Part 13

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.

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.

CARIES most frequently occurs in the heads of long and in the 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.

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.

“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.