cancellated structure, in some of a dark, in others of a light colour;
or it is occupied, in the recent state, by a substance resembling
lard. The surrounding bone is much softened, and, after maceration,
becomes exceedingly light. The disease is generally confined to one or
two bones, but occasionally involves a whole chain. It may be limited
to a part of one bone in a joint, or may embrace the whole of it. Its
extent will depend on the severity of the primary action, or on the
degree and duration of the pressure of fluid which has been allowed to
exist, whether from the nature of the superincumbent texture or the
carelessness of the surgeon.
Interstitial absorption of those bones which are in the neighbourhood
of the carious ulceration often occurs in the tarsus and carpus. The
superincumbent integuments are livid and cold, and pain is felt in
the situation of the bones; yet they are not affected with continuous
ulceration, but portions of their substance are gradually removed
by absorption, so that they are much loosened in texture, and may
be altogether destroyed, or come to consist merely of a thin and
reticulated osseous shell, whilst at the same time their cartilaginous
surfaces often remain in their healthy condition.
The constitutional disorder attendant on caries is at first very great;
the sympathetic fever is followed by hectic, under which, and the
discharge, many patients sink. The general affection in some degree
keeps pace with the local in violence and duration. The irritation is
in some cases so great as to destroy the patient in a very few months
or weeks; but not unfrequently a constitution, by no means strong, will
be enabled to bear up for a long period under very extensive disease of
a bone. The paroxysms of pain and inflammation occasion fresh attacks
of constitutional derangement: this occurs till the patient’s health
and strength are exhausted, and he sinks under the disease, or is
relieved by the spontaneous or artificial removal of the cause.
A natural cure of caries may occur in consequence of the diseased
parts so far recovering their natural degree of vascular action as to
form granulations and repair the breach; but most frequently it is
necessary, for the accomplishment of this purpose, that incited action
occur to a very considerable degree; and the diseased parts, already
extremely weak, have not sufficient power to withstand the action, but
perish; whilst the action of the surrounding parts, not being increased
to such a degree as to overcome their powers, throws off the dead,
secretes a more bland discharge, and deposits healthy granulations,
which gradually fill up the cavity.
_Treatment._—In inflammation of bone, resolution must be brought
about, if possible; the other terminations are to be prevented by all
possible means, since they frequently endanger the limb, and even the
life, of the patient, and, at best, never admit of a speedy cure. To
promote resolution, blood must be drawn copiously from the part; and
general bleeding may also be required, though in some constitutions it
cannot be safely carried to any great extent. After local bleeding,
fomentations assiduously applied will tend much to relieve the
sufferings of the patient. Purgatives, nauseating doses of antimony,
and all safe measures likely to subdue the vascular action, must at the
same time be adopted. Free incisions through the periosteum sometimes
relieve the pain, and cut short the disease, the distended vessels
being thereby emptied; but such practice is only a last resource, when
the action has resisted all other means, and threatens an unfavourable
termination. If, notwithstanding the resolutive means employed, the
inflammation proceeds unabated, and suppuration occurs, the effused
pus ought never to be allowed to remain on the surface of the bone,
but must be evacuated by early incision. Otherwise the pressure of
the extraneous fluid will cause absorption of the bone, or detachment
of periosteum and superficial necrosis; the absorbed surface will,
in its turn, secrete pus, and thus an ulcer will be produced; and,
from the vascular action becoming debilitated in consequence of the
previous incitation, that ulcer will in all probability degenerate into
caries. Much mischief is produced by squeezing and bandaging tightly
the inflamed parts, as can readily be understood; yet such practice is
frequently adopted after suppuration. By it the inflammatory action
is excited anew, the formation of matter is very much increased, and
however useful such manipulation may be in stiffness of a joint, or
mere swelling of bursæ, and sheaths of tendons, still, in inflammation
and abscess of bones or joints it is extremely prejudicial, and from
its indiscriminate employment by those ignorant of the profession,
many limbs have been destroyed. General chronic periostitis, which
is produced by exposure to cold, or occurs after or during mercurial
courses, and is often supposed to be a symptom of syphilis, is relieved
by the internal exhibition of the bichloride of mercury, or other
mercurial preparations, combined with sarsaparilla and diaphoretics.
In many instances such an affection will yield to no other treatment;
and thus the practitioner is occasionally obliged to have recourse to
a somewhat paradoxical practice, that of giving mercury for a disease
which seems to have been produced by that mineral.
In inflammation of the short bones or heads of the long bones, if
the action does not yield to topical bleeding and becomes chronic,
counter-irritants must be employed. Blisters repeated are often useful
in subduing the remaining action, and in obstinate cases small caustic
issues are sometimes of service. During the adhesion of the eschar, the
best application is a common poultice or water dressing, which, on the
separation of the dead part, may be exchanged for any simple ointment,
it not being at all desirable in general to check the discharge and
heal up the breach of surface. Moxa is sometimes employed to make an
issue in these and other cases, but it is not superior in any respect
to the potential cautery, whilst its employment is generally very
alarming to the patient. The sores following the use of the moxa are
in some instances tedious in healing; and this may be ascribed to
the vitality of the surrounding parts having been diminished by the
application.
In cases of atrophy of bone, and where there is reason to suspect
the scrofulous or tubercular deposit to be going on, the affected
part should not be much used, and means taken to give tone to the
system. Preparations of iron are often exhibited with advantage. The
combination of iodine with iron may sometimes answer. Abscesses should
be opened early, so as to prevent extension of the mischief. In abscess
in the shafts of the long bones, it is occasionally necessary to make
an opening through the outer lamella by the trephine, so as to evacuate
its contents. Some instructive cases have been given by Sir B. Brodie,
illustrative of the good effects of this practice. I subjoin one out of
many from my own hospital practice.
“W. A., aged 22, was admitted Oct. 26, 1837, under the care of Mr.
Liston. He is a policeman of weak conformation. He states that when
about six or seven years of age he was first attacked with an aching
pain in the right leg, near its middle, and since that period has
been subject to three or four attacks every year. These usually were
experienced in the spring, during rough, windy, and cold weather, and
continued from one to three weeks. The pain was always aggravated at
night, and so trifling in the day that he was always able to go about.
These attacks ceased to occur when he was between 15 and 16 years of
age, and since that time, until last May, he has been free from them.
He states that up to about his 16th year the bone of the leg gradually
enlarged in its middle portion, but then became stationary, and at
the period of entering the police the difference between the bones of
both legs was not great; this was about two years ago. Since then he
has been accustomed to walk for a considerable length of time daily.
During some months he was obliged to do the night work, and then he
was much exposed to cold and wet. Last May, while thus engaged, he
experienced again an aching pain in the middle of the right tibia; this
was aggravated at night; and after a fortnight’s duration, during which
it became gradually worse, he was obliged to give up his duties in
the police, being unable to continue them any longer. At this time he
consulted the surgeon of the subdivision with which he was connected;
his treatment was fomentations to the leg and aperient medicine
occasionally. Not being much relieved by this, he afterwards ordered
the application of leeches on three several occasions, and mercury to
salivation. At the end of three weeks he returned to his duty. In the
latter part of September he was again attacked with pain during night
duty; this pain increased rapidly in severity, and after three nights
he was again obliged to leave duty. He was now treated again with the
frequent and copious application of leeches at different intervals,
and likewise took some pills, which did not affect his mouth. This
treatment, with frequent fomentations, was persevered in for a month,
but without permanent benefit, and then he was brought to this
hospital. Has never had any syphilitic complaint.
“_Present state._—Has an enlargement of the tibia about its middle
third, of a diffused character, and which seems to extend a good
deal inwards and backwards; in this part he experiences a throbbing
and lancinating pain at night; during the day he is in general easy;
at night there is considerable heat and swelling in the leg; tongue
whitish; appetite good. The following pills were ordered:—℞.
Bichloride of mercury, two grains; powder of gum guiacum, two scruples;
oil of sassafras, ten minims; extract of sarsaparilla, four scruples.
To be divided into twenty-four pills, of which let two be taken three
times a day. Apply eighteen leeches to the affected part.
“Nov. 4. The leeches were repeated; much the same.
“8. Symptoms as before. As he complains of pain over the eyebrow, with
nausea, let the mercury be left off. A variety of constitutional and
local treatment has been pursued during Mr. Liston’s absence from the
hospital, but without affording any relief; the patient’s nights were
passed in great agony, and his general health began to suffer. On the
27th, after consultation with Mr. Fisher, the surgeon to the Police
Force, Mr. Liston had the patient carried into the operating theatre.
He made an incision along the spine of the tibia of about three inches
in extent; another shorter one was made to fall on this at right
angles from the inner side. The surface of the bone thus exposed was
perforated to the depth of fully half an inch by a small trephine. A
very dense circle was removed from the perforation; still the fluid,
which was suspected to exist, did not appear. Mr. Liston, encouraged by
the intense pain complained of as the process of perforation proceeded,
again applied the crown of the instrument, and after a few more turns,
brought out a further circle of considerable thickness, and this was
forthwith followed by a flow of well-digested purulent matter.
[Illustration]
“28. Complains of no pain comparatively; slept well last night after
an anodyne draught; has felt much relieved since the operation; a
good deal of matter was discharged from the sore during the night;
water-dressing to be applied to the wound.
“30. Slept well without any anodyne the last two nights. The relief
afforded by the operation is felt more now than it was at first. The
wound discharges a good deal. A tonic mixture, containing infusion of
gentian, sulphate of magnesia, and sulphuric acid, was ordered.
“Dec. 2. The wound looks florid and clean; granulations are springing
up; general health very much improved.
“4. The edges of the wound are thickened by the granulations; the
discharge from the wound still considerable; feels quite well in health.
“12. The wound continues much the same; the rollers have been
discontinued.
“14. Feels himself gaining strength daily; can walk without pain; wound
is contracting and hard; granulations seem to lessen the depth of the
opening in the bone; there appears to be no sequestrum.”
When caries is fairly established, and the integuments have given
way, the best and most successful proceeding is that pointed out by
nature—destruction of the diseased portion; and the means must vary
according to the particular circumstances. In many cases, nature seems
to wait but for the separation of the sickly parts, either by accident,
or by the interference of art. The means are to remove, partially or
wholly, the diseased part, or to effect such a change of action as will
throw it off. The first indication will be accomplished by trephines,
scoops, saws, and forceps; the second by active escharotics; frequently
both are required.
If there be extensive disease in the medullary canal of a bone, several
perforations may require to be made, and these may be connected by the
use of a small saw, or the cutting forceps. The diseased cancelli, thus
exposed, can be readily removed by the scoop or graver, as recommended
by Mr. Hey, primus, in his excellent work. If, with the probe, it
is ascertained that a portion of the cancellated texture has become
dead and loose, it is to be removed after dilatation of the external
opening. It may frequently be difficult to distinguish in the effused
blood, between what is diseased and what is not; it will often be
necessary afterwards to cauterise freely the exposed surface, and
for this purpose the oxidum hydrargyri rubrum ought generally to be
preferred. The slough will soon be thrown off, and healthy granulations
fill up the breach. The application of the actual cautery may be by
some considered necessary: at one time I employed this remedy very
extensively in caries, and occasionally with very good success; I have
since, however, been led to change my opinion, and am now inclined to
prefer the potential cautery already mentioned. By the application of
the red-hot iron, the diseased portion is destroyed effectually, but
at the same time the vitality of the surrounding parts is often very
much weakened and their power of reparation diminished, so that they
are incapable of assuming a sufficient degree of action for throwing
off the dead part; their action being increased whilst their power is
diminished, they may become affected with caries, and thus, instead
of being arrested, the original disease will either be increased,
or extensive necrosis may take place. The red oxide of mercury is
not calculated to produce such bad effects; it does not spread or
insinuate itself into the bony tissue, as liquid caustics are apt to
do; and it is sufficiently powerful for complete destruction of the
diseased parts. It will be necessary to keep the wound open, by proper
dressings, till all the dead portions of bone be discharged, and every
part of the parietes of the cavity produce healthy granulations: if
the discharge be offensive, its fetor may be corrected by the use
of spirituous applications, such as the tinctures of myrrh, opium,
or aloes, separately or combined. After healthy granulations have
appeared, and the cavity has begun to contract, light dressing is all
that is necessary.
In operating on the carpal and tarsal bones for removal of caries, the
surgeon must be well acquainted with the connexions and relations of
the parts. If one bone is diseased, its removal will be sufficient; if
several, the operation becomes more painful and difficult. When one
only of the tarsal or carpal bones is almost completely destroyed,
and the surfaces of those articulated with it are also more or less
affected, it is not sufficient or safe merely to remove the loosely
attached portions of the one primarily attacked; the diseased parts
of those surrounding it must also be taken away, and it will often be
necessary to apply the caustic afterwards. In caries of the distal
range of bones, the bases of those supported by them are in general
involved, and must also be removed. If one only is diseased, with the
base of the metacarpal or metatarsal bone attached to it, the removal
of these will be enough, and can be accomplished without difficulty.
Some have recommended the total extirpation of a metacarpal or
metatarsal bone, leaving the finger or toe appended; but the member,
when thus left unsupported, can never become of any service to the
patient, and may be productive of much inconvenience; whilst removal
of them, along with the diseased bone, renders the operation much more
easy of execution. If the whole disease can be extirpated, leaving the
surfaces of the surrounding bones covered with healthy cartilage, the
use of the caustic is not required, and would be productive of harm;
but wherever it is impossible to avoid encroaching on the cancellated
texture, such as of the os calcis, which it would be unsafe or
imprudent to take away entirely, its use is then indispensable. After
the removal of carious bones, the symptoms soon disappear, and the
patient obtains a rapid, and often permanent cure. The instruments for
these operations, and the method of performing them, will be afterwards
mentioned. In conclusion, it may be remarked that the temporary
cicatrix of a sore leading to a diseased bone has a very different
appearance from the sound scar which is formed after its removal. The
former is bluish, soft, on a level with the surrounding parts, and
moveable; the latter is depressed, white, and firmly adherent to the
bone.